Post-traumatic glomus tumor of the left anterior supraclavicular nerve: a case report.

OBJECTIVES: Peripheral nerve glomus tumors are extremely rare and occur with typical symptoms of peripheral neuropathic pain. Clinicians hardly consider this entity when faced with the swelling of a peripheral nerve and the diagnosis is reached only with histological examination. Nerves of limbs are usually affected and the solid glomus tumor is the most frequent histological variant. CASE DESCRIPTION: A 55-year-old man presented with a glomus tumor of the anterior supraclavicular nerve of the left cervical plexus, misdiagnosed clinically and radiologically as neuroma. Despite the preoperative suspicion and the intraoperative appearance, the histological examination revealed a glomus tumor with a prevalent muscular component, a glomangiomyoma. Once the tumor was removed, pain regressed completely. CONCLUSIONS: Because of its rarity, pre-operative diagnosis of glomus tumors is still a challenge, especially when arising from peripheral nerves. In the presence of chronic localized neuroma-type pain and sensitivity, glomus tumors should be considered in the pool of differential diagnosis, even if the imaging is not conclusive.

How to Identify Cervical Traumatic Neuromas in the Post-operative Neck Dissection: Brief Review of the Cervical Plexus Ultrasound.

Cervical traumatic neuromas (CTNs) are a non-neoplastic hyperplasia of damaged nerves and may be misinterpreted as metastatic lymph nodes during cervical ultrasound of patients with thyroid cancer after lateral neck dissection, resulting in unnecessary and painful fin-needle aspiration biopsy. The anatomy of the cervical plexus is challenging, and the correct identification and recognition of its neural roots and branches on ultrasound are key to the correct CTN diagnosis. This review outlines the US technique used to characterize CTNs in 10 standardized steps and describes the sonographic features of the cervical plexus, to assist the radiologist in the recognition of CTNs and their differentiation from lymph node metastases.

Diagnosis of cervical plexus tumours by high-frequency ultrasonography.

BACKGROUND: Cervical plexus (CP) tumours are difficult to diagnose because of atypical symptoms. This study aimed to summarize the features of a normal CP and CP tumours observed on high-frequency ultrasonography. METHODS: The ultrasound data of 11 CP tumour patients and 22 normal volunteers were collected. All 11 patients underwent magnetic resonance imaging (MRI), and 4 patients also underwent computed tomography (CT). The imaging data were compared with surgery and pathology data. RESULTS: The C7 vertebra and bifurcation of the carotid common artery (CCA) were useful anatomic markers for identifying the CP. In contrast to the C1 nerve (22.7%), the C2-4 nerves were well displayed and thinner than the brachial plexus (P < 0.05). CP tumours were more common in females (72.7%) and generally located at C4 (72.7%) on the right side (81.8%). Additionally, the nerve trunk in tumour patients was obviously wider than that in normal controls (7.49 ± 1.03 mm vs 2.67 ± 0.36 mm, P < 0.01). Compared with pathology, the diagnostic rates of CP tumours by MRI, CT and high-frequency ultrasound were 72.7% (8/11), 25% (1/4) and 90.9% (10/11), respectively. CONCLUSIONS: The diagnosis of CP neuropathy is accurate and reliable by high-frequency ultrasound, and the C7 vertebra and bifurcation of the CCA are useful anatomic markers in CP ultrasonography.

Influence of Anatomic Conditions on Efficacy and Safety of Combined Intermediate Cervical Plexus Block and Perivascular Infiltration of Internal Carotid Artery in Carotid Endarterectomy: A Prospective Observational Trial.

Ultrasound-guided intermediate cervical plexus blockade with perivascular infiltration of the carotid artery bifurcation perivacular block (PVB) is a reliable technique for regional anesthesia in carotid endarterectomy (CEA). We investigated the effect of the carotid bifurcation level (CBL) on PVB efficacy and safety in patients undergoing CEA. This prospective observational cohort study included 447 consecutive CEA patients who received PVB over a 6-y period. Vascular and neurologic puncture-related complications were recorded. The CBL was localized at the low level (C4 and C5 vertebra, low-level [LL] group) in 381 (85.2%) patients and at the high level (C2 and C3 vertebra, high-level [HL] group) in 66 (14.8%) patients. Local anesthetic supplementation by surgeons was necessary in 64 (14.3%) patients in the LL group and 38 (59.4%) patients in the HL group (p < 0.001) and was associated with a higher rate of central neurologic complications in the HL group (p = 0.031). Therefore, the efficacy of the PVB may be influenced by the CBL.

[Superficial cervical plexus block in ear surgery: A case report]. / Kulak cerrahisinde yüzeyel servikal pleksus blogu: Olgu sunumu.

The aim of this study was to share our experience with the application of a superficial cervical plexus block in the ear operation of a 59-year-old male patient. The superficial cervical plexus provides sensory innervation of the superficial structures of the anterolateral neck, ear, and shoulder. Ultrasound-guided cervical plexus block may be an alternative method for both anesthesia and analgesia in ear surgery.

High-Resolution Ultrasonography of the Transverse Cervical Nerve.

The transverse cervical nerve (TCN) is a superficial cutaneous branch of the cervical plexus that innervates the skin of the anterolateral neck. Therefore, it is exposed to injury in anterolateral cervical surgery, which can cause neuropathic pain. To provide a method with which to relieve patients' pain, this study aimed to evaluate the possibility of visualization, diagnostic assessment and blockade of the TCN with high-resolution ultrasound (HRUS). HRUS with high-frequency probes (15-22 MHz), guided ink-marking and consecutive dissection on both sides in nine fresh cadaver necks (n = 18) was conducted. On both sides of 20 healthy volunteers (n = 40), the distances between the greater auricular nerve (GAN) and the TCN at the posterior border of the sternocleidomastoid muscle were measured. Finally, cases referred to HRUS examinations because suspected TCN lesions were assessed. The TCN was visible in all anatomic specimens and in healthy volunteers. Dissection confirmed HRUS findings in all anatomic specimens (100%). In healthy volunteers, the mean distance between the GAN and the TCN was 10.42 ± 3.20 mm. The median visibility, rated on a five-point Likert scale, was four, reflecting good diagnostic quality. There were six patients with visible abnormalities on HRUS. This study confirmed the reliable visualization of the TCN with HRUS in anatomic specimens, healthy volunteers and patients.

Peripheral nerve blocks in the cervical region: from anatomy to ultrasound-guided techniques.

Cervical plexus nerve blocks have been employed in various head and neck operations. Both adequate anaesthesia and analgesia are attained in clinical practice. Nowadays, ultrasound imaging in regional anaesthesia is driven towards a certain objective that dictates high accuracy and safety during the implementation of peripheral nerve blocks. In the cervical region, ultrasound-guided nerve blocks have routinely been conducted only for the past few years and thus only a small number of publications pervade the current literature. Moreover, the sonoanatomy of the neck, the foundation stone of interventional techniques, is very challenging; multiple muscles and fascial layers compose a complex of compartments in a narrow anatomic region, in which local anaesthetics are injected. Therefore, this review intends to deliver new insights into ultrasound-guided peripheral nerve block techniques in the neck. The sonoanatomy of the cervical region, in addition to the cervical plexus, cervical ganglia, superior and recurrent laryngeal nerve blocks are comprehensively discussed.

Great auricular nerve schwannoma in neck region: a case report with the risk of medical disputes.

BACKGROUND: Great auricular nerve schwannoma is extremely rare. Herein, we reported the first case of schwannoma arising from great auricular nerve trunk. CASE PRESENTATION: A 29 year-old female complained of a slowly-growing superfacial neck mass for 6 months. MRI revealed a high possibility of schwannoma. Although the patient underwent successfully surgical removal of the tumor, ipsilateral numbness of both auricle and peripheral skin developed due to traction of the nerve. Immunohistochemistry staining confirmed the diagnosis of schwannoma. And the patient has been followed regularly. CONCLUSION: For superficial cervical tumors, the cervical plexus cutaneous nerve should be considered if MRI and other imaging findings suggest neurogenic tumors.

Distribution Patterns of Vasculature Around Cervical Nerve Roots.

BACKGROUND: To the authors' knowledge, there has not been an ultrasound study of the vulnerable vessels in a C3-7 cervical nerve root block (CNRB). OBJECTIVES: To evaluate the prevalence of vulnerable vessels around the target of a CNRB at the cervical nerve root of C3-7 levels in a clinical setting. DESIGN: Retrospective, cross-sectional study. SETTING: General teaching hospital, rehabilitation unit. PARTICIPANTS: A total of 104 patients complaining of neck or arm pain with no prior surgical history and who had undergone a CNRB at an outpatient clinic from May 2015 to December 2017 were included. MAIN OUTCOME MEASUREMENTS: The prevalence of vulnerable vessels as seen on a preprocedure ultrasound scan around the target of a CNRB at the cervical nerve root of C3-7 levels. RESULTS: Out of 104 cases, the C3 level had 7 blood vessels (8.33%), the C4 level had 14 blood vessels (13.86%), the C5 level had 17 blood vessels (16.35%), the C6 level had 27 blood vessels (25.96%), and the C7 level had 31 blood vessels (29.81%) either at the targeted cervical nerve root or at the site of the imaginary needle's projected pathway to the targeted cervical nerve root. CONCLUSION: There was a substantial prevalence of vulnerable vessels either at the targeted nerve root or at the site of the needle's projected pathway to the nerve root.

Ultrasound-guided intermediate cervical plexus and additional peripheral facial nerve block for carotid endarterectomy : A prospective pilot study.

BACKGROUND AND OBJECTIVES: Ultrasound-guided intermediate cervical plexus block with perivascular local anesthetic infiltration is an established anesthetic procedure for carotid endarterectomy. In this prospective pilot study an additional subplatysmal block of the superficial ansa cervicalis is presented for the first time. The target structures are the anastomoses between the facial nerve (cervical and marginal mandibular branches) and cervical plexus. METHODS: An ultrasound-guided intermediate cervical plexus block (20 ml of ropivacaine 0.75%) was performed (n = 28). Then, depending on the individual sonoanatomy, 5 ml of prilocaine 1% was injected into the carotid sheath (group 1: no perivascular infiltration, n = 14, group 2: perivascular infiltration, n = 14). The third step was subplatysmal injection of 5 ml of prilocaine 1% between the medial edge of the sternocleidomastoid muscle and the submandibular gland (n = 28). The investigated parameters included the need for supplementation and block-related side effects. RESULTS: The requirement for supplemental local anesthetic infiltration in the skin incision area was minimal at mean (M) 1.1 ml (standard deviation (SD) ±2.4 ml). Perivascular infiltration in group 2 significantly decreased the total amount of local anesthetic supplemented: group 1 M = 4.2 ml (SD = ±3.1 ml), group 2 M = 1.7 ml (SD = ±2.0 ml) (p = 0.018). The incidence of block-related side effects was not significantly different between the two groups. CONCLUSION: This study presents an ultrasound-guided subplatysmal block of the superficial ansa cervicalis for the first time, with the aim of optimizing anesthesia quality during surgical interventions in the carotid triangle.

Management of Great Auricular Neuralgia Confirmed by Electrophysiologic Examination: A Case Report.

The great auricular nerve (GAN) is a sensory branch of the cervical plexus originating from the C2 and C3 nerve roots that innervates the external ear, mandibular angle, and parotid gland. Since idiopathic GAN neuralgia is a rare condition and branches of the GAN overlap with other cervical and cranial nerves, its diagnosis is challenging and can be confused with other facial neuralgias. This article describes the case of a 55-year-old woman with intractable unilateral periauricular and lateral head pain. No significant findings were found on cervical and brain imaging. At first, the patient was suspected to be suffering from trigeminal neuralgia or great occipital neuralgia; however, the symptoms persisted despite pharmacotherapy, cervical plexus and medial branch block, and repetitive transcranial magnetic stimulation. On the basis of an electrophysiologic examination, the patient was diagnosed as having GAN lesions. Pain subsided immediately after ultrasound-guided GAN block with local anesthetics and steroids. These findings indicate that electrophysiologic studies are helpful for accurately diagnosing patients with unclear pain in the periauricular and lateral head.

Pros and Cons of C2 Nerve Sectioning/Preservation in Posterior Fusion for Congenital Atlantoaxial Dislocation.

OBJECTIVE: Deliberate C2 nerve root sectioning and its preservation have been described during posterior fusion for atlantoaxial dislocation (AAD). However, the associated outcomes have been less studied, especially in congenital AAD. Our objective was to study the clinical outcomes after C2 nerve root sectioning and the feasibility of C2 preservation in these patients. METHODS: The data from 190 patients were retrospectively studied. The decision to cut or preserve the C2 nerve root was determined by the preoperative radiologic findings and intraoperative suitability of its preservation. During follow-up, the patients were questioned about C2 nerve-related dysfunction. The pros and cons of sectioning or preservation of the C2 nerve root and the related feasibility factors are also described. RESULTS: Complex C1-C2 anatomy that required extensive dissection and drilling was seen in 139 patients. After C2 nerve root sectioning in 178 patients, none reported bothersome hypoesthesia, paresthesia, or dysesthesia that required medication. However, 9 patients (5.1%) developed nonhealing occipital ulcers and most required flap coverage or a skin graft. C2 nerve root preservation is feasible with an adequate inferior C1 lateral mass and normal-size ganglion. In patients with C1-occipital condyle hypoplasia, extremely oblique joints, spondyloptosis, incurved occiput, pseudofacets, and anomalous vertebral artery, preservation of the C2 nerve root is difficult. CONCLUSIONS: The advantages of sectioning the C2 nerve root are many. However, a subset of patients is prone to morbid occipital neuropathic ulcers. After C2 nerve sectioning, one should be cautious of such complications. C2 nerve root preservation should be strongly considered for patients with favorable anatomy.

Perineural Spread of Melanoma to the Brachial Plexus: Identifying the Anatomic Pathway(s).

BACKGROUND: Perineural spread of melanoma is a well-known mechanism of metastasis in cases involving cranial nerves. Brachial plexus involvement is rare, and the pathway is unknown. METHODS: A retrospective review of the Mayo Clinic database was performed to identify patients with a history of melanoma and brachial plexus compromise treated between 1994 and 2017. Inclusion criteria were a history of melanoma, a clinical diagnosis of brachial plexopathy, radiologic features consistent with perineural spread, and biopsy of melanoma within nerves. RESULTS: We identified 42 patients (24 men and 18 women; median age, 61 years; range, 37-84 years) with a history of melanoma and brachial plexopathy. On a review of clinical information, 2 cases met our inclusion criteria. Both patients presented with progressive brachial plexopathy, and imaging studies revealed features consistent with perineural spread. In 40 excluded patients, brachial plexopathy was caused by metastasis to axillary lymph nodes (n = 11), trauma (n = 8), post-surgical sequelae (n = 7), tumors other than melanoma (n = 5), inflammation (n = 5), radiation (n = 2), a combination of radiation and postsurgical changes (n = 1), and radiculopathy (n = 1). CONCLUSIONS: The 2 patients identified had similar clinical and radiologic features. We believe that there is a pattern of perineural spread to the brachial plexus through the cervical plexus. A literature review identified several recently published cases demonstrating an analogous mechanism of melanoma spread involving upper cervical nerves, supporting our proposed pathway.

[Cervical Plexus Blocks]. / Zervikale Plexusblockaden.

Blockades of the cervical plexus are established anesthesia procedures, not only in the context of operative carotid revascularizations. Recent investigations define inner sonoanatomic landmarks as well as the importance of brain nerves for innervation in the neck region. The present practice-oriented article discusses current study results, alternative techniques (ultrasound- versus landmark-guided) and fields of application (carotid desobliteration, surgery of the shoulder, ear and infraclavicular region).