case_images: PMC11090597_01
case_images: (a-c) Magnetic resonance imaging T1 imaging of the left brachial plexus schwannoma. (a) Sagittal view of the brachial plexus schwannoma with arrows locating the tumor. (b) Coronal view of the schwannoma with maximal height annotated. (c) Axial view of the schwannoma with arrows locating the tumor.
case_images: SNI-15-135-g001.jpg
case_images: PMC11090597_01_SNI-15-135-g001.jpg
case_images: F1
case_images: Follow-up MRI revealed an interval increase in the size of the residual tumor to 65 cm x 31 cm x 27 cm [Figures 1a-c] spanning the C7-T1 nerve roots to the inferior trunk of the BP.
case_images: Patient positioning and preoperative marking. Black box covering surgeon initials for preoperative site marking.
case_images: SNI-15-135-g002.jpg
case_images: PMC11090597_01_SNI-15-135-g002.jpg
case_images: F2
case_images: The patient was positioned supine with the head turned to the right under general anesthesia, and a curvilinear incision [Figure 2] was created along the patient's previous scar and extended for supraclavicular and infraclavicular exposure.
case_images: (a-c) Clavicular osteotomy with orthopedic surgery. (a) Mid-clavicular osteotomy. (b) Resected mid-clavicular segment. (c) Clavicular window to the brachial plexus.
case_images: SNI-15-135-g003.jpg
case_images: PMC11090597_01_SNI-15-135-g003.jpg
case_images: F3
case_images: At this time, the orthopedic surgery team osteotomized a 2 cm block of the mid-clavicle [Figures 3a and b], creating a window [Figure 3c].
case_images: Letters corresponding to intraoperative vessel loops. A. Upper trunk; B. Schwannoma and scar tissue; C. Red loops leading to subclavian artery; D. Lateral cord; E. Musculocutaneous nerve; F. Median nerve.
case_images: SNI-15-135-g004.jpg
case_images: PMC11090597_01_SNI-15-135-g004.jpg
case_images: F4
case_images: The subclavius and pectoralis minor were transected for exposure of the underlying neurovascular structures with embedded scar tissue and schwannoma [Figure 4]. Vessel loops were then used to identify neurovascular structures, and electromyography monitoring was used to identify the BP components [Figure 4].
case_images: Letters corresponding to intraoperative vessel loops. A. Upper trunk; B. Middle trunk; C. Lower trunk, C8 nerve root; D. Phrenic nerve; E. Lower trunk, T1 nerve root; F. Subclavian artery; G. Lateral cord; H. Median nerve; I. Musculocutaneous nerve; J. Medial clavicle; K. Lateral clavicle.
case_images: SNI-15-135-g005.jpg
case_images: PMC11090597_01_SNI-15-135-g005.jpg
case_images: F5
case_images: On identification of the schwannoma in the lower trunk, EMG was utilized to determine a safe entry zone and a gross total resection was completed with a predominantly extracapsular approach [Figure 5].
case_images: Mid-clavicular segment refixated with Synthes plate and demineralized bone matrix, aspirate, and bone marrow mixture. Jackson-Pratt drains are placed deep to the clavicle.
case_images: SNI-15-135-g006.jpg
case_images: PMC11090597_01_SNI-15-135-g006.jpg
case_images: F6
case_images: Orthopedic surgery colleagues returned to refix the clavicle with a plate and screws [Figure 6].