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NI FEATURE: FACING ADVERSITY…TOMORROW IS ANOTHER DAY! - LETTER TO EDITOR
Year : 2017  |  Volume : 65  |  Issue : 4  |  Page : 864-866

Contralateral brachial plexus injury following retromastoid suboccipital craniotomy: A report and review of literature


Department of Neurosurgery and Neuroanaesthesiology and Critical Care, All India Institute of Medical Sciences, New Delhi, India

Date of Web Publication5-Jul-2017

Correspondence Address:
Shashwat Mishra
A-31, Gyandeep Apartment, Mayur Vihar Phase 1, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/neuroindia.NI_264_17

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How to cite this article:
Singla R, Sharma R, Mishra S, Prabhakar H. Contralateral brachial plexus injury following retromastoid suboccipital craniotomy: A report and review of literature. Neurol India 2017;65:864-6

How to cite this URL:
Singla R, Sharma R, Mishra S, Prabhakar H. Contralateral brachial plexus injury following retromastoid suboccipital craniotomy: A report and review of literature. Neurol India [serial online] 2017 [cited 2019 Dec 15];65:864-6. Available from: http://www.neurologyindia.com/text.asp?2017/65/4/864/209501




Sir,

Neurosurgical procedures are generally of long duration. Often, the patients s are required to be positioned i n a unique manner to allow appropriate exposure of the surgical area of interest. The prolonged positioning of the patient in unique positions can lead to post-operative complications. Lateral rotation of the head is often performed while creating a surgical corridor to the cerebello-pontine angle in supine position. In light of the available literature, we report a case of contralateral brachial plexus injury as a complication of complex head positioning in vestibular schwannoma surgery in supine position with a lateral head turn.

A 44-year old woman presented with complaint of right-sided hearing difficulty, tinnitus, right sided facial numbness and imbalance while walking for one year. She did not have associated medical illness nor had undergone previous surgical intervention. The patient was of thin built with a height of 154 cm and a weight 50 kgs (body mass index = 21.08 kg/m 2). Fundus examination showed papilledema. There was 20% sensory loss on the right side of the face in V2 and V3 distribution with House-Brackmann grade 2 facial weakness and sensorineural hearing loss on the right side. Cerebellar signs were prominent on the right side with gait imbalance on walking. Deep tendon reflexes were exaggerated (3+) in bilateral upper and lower limbs. Contrast enhanced magnetic resonance imaging of the brain [Figure 1] showed a 4.1 × 4.1 × 4 cm right cerebellopontine angle mass showing marked enhancement with central non-enhancing necrotic/cystic areas with extension into the right internal acoustic canal (IAC).
Figure 1: Pre-operative post-gadolinium T1 MRI showing a 4.1 × 4.1 × 4 cm mass in the right cerebellopontine angle with extension into the right internal auditory canal showing marked enhancement with central non-enhancing necrotic/cystic area

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Right retromastoid suboccipital craniotomy (RMSOC) and tumor excision in supine position with left lateral head turn was planned. The patient's right shoulder was gently retracted inferiorly using an adhesive tape in order to improve access to the surgical field while at the same time careful attention was given to avoid excessive traction to the ipsilateral brachial plexus. A shoulder roll was placed on the right side. The head was turned 30 degrees to the left, the neck was slightly flexed and the vertex was tilted slightly down to adequately expose the right retro-auricular area. Surgery lasted for seven hours with no intra-operative episodes of prolonged hypotension and gross total excision of the tumor could be achieved in an uneventful manner.

On the first post-operative day, a swelling was noted over the left side of neck along with weakness of the left shoulder and elbow. The power was 1/5 at the left shoulder joint and 1/5 at the left elbow joint according to Medical Research Council (MRC) scale. There was no weakness in the right upper limb. There was House-Brackmann Grade 4 facial weakness on the right side which was attributed to the fact that the facial nerve could not be anatomically preserved during surgery. The neck swelling increased in size till post-operative day 2 and then became constant in size. The patient was electively kept intubated till post-operative day 3 to avoid respiratory compromise due to the swelling on the left side of neck. Ultrasonography (USG) of the neck was performed on post-operative day 3, which demonstrated a swelling of the sternocleidomastoid on the left side with surrounding edema and thinning of the left internal jugular vein [Figure 2]. The patient was managed conservatively and the electromyography (EMG) and nerve conduction velocity (NCV) was performed on post-operative day 6, which showed features suggestive of neuropraxia involving the left C5-7 nerve roots. The left upper limb muscle strength improved to 2/5 at the shoulder joint and 3/5 at the elbow joint by post operative day 7 and patient was discharged with only partial recovery of the left upper limb muscle strength and residual swelling. At follow up after 3 months, patient showed improvement with 4/5 muscle strength at the shoulder and elbow joints. The swelling had subsided completely.
Figure 2: Ultrasound of the neck showing subcutaneous collection seen on the left side. No evidence of hematoma or internal jugular vein (IJV) thrombosis is seen on the left side. A decrease in calibre of left IJV is noted in that area (arrow) as a result of mass effect from the ipsilateral overlying bulky sternocleidomastoid muscle

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Berwick et al., have highlighted that the firm attachment of the prevertebral fascia to the brachial plexus keeps it relatively immobile, increasing the possibility of injury during extreme neck movements.[1] On reviewing the literature, we came across four case reports of brachial plexus injuries associated with contralateral neck swelling in patients undergoing cranial surgeries. A detailed comparison of the current case in the light of existing reports has been shown in [Table 1].[2–5] Another special clinical entity relevant to our case is idiopathic brachial neuritis as described by Malamat et al., which may be triggered in the post-operative period and can mimic brachial plexus injuries due to malpositioning.[6] However, such cases have patchy involvement of the shoulder girdle that is often preceded by intense pain, which was not seen in the current case.
Table 1: Summary of case reports of brachial plexus palsy following a craniotomy

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In our patient, we postulate that the possible cause of brachial plexus palsy was excessive neck rotation for a long duration (~7 hours) leading to impaired venous drainage on the contralateral side, with consequent cascade of ischemic cell injury in the neck muscles leading to swelling of the neck muscles. This compressed the brachial plexus nerve roots leading to contralateral brachial palsy. Our hypothesis is in consensus with the one given by Bhardwaj et al. in their case report.[2] The outcome at follow up was good and neurological improvement was documented in all the reported cases, including the current case indicating the self-limiting nature of the palsy.

This report is an attempt to re-emphasize the role of appropriate positioning during neurosurgical procedures. It is necessary to highlight such rare complications as simple precautions on the part of the surgical team can greatly reduce the post-operative morbidity of the patients.



 
 » References Top

1.
Berwick JE, Lessin ME. Brachial plexus injury occurring during oral and maxillofacial surgery: A case report. J Oral Maxillofac Surg 1989;47:643-5.  Back to cited text no. 1
    
2.
Bhardwaj D, Peng P. An uncommon mechanism of brachial plexus injury. A case report. Can J Anaesth 1999;46:173-5.  Back to cited text no. 2
    
3.
Shimizu S, Sato K, Mabuchi I, Utsuki S, Oka H, Kan S, et al. Brachial plexopathy due to massive swelling of the neck associated with craniotomy in the park bench position. Surg Neurol 2009;71:504-8.  Back to cited text no. 3
    
4.
Hébert-Blouin M-N, Chowdhry SA, Abrahams PH, Spinner RJ. An unusual anatomical explanation for contralateral upper extremity weakness after frontal craniotomy. Clin Anat N Y N 2009;22:840-5.  Back to cited text no. 4
    
5.
Fusco MR, Cure JK, Riley KO. Contralateral brachial plexus palsy and Horner syndrome following vestibular schwannoma resection: A complication of patient positioning. Interdiscip Neurosurg 2014;1:35-7.  Back to cited text no. 5
    
6.
Malamut RI, Marques W, England JD, Sumner AJ. Postsurgical idiopathic brachial neuritis. Muscle Nerve 1994;17:320-4.  Back to cited text no. 6
    


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