Dosimetric analysis and clinical outcomes of brachial plexus as an organ-at-risk in head-and-neck cancer patients treated with intensity-modulated radiotherapy

Objectives: To document the dose received by brachial plexus (BP) in patients treated with intensity-modulated radiotherapy (IMRT) for head-and-neck squamous cell carcinoma (HNSCC) and report the incidence of brachial plexopathy. Methods: Newly diagnosed patients of HNSCC treated with radical or adjuvant IMRT were included in this retrospective study. No dosimetric constraints were applied for BP maximum dose equivalent dose (EQD2 α/β = 3). Patients with minimum 6-month follow-up were included and patients with suspicion of plexopathy were evaluated further. Results: Sixty-seven patients were eligible and 127 BP were analyzed. The mean BP maximum dose (BPmax) was 62.4 Gy (+6.9), while mean BP volume was 28.1 cc (+4.1). Proportion of patients receiving BPmax >66 and >70 Gy were 34.7% and 14.2%. The mean BPmax for T4 tumors was significantly higher than T1 tumors (65 vs. 57.5 Gy, P = 0.005) but when adjusted for N-category, T-category was not independently significant in accounting for BPmax >66 or >70 Gy. Mean BPmax for N0 versus N2+ was 59.8 versus 65.6 Gy (P = 0.0001) and N1 versus N2+ was 61.6 versus 65.6 Gy (P = 0.018). After adjusting for T-category, patients with N2+ had a mean 4.2 Gy higher BPmax than N0-N1 (P = 0.0001). Stage III–IV patients had a mean six Gy higher BPmax doses than Stage I–II disease (P = 0.0001). With a median follow-up of 28 months (interquartile range 16–42), no patient had brachial plexopathy. Conclusion: Clinically significant plexopathy was not seen in spite of majority having over 2-years follow-up and a third of patients having dose above the recommended tolerance. Only nodal category independently influenced dose to the brachial plexii

Subacute Brachial Radiculoplexitis Following Herpes Zoster Infection / 대한임상신경생리학회지

Brachial radiculoplexitis is characterized by acute onset of shoulder and arm pain followed by weakness and sensory loss. Brachial radiculoplexitis by herpes zoster is a rare disease, which can be diagnosed by careful history, electrodiagnosis and MRI. It has remained uncertain about clinical characteristics, treatment, and prognosis. Better understanding of this disease helps earlier diagnosis and prompt treatment to minimize neurologic sequale. We present two cases of subacute brachial radiculoplexitis preceded by herpes zoster infection.

Prolonged blepharoptosis following repeated stellate ganglion block in a patient with brachial plexopathy after thoracoscopic surgery / 영남의대학술지

A 34-year-old female was suffered from pain and numbness of right arm for 2 months after undergoing a thoracoscopic procedure for a posterior mediastinal mass that was diagnosed as neurilemmoma. The patient was diagnosed as a complex regional pain syndrome type 2 with brachial plexopathy developed during thoracoscopic excision of posterior mediastinal mass, and stellate ganglion block (SGB) with 0.2% ropivacaine 10 mL was performed every 3-4 days. The patient revealed slightly prolonged blepharoptosis as Horner syndrome accompanied after every SGB and recovered. However, following the 23rd SGB, the blepharoptosis persisted and patient was recovered spontaneously from blepharoptosis after about 12 months. The possibility that the persistent blepharoptosis might be caused by brachial plexopathy related to patient's pathology or surgical manipulation and/or repeated SGB. If Horner syndrome occurs, its etiology should be assessed, and it would be necessary to explain and to assure the patient the possibility of recovery spontaneously from the complication within a year, without any sequelae.

Brachial Plexopathy Caused by Vertebral Artery Dissection

No abstract available.

Plexopatía braquial secundaria a tumor maligno de la vaina del nervio periférico / Brachial plexopathy secondary a malignant tumor of the peripheral nerve sheath

Introducción: el plexo braquial puede verse afectado por patología neoplásica tanto primaria como secundaria. Los tumores primarios del plexo braquial son entidades poco frecuentes, aunque algunos, como el tumor maligno de la vaina del nervio periférico pueden tener un comportamiento agresivo. Caso clínico: se presenta una mujer de 31 años con disestesias y debilidad progresiva en el miembro superior izquierdo. El estudio neurofisiológico mostró afectación del plexo braquial izquierdo. En la resonancia magnética se observó una masa de tejido blando que invadía el plexo braquial. El estudio histológico fue compatible con un tumor maligno de la vaina del nervio periférico. Conclusiones: el tumor maligno de la vaina del nervio periférico es un tumor altamente agresivo que puede aparecer en pacientes sin datos clínicos de neurofibromatosis tipo 1. Debe mantenerse un elevado nivel de sospecha con el objetivo de no retrasar el diagnóstico para así poder realizar un tratamiento lo más conservador posible.

Introduction. Malignant peripheral nerve sheath tumor (MPNST) are sarcomas that are rarely located in the upper limb. Clinical case. We present a 31- year-old woman with progressive dysesthesia and weakness of the left upper limb. The neurophysiological study showed damage in the left brachial plexus. A soft tissue mass that was invading the plexus was observed in the magnetic resonance image. The anatomopathological study was compatible with MPNST diagnosis. Conclusions. Intrinsic tumors of the brachial plexus are uncommon. A MPNST is an extremely aggressive mesenchymal tumor that is seldom rooted in the brachial plexus.

Pancoast tumor as a cause of profound brachial plexopathy.

Pancoast tumor is also called superior sulcus tumor. The classic presentation is an aching pain about the shoulder region with some radiation to the scapula and weakness in the intrinsic hand muscles unilaterally (C8-T1 distribution). This case report demonstrates a rare case of Pancoast tumor which involved the fifth cervical through the first thoracic nerve roots with pain and severe muscle weakness throughout the arm.

True neurogenic thoracic outlet syndrome in a competitive swimmer: a case report of this rare association

True neurogenic thoracic outlet syndrome (TOS) is an uncommon disorder despite of be a frequent reason for referral to the EMG laboratories. We describe the second case in the literature of true TOS in a competitive swimmer with progressive weakness and severe atrophy of the left thenar eminence. EMG showed lower trunk plexopathy. X-ray and MRI of the cervical spine and brachial plexus were normal. Surgical exploration evidenced the lower trunk retracted and pulled by a fibrous band. It was excised and neurolysis of the plexus was done with gradual improvement of function. We discuss the possible pathophysiology of this association.

A síndrome do desfiladeiro torácico verdadeiro é condição incomum, apesar de ser uma razão freqüente de encaminhamento aos laboratórios de eletroneuromiografia. Nós descrevemos o segundo caso na literatura desta doença rara em um nadador competitivo com fraqueza e atrofia severa da eminência tenar esquerda. A ENMG mostrou plexopatia do tronco inferior. O RX e as ressonâncias magnéticas da coluna cervical e do plexo braquial foram normais. Exploração cirúrgica mostrou o tronco inferior tracionado por uma banda fibrosa. Ela foi ressecada e procedeu-se a neurólise do plexo com melhora gradual da função. Nós discutimos a possível fisiopatologia desta associação.

Imaging of the Brachial Plexus

MR (magnetic resonance) imaging of the brachial plexus is challenging because of the complex and tangled anatomy of the brachial plexus and the multifariouness of pathologies that can put on it. Improvements in imaging techniques, including the availability of high resolution MR image systems and high channels multidetector computed tomography (CT), have led to more accurate diagnoses and improved serve for treatment planning. For the purpose of imaging and treatment of the brachioplexopathy, it is considerate to divide traumatic and nontraumatic diseases affecting the brachial plexus. MRI is the current gold standard imaging modality for nontraumatic brachial plexopathy. CT myelography is the preferred for the diagnosis of nerve root avulsions affecting the brachial plexus. Other modalities, such as CT, ultrasonography and positron emission tomography, have a limited role in the evaluation of brachial plexus pathology. High-quality, high-resolution MRI remains the main tool for imaging the brachial plexopathy.

Epiphyseal Fracture-Separation of the Distal Humerus Suspected Brachial Plexus Injury : A case report

The epiphyseal fracture-separation of the distal humerus is extremely rare injury in neonates. It is frequently misdiagnosed as a elbow dislocation owing to the invisible cartilagenous portion of the distal humerus in roentgenograms. We described a case, 9-day-old neonate with finally diagnosed the Salter-Harris type 1 injury of the distal humeral epiphysis. He was referred for further evaluation of 'refusal to use the left arm' from a local clinic. The injury had initially misdiagnosed as normal roentgenograms by a locaorthopedic specialist, so we preferentially give an impression of the brachial plexus injury or the hemiplegic cerebral palsy. But electromyography and brain magnetic resonance imaging were negative findings. A neonate was referred to the pediatric orthopedic subspecialist and properly diagnosed. He was treated with the closed reduction and the percutaneous pinning. No complication has occurred.

Diagnostic Usefulness of Electrodiagnostic Study and Magnetic Resonance Imaging to Preganglionic Brachial Plexopathy

OBJECTIVE: This study aims at evaluating the usefulness of the electrodiagnostic study (EDx) and the magnetic resonance imaging (MRI), which are performed before surgical operation of brachial plexus injury. METHOD: We reviewed 57 cases of brachial plexopathy diagnosed with surgical findings. EDx and MRI were performed to the patients before surgery. Based upon intraoperative findings, we evaluated the occurrence of preganglionic root injury and subsequently each injured spinal root level. RESULTS: EDx and MRI for preganglionic root injuries showed 92.1% and 78.9% of diagnostic sensitivity and 63.2% and 42.9% of diagnostic specificity, respectively. The followings were about each injured spinal root level. EDx showed that the sensitivities of C5, C6, C7, C8, T1 were 91.4%, 91.4%, 92.6%, 96%, 95.8%, and their specificities were 59.1%, 59.1%, 56.7%, 68.8%, 66.7%. MRI showed that the sensitivities were 47.4%, 57.9%, 58.3%, 75%, 66.7%, and their specificities were 57.1%, 71.4%, 78.6%, 85.7%, 85.7%. CONCLUSION: As for preganglionic brachial plexopathy, EDx was more useful than MRI to diagnose preganglionic root injury and determine the level of injured spinal root.

Brachial Plexopathy Caused by Pancoast Tumor: A case report

Pancoast tumor is a specific lung carcinoma that has symptoms according to the location. It often involves the extrathoracic structure more than parenchyme of lung, that cause shoulder pain. A 61-years old man had been complaining of shoulder pain and limitation of range of motions of shoulder joint. Conservative management of the shoulder pain was not effective with physical therapy and injection therapy and the symptom of right upper extremity radiating pain had been aggravated. We had examination of the eletro-diagnostic test in 17 months after shoulder pain was developed. The findngs of the electrodiagnostic test was suspected as the injury of lower trunk of brachial plexus, so we had checked MRI on brachial view. The pancoast tumor was found in the extrathoracic region that invaded the lower trunk of the brachial plexus. The shoulder pain related with tumor was rare and could cause brachial plexopathy.

The Prognosis of Preganglionic Brachial Plexus Injuries by Electrodiagnosis

OBJECTIVE: To document the neurological recovery of the preganglionic lesion of brachial plexus, both clinically and electrodiagnostically. METHOD: Sixteen male and three female patients were evaluated. Ages of the patients ranged from 1 to 45 years with the mean age of 25.2+/-14.3 years. We studied retrospectively the improvements of 43 injured nerves and its innervated muscles of 19 patients retrospectively according to the complete or incomplete nature of the injuries by the electromyographic findings. We compred the results of initial and final examinations by the electromyographic and clinical findings including a muscle strength test. RESULTS: In the complete injuries, 84.0% of the cases showed a minimal or no improvement in muscle strength whereas in the incomplete injuries, 88.2% of the cases showed a greater than moderate improvement in muscle strength. The cases in which no compound muscle action potential could be evoked on the initial study, showed the improvements of greater than 3/5 muscle strength only in 20.0%. However 71.5% of cases with the initial amplitude between 0.1 & 0.5 mV and 100.0% of cases with the initial amplitude greater than 0.5 mV showed the muscle strength greater than 3/5. CONCLUSION: The prognosis for the neurological recovery was significantly poor in the complete preganglionic lesions of brachial plexus injuries but in the incomplete lesions, the prognosis was extremely good. It would be crucial for the initial CMAP being greater than 0.5 mV to expect the recovery of muscle strength to the functional level. Rehabilitative or operative management should be instituted based on the electrodiagnostic findings.

Acute brachial neuropathy: electrophysiological study and clinical profile

Acute brachial neuropathy (ABN) is a rare disease, characterized by an acute or subacute onset of pain followed by weakness of shoulder or arm muscles without trauma or traction injury. So the diagnosis of this clinical entity is not easy. The purpose of this study was to analyze retrospectively the ABN in 14 cases focusing on the clinical profile and to evaluate the effectiveness of electrophysiologic study in diagnosis of ABN with a new result helpful in localizing a brachial plexus disorder. The most helpful electrophysiologic data of ABN in my patients seemed to be abnormalities of low amplitude, abnormal right to left difference of compound motor action potentials (CMAPs) and sensory nerve action potentials (SNAPs) in axillary nerve, ulnar or median nerves. Results of nerve conduction velocity, terminal and F-wave latency were not as useful. But the electromyogram was most helpful in localization of upper or lower plexus lesions and cervical radiculopathy. The most striking clinical feature of ABN was the rapid onset of pain followed by the development of muscle weakness of shoulder girdle after a variable period or within four days. In contrast to other reports, intrinsic hand muscle weakness was observed in 3 cases with sensory changes in ulnar nerve distribution. The cervical radiculopathies (C5-C7 roots) were simultaneously combined with ipsilateral axillary neuropathy in 3 cases. In this study, decreased amplitude, abnormal right to left difference of SNAPs and CMAPs, and neurogenic EMG findings with normal data of NCV, terminal and F-wave latencies suggest that the pathology of ABN might not be a demyelinating process, but axonopathy.