Plexopathy In Patients Research Articles

Left brachial plexopathy after prone positioning with COVID-19: a case series

Prone positioning is a strategy shown to reduce mortality in patients who are mechanically ventilated for acute respiratory distress syndrome and has been used in the COVID-19 pandemic. It is not, however, without complications. Barotrauma, pressure sores, ventilator associated pneumonia and peripheral nerve injuries have all been implicated as complications of prone positioning. There have also been several reports of brachial plexopathy in patients who have undergone prolonged mechanical ventilation with prone positioning. Patient characteristics including body weight index, degree of critical illness, and suboptimal prolonged positioning have all been suggested as possible contributing factors, although, there has been less discussion concerning the action of rolling patients, and how it may contribute to the development of injuries. We describe 3 cases of left brachial plexus injury in patients who were consistently rolled on their left sides. Patients presented with isolated left upper extremity weakness without any structural etiology found on imaging. Electrodiagnostic studies subsequently confirmed a left brachial plexopathy in each of the cases. We suggest that the action of proning patients may contribute to injury. This observation has not yet been suggested in the literature, and carries clinical relevance, as greater attention and meticulous care may need to be employed when moving these individuals.

Radiation-Induced Brachial Plexopathy in Patients With Breast Cancer Treated With Comprehensive Adjuvant Radiation Therapy

PurposeOur purpose was to describe the risk of radiation-induced brachial plexopathy (RIBP) in patients with breast cancer who received comprehensive adjuvant radiation therapy (RT). Methods and MaterialsRecords for 498 patients who received comprehensive adjuvant RT (treatment of any residual breast tissue, the underlying chest wall, and regional nodes) between 2004 and 2012 were retrospectively reviewed. All patients were treated with conventional 3 to 5 field technique (CRT) until 2008, after which intensity modulated RT (IMRT) was introduced. RIBP events were determined by reviewing follow-up documentation from oncologic care providers. Patients with RIBP were matched (1:2) with a control group of patients who received CRT and a group of patients who received IMRT. Dosimetric analyses were performed in these patients to determine whether there were differences in ipsilateral brachial plexus dose distribution between RIBP and control groups. ResultsMedian study follow-up was 88 months for the overall cohort and 92 months for the IMRT cohort. RIBP occurred in 4 CRT patients (1.6%) and 1 IMRT patient (0.4%) (P = .20). All patients with RIBP in the CRT cohort received a posterior axillary boost. Maximum dose to the brachial plexus in RIBP, CRT control, and IMRT control patients had median values of 56.0 Gy (range, 49.7-65.1), 54.8 Gy (47.4-60.5), and 54.8 Gy (54.2-57.3), respectively. ConclusionsRIBP remains a rare complication of comprehensive adjuvant breast radiation and no clear dosimetric predictors for RIBP were identified in this study. The IMRT technique does not appear to adversely affect the development of this late toxicity.

Intense 18F-Flourodeoxyglucose Uptake in Brachial Plexus of Patients with Brachial Plexopathy.

Brachial plexopathy is a significant cause of pain and disability in patients with breast cancer. Major causes of brachial plexopathy in patients with breast cancer are metastatic invasion or radiation damage to the plexus. Differentiation between the two pathologies is important for appropriate treatment planning. The complicated anatomy of the plexus makes this a difficult area to image accurately. Magnetic resonance imaging (MRI) is the imaging modality of choice for diagnostic evaluation of these cases. We presented a case to demonstrate the role of 18F-flourodeoxyglucose positron emission tomography/computerized tomography for confirming metastatic brachial plexopathy when MRI findings were suspicious and for differentiating radiation-induced brachial plexopathy from metastatic plexopathy.

Characteristics of metastatic brachial plexopathy in patients with breast cancer.

Brachial plexopathy in cancer patients is a rare but significant complication that causes pain and disability of the upper extremities. Clinical features of breast cancer patients with metastatic brachial plexopathy (MBP) have not been studied. We aimed to investigate the characteristics of MBP in breast cancer patients. We retrospectively reviewed medical records of patients with breast cancer with MBP who visited Asan Medical Center from 2000 to 2016; we enrolled 44 patients. We comprehensively reviewed the characteristics, range of metastatic lymph nodes, initial symptoms, location, and severity of brachial plexus injury by electrodiagnostic study, radiologic findings, and associated complications. The mean age of patients with MBP was 51.9 ± 9.3years; 25% were diagnosed with stage IV breast cancer at initial diagnosis. Weakness was the most common initial symptom of MBP (52.3%). Most patients showed limitation of shoulder range of motion and pain; 66% of patients exhibited malignant lymphedema. Forty-one patients were evaluated by electromyography; upper nerve trunk involvement (22.0%) was more frequent than lower nerve trunk involvement (9.8%). Nineteen patients underwent brachial plexus MRI, and supraclavicular area (SCA) metastasis was most frequent (57.9%). Sixteen patients were examined by both brachial plexus MRI and electromyography; patients with SCA metastasis exhibited significantly more frequent malignant lymphedema (p = 0.019) and upper nerve trunk involvement (p = 0.035), compared with patients with non-SCA metastasis. Our study revealed clinical features of MBP in breast cancer patients. Additional diagnostic evaluation focused on metastasis or aggravated metastatic tumor is needed when breast cancer patients are diagnosed with brachial plexopathy.

Radiation-induced brachial plexopathy in patients with nasopharyngeal carcinoma: a retrospective study.

Radiation-induced brachial plexopathy (RIBP) is one of the late complications in nasopharyngeal carcinoma (NPC) patients who received radiotherapy. We conducted a retrospective study to investigate its clinical characteristics and risk factors. Thirty-onepatients with RIBP after radiotherapy for NPC were enrolled. Clinical manifestations of RIBP, electrophysiologic data, magnetic resonance imaging (MRI), and the correlation between irradiation strategy and incidence of RIBP were evaluated. The mean latency at the onset of RIBP was 4.26 years. Of the symptoms, paraesthesia usually presented first (51.6%), followed by pain (22.6%) and weakness (22.6%). The major symptoms included paraesthesia (90.3%), pain (54.8%), weakness (48.4%), fasciculation (19.3%) and muscle atrophy (9.7%). Nerve conduction velocity (NCV) and electromyography (EMG) disclosed that pathological changes of brachial plexus involved predominantly in the upper and middle trunks in distribution. MRI of the brachial plexus showed hyper-intensity on T1, T2, post-contrast T1 and diffusion weighted whole body imaging with background body signal suppression (DWIBS) images in lower cervical nerves. Radiotherapy with Gross Tumor volume (GTVnd) and therapeutic dose (mean 66.8±2.8Gy) for patients with lower cervical lymph node metastasis was related to a significantly higher incidence of RIBP (P<0.001). Thus, RIBP is a severe and progressive complication of NPC after radiotherapy. The clinical symptoms are predominantly involved in upper and middle trunk of the brachial plexus in distribution. Lower cervical lymph node metastasis and corresponding radiotherapy might cause a significant increase of the RIBP incidence.

Brachial plexus dose tolerance in head and neck cancer patients treated with sequential intensity modulated radiation therapy.

PurposeWe aimed to study the radiation induced brachial plexopathy in patients with head and neck squamous cell carcinoma (HNSCC) treated with Sequential Intensity Modulated Radiation Therapy (S-IMRT).Methods and materialsThis IRB approved study included 68 patients with HNSCC treated consecutively. Detailed dose volume histogram data was generated for ipsilateral and contralateral brachial plexus (BP) volumes receiving a specified dose (Vds) i.e. V50-V75 and dose in Gray covering specified percent of BP volume (Dvs) i.e. D5-D30 and maximum point doses (Dmax). To assess BP injury all patients’ charts were reviewed in detail for sign and symptoms of BP damage. Post-hoc comparisons were done using Tukey-Kramer method to account for multiple significance testing.ResultsThe mean and maximum doses to BP were significantly different (p < .05) based on tumor site, nodal status and tumor stage. The mean volume to the ipsilateral BP for V50, V60, V70, and V75 were 7.01 cc, 4.37 cc, 1.47 cc and 0.24 cc, respectively. The mean dose delivered to ≤5% of ipsilateral BP was 68.70 Gy (median 69.5Gy). None of the patients had acute or late brachial plexopathy or any other significant neurological complications, with a minimum follow up of two years (mean 54 months).ConclusionsIn this study cohort, at a minimum of two-years follow up, the mean dose of 68.7Gy, a median dose to 69.5Gy to ≤5% of ipsilateral BP, and a median Dmax of 72.96Gy did not result in BP injury when patients were treated with S-IMRT technique. However, longer follow up is needed.

Lumbar plexopathy following instrumented posterior lumbar interbody fusion: a complication with use of Hohmann’s retractor

A series of 12 patients in our centre following single level instrumented posterior lumbar interbody fusion at L4-L5 developed unexplainable motor weakness in the proximal lumbar nerve roots (L2, L3) and numbness of the whole limb, a clinical picture resembling lumbar plexopathy. Even though lumbar plexopathy has been reported following gynaecological procedures and in transpsoas interbody fusion surgeries, there is no literature reporting this complication following conventional instrumented posterior lumbar interbody fusions. Retrospective observational study. To find the possible mechanism of development of lumbar plexopathy in patients who underwent posterior lumbar interbody fusion surgeries in our centre. We analyzed retrospectively the medical records, electrophysiological reports of the patients, literatures on the anatomy of lumbar plexus and other literature reporting similar complications. We also dissected lumbar plexus of three cadavers and simulated surgical technique on them to find the mechanism of development of this unusual complication. We found injury to lumbar plexus that probably occurred intraoperatively with Hohmann's retractor that was used for retraction of the paraspinal muscles. This theory was favoured by many clinical factors and further confirmed by cadaveric dissections. We conclude that surgical technique with improper use of Hohmann's retractor causes traction and compression injury to the lumbar plexus resulting in this complication. We propose proper technique of insertion of Hohmann's retractor and also recommend use of modified Hohmann's retractor with shorter tips for spinal procedures to prevent such complication.

Brachial Plexus Dose Tolerance in Head-and-Neck Cancer Patients Treated With Sequential Intensity Modulated Radiation Therapy

Purpose: We aimed to study the radiation induced brachial plexopathy in patients with head and neck squamous cell carcinoma (HNSCC) treated with Sequential Intensity Modulated Radiation Therapy (S-IMRT). Methods and materials: This IRB approved study included 68 patients with HNSCC treated consecutively. Detailed dose volume histogram data was generated for ipsilateral and contralateral brachial plexus (BP) volumes receiving a specified dose (Vds) i.e. V50-V75 and dose in Gray covering specified percent of BP volume (Dvs) i.e. D5-D30 and maximum point doses (Dmax). To assess BP injury all patients’ charts were reviewed in detail for sign and symptoms of BP damage. Post-hoc comparisons were done using Tukey-Kramer method to account for multiple significance testing. Results: The mean and maximum doses to BP were significantly different (p<.05) based on tumor site, nodal status and tumor stage. The mean volume to the ipsilateral BP for V50, V60, V70, and V75 were 7.01 cc, 4.37 cc, 1.47 cc and 0.24 cc, respectively. The mean dose delivered to ≤5% of ipsilateral BP was 68.70 Gy (median 69.5Gy). None of the patients had acute or late brachial plexopathy or any other significant neurological complications, with a minimum follow up of two years (mean 54 months). Conclusions: In this study cohort, at a minimum of two-years follow up, the mean dose of 68.7Gy, a median dose to 69.5Gy to ≤5% of ipsilateral BP, and a median Dmax of 72.96Gy did not result in BP injury when patients were treated with S-IMRT technique. However, longer follow up is needed.

Brachial Plexopathy in Apical Non-Small Cell Lung Cancer Treated With Definitive Radiation: Dosimetric Analysis and Clinical Implications

Data are limited on the clinical significance of brachial plexopathy in patients with apical non-small cell lung cancers (NSCLC) treated with definitive radiation therapy. We report the rates of radiation-induced brachial plexopathy (RIBP) and tumor-related brachial plexopathy (TRBP) and associated dosimetric parameters in apical NSCLC patients. Charts of NSCLC patients with primary upper lobe or superiorly located nodal disease who received ≥50 Gy of definitive conventionally fractionated radiation or chemoradiation were retrospectively reviewed for evidence of brachial plexopathy and categorized as RIBP, TRBP, or trauma-related. Dosimetric data were gathered on ipsilateral brachial plexuses (IBP) contoured according to Radiation Therapy Oncology Group atlas guidelines. Eighty patients were identified with a median follow-up and survival time of 17.2 and 17.7 months, respectively. The median prescribed dose was 66.6 Gy (range, 50.4-84.0), and 71% of patients received concurrent chemotherapy. RIBP occurred in 5 patients with an estimated 3-year rate of 12% when accounting for competing risk of death. Seven patients developed TRBP (estimated 3-year rate of 13%), comprising 24% of patients who developed locoregional failures. Grade 3 brachial plexopathy was more common in patients who experienced TRBP than RIBP (57% vs 20%). No patient who received ≤78 Gy to the IBP developed RIBP. On multivariable competing risk analysis, IBP V76 receiving ≥1 cc, and primary tumor failure had the highest hazard ratios for developing RIBP and TRBP, respectively. RIBP is a relatively uncommon complication in patients with apical NSCLC tumors receiving definitive doses of radiation, while patients who develop primary tumor failures are at high risk for developing morbid TRBP. These findings suggest that the importance of primary tumor control with adequate doses of radiation outweigh the risk of RIBP in this population of patients.

Dose Constraints to Prevent Radiation-Induced Brachial Plexopathy in Patients Treated for Lung Cancer

As the recommended radiation dose for non-small-cell lung cancer (NSCLC) increases, meeting dose constraints for critical structures like the brachial plexus becomes increasingly challenging, particularly for tumors in the superior sulcus. In this retrospective analysis, we compared dose-volume histogram information with the incidence of plexopathy to establish the maximum dose tolerated by the brachial plexus. We identified 90 patients with NSCLC treated with definitive chemoradiation from March 2007 through September 2010, who had received >55 Gy to the brachial plexus. We used a multiatlas segmentation method combined with deformable image registration to delineate the brachial plexus on the original planning CT scans and scored plexopathy according to Common Terminology Criteria for Adverse Events version 4.03. Median radiation dose to the brachial plexus was 70 Gy (range, 56-87.5 Gy; 1.5-2.5 Gy/fraction). At a median follow-up time of 14.0 months, 14 patients (16%) had brachial plexopathy (8 patients [9%] had Grade 1, and 6 patients [7%] had Grade ≥2); median time to symptom onset was 6.5 months (range, 1.4-37.4 months). On multivariate analysis, receipt of a median brachial plexus dose of >69 Gy (odds ratio [OR] 10.091; 95% confidence interval [CI], 1.512-67.331; p = 0.005), a maximum dose of >75 Gy to 2 cm(3) of the brachial plexus (OR, 4.909; 95% CI, 0.966-24.952; p = 0.038), and the presence of plexopathy before irradiation (OR, 4.722; 95% CI, 1.267-17.606; p = 0.021) were independent predictors of brachial plexopathy. For lung cancers near the apical region, brachial plexopathy is a major concern for high-dose radiation therapy. We developed a computer-assisted image segmentation method that allows us to rapidly and consistently contour the brachial plexus and establish the dose limits to minimize the risk of brachial plexopathy. Our results could be used as a guideline in future prospective trials with high-dose radiation therapy for unresectable lung cancer.

Dose Constraints to Prevent Radiation-induced Brachial Plexopathy in Patients Treated for Lung Cancer

Dose Constraints to Prevent Radiation-induced Brachial Plexopathy in Patients Treated for Lung Cancer

Lumbosacral Plexopathy Due to Common Iliac Artery Aneurysm Misdiagnosed as Intervertebral Disc Herniation

We report a case of lumbosacral plexopathy caused by an isolated aneurysm in the common iliac artery. The patient presented with low back and buttock pain radiating to the right leg and numbness in the L5 and S1 dermatomes. A computed tomography scan showed an aneurysm of the right common iliac artery. This case serves to increase awareness of the possibility of lumbosacral plexopathy in patients with symptoms of a prolapsed intervertebral disc.

Paraneoplastic Brachial Plexopathy in a Patient With Hodgkin's Disease

We describe a case of inflammatory brachial plexopathy that occurred in the context of a mild, diffuse sensorimotor peripheral neuropathy associated with Hodgkin's disease. Clinical, electrophysiologic, and pathologic studies helped distinguish this disorder from other causes of brachial plexopathy in patients with cancer. Treatment with corticosteroids seemed beneficial in this patient. We suggest that this may be another type of paraneoplastic condition associated with Hodgkin's disease.