The brachial plexus is an anatomically complex structure. Tumors that originate from the brachial plexus are rare and present clinical challenge for neurosurgeons due to the anatomical complexity. We present the case of 59-year-old male patient with right hand weakness who was diagnosed with a neurogenic tumor originating from brachial plexus. He underwent wide the excision of tumor through the anterior supraclavicular approach. Postoperatively, the patient developed right arm numbness and motor weakness. At 2 month following the removal of tumor, he recovered normal function.
Peripheral nerve tumors are a heterogeneous group of mostly benign tumors that are rare in the general population. These tumors can be divided into 2 groups, peripheral nerve sheath and non-neural sheath tumors. Neurofibromas are composed of a mix of Schwann cells, perineurial-like cells, and fibroblasts, interspersed with nerve fibers, wire-like strands of collagen, and a myxoid matrix
The management of brachial plexus tumors requires a complete understanding of the anatomy, and a surgeon needs to understand a patient’s clinical presentation, pathologic variation, and surgical techniques for operation
A 59-year-old man presented with a slow growing painless mass in the right supraclavicular region. Although the mass was painless, he had been suffering from a tingling sensation and radiating pain on the right ulnar side of the forearm for three years. On physical examination, he had a firm mass on the right supraclavicular region. He had right hand weakness (hand grasping grade 4+/5). His personal medical history was without any remarks and there was no family history of a similar tumor.
In the enhanced computed tomography scans, a 5.7×4.4×4.5 cm-sized low density peripheral enhancing fusiform – shaped mass was observed on the right side and behind the clavicle (
The patient underwent a wide excision of the tumor through an anterior supraclavicular approach. An oblique incision parallel to the lateral border of the sternocleidomastoid (SCM) from just below the mastoid process to the clavicle with a transverse limb laterally at the level of the clavicle was made to form zigzag. The platysma was divided to and develop sub-platysmal flaps. The SCM muscle was checked and divided. The omohyoid muscle was identified, and the well-capsulized tumor mass below the omohyoid muscle was identified. It compress toward the upper and middle trunk of the brachial plexus (
The tumor was pathologically diagnosed as a neurofibroma. Histologically, the tumor was composed of spindle shaped cells on a loose myxoid background (
Postoperatively, the patient developed right arm numbness and motor weakness (hand grasping motor grade 4). After 2 months, the patient recovered normal function.
Tumors of the brachial plexus are relatively rare and present a clinical challenge for neurosurgeons
Symptoms and signs of peripheral nerve tumors are caused by direct nerve invasion, involvement of surrounding tissues, or mass effects
In the case of brachial plexus lesions, an MRI with contrast is the study of choice to delineate the margins of the tumor from surrounding tissues
The choice of surgical approach is important and can be selected according to the size of the tumor, its location, and its relationship with adjacent organs. An anterior supraclavicular approach has been used to treat most tumors involving the roots and trunks
Regardless of the approach selected, the operative steps for the resection of most neural sheath tumors are similar. The proximal and distal aspects of the tumor are identified, and the tumor is isolated from the surrounding neurovascular structures
Although the success rate for the surgical resection of brachial plexus tumors is high, complications can arise. Paresthesias, weakness, and postoperative pain generally recover with time and physical therapy. A common complication of the supraclavicular approach for tumor resection is phrenic nerve paralysis, which usually improves with time
From this case, we learned that when we encounter a supraclavicular mass, neurogenic tumors should be considered in the differential diagnosis. The resection of tumors is the choice treatment for most tumors originating from the brachial plexus. The appropriate surgical approach is an intraoperative microsurgical dissection technique with understanding of the complex anatomy of the brachial plexus and intraoperative monitoring is required to improve patient outcome.
No potential conflict of interest relevant to this article was reported.
A coronal neck computed tomography (enhanced) image show a 5.7×4.4×4.5 cm low attenuating fusiform-shaped mass (A). In the enhanced T1-weighted axial magnetic resonance imaging (MRI), a high signal mass with fluid-fluid level was observed (B). An enhanced T1-weighted coronal MRI showed a peripheral enhancing mass that originated from the lower trunk and compressed toward the upper and middle trunk of the brachial plexus (C).
Intraoperative findings during tumor mass removal. Well capsulized tumor mass (white star) was exposed and found to originate from the lower trunk of brachial plexus. The tumor compressed upwardly both the upper (white arrow) and middle (black arrow) trunk of brachial plexus.
Light microscopic exam showed the proliferation of spindle cells on a loose myxoid background (hematoxylin and eosin stain [H&E], ×200 magnification).