Supraclavicular Brachial Plexus Approach for Excision of C8 Nerve Root Schwannoma: 3-Dimensional Operative Video.

Brachial plexus tumors are uncommon lesions in young adults. The majority of these are benign peripheral sheath tumors. In this 3-dimensional video, we present a case of a 19-yr-old female who presented to the neurosurgical outpatients with an anterior neck lump. It has been present for months, causing occasional numbness and paraesthesia in the distribution of the left ring finger. There was no objective weakness in finger flexion with normal long flexors reflexes. The cervical spine and supraclavicular brachial plexus were investigated with a magnetic resonance imaging (Gadolinium) scan (Figure 1). It demonstrated 30 × 20 × 20 mm lesion adjacent to the C8 nerve arising from the neural foramen, however, mostly occupying the space lateral to it. The patient was consented for resection of the tumor. This was done via the supraclavicular brachial plexus approach. The brachial plexus nerves were macroscopically demonstrated lateral to the anterior scalene muscle. The intraoperative electrophysiology was used to directly stimulate the nerves, which aided in accurate tracking during the dissection. The tumor was exposed after tracing the C8 nerve deep and medial to the anterior scalene muscle. It was resected down to the foramen, reaching the level of the epidural venous plexus, while C8 was spared. The patient recovered with no neurological deficit. The histopathology confirmed grade 1 schwannoma. Subsequently, there was no radiological follow-up performed. This case demonstrates the surgical dissection of supraclavicular brachial plexus in 3-dimensions while describing the unusual dissection medial to scalenus anterior muscle.

Calcaneotalar ratio: a new concept in the estimation of the length of the calcaneus.

Maintaining the calcaneal length after calcaneal fractures is vital to restoring the normal biomechanics of the foot, because it acts as an important lever arm to the plantarflexors of the foot. However, estimation of the length of the calcaneus to be reconstructed in comminuted calcaneal fractures can be difficult. We propose a new method to reliably estimate the calcaneal length radiographically by defining the calcaneotalar length ratio. A total of 100 ankle radiographs with no fracture in the calcaneus or talus taken in skeletally mature patients were reviewed by 6 observers. The anteroposterior lengths of the calcaneus and talus were measured, and the calcaneotalar length ratio was determined. The ratio was then used to estimate the length of the calcaneus. Interobserver reliability was determined using Cronbach's α coefficient and Pearson's correlation coefficient. The mean length of the calcaneus was 75 ± 0.6 mm, and the mean length of the talus was 59 ± 0.5 mm. The calcaneotalar ratio was 1.3. Using this ratio and multiplying it by the talar length, the mean average estimated length of the calcaneus was within 0.7 mm of the known calcaneal length. Cronbach's α coefficient and Pearson's correlation coefficient showed excellent interobserver reliability. The proposed calcaneotalar ratio is a new and reliable method to radiographically estimate the normal length of the calcaneus when reconstructing the calcaneus.