Uncommon presentation and complications of herpes zoster infection involving the cervical, vagus and accessory nerves which caused a delay in diagnosis and treatment

A 70-year-old man with a history of invasive anal squamous cell carcinoma treated with excision and chemoradiation presented to the emergency department with right-sided neck pain and submandibular lymphadenopathy. CT imaging of the head and neck was unrevealing. The patient eventually developed cranial nerves X and XI dysfunction, manifesting as severe vocal cord paralysis (dysphonia), dysphagia, asymmetric palate elevation/deviation and trapezius muscle atrophy, in addition to scalene muscle atrophy. After an extensive workup, the patient’s symptoms were determined to be due to sequelae of varicella zoster infection, which was confirmed with antibody titers. The patient’s dysphagia and dysphonia eventually improved with vocal cord medialisation injection and Botox injection. However, despite delayed treatment with acyclovir and valacyclovir, the patient continued to have neuropathic pain and exhibit signs of CN X and CN XI paresis, in addition to scalene muscle atrophy.

Exercise-induced Thoracic Outlet Syndrome and Concomitant Osteomyelitis in Cervical Rib with a Possible Familial Origin, a Case Report.

BackgroundCervical ribs are a rare and usually asymptomatic occurrence. Most are identified incidentally by Roentgenogram (X-rays). However, occasionally they can cause nerve impingements and compressive symptoms. In cervical ribs, osteomyelitis secondary to trauma is unheard of. We report such a case made more interesting by the familial presence of bilateral cervical ribs in 2 generations. This indicates a possible familial origin. Case presentationA 26-year-old woman known to have fibromyalgia presented with left shoulder pain and fever episodes. She was recently discharged from intensive physiotherapy for fibromyalgia management, but the pain aggravated instead of getting better unilaterally in the left arm after discharge. Electric shock-like sensations and reduced strength accompanied this. An evaluation revealed leukocytosis and S. aureus positive blood and urine cultures along with bilateral complete cervical ribs showing pseudoarthrosis of anterior left cervical rib. A collection was noted in the left scalene muscle near the pseudoarthrosis accompanying focal edema suggesting osteomyelitis. Transthoracic echocardiogram (TTE) ruled out infective endocarditis. Thoracic surgery recommended conservative management, and appropriate antibiotics were given, which resulted in the negative culture on day 6. The patient was discharged on appropriate analgesia, and her pain was significantly improved on discharge.ConclusionsThis is the first reported case of osteomyelitis in the cervical rib. This report also highlights the possibility of cervical ribs having a familial origin. Additionally, as in our patient, certain exercises can be a risk factor for inducing TOS in patients with cervical rib.

A Rare Clinical Report of Intramuscular Hemangioma of the Middle Scalene Muscle

Intramuscular hemangioma (IMH) is an uncommon benign vascular lesion, which develops in skeletal muscles and it accounts for <1% of all hemangiomas. The accurate diagnosis is often difficult because the clinical and radiological findings are not specific. The gold standard treatment of IMH is surgical resection. We present a rare clinical report of IMH of the middle scalene muscle that was treated successfully with preoparative embolization and surgical excision.

Anatomically Complete Supraclavicular Reoperation for Recurrent Neurogenic Thoracic Outlet Syndrome: Clinical Characteristics, Operative Findings, and Long-term Outcomes

Background: The clinical outcomes of reoperations for recurrent neurogenic thoracic outlet syndrome (NTOS) remain undefined. Methods: From 2009 to 2019, 90 patients with recurrent NTOS underwent anatomically complete supraclavicular reoperation after previous operation(s) performed at other institutions using either supraclavicular (Prev-SC = 48), transaxillary (Prev-TA = 31), or multiple/combination (Prev-MC = 11) approaches. Prospectively maintained data were analyzed retrospectively. Results: The mean patient age was 39.9 ± 1.4 years, 72% were female, and the mean interval after previous operation was 4.1 ± 0.6 years. The mean Disabilities of the Arm, Shoulder, and Hand (QuickDASH) score was 62 ± 2, reflecting substantial preoperative disability. Residual scalene muscle was present in 100% Prev-TA, 79% Prev-SC, and 55% Prev-MC ( P < .05). Retained/residual first rib was present in 90% Prev-TA, 75% Prev-SC, and 55% Prev-MC ( P < .05). There were no differences in operative time (overall 210 ± 5 minutes), length of hospital stay (4.7 ± 0.2 days), or 30-day readmissions (7%). During follow-up of 5.6 ± 0.3 years, the improvement in QuickDASH scores was 21 ± 2 (36% ± 3%) ( P < .01) and patient-rated outcomes were excellent in 10%, good in 36%, fair in 43%, and poor in 11%. Conclusions: Anatomically complete decompression for recurrent NTOS can be safely and effectively accomplished by supraclavicular reoperation, regardless of the type of previous operation. Residual scalene muscle and retained/residual first rib are more frequently encountered after transaxillary operations than after supraclavicular or multiple/combined operations. Supraclavicular reoperation can achieve significant symptom reduction and functional improvement for approximately 90% of patients with recurrent NTOS.

Neuroanatomical relationship between Jingbi and the brachial plexus

Background: This study examined the stratified anatomy of the traditional acupuncture point Jingbi and the neuroanatomical relationship between Jingbi and the brachial plexus, and investigated neural pathways that could be affected by acupuncture stimulation at Jingbi. Methods: Twelve dissected specimens were used to study the pathway of an acupuncture needle inserted at Jingbi. The stratified anatomy and the neuroanatomical relationship between Jingbi and the brachial plexus were studied. Our samples were grouped by gender and cause of death for comparative analysis. Results: All needles ( n = 24, on both sides of a total of 12 cadavers) punctured the anterior scalene muscle medial to the brachial plexus and external jugular vein, lateral to the phrenic nerve and internal jugular vein, and superior to the clavicle and subclavian artery/vein. The depth of needle insertion at Jingbi on the right side of male samples was 28.0 (interquartile range (IQR), 22.5–30.8) mm, which was approximately 8 mm deeper than for female subjects ( p < 0.05). The needle was 3.0 (IQR, 2.0–5.0) mm and 7.0 (IQR, 5.5–8.0) mm medial to the brachial plexus on the left and right sides, respectively. Conclusion: Deep needle insertion at Jingbi can puncture the anterior scalene muscle. The mechanism of action of acupuncture stimulation at Jingbi might be related to its close relationship with the brachial plexus. Significant differences in needling depth were observed when our samples were grouped by gender. More studies are needed.

Throwing can Increase the Stiffness of the Scalene Muscle

Objectives: Thoracic outlet syndrome (TOS) has been reported as a set of symptoms due to the compression of the brachial plexus and subclavian vessels in the region of the thoracic outlet1. As a type of TOS, scalenus anticus syndrome involves the compression of the brachial nerves as they pass through the interval surrounded by the anterior and middle scalene muscles, and the first rib bone or cervical rib2. Recently, exercise-induced TOS is becoming more common in athletes, especially for those who perform repetitive overhead and hyperabduction maneuvers with upper limbs, such as baseball players. However, the effect of throwing on the stiffness of the scalene muscles is unknown. Thus, the purpose of this study was to quantitatively measure the stiffness of the scalene muscles using real-time shear wave elastography (SWE). The stiffness of scalene muscles was hypothesized to increase for the throwing side of baseball players. Methods: Thirty college baseball players (age range 19 to 21 years) were included for this study. Ultrasonic SWE with a 2-10 MHz linear array probe transducer (Aixplorer; SuperSonic Imagine, Aix-en-Provence, France) was used to assess the stiffness of the anterior and middle scalene muscles. Each participant was sited. The measurements were performed in two arm positions; 1) adducted and neutral rotation of the shoulder 2)90 degree of abduction and external rotation of shoulder with elbow flexed to simulate a clinical examination known as Roos test3. In both of the arm positions, the transducer was positioned just superior to the clavicular bone, parallel to its axis. Transducer was moved superiorly and tilted to visualize the superior surfaces of the anterior and middle scalene muscles parallel to the surface of the fifth cervical nerve simultaneously (Figure 1A). In this position, shear wave elastography was performed to measure the elasticity of each scalene muscle as its stiffness. Each muscle was divided into superior and deep areas. In both areas of each muscle, three 3mm-diameter circles were set to measure the elasticities of the scalene muscles and its averaged data in each area was defined as each stiffness (Figure 1B). A repeated-measures analysis of variance (ANOVA) was used to compare the elasticity of superior and deep areas in anterior and middle scalene muscles in throwing and non-throwing side. Values of p<0.05 were considered statistically significant. Results: For the throwing side, higher stiffness was found in the deep part of the middle scalene muscle compared to the superior and deep parts of the anterior scalene muscle with an adducted and neutrally rotated shoulder (p=0.0433). Moreover, the muscle stiffness was significantly higher in the superior and deep part of the middle scalene muscle than in the superior and deep parts of anterior scalene muscle in an abducted and externally rotated position of shoulder (p =0.00187). Meanwhile, no significant difference was found in the anterior and middle scalene muscles for the non-throwing side in both arm positions. Conclusion: In professional athletes with TOS who experienced surgical treatment, moderate to severe hypertrophy of the anterior scalenus muscles has been reported to be found4. Meanwhile, although the stiffness of the scalene muscles can be also related to the compression on the brachial plexus and on subclavian vessels in the region of the thoracic outlet, its quantitative measurements in the scalene muscles has not been reported. In this study, at throwing side, the muscle stiffness significantly increased in the superior area of middle scalene muscle in throwing side. While no contribution was identified in the scalene muscles at non-throwing side. As a result, repeat throwing motion can increase the stiffness of the middle scalene muscle. As a result, the brachial plexus and/or the subclavian artery could be compressed at the interscalene triangle. Throwing athletes with TOS should be treated, considering the stiffness of the middle scalene muscle, even conservative or surgical treatment. Our study was the first study to evaluate the effects of throwing on the stiffness of the scalene muscles in throwing athletes. Repetitive throwing motion can affect the stiffness of middle scalene muscle. Reduction of the middle scalene muscle should be considered to treat throwing athlete who has TOS. [Figure: see text]