Cervico-mediastinal schwannoma of the vagus nerve: resection with intraoperative nerve monitoring

Schwannomas are usually benign, single, encapsulated, slow-growing tumours originating from cranial or spinal nerve sheaths. The vagus nerve involvement at the mediastinal inlet is very uncommon. For anatomical reasons, the resection of cervical and mediastinal schwannoma of the vagus nerve has a high risk of vocal fold paralysis. We describe the case of a 67-year-old female with a cervico-mediastinal schwannoma of the vagus nerve that we removed using the intraoperative neuromonitoring technique. The patient presented with mild hoarseness and complained of discomfort behind the jugular notch. Neck and chest computerized tomography described a 35 × 30 mm solid lesion behind the left clavi-sternal junction; preoperative fine needle aspiration cytology revealed schwannoma. Resection of the mass was performed with a cervical approach and the vagus nerve tumour was completely removed under continuous neuromonitoring (NIM-3^® System), preserving the vagus and the recurrent laryngeal nerve function. Pathology on the resected mass documented A-type schwannoma with “ancient schwannoma” areas. The intraoperative neurostimulation and neuromonitoring approach for the resection of vagus schwannoma are recommended because it may reduce the risk of injury to the vagus and to the recurrent laryngeal nerve.     

Schwannoma of the brachial plexus mimicking an apical lung tumor

Primary tumors of the brachial plexus are unusual. We describe a patient with a large schwannoma of the lower trunk of the brachial plexus that had the radiologic appearance of an apical lung mass. Use of a posterior subscapular approach as well as intraoperative nerve action potential recording permitted resection with spared function.     

Intraoperative electrophysiologic studies on the functions of nerve roots involved in cervical dumbbell-shaped schwannoma and their clinical utility

BACKGROUND: It is difficult to expect the degree of neurologic deficits after resection of involved nerve roots before and during the surgery for cervical dumbbell-shaped schwannoma. We present the results of studies for cervical nerve root functions in patients with cervical schwannoma using intraoperative electrophysiologic assessment and the potential of their clinical relevance is also discussed. OBJECTIVE: To present the utility of intraoperative electrophysiologic studies to detect the functions of the nerve roots involved in cervical schwannoma and adjacent nerve roots. METHODS: Five patients with dumbbell-shaped cervical schwannoma arising from the cervical nerve roots composing the brachial plexus were studied. Compound muscle action potentials (CMAPs) after stimulation of nerve roots involved in the schwannoma were recorded from upper limb muscles anatomically correspond to their myotome. Adjacent nerve roots were also stimulated. Motor-evoked potentials (MEPs) after transcranial electric stimulation were also recorded during surgery. In 3 patients, sensory nerve action potentials (SNAPs) after digital nerve stimulation were also recorded from cervical nerve roots. RESULTS: In 4 patients, CMAPs after stimulation of cervical nerve roots involved with the schwannoma were not obtained or were very small compared with those obtained after stimulation of adjacent nerve roots. In 2 of 4 patients, SNAPs after digital nerve stimulation were recorded with small amplitude from the nerve roots involved in schwannoma. Minimal (n=2, within 80% attenuation of amplitude) or no changes (n=2) were observed after total resection of the schwannoma and no apparent motor weakness occurred in these 4 patients. In a patient with cervical schwannoma involved in C8 nerve root, CMAPs with large amplitude were recorded after stimulation of the C8 nerve root. SNAPs after stimulation of digit V were recorded with larger amplitude from the T1 root compared with those recorded from the C8 nerve root. Intradural parts of the tumor arising from C8 posterior rootlets were completely removed after transaction of posterior rootlets. During removal of intraforaminal parts of the tumor, motor evoked potentials were decreased over 50% of controls. Incomplete removal was chosen to avoid deterioration of motor function. Transient dysesthesia of digit V and slight weakness occurred after surgery. CONCLUSIONS: The residual function of motor and sensory nerve roots involved with cervical schwannoma differed between individuals and could be detected using intraoperative electrophysiologic assessment.     

Schwannoma arising from brachial plexus with intrathoracic extension; report of a case

We report a case of schwannoma arising from brachial plexus with intrathoracic extension. An 18-year-old man demonstrated a tumor shadow at the right pulmonary apex area. In the 2-months of follow-up, tumor size had been growing rapidly. Chest computed tomography (CT) and magnetic resonance imaging (MRI) revealed a giant tumor mass infiltrated right lung. We perfomed operation under the posterolateral incision approach. The pathological diagnosis was schwannoma. We resected this tumor safely and conserved with the seventh, eighth cervical nerve of the brachial plexus under posterolateral incision approach.     

术中超声精准引导下闭合复位弹性髓内钉固定治疗锁骨骨折的疗效

目的:探讨超声精准引导在锁骨骨折闭合复位弹性髓内钉（TEN）固定手术中的应用效果。方法:回顾性分析2017年1月至2019年3月山东省文登整骨医院急诊创伤科术中在超声精准引导下进行骨折闭合复位TEN固定治疗的40例新鲜锁骨骨折患者资料。男25例,女15例;年龄25~68岁,平均52.1岁;左侧27例,右侧13例。观测术...     

Endoscopic exploration of the brachial plexus: technique and topographic anatomy--a study in fresh human cadavers

OBJECTIVE: The indications for and timing of brachial plexus exploration in closed injuries are controversial. The time-consuming surgery proves its worth in some cases, whereas spontaneous regeneration might have been possible in others. The differentiation is difficult, because no investigational method reveals the exact morphological correlates of the nerve lesions. Minimally invasive, direct observation of the structures is a possible solution. Here we describe our surgical technique and the anatomic features of the normal brachial plexus appreciated with the endoscope. METHODS: Twenty-one brachial plexus in 11 fresh cadavers were investigated. Endoscopic exploration was performed at the supraclavicular and infraclavicular levels. The method involves insertion of an optic shaft-integrated retractor through a stab wound; retraction of landmark muscles produces a working space, into which other instruments are introduced for dissection. After completion of endoscopic surgery, open dissection was performed to verify the endoscopically identified structures and to assess iatrogenic injuries. RESULTS: The omohyoid muscle is a reliable landmark in the supraclavicular region, beneath which the suprascapular nerve can be observed. Following the suprascapular nerve proximally leads to the plexus trunks. Infraclavicular exploration first reveals the axillary artery. The plexus and its nerves are traced around this artery. The anatomic features were constant in all cases, with variations in fat accumulation depending on the corporeal constitution. We detected iatrogenic injuries to the medial circumflex humeral vessels in two cases. No nerve injuries were observed. CONCLUSION: The endoscopic technique combined with intraoperative nerve stimulation studies might provide important information on the type of morphological damage in closed brachial plexus injuries and thus might become an important tool for determination of the surgical treatment strategy. Clinical work is under way.     

26例臂丛神经鞘瘤的显微手术治疗

目的探讨臂丛神经鞘瘤显微手术的治疗要点。方法回顾性总结2000年1月～2009年10月我院收治的26例臂丛神经鞘瘤患者的临床资料,其中臂丛上干11例,中干10例,内侧束2例,外侧束1例,C5-71例,C6-71例,均实行显微镜下手术切除。结果 26例患者臂丛神经鞘瘤均完整切除,术后无臂丛神经受损表现。病理提示Antoni A型18例,Antoni B型8例。随访6个月到10年,无一例复发。结论臂丛神经鞘瘤的显微外科手术治疗应尽量避开神经纤维,保护好神经干,逐层剥离包膜,将瘤体完整切除,多能获得较满意的疗效。     

A case of schwannoma arising in brachial plexus with intrathoracic extension]

A case of benign schwannoma arising in the brachial plexus with intrathoracic extension was presented. The patient was a 55-year-old man, who was pointed out an abnormal shadow in the left apical region on routine chest X-ray examination. MRI showed that the mass extended to the lowest trunk of the brachial plexus. He had no complaint. Therefore, a diagnostic operation was performed. The tumor was subcapsularly resected with thoracoscopic surgery. Histopathological examination revealed a schwannoma (Antoni type A and B). It should be kept in mind that tumors arising in the brachial plexus are a probable differential diagnosis for tumors at the pulmonary apex, even if no neurological symptoms are seen in the upper extremities.     

Surgical treatment with Ligasure Precise of schwannoma of brachial plexus: case report

English version We present a case of bulky schwannoma arising from the brachial plexus treated by a new surgical device. A 38-year-old man presented with a slow-growing left-sided supraclavicular mass and complained paresthesia of the third and forth fingers of the hand and forearm weakness. Physical examination revealed Tinel's sign. A CT-scan revealed a solid mass situated in the left profound supraclavicular fossa. The tumour was resected with the utilization of bipolar vessel sealing system (Ligasure Precise). This device is very useful in sutureless removal of masses localized in deep supraclavicular fossa. During the operation, care was taken to preserve the nerve function.     

Neurogenic tumors of the brachial plexus: report of two cases.

Two cases of solitary neurogenic tumors of the brachial plexus unassociated with von Recklinghausen's disease are presented. One patient had a malignant schwannoma. The lesion of the other patient was benign and was diagnosed pathologically as a plexiform neurofibroma. These uncommon neurogenic tumors of the brachial plexus unassociated with von Recklinghausen's disease pose diagnostic and surgical problems. The initial clinical presentation is usually that of a painless supraclavicular mass. At the time of surgical exploration, the exact site or nerve of origin cannot always be identified. If motor loss is caused by such a tumor of the brachial plexus, it usually indicates a malignant lesion and a poor prognosis. Although wide radical excision of a malignant neurogenic tumor is indicated surgically, one of our patients had an early malignant recurrence that necessitated immediate amputation.     

Entrapment neuropathy contributing to dysfunction after birth brachial plexus injuries

Although surgical treatment of brachial plexus birth palsy has yielded encouraging results, persistent inability to abduct and elevate the shoulder is common even in children with excellent return of arm and hand function. The reason for deltoid weakness in the afflicted children is not completely understood and may be multifactorial. Clinical observations, including a pattern of position-dependent weakness, suggest that primary nerve damage may not be the sole cause. The authors performed a retrospective chart study to investigate the outcome of surgical treatment to augment shoulder function in a series of 10 children (ages 9 months to 8 years) with inadequate external rotation of the shoulder and inability to actively raise the arm beyond 90 degrees from a birth brachial plexus injury. At follow-up 6 months after surgery, increased shoulder range of motion was noticed in all, with significantly increased abduction/elevation in 8 of the 10 children. Analysis of data, including pre- and postoperative functional testing and intraoperative electrophysiologic monitoring, led to the conclusion that secondary compression of the axillary nerve in the quadrangular space is a separate and common reason for impairment in children with brachial plexus birth palsy and persistent weakness of the deltoid muscle and may provide an important reason for early intervention.     

Neurinoma of the brachial plexus: 2 case reports

Neurinomas, also referred to as neurilemmomas and schwannomas, are rare benign tumours of the peripheral nerves. A small percentage of these lesions arise from the brachial plexus. The Authors report two cases of schwannoma arising from the brachial plexus. Such lesions, usually asymptomatic, may cause sensitivity alterations or, less frequently, motor deficits in the involved arm. Tumour enucleation, avoiding damage to any of the nervous fascicles, is the treatment of choice.     

Contralateral C7 transfer in adult plexopathies

In the current study, a retrospective review of 56 patients with posttraumatic root avulsion brachial plexus injuries who underwent contralateral C7 transfer using the selective contralateral C7 technique is presented. The intraoperative findings of the involved brachial plexus, the surgical technique of preparation of the donor C7 nerve root, and the various neurotization procedures are reported. The surgical outcomes as well as the potential adverse effects of the procedure are analyzed. We conclude from this study that the selective contralateral C7 technique is a safe procedure that can be applied successfully for simultaneous reconstruction of several different contralateral muscle targets or for neurotization of cross chest nerve grafts for future free muscle transplantation.     

Brachial plexus endoscopy: feasibility study on cadavers

The development of a minimally invasive technique for exploration of the brachial plexus seems a logical step towards refinement of diagnosis and treatment. For certain pathological conditions, minimally invasive techniques have become the method of choice; for others, they remain as an ancillary option for assistance during open surgery. We have developed a full endoscopic technique for brachial plexus exploration. Our endoscopic technique used saline liquid infusion in seven brachial plexus of four cadavers. Five portals have been described and the endoscopic landmarks also. We were able to demonstrate excellent views and adequate possibilities for cadaver plexus dissection and its anatomic landmarks and portals. LEVEL OF EVIDENCE: 4.     

Magnetic resonance imaging in brachial plexus injury

Brachial plexus injury represents the most severe nerve injury of the extremities. While obstetric brachial plexus injury has showed a reduction in the number of cases due to the improvements in obstetric care, brachial plexus injury in the adult is an increasingly common clinical problem. The therapeutic measures depend on the pathologic condition and the location of the injury: Preganglionic avulsions are usually not amenable to surgical repair; function of some denervated muscles can be restored with nerve transfers from intercostals or accessory nerves and contralateral C7 transfer. Postganglionic avulsions are repaired with excision of the damaged segment and nerve autograft between nerve ends or followed up conservatively. Magnetic resonance imaging is the modality of choice for depicting the anatomy and pathology of the brachial plexus: It demonstrates the location of the nerve damage (crucial for optimal treatment planning), depicts the nerve continuity (with or without neuroma formation), or may show a completely disrupted/avulsed nerve, thereby aiding in nerve-injury grading for preoperative planning. Computed tomography myelography has the advantage of a higher spatial resolution in demonstration of nerve roots compared with MR myelography; however, it is invasive and shows some difficulties in the depiction of some pseudomeningoceles with little or no communication with the dural sac.     

Brachial plexus catheter reservoir for the treatment of upper-extremity cancer pain: technical case report

OBJECTIVE AND IMPORTANCE: Infiltration of the brachial plexus with anesthetics can provide relief of upper-extremity pain from invasive cancer. Because the analgesia is short-lived, however, repeated invasive treatments are necessary. We describe the implantation of a catheter reservoir system, in which anesthetic injections through a subcutaneous port resulted in anesthetic infiltration of the brachial plexus. CLINICAL PRESENTATION: A 47-year-old Hispanic man with squamous cell carcinoma of the larynx had undergone surgical resection, radiation treatment, and chemotherapy. Two years later, he had locally recurrent disease involving the brachial plexus, neck, and chest wall. The patient's pain was minimally responsive to narcotics, which also caused severe nausea and anorexia. TECHNIQUE: The brachial plexus was localized percutaneously with a needle electrode stimulator. Contrast injection under fluoroscopy confirmed entry into the plexus sheath. With use of the Seldinger technique, two Silastic catheters were placed within the brachial plexus and attached with a "Y" connector to a reservoir. The patient experienced complete relief of upper-extremity pain after a test injection with xylocaine. Thereafter, serial injections of bupivacaine with triamcinolone at 1-week intervals provided complete pain relief. After the treatments were initiated, the patient reported improved sleep and an improvement in his quality of life. CONCLUSION: A catheter reservoir system for brachial plexus analgesia can provide safe and effective analgesia for upper-extremity pain. This technique negates the need for repeated invasive procedures and avoids the complications of neurolysis.     

臂丛神经鞘膜瘤的手术治疗

目的 探讨臂丛神经鞘膜瘤的显微外科手术治疗。方法 1975年至今共收治臂丛神经鞘膜瘤17例，源自臂丛上干7例，中干8例，C5、6神经根1例，外侧束1例。14例行显微外科手术切除肿瘤，3例曾在外院误将肿瘤与神经干一并切除，行神经移植修复术。结果14例术后神经功能正常，随访6个月至10年，无1例复发。3例误将臂丛上干切除行神经缺损修复者，术后均有不同程度的功能恢复，效果良好。结论 臂丛神经鞘膜瘤在手术显微镜下逐层剥离包膜，完整切除瘤体，保护好神经干，均能获得较满意的疗效。     

Brachial plexus paralysis after thoracoscopic esophagectomy for esophageal cancer in the prone position: A thought-provoking case report of an unexpected complication

IntroductionDuring prone esophagectomy, placement of a port in the third intercostal space for upper mediastinal dissection requires adequate axillary expansion. To facilitate this, the right arm is elevated cranially and simultaneously turned outward. Brachial plexus paralysis associated with esophagectomy in the prone position has not been documented.Presentation of caseA 58-year-old man diagnosed with middle intrathoracic esophageal cancer was referred to our department. Thoracoscopic esophagectomy in the prone position was performed following neoadjuvant chemotherapy. After surgery, he complained of difficulty moving his right arm. Physical examination revealed perceptual dysfunction and movement disorder in the territory of cervical spinal nerve 6. Magnetic resonance imaging indicated the injury in the right posterior cord of the brachial plexus at the costoclavicular space. Therefore, we diagnosed the patient with right brachial plexus injury caused by the intraoperative position. The postoperative course was uneventful other than the brachial plexus paralysis, and he was discharged on postoperative day 23. He underwent continuous rehabilitation as an outpatient, and the right brachial plexus paralysis had completely disappeared by 2 months after surgery.DiscussionThis is the first case of brachial plexus injury during thoracoscopic esophagectomy in the prone position. In prone esophagectomy, managing the patient’s position, especially the head and arm positions, is so important to avoid brachial plexus injury due to intraoperative positioning.ConclusionThe clinicians should consider managing the patient’s position with anatomical familiarity to avoid brachial plexus injury due to intraoperative positioning.     

Outcomes of surgery in 1019 brachial plexus lesions treated at Louisiana State University Health Sciences Center

OBJECT: Outcomes of 1019 brachial plexus lesions in patients who underwent surgery at Louisiana State University Health Sciences Center during a 30-year period are reviewed in this paper to provide management guidelines. METHODS: Causes of brachial plexus lesions included 509 stretches/contusions (50%), 161 plexus tumors (16%), 160 thoracic outlet syndromes (TOSs, 16%), 118 gunshot wounds (12%), and 71 lacerations (7%). Many features of clinical presentation, including prior treatment, patient's neurological status, results of electrophysiological studies, intraoperative findings, and postoperative level of function, were studied. The minimum follow-up period was 18 months and the mean follow-up period was 42 months. Repairs were best for injuries located at the C-5, C-6, and C-7 levels, the upper and middle trunk, the lateral cord to the musculocutaneous nerve, and the median and posterior cords to the axillary and radial nerves. Conversely, results were poor for injuries at the C-8 and T-1 levels, and for lower trunk and medial cord lesions, with the exception of injuries of the medial cord to the median nerve. Outcomes were most favorable when patients were carefully evaluated and selected for surgery, although variables such as lesion type, location, and severity, as well as time since injury also affected outcome. This was true also of TOSs and tumors arising from the plexus, especially if they had not been surgically treated previously. CONCLUSIONS: Surgical exploration and repair of brachial plexus lesions is technically feasible and favorable outcomes can be achieved if patients are thoroughly evaluated and appropriately selected.