Treatment of Ruptured Meningocele Post-Brachial Plexus Surgery: Potential Life-Threatening Complication-An Unique Case Report of Management of Ruptured Meningocele Post-Brachial Plexus Surgery to Avoid Dreadful Complication

Introduction: Formation of meningocele in brachial plexus injury is known and can be diagnosed on magnetic resonance imaging (MRI). It is mainly reported in brachial plexus root avulsion injuries and does not require specific treatment. We report accurate diagnosis and management of dreadful complication due to rupture of meningocele post-brachial plexus exploration. Case Report: A 23-year-old engineer presented at 4 months post-bike accident right side extended brachial plexus injury involving C5, C6, and C7. On MRI, he had meningocele in C6-7 root region. We performed supraclavicular exploration of brachial plexus and distal nerve transfers for shoulder abduction and elbow flexion. During surgery, the meningocele was ruptured. As the cyst was deep and extending toward apex of lung, the diagnosis of fluid drained had to be distinguished from pleural fluid with cerebrospinal fluid (CSF). We found hemo-glucose test and beta-2-transferrin levels are mandatory to confirm the diagnosis. Post-surgery, the patient had drainage of almost 500 cc of CSF from wound every day for 3 days. This was managed by repeat MRI and finally lumbar puncture drainage helped to seal the meningocele in neck. Conclusion: Meningocele in brachial plexus injury is common but rupture of cyst can be fatal. To confirm the origin of fluid, beta-2-transferin level is more specific test than the hemo-glucose test. Lumbar puncture and drainage away from neck can be more reliable modality of treatment in case of intraoperative rupture of such cysts if drainage is excessive postoperatively. Keywords: Meningocele rupture, cerebrospinal fluid leak, accurate diagnosis, management.

The nerve to the levator scapulae muscle as donor in brachial plexus surgery: an anatomical study and case series

OBJECTIVENerve transfers are commonly used in treating complete injuries of the brachial plexus, but donor nerves are limited and preferentially directed toward the recovery of elbow flexion and shoulder abduction. The aims of this study were to characterize the anatomical parameters for identifying the nerve to the levator scapulae muscle (LSN) in brachial plexus surgery, to evaluate the feasibility of transferring this branch to the suprascapular nerve (SSN) or lateral pectoral nerve (LPN), and to present the results from a surgical series.METHODSSupra- and infraclavicular exposure of the brachial plexus was performed on 20 fresh human cadavers in order to measure different anatomical parameters for identification of the LSN. Next, an anatomical and histomorphometric evaluation of the feasibility of transferring this branch to the SSN and LPN was made. Lastly, the effectiveness of the LSN-LPN transfer was evaluated among 10 patients by quantifying their arm adduction strength.RESULTSThe LSN was identified in 95% of the cadaveric specimens. A direct coaptation of the LSN and SSN was possible in 45% of the specimens (n = 9) but not between the LSN and LPN in any of the specimens. Comparison of axonal counts among the three nerves did not show any significant difference. Good results from reinnervation of the major pectoral muscle (Medical Research Council grade ≥ 3) were observed in 70% (n = 7) of the patients who had undergone LSN to LPN transfer.CONCLUSIONSThe LSN is consistently identified through a supraclavicular approach to the brachial plexus, and its transfer to supply the functions of the SSN and LPN is anatomically viable. Good results from an LSN-LPN transfer are observed in most patients, even if long nerve grafts need to be used.

Hand Surgery in Cambodia

As a lower middle-income nation, Cambodia has made significant improvements in basic health but hand surgery development continues to lag behind due to scarcity of trained and quality surgical manpower. Most of the hand surgery development locally has been due to surgical volunteers from Asia, Europe, and the United States. The introduction of a structured and systematic community-oriented hand surgery training over a 5-year period was successful in producing local surgeons to meet the basic needs of hand surgery patients. Brachial plexus surgery has benefited significantly, with local surgeons able to independently manage cases with minimal support. With the expansion of local surgical manpower and guidance, motivation, and assistance of regional hand surgeons, the future of hand surgery in Cambodia looks promising.

Surgical Managementof Brachial Plexus Injury

Brachial plexus injury is an injury of the shoulder nerve that often happens in young adult. It has a relatively high disability rate. The clinical outcomes of brachial plexus surgery to date are still disappointing, especially for the total plexus injury that affects the C5-T1. However, expectations remain with the advance of technology and more recent surgery techniques, specifically the emergence of distal neural transfer. This was a retrospective study with 9 brachial plexus injury patients, since 2012-2017. The aim to evaluate surgical strategies outcome of the management. The principle of handling brachial plexus palsy when conservatives fail is surgery, like autologous graft, neural transfer, neurolysis, and direct suture. Improvement of elbow flexion is the utmost priority and shoulder stabilization as well. Various techniques are used lately, but to date, they have not been able to improve the functioning of the patient's fingers.