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1/16. Atypical brachial plexopathy with pseudotumor cerebri.

    A 24-year-old woman with previously known pseudotumor cerebri syndrome (PTCS) presented with severe pain in the neck and shoulders followed by the classical symptoms and signs of bilateral brachial neuritis. At the same time, there was a recurrence of the PTCS which had been in remission for more than one-and-a-half years. Despite treatment with high doses of methylprednisolone, intravenous immunoglobulins and repeated cerebrospinal fluid drainage, both brachial plexopathy and the PTCS continued to worsen. Both lumbosacral plexuses became involved and the visual acuity deteriorated to a level such that a lumboperitoneal shunt had to be inserted. The neurological condition started to improve progressively after 8 weeks. This case is, to our knowledge, the first where brachial plexopathy has been described in association with a PTCS. Although the pathogenesis of this association is not clear, there are enough data to suggest the existence of a continuum between extended brachial plexopathy and Guillain Barre syndrome, with which PTCS has been associated in some instances.
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2/16. Schwannoma of the suprascapular nerve presenting with atypical neuralgia: case report and review of the literature.

    Compressive lesions of the suprascapular nerve produce weakness and atrophy of the supra- and infraspinatus muscles and a poorly defined aching pain along the posterior aspect of the shoulder joint and the adjacent scapula. Entrapment neuropathy of the suprascapular nerve is fairly common whereas tumorous lesions are rare; among the latter ganglion cysts are frequently seen. An isolated solitary schwannoma of the suprascapular nerve presenting with atypical neuralgic pain is exceptional. The location of a schwannoma under the firm deep cervical fascia in the posterior triangle of the neck is implicated in the genesis of neuralgic pains mimicking the suprascapular entrapment syndrome. One such case is reported with discussion of the relevant clinical features.
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3/16. Posterior subscapular approach for specific brachial plexus lesions.

    The surgical technique for exposure of the brachial plexus via a posterior subscapular approach is reviewed, with its relevant anatomy. The author has used this approach for four brachial plexus procedures. The indications for this approach will be discussed, and a case history presented to illustrate the benefits of this procedure in recurrent thoracic outlet syndrome.
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4/16. Disuse osteoporosis as evidence of brachial plexus palsy due to intrauterine fetal maladaptation.

    We report what may be overlooked evidence of the effects of intrauterine maladaptation as a cause of brachial plexus palsy. A case of total brachial plexus palsy in the posterior arm associated with Horner's syndrome and severe demineralization of the bones of the affected arm is analyzed. In this litigated case, a report of marked demineralization of the bones of the affected arm was analyzed by the plaintiff's radiology expert as diagnostic of disuse osteoporosis. The presence of clear-cut evidence of disuse osteoporosis during the early neonatal period is compelling evidence of an intrauterine onset of brachial plexus palsy.
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5/16. Bilateral neurogenic thoracic outlet syndrome.

    We report a case of bilateral neurogenic thoracic outlet syndrome (TOS). Electrophysiological examination suggested the presence of bilateral lower brachial plexus neuropathy. radiography showed rudimentary bilateral cervical ribs. In the cases reported in the literature to date, the clinical findings are typically unilateral despite the common presence of bilateral bony abnormalities. Neurogenic TOS should be considered in young women, even if they present with bilateral symptoms, when they have occupations requiring strenuous activity of the upper limbs.
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6/16. conversion disorder mimicking Dejerine-Roussy syndrome (thalamic stroke) after spinal cord stimulation.

    OBJECTIVE: Dejerine-Roussy syndrome is a complex of various signs and symptoms in patients suffering from central thalamic pain, usually secondary to a vascular etiology. We describe a patient presenting with the potentially devastating signs and symptoms of thalamic stroke, at least temporally related to spinal cord stimulator implantation. The etiology of the patient's affliction was subsequently revealed to be a conversion disorder.Case report A 37-year-old woman presented for spinal cord stimulation as treatment of her brachial plexopathy after failure of conservative therapy. Before implantation, she underwent a clinical interview with a psychologist and psychometric testing. No psychological pathology was detected. Trial and permanent implantation of the cervical stimulator lead and pulse generator were uneventful. Eleven days after receiving the permanent implant, the patient experienced right-sided hemicorporal numbness and burning dysesthesia. The patient was admitted, and a diagnosis of Dejerine-Roussy syndrome (thalamic stroke) was made. She was discharged, and her symptomatology waxed and waned over a period of weeks. The patient was subsequently admitted for psychiatric evaluation because of anxiety attacks. During her protracted admission, her psychiatrists strongly suspected a conversion disorder. The stimulator was removed, and the patient received supportive care only. Within 6 months, sensory symptoms and all motor deficits had completely resolved. CONCLUSIONS: Despite careful preoperative evaluation, latent psychosocial issues may limit the effectiveness of spinal cord stimulation. We present a case of conversion disorder masquerading as Dejerine-Roussy syndrome after spinal cord stimulation. The implications of the failure of preoperative psychological evaluation and screening to avert implantation are discussed.
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7/16. Radiculoplexopathy with conduction block caused by acute Epstein-Barr virus infection.

    The authors report a case of cervicobrachial radiculoplexopathy with proximal conduction block (CB), associated with acute Epstein-Barr virus (EBV) infection. The patient presented with pain, paresthesias, and monomelic weakness in the left C7-8, and T1 myotomes. The illness was monophasic with rapid recovery. Neurophysiologic studies demonstrated CB in the proximal left median and ulnar nerve segments. The authors conclude that this syndrome resulted from a postinfectious process following acute EBV infection.
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8/16. Levetiracetam as an adjunctive analgesic in neoplastic plexopathies: case series and commentary.

    Certain types of pain associated with cancer may be difficult to treat with standard therapies, often resulting in intractable pain and suffering for the patient. The use of an opioid as analgesic monotherapy can lead to poorly controlled pain as well as multiple side effects. Non-opioid adjunctive analgesics, such as antidepressants and antiepileptic drugs (AEDs) often improve both pain control, and side effect prevalence. Levetiracetam is an AED with unique mechanisms of action that may have analgesic properties in various pain syndromes. Seven patients with neoplasms involving neural structures (four invading the brachial plexus, and three the lumbosacral plexus) had severe pain of 8 to 9 out of 10 on a visual analog scale (VAS), despite the use of parenteral opioids and various adjunctive therapies. These patients were treated with oral levetiracetam titrated over days to two weeks, depending on the location of pain, drug response, and tolerance to tapering of opioid analgesics. Opioid and adjunctive analgesic use and VAS scores were recorded periodically. The maximum levetiracetam dose ranged from 500 mg to 1500 mg BID. All patients experienced pain control improvement after the addition of levetiracetam, with VAS scores decreasing from 8-9 out of 10 to 0-3 out of 10 within two to 14 days of therapy initiation. overall opioid use decreased by at least an estimated 70%, without drug related adverse events. In this small series of patients, levetiracetam effectively and safely improved pain relief in patients with neoplastic plexopathies previously resistant to standard analgesic approaches.
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9/16. Bilateral isolated phrenic neuropathy causing painless bilateral diaphragmatic paralysis.

    The authors report four patients with a syndrome of painless bilateral isolated phrenic neuropathy. Electrophysiologic testing demonstrated active denervation restricted to the diaphragm. Long-term recovery was poor. The authors conclude that bilateral isolated phrenic neuropathy is a cause of painless diaphragmatic paralysis distinguishable from immune brachial plexus neuropathy and other neuromuscular disorders with similar clinical presentation.
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10/16. Brachial plexopathy due to malignant peripheral nerve sheath tumor in neurofibromatosis type 1: case report and subject review.

    Neurofibromatosis type 1 (NF1) is a common tumor predisposition syndrome affecting approximately 1 in 4,000 persons. It is an autosomal-dominant disorder with half of the cases resulting from spontaneous mutations. This genetic defect leads to the formation of benign tumors or neurofibromas of the peripheral nervous system. Dermal neurofibromas may cause local discomfort and itching but are rarely associated with neurological deficit and do not undergo malignant change. The more extensive plexiform neurofibromas produce neurological complications in 27%-43% of patients with NF1 and may undergo malignant degeneration in 5% of cases. patients with NF1 who develop pain or new neurological symptoms should have a rapid and thorough assessment for malignancy. In this report, we illustrate this point by presenting a patient who developed acute shoulder pain and weakness due to malignant degeneration of a plexiform neurofibroma involving the left brachial plexus, and review the literature on this subject.
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