Primary brachial plexus tumors: imaging, surgical, and pathological findings in 25 patients

Tumors of the brachial plexus region: A 15-year experience with emphasis on motor and pain outcomes and literature review

Background

Brachial plexus region tumors are rare. In this study, we reviewed our experience with resection of tumors involving or adjacent to the brachial plexus to identify patterns in presentation and outcome.

Methods

We report a retrospective case series of brachial plexus tumors operated on by a single surgeon at a single institution over 15 years. Outcome data were recorded from the most recent follow-up office visit. Findings were compared to a prior internal series and comparable series in the literature.

Results

From 2001 to 2016, 103 consecutive brachial plexus tumors in 98 patients met inclusion criteria. Ninety percent of patients presented with a palpable mass, and 81% had deficits in sensation, motor function, or both. Mean follow-up time was 10 months. Serious complications were infrequent. For patients with a preoperative motor deficit, the rate of postoperative motor decline was 10%. For patients without a preoperative motor deficit, the rate of postoperative motor decline was 35%, which decreased to 27% at 6 months. There were no differences in motor outcome based on extent of resection, tumor pathology, or age.

Conclusion

We present one of the largest recent series of tumors of the brachial plexus region. Although the rate of worsened postoperative motor function was higher in those without preoperative weakness, the motor deficit improves over time and is no worse than antigravity strength in the majority of cases. Our findings help guide patient counseling in regard to postoperative motor function.

Patient demographics, tumor characteristics, and outcomes following surgical treatment of benign and malignant brachial plexus tumors: a systematic review

BACKGROUND

Various treatment options have been introduced for the management of primary tumors of the brachial plexus (BP), ranging from conservative therapy to wide local excision with/without postoperative chemoradiotherapy. However, no consensus exists regarding optimal treatment strategies based on collated and published data.

OBJECTIVE

The aim of this study was to investigate the clinicopathological characteristics and outcome of patients with primary tumors of the BP who underwent surgical treatment.

DATA SOURCES

A systematic search of the four main online databases, including Web of Science (WOS), PubMed, Scopus, and Google Scholar, was conducted.

STUDY SELECTION

All related articles addressing the clinical outcome and role of surgical interventions for management of primary tumors of the BP.

INTERVENTION

Optimal surgical and radiotherapeutic interventions for benign and malignant lesions based on the pathologic characteristics and location of primary BP tumors.

RESULTS

A total of 687 patients (693 tumors) with a mean age of 41.7±8.7 years old were evaluated. In total, 629 (90.8%) tumors were benign, and 64 (9.2%) were malignant, with a mean tumor size of 5.4±3.1 cm. The location of the tumor was reported for 639 patients. For these tumors, 444 (69.5%) originated from the supraclavicular region, and 195 (30.5%) were infraclavicular. The trunks were the most common location for tumor involvement, followed by the roots, cords, and terminal branches. Gross total resection was achieved in 432 patients and subtotal resection (STR) was performed in 109 patients. With neurofibromas, STR still resulted in good outcomes. The outcomes following treatment of malignant peripheral nerve sheath tumors were poor regardless of the type of resection. In general, symptoms related to pain and sensory issues resolved rapidly postoperatively. However, the resolution of motor deficits was often incomplete. Local tumor recurrence occurred in 15 (2.2%), patients and distant metastasis was observed in only eight (1.2%) cases. The overall mortality was 21 (3.1%) patients among the study population.

LIMITATIONS

The main limitation was the lack of level I and II evidence.

CONCLUSIONS

The ideal management strategy for primary BP tumors is complete surgical resection. However, in some cases, particularly for neurofibromas, STR may be preferable to preserve maximal neurological function. The degree of surgical excision (total or subtotal) mainly depends on the pathological characteristics and primary location of the tumor.

Benign Peripheral Non-cranial Nerve Sheath Tumors of the Neck

Benign peripheral non-cranial nerve sheath tumors are rare lesions, including both schwannomas and neurofibromas. These tumors arise from Schwann cells, and may originate from any peripheral, cranial, or autonomic nerve. Most of them are localized and sporadic but multifocal systemic forms can occur. Cervical sympathetic chain, brachial plexus, cervical plexus and spinal roots and nerves are the major nerve systems commonly affected. Dumbbell-shaped intra- and extradural tumors occur most commonly in the cervical spine, as well as purely extradural and paravertebral tumors. The management of these tumors has improved greatly owing to the developments in imaging techniques and surgical innovations such as endoscopically assisted approaches and robotic surgery. Microsurgical intracapsular excision of the tumor helped by the use of intraoperative fluorescent dyes and intraoperative neurophysiological monitoring minimize postoperative neural deficit, since most schwannomas are encapsulated. Most tumors can be removed with a low rate of complications and recurrence. Radiotherapy should be considered for growing lesions that are not amenable to surgery. In asymptomatic patients, observation and serial scans is an option for elderly infirm patients.

Tumor-like disorder of the brachial plexus region in a patient with hemophilia: A case report

BACKGROUND

Various tumors and tumor-like disorders, originating from the neural sheath, as well as other types, may affect the brachial plexus region. Due to the infrequent presentation, brachial plexus palsy caused by spontaneous hematoma in patients with hemophilia might miss the treatment by early surgical decompression and progress to permanent nerve damage.

CASE SUMMARY

The case reported here was a 30-year-old man with hemophilia, as well as both sensory and motor dysfunction of the left upper extremity. A presumptive diagnosis of brachial plexus tumor was initially made, which was subsequently confirmed to be an organized chronic hematoma rather than a neoplasm. The hemophilia-induced expanding hematoma compressing the brachial plexus was considered to be the main reason for the patient’s complaints. The clinical symptoms were alleviated and the involved nerves partially recovered at a follow-up of 1 year.

CONCLUSION

Early surgical intervention is crucial and it seems to be an essential precondition for recovery of nerve function in brachial plexus lesions.

Management of benign nerve sheath tumors of the brachial plexus: relevant diagnostic and surgical features. About a series of 17 patients (19 tumors) and review of the literature

Brachial plexus (BP) tumors are rare, potentially difficult-to-manage lesions. The method is retrospective chart analysis. Among the 17 patients, four had neurofibromatosis and one schwannomatosis (NF +). The latter has bilateral BP tumors that remain stable on MRI at a 6.5 year follow-up. Another NF + patient has bilateral non-operable BP plexiform neurofibromas. The complaints of the 15 operated patients were radiated pain, a mass, local pain, paresthesia, a neurological deficit (n = 15, 12, 7, 10, 7). On MRI, the tumors appeared as nodular or ovoid large masses. Four operated tumors were proximal, reaching the foramen. The FDG-PET scan (n = 4) always showed tumor hypermetabolism. A preoperative percutaneous biopsy was done in three patients before neurosurgical consultation; one of them developed neurogenic pain and a sensory deficit following two percutaneous biopsies for a misinterpreted cervical lymphadenopathy. Surgery was performed using a supra-, infra-, supra- + infra-clavicular or posterior subscapular approach (n = 8, 3, 3, 1). Intraoperative electrophysiology was used in all patients. Complete or gross total resection was achieved in 14 patients. Two patients had fascicle reconstruction with grafts. Pathology revealed 13 schwannomas and two neurofibromas. Neurogenic pain transiently developed or worsened after surgery in five patients. At last follow-up, a mild deficit remained in four patients (preexisting in three). No recurrence had occurred. We conclude that a thorough examination of any patient with a cervical or axillary mass is crucial to avoid misinterpretation as a lymphadenopathy. MRI is the best imaging modality. Most BP benign tumors can be completely and safely resected through the use of microsurgical techniques and intraoperative electrophysiology.

Brachial plexus tumors extending into the cervicothoracic spine: a review with operative nuances and outcomes

BACKGROUND

The rarity and anatomical complexity of brachial plexus tumors (BPTs) impose many challenges onto surgeons performing surgical resections, especially when these tumors invade the cervicothoracic spine. Treatment choices and surgery outcomes heavily depend on anatomical location and tumor type.

METHODS

The authors performed an extensive review of the published literature (PubMed) focusing on "brachial plexus tumors" that identified invasion of the cervicothoracic spine.

RESULTS

The search yielded 2774 articles pertaining to "brachial plexus tumors". Articles not in the English language or involving cervicothoracic spinal invasion were excluded.

CONCLUSIONS

Recent research has shown that the most common method used to resect tumors of the proximal roots is the dorsal subscapular approach. Despite its association with high morbidity rate, this technique offers excellent exposure to the spinal roots and intraforaminal portion of the spinal nerve. The dorsal approach is used to resect recurrent lower trunk tumors and dumbbell-shaped neurofibromas, yet it is also the least common overall approach used in brachial plexus tumor resections. The ventral or anterior technique is commonly used to resect tumors at the cord to division level, and root to trunk level. Motor complications, transient nerve palsy, and bleeding are among the most common complications of the anterior supraclavicular approach. Further controlled studies are needed to fully determine the optimal surgical approach used to obtain the best outcomes and least complications for each type of brachial plexus tumor.

Perineural spread to the brachial plexus: a focused review of proposed mechanisms and described pathologies

BACKGROUND

Perineural spread (PNS) is an emerging mechanism for progressive, non-traumatic brachial plexopathy. We aim to summarize the pathologies (tumor and infection) shown to have spread along or to the brachial plexus, and identify the proposed mechanisms of perineural spread.

METHODS

A focused review of the literature was performed pertaining to pathologies with identified perineural spread to the brachial plexus.

RESULTS

We summarized pathologies currently reported to have PNS in the brachial plexus and offer a structure for understanding and describing these pathologies with respect to their interaction with the peripheral nervous system.

CONCLUSIONS

Perineural spread is an underrepresented entity in the literature, especially regarding the brachial plexus. It can occur via a primary or secondary mechanism based on the anatomy, and understanding this mechanism helps to support biopsies of sacrificial nerve contributions, leading to more effective and timely treatment plans for patients.

Do not forget the brachial plexus-prevalence of distal brachial plexus pathology on routine shoulder MRI

OBJECTIVES

Most of the shoulder magnetic resonance imaging (MRI) examination focuses on internal joint structures but disregarding other structures like the distal brachial plexus, which may miss important findings. Hereby, we attempt to evaluate the prevalence of distal brachial plexus abnormalities and/or muscular denervation changes seen on routine shoulder MRI examinations and discuss common pathologies affecting the distal brachial plexus.

MATERIAL AND METHODS

A total of 701 routine shoulder MRI studies were evaluated. The evaluation of each exam was focused on the visualized brachial plexus elements and musculature abnormalities in each case. If any abnormalities of plexus and/or musculature were found, potential underlying etiologies such as paralabral or spinoglenoid notch cysts, infiltrative/primary masses on imaging, history of prior viral illness, and radiation therapy were searched. It was then confirmed whether the abnormal findings were mentioned in the exam reports or not.

RESULTS

Thirty-four cases (4.85%) demonstrated abnormal findings of the visualized brachial plexus cords or branches and/or musculature. It was observed that in 35.3% of exam reports these findings were not mentioned, mainly missing subtle nerve abnormalities, but correctly reporting and interpreting the encountered muscle abnormalities.

CONCLUSION

The distal brachial plexus and its branches should be included in the search pattern for shoulder MRI examinations.

KEY POINTS

• Normal T2 signal of the brachial plexus is iso- to slightly hyperintense to muscle but less signal intense than fluid. • Diffuse, geographic muscle edema is an indirect sign of brachial plexus pathology. • Increased T2-weighted nerve signal with or without caliber or course change should be reported and followed up to find the underlying etiology.

Large venous hemangioma of brachial plexus

In this report, we present a rare case of a vascular brachial plexus tumor. The patient was a 29-year-old woman with the chief complaint of progressive enlargement of a soft tissue mass in the left upper extremity, without any pain or sensory, motor, or neurologic deficits. The soft tissue mass had presented in the left deltopectoral groove eight years ago. However, the patient had not been evaluated in the past eight years and was only recently admitted to a referral hospital. After complete examination, she underwent surgery for a nerve sheath tumor of the brachial plexus.

Pediatric peripheral nerve tumors: clinical and surgical aspects

PURPOSE

Pediatric peripheral nerve tumors (PNTs) are rare. Most are related to neurofibromatosis type 1 (NF1) with the potential for malignancy. An ongoing debate occurs about the best approach to such patients. This study describes a cohort of pediatric patients with PNTs and discusses clinical characteristics and surgical treatment.

METHODS

We retrospectively reviewed the charts of seven pediatric patients with eight PNTs surgically treated from 2007 to 2018. Information concerning patient demographics, clinical presentation, PNTs characteristics, treatment choice, and outcome were recorded.

RESULTS

All children presented with intense pain and a palpable mass. Three of the eight tumors were associated with a neurological deficit. Among the four patients with NF1, two had a neurofibroma and two a malignant peripheral nerve sheath tumor (MPNST). Histologically, three of the lesions were a benign peripheral nerve sheath tumor (BPNST), three a MPNST, and one each a desmoid tumor and Ewing's sarcoma. Two of the eight tumors underwent partial tumor excision and six gross total excisions.

CONCLUSIONS

Intense pain at rest, day, and/or night, preventing normal activities; a palpable, hard, immobile mass; an intense Tinel's sign related to the lump; clinical evidence of NF1; and high-speed growth of a tumor in the trajectory of the nerve or plexus should alert the clinician to the potential for malignancy. Preoperative biopsy is not indicated when clinical and imaging findings suggest a benign tumor. The surgical management of PNTs must be to achieve total resection, including wide margins with malignant tumors, though this is not always possible.

Huge brachial plexus schwannoma, masking as a cystic neck mass

Schwannomas are solitary, benign tumors arising from the nerve sheaths. They are frequently reported in the thorax predominantly in the posterior mediastinum, but are rarely seen to arise from the brachial plexus. Schwannomas are well demarcated lesions with a slow insidious growth. Presented is a case of a large brachial plexus schwannoma, masking as a cystic lesion in the lateral neck. The patient presented with concerns of a cystic mass progressively increasing in size over a period of four years, initially symptomless, but later caused numbness and tingling sensation over his right forearm, tip of right thumb and index finger. Following histological confirmation via fine needle aspiration and magnetic resonance imaging, the patient underwent surgical excision where by the tumor was dissected from its attachment to the nerve sheath. The patient recovered well, and by the third day post operatively, his neurological symptoms resolved completely. Upon follow up in clinic 1-week post-surgery, the scar had healed well, and his numbness or tingling sensation remained in abeyance. This case illustrates that a schwannoma may present insidiously as a cystic lesion and its possible origin may arise from the brachial plexus.

Analysis According to Characteristics of 18 Cases of Brachial Plexus Tumors : A Review of Surgical Treatment Experience

Objective

Because the anatomical structure of the brachial plexus is very complex, surgical treatment of tumors in this region is challenging. Therefore, a lot of clinical and surgical experience is required for successful treatment; however, many neurosurgeons have difficulty accumulating this experience owing to the rarity of brachial plexus tumors. The purpose of this report is to share our surgical experience with brachial plexus tumor with other neurosurgeons.

Methods

The records of 18 consecutive patients with brachial plexus tumors who underwent surgical treatment between January 2010 and December 2017 in a single institution were retrospectively reviewed. The surgical approach was determined according to the tumor location and size, and intraoperative neurophysiological monitoring (IONM) was used in most of cases to prevent iatrogenic nerve injury during surgery. In addition, to evaluate the differences in tumor characteristics according to pathologic diagnosis, the tumors were divided twice into two groups, based on two separate classifications, and statistical analysis was performed.

Results

The 18 brachial plexus tumors comprised 15 (83.3%) benign peripheral nerve sheath tumors including schwannoma and neurofibroma, one (5.6%) malignant peripheral nerve sheath tumor, one (5.6%) benign tumor of non-neural sheath origin (neurogenic cyst), and one (5.6%) metastatic tumor (papillary carcinoma). The authors analyzed relationship between tumor size/location and tumor characteristic parameters such as age, size, right-left, and pathology. There were no statistically significant differences except a tendency of bigger tumor size in young age.

Conclusion

For a successful surgical outcome, an appropriate surgical approach is essential, and the appropriate surgical approach is determined by the location and size of the tumor. Furthermore, applying IONM may prevent postoperative complications and it is favorable option for brachial plexus tumors surgery.

Case report: synovial sarcoma of the axilla with brachial plexus involvement

BACKGROUND

Synovial sarcoma is a rare soft tissue sarcoma which most commonly affects the extremities of young adults. Axilla involvement by this sarcoma is very rare especially with involvement of the brachial plexus. This combination adds to the challenge in approaching such tumors which might significantly affect survival and function.

CASE PRESENTATION

Herein, we present a 48-year-old female patient who presented with an isolated painless lump in her right axilla. Initially, her workup, looking for possible breast cancer, included fine-needle aspiration (FNA) which did not provide the diagnosis. Core-needle biopsy, performed later, revealed monophasic synovial sarcoma. Her workup studies revealed no metastasis. Then, through extensile deltopectoral approach, the tumor was dissected out from within the brachial plexus. Ulnar nerve was sacrificed in order not to compromise the surgical margins which were confirmed tumor free by final pathology. The patient did not receive chemotherapy or radiation upon consultations with medical and radiation oncology teams. Her follow-up revealed no tumor recurrence with no restriction of her right shoulder motion.

CONCLUSION

Our case report represents a very rare occurrence of synovial sarcoma in the axilla with involvement of the brachial plexus. When clinical and radiological findings are suggestive of soft tissue sarcoma of the axilla, we recommend getting core-needle biopsy rather than fine-needle aspiration for earlier diagnosis. Early referral and multidisciplinary approach may contribute to better management.

The Surgical Management of Symptomatic Benign Peripheral Nerve Sheath Tumors of the Neck and Extremities: An Experience of 442 Cases

BACKGROUND

The occurrence of benign peripheral nerve sheath tumors (PNSTs) is not uncommon. The surgical excision of symptomatic benign PNSTs along with preservation of the affected nerve and its function is an ideal treatment option.

OBJECTIVE

To analyze the outcome with respect to morbidity, extent of resection, and recurrence, and to review and compare our results with those reported in literature.

METHODS

A retrospective review of clinical and radiological findings of 442 patients with benign PNSTs involving the neck and extremities treated surgically from 2000 to 2014 was performed.

RESULTS

In our series, benign PNSTs involved the extremities in 290 (65.6%) patients and the brachial plexus in 146 (33%) patients, and 6 (1.4%) patients had tumors of the extracranial portion of the vagus and hypoglossal nerves in the neck. The mean age of patients was 38 yr. The presenting features were painful mass and paresthesia. Preoperative motor weakness in the extremity was noted in 15.6% of patients. The common nerves involved by the tumors were the ulnar nerve (15.8%), sciatic nerve (12.7%), and upper cervical roots (11.5%). The excision was total in 81.2%, gross total (>90%) in 17.9%, and subtotal (>50%) in 0.9% patients. In 17.6% of patients, there was severe postoperative neurogenic pain. In 28 (6.3%) patients, a new motor deficit was noted following surgery. Recurrence was seen in 2 patients in our series. The mean follow-up was 30.2 mo.

CONCLUSION

Benign PNSTs have excellent clinical outcome, and the goal for surgical treatment is total to gross total excision of the tumor with neural preservation.

ACR Appropriateness Criteria® Plexopathy

MRI without and with contrast is the most accurate imaging method to determine whether a process is intrinsic or extrinsic to a nerve of the brachial or lumbosacral plexus. However, there are no Current Procedural Terminology codes to correspond to imaging studies of the brachial or lumbar plexus discretely. This assessment uses "MRI of the brachial plexus" or "MRI of the lumbosacral plexus" as independent entities given that imaging acquisition for the respective plexus differs in sequences and planes compared with those of a routine neck, chest, spine, or pelvic MRI, yet acknowledges the potential variability of ordering practices across institutions. In patients unable to undergo MRI, CT offers the next highest level of anatomic evaluation. In oncologic patients, PET/CT imaging can identify the extent of tumor involvement and be beneficial to differentiate radiation plexitis from tumor recurrence but provides limited resolution of the plexus itself. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer-reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Head and Neck Schwannomas: A Surgical Challenge-A Series of 5 Cases

Background

Schwannomas, also known as neurilemmomas, are benign peripheral nerve sheath tumors. They originate from any nerve covered with schwann cell sheath. Schwannomas constitute 25–45% of tumors of the head and neck. About 4% of head and neck schwannomas present as a sinonasal schwannoma. Brachial plexus schwannoma constitute only about 5% of schwannomas. Cervical vagal schwannomas constitute about 2–5% of neurogenic tumors.

Methods

We present a case series of 5 patients of schwannomas, one arising from the maxillary branch of trigeminal nerve in the maxillary sinus, second arising from the brachial plexus, third arising from the cervical vagus, and two arising from cervical spinal nerves.

Result

Complete extracapsular excision of the tumors was achieved by microneurosurgical technique with preservation of nerve of origin in all except one.

Conclusion

Head and neck schwannoma though rare should be considered as a differential diagnosis of a unilateral slow growing mass in the head and neck region, particularly in an adult. Schwannomas are always a diagnostic dilemma as they are asymptomatic for long time, and histopathology is the gold standard for diagnosis. As a rule, treatment is surgical and dictated by the location of the tumor and nerve of origin. Due to its rarity, complex anatomical location and morbidity risk postexcision, they can pose a formidable challenge to surgeons. This study aims to describe the presentation, workup, surgical technique, and outcome.

Importance of Sonography for Guiding Central Venous Cannulation in Patients with Neurofibromatosis

A 15-year-old boy with neurofibromatosis type 1 (NF1) was referred to us for central venous catheter insertion, and on ultrasound of the neck, he was found to have extensive involvement of the brachial plexus due to the nerve sheath tumour. Multiple hypoechogenic lesions resembling the internal jugular vein and internal carotid artery were visualised and could be differentiated from the vessels by Doppler ultrasound. The importance of analyzing sonographic images of nerve sheath tumours, which can mimic blood vessels, and the importance of Doppler ultrasound for guiding central venous catheters in such patients to avoid nerve injury are discussed in this case report.

Radiologic manifestation of the malignant peripheral nerve sheet tumor involving the brachial plexus

A 63-year-old African American female with history of bilateral breast cancer status after lumpectomy and radiation therapy presented with right hand, wrist, and arm pain. She was found to have a right axillary mass and a large lesion in the right brachial plexus. A biopsy of the brachial plexus mass came back as a malignant peripheral nerve sheath tumor. This case report illustrates the critical value of multiple imaging modalities in definitive diagnosis of this rare pathologic entity.

Combined Video-Assisted Thoracic Surgery and Posterior Spinal Surgery for the Treatment of Dumbbell Tumor of the First Thoracic Nerve Root

Although several cases of a dumbbell tumor of thoracic nerve roots have been reported, reports on the surgical procedures for a dumbbell tumor of the first thoracic (T1) nerve root are rare. Surgeons should be cautious, especially when performing a surgical procedure for a dumbbell tumor of the T1 nerve root because the tumor is anatomically located adjacent to important organs and because the T1 nerve root composes the lower trunk of the brachial plexus with the eighth cervical nerve root. We present cases with dumbbell tumors of the T1 nerve root that were treated with combined surgical treatment to remove the tumor. We first performed video-assisted thoracic surgery (VATS) to release the organs anteriorly and then performed posterior spinal surgery in the prone position. The combined VATS and posterior spinal surgery may become a standard surgical procedure for the treatment of dumbbell tumors of the T1 nerve root.

[Complications in brachial plexus surgery]

OBJECTIVE

Although traumatic brachial plexus injuries are relatively rare in trauma patients, their effects on the functionality of the upper limb can be very disabling. The authors' objective was to assess the complications in a series of patients operated for brachial plexus injuries.

MATERIAL AND METHOD

This was a retrospective evaluation of patients operated on by the authors between August 2009 and March 2013.

RESULTS

We performed 36 surgeries on 33 patients. The incidence of complications was 27.7%. Of these, only 1 (2.7%) was considered serious and associated with the procedure (iatrogenic injury of brachial artery). There was another serious complication (hypoxia in patients with airway injury) but it was not directly related to the surgical procedure. All other complications were considered minor (wound dehiscence, hematoma, infection). There was no mortality in our series.

CONCLUSIONS

The complications in our series are similar to those reported in the literature. Serious complications (vascular, neural) are rare and represent less than 5% in all the different series. Given the rate of surgical complications and the poor functional perspective for a brachial plexus injury without surgery, we believe that surgery should be the treatment of choice.

Resection of Primary Brachial Plexus Tumor via a Modified Supraclavicular Approach

Benign peripheral nerve sheath tumors are generally considered curable lesions, and surgical resection is recommended as the primary line of treatment. When these tumors occur in the brachial plexus, they are most frequently accessed via the supraclavicular approach. Traditional descriptions of this approach have included either transection of sternocleidomastoid (SCM) muscle fibers or disarticulation of the clavicular head of the SCM muscle. This report presents a simple and easy-to-adapt modification of the supraclavicular approach that offers greater preservation of the SCM muscle. The modification primarily consists of the creation of an intramuscular window between the sternal and clavicular heads of the SCM via the splitting and dilation SCM muscle fibers. This technique minimizes the disruption of SCM muscle tissue compared with previous descriptions and may be associated with improved postoperative pain and return to function.

"Huge axillary mass - neurofibroma brachial plexus"

Axillary swelling arising from soft tissue is not uncommon. Lipoma, Lymphadenopathy due to Kochs or Lymphoma are commonest swellings seen but firm to hard non tender mass arising from maninges of Brachial plexus is not so common. Usually these masses are benign but one may come across malignant tumour. Twenty-three year male presented with mass in anterior chest wall & arm pit having no other specific complaints, was diagnosed as Spindle cell tumour on FNAC & excision biopsy turned out to be Neurofibroma of Brachial plexus.

Desmoid tumour of the brachial plexus

Desmoid tumours of the brachial plexus are rare and may occur in extra-abdominal sites. The tumours are of fibroblastic origin and, although benign, are locally aggressive. Their relationship to critical neurovascular structures in their anatomic locations presents a challenge to the operating surgeons trying to adhere to the principles of surgery. Surprisingly little neurosurgical literature exists which was devoted to this topic despite the challenge these lesions present in surgery both at surgery and in choosing adjuvant therapies. We report a case of a large brachial plexus tumour in a patient which was diagnosed radiologically and histopathologically and the patient underwent surgical excision with good outcome. Desmoid tumours histologically are benign and are usually composed of proliferating, benign fibroblasts in an abundant matrix of collagen. They do not transform into malignant tumours or metastasize. Surgery is the mainstay of treatment; however, adjuvant radiation and chemotherapy remain controversial.

Neural sheath tumors of the brachial plexus: a multidisciplinary team-based approach

Peripheral tumors of the brachial plexus, although rare, provide an opportunity for the plastic surgeon to coordinate a multidisciplinary team and achieve excellent outcomes. Most of the case series are reported from the neurosurgical literature. We report on the experience of the Kaiser Permanente Brachial Plexus Clinic over a recent 2-year period. A retrospective review was conducted to examine the medical records, radiographic images, operative reports, and pathologic findings of 13 consecutive patients with peripheral nerve sheath tumors of brachial plexus origin. Of the 10 patients requiring surgical exploration, 90% had significant improvement or resolution of pain, with sensory and motor recovery showing mixed results. Average follow-up consisted of 2 years with occupational therapy beginning shortly after operative intervention. Our results are similar to or better than those published in the literature. The plastic surgeon with subspecialty training can safely and successfully treat tumors of the brachial plexus by implementing a multidisciplinary approach.

Diagnosis of brachial and lumbosacral plexus lesions

To most doctors, brachial and lumbosacral plexopathies are known as difficult disorders, because of their complicated anatomy and relatively rare occurrence. Both the brachial, lumbar, and sacral plexuses are extensive PNS structures stretching from the neck to axillary region and running in the paraspinal lumbar and pelvic region, containing 100000-200000 axons with 12-15 major terminal branches supplying almost 50 muscles in each limb. The most difficult part in diagnosing a plexopathy is probably that it requires an adequate amount of clinical suspicion combined with a thorough anatomical knowledge of the PNS and a meticulous clinical examination. Once a set of symptoms is recognized as a plexopathy the patients' history and course of the disorder will often greatly limit the differential diagnosis. The most common cause of brachial plexopathy is probably neuralgic amyotrophy and the most common cause of lumbosacral plexopathy is diabetic amyotrophy. Traumatic and malignant lesions are fortunately rarer but just as devastating. This chapter provides an overview of both common and rarer brachial and lumbosacral plexus disorders, focusing on clinical examination, the use of additional investigative techniques, prognosis, and treatment.

Primary Benign Brachial Plexus Tumors

Primary benign brachial plexus tumors are rare. They pose a great challenge to the neurosurgeon, because the majority of patients present with minimal or no neurological deficits. Radical to complete excision of the tumor with preservation of neurological function of the involved nerve is an ideal surgical treatment option with benign primary brachial plexus tumor surgery. We present a review article of our 10-year experience with primary benign brachial plexus tumors surgically treated at King Edward Memorial Hospital and P.D. Hinduja National Hospital from 2000 to 2009. The clinical presentations, radiological features, surgical strategies, and the eventual outcome following surgery are analyzed, discussed, and compared with available series in the world literature. Various difficulties and problems faced in the management of primary benign brachial plexus tumors are analyzed. Irrespective of the tumor size, the indications for surgical intervention are also discussed. The goal of our study was to optimize the treatment of patients with benign brachial plexus tumors with minimal neurological deficits. It is of paramount importance that brachial plexus tumors be managed by a peripheral nerve surgeon with expertise and experience in this field to minimize the neurological insult following surgery.

Medical imaging in the diagnosis and management of cancer pain

Within the past few decades medical imaging has evolved very rapidly, now becoming an indispensable tool for the diagnosis, treatment, and follow-up of patients with cancer-related pain. Multiple imaging modalities are available for the assessment of cancer patients, each one with different advantages and limitations that are important to consider at the time we order a diagnostic study or plan an image-guided procedure. This article reviews the role that various imaging modalities play in the management of cancer pain and provides an overview of the latest technological advances.

Management of brachial plexus region tumours and tumour-like conditions: relevant diagnostic and surgical features in a consecutive series of eighteen patients

BACKGROUND

Tumours of the brachial plexus region are rare and most publications are case reports or studies with a small series of patients. The aim of this study is to present our experience in managing these lesions.

METHODS

We review 18 patients with tumours in the brachial plexus region submitted to surgical treatment in a 6 year period, including their clinical presentation, neuro-imaging data, surgical findings and outcome.

FINDINGS

The tumours comprised a heterogeneous group of lesions, including schwannomas, neurofibromas, malignant peripheral nerve sheath tumour (MPNST), sarcomas, metastases, desmoids and an aneurysmal bone cyst. The most common presentation was an expanding lump (83.33%). Eleven tumours were benign and 7 were malignant. Neurofibromatosis was present in only 2 patients (11.11%). Gross total resection was achieved in 14 patients and sub-total resection in the others. Only 3 patients presented with new post-operative motor deficits. The incidence of complications was low (16.5 %).

CONCLUSIONS

The majority of tumours were benign and most of them could be excised with a low incidence of additional deficits. Some of the malignant tumours could be controlled by surgery plus adjuvant therapy, but this category is still associated with high morbidity and mortality rates.

Tumours of peripheral nerves in the upper extremity: a 22-year epidemiological study

Peripheral nerve tumours are uncommon. Our aims were to calculate the incidence and relative frequencies, to define sites of nerve tumours and to judge preoperative symptoms and outcomes of intervention. The results of 53 patients, with 68 tumours and histopathological diagnoses of true neoplasms, who had been operated on at the Department of Hand Surgery, Malmo, Sweden, between 1986 and 2007, were analysed. Schwannomas were the most common tumour (n=42). The incidence of schwannomas was 0.62/100 000 inhabitants/year in Malmo during that time period. The median nerve was most affected, closely followed by the ulnar and digital nerves. The preferred sites were the forearm, the thumb, and the digits. The most common preoperative symptom was pain. Loss of sensation was the most common postoperative complication. However, 33/53 patients (62%) were completely free of symptoms after excision. Patients should be provided with meticulous information preoperatively.

Tumors of the brachial plexus

✓Tumors of the brachial plexus are relatively rare and present a clinical challenge for the neurosurgeon. The management of these tumors therefore requires not only an understanding of the complex anatomy of the brachial plexus but also an appreciation of the appropriate surgical approach to the various tumors that may be encountered. Over a 30-year period (1969–1999), 226 patients with brachial plexus tumors were evaluated and surgically treated by the senior authors (R.L.T., D.G.K.). In the present paper they review the most common benign and malignant brachial plexus tumors and discuss management and surgical principles established through their experience at the Louisiana State University Health Sciences Center.

T1-nerve root neuroma presenting with apical mass and Horner's syndrome

Background

The appearance of dumbbell neuroma of the first thoracic root is extremely rare. The extradural component of a T1-dumbbell neuroma may present as an apical mass. The diagnosis of hand weakness is complex and may be delayed in T1-neuroma because of absence of the palpable cervical mass. One-stage removal of a T1-root neuroma and its intrathoracic extension demanded an extended posterior midline approach in the sitting position.

Case presentation

A 51-year old man had suffered a traumatic partial tendon rupture of his wrist flexor muscles 6 years ago. Since the incident he occasionally felt fullness and tenderness in the affected forearm with some tingling in his fingers bilaterally. During the last two years the hand weakness was continuous and hypotrophy of the medial flexor and intrinsic hand muscles had become apparent. Electrophysiological studies revealed an ulnar neuropathy in addition to mild median and radial nerve dysfunction, including a mild contralateral carpal tunnel syndrome. The diagnostic work-up for multiple mononeuropathy in the upper extremity was negative. Repeated electrophysiological studies revealed fibrillations in the C7 paravertebral muscles on the affected side. Chest x-ray revealed a large round apical mass on the affected side. A Horner's syndrome was noted at this point of diagnostic work-up. MRI of the cervical and thoracic spine revealed a dumbbell T1 neuroma enlarging the intervertebral foramen at T1-2 and a 5 cm large extradural tumor with extension into the apex of the ipsilateral lung. The patient underwent surgery in sitting position using a left dorsal midline approach. Although the T1 root could not be preserved, the patient's neurological condition was unchanged after the surgery.

Conclusion

Extended posterior midline exposure described here using hemilaminectomy, unilateral facetectomy and costo-transversectomy is efficient and safe for one-stage removal of dumbbell tumors at the T1 level with a predominantly extraforaminal component in the apex of the lung extending up to 6–7 cm laterally. Horner's syndrome, if present and observed, may significantly narrow the differential diagnosis of hand weakness caused by T1-root tumors.

Atypical and malignant peripheral nerve-sheath tumors of the brachial plexus: report of three cases and review of the literature

Tumor involvement of the brachial plexus is uncommon. The most common intrinsic neoplasms involving the brachial plexus are benign neurilemmomas and neurofibromas that are usually associated with neurofibromatosis-1 (NF-1). Solitary neurofibromas unassociated with NF-1 are very uncommon. Malignant peripheral nerve-sheath tumors (MPNST) are rare at this site, arising spontaneously or in the context of NF-1. This presentation discusses the clinical presentation, pathology, and management of these tumors, which usually occur in young adults. MPNST are intermediate or high-grade sarcomas with a high risk of local and distant spread. Approximately 50% of MPNST arise in patients with NF-1, and therefore these patients should be thoroughly investigated for any new symptoms or masses. MPNST of the brachial plexus should be treated with an adequate wide local excision, with adjuvant high-dose radiotherapy pre- or postoperatively. The role of chemotherapy in the treatment of MPNST is not clearly defined, but it may have some benefit in salvaging treatment failures.

Unusual cervical mass - A surgical dilemma and unfortunate sequelae

The differential diagnosis of a neck mass encompasses a broad range of possibilities including congenital cysts, inflammatory masses and both primary and metastatic neoplasms. A clear understanding of the normal anatomy of the neck and a high index of suspicion with a detailed history elicitation, proper physical examination and adjunctive test reports all lead to an accurate diagnosis. This is a case report of a thirty three year old lady who presented with a mass in the posterior triangle of neck with paraesthesia and mild weakness of the upper limb of the same side. The diagnostic evaluation revealed possibility of Schwannoma of the Brachial plexus and the surgical management posed a great surgical dilemma and led to cervical 5(th) and 6(th) trunk paralysis. We performed a second stage Sural nerve grafting.

Imaging the anatomy of the brachial plexus: review and self-assessment module

OBJECTIVE

The educational objectives of this continuing medical education activity are to describe the normal anatomy of the brachial plexus, to name the most common symptoms associated with a brachial plexopathy, to describe the most common imaging findings resulting from trauma to the brachial plexus, to describe the imaging manifestations of common neoplasias affecting the brachial plexus, and to also describe the imaging findings and symptoms related to irradiation-induced brachial plexopathies.

CONCLUSION

In this article, I have illustrated and described the normal anatomy of the brachial plexus; the most common symptoms related to brachial plexopathy; and imaging findings related to trauma, tumors, and irradiation affecting the brachial plexus.