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.

A Rare and Unique Complication of Pins and Rubbers Traction System (Suzuki frame) while Managing Simple PIPJ Fracture-dislocation.

Introduction: The management of acute proximal interphalangeal (PIP) joint fracture-dislocation by dynamic external fixator is widely practiced method. The complications such as pin loosening or non-union or stiffness are known and can be treated well. The over distraction causing vascular compromise and calcification of volar plate jeopardizing the function and viability of the affected digit is not reported so far. Case Report: We report a case of 2 weeks post-traumatic ring finger PIP joint fracture-dislocation in a 21-year-old male which was treated by pins and rubber dynamic traction method. The affected digit was found cold and lengthened at 3 weeks of distraction causing vascular compromise. The X-ray showed over distraction by 1.5 cm at PIP joint. The digit was salvaged by removing distractor and applying splintage. Later, at 6 weeks, X-ray showed volar plate calcification causing joint stiffness. This was tackled by volar plate arthroplasty. At 2 months, the patient got 20-80° movement without pain. Conclusion: The dynamic pins and rubber traction system for acute PIP joint injury can result in complication like over distraction leading vascular compromise. The clinical and radiological assessment with such technique is mandatory once a week to avoid missing such disasters. Even if such complication occurs, immediate fixator removal and splintage can save the digit. Once it survives, secondary procedure for gaining movement or stabilizing the joint like volar plate arthroplasty can be considered.

Late-onset schizophrenia with isolated cavum vergae: Case report and literature review.

Cavum septum pellucidum (CSP) and cavum vergae (CV) have separately and together been associated with an increased risk of neurodevelopmental disorders and psychosis; however, there is little literature on the psychopathological significance of isolated CV, and no previous report of isolated CV in late-onset psychosis. We describe an 80-year-old woman who presented with a 1-month history of psychotic symptoms qualifying for a diagnosis of schizophreniform disorder. Physical (including neurological) examination, bedside cognitive testing, and laboratory investigations were all within normal limits. A magnetic resonance imaging scan of the brain revealed an insignificant CSP with prominent CV. The patient showed almost complete recovery from psychosis after 4-6 weeks of treatment with quetiapine (200 mg/day). She maintained improvement with this medication at an 18-month follow-up; medication taper was associated with re-emergence of hallucinations. We briefly discuss CSP and CV in the context of vulnerability to psychosis. We examine whether isolated CV is a benign and incidental finding versus a biological risk factor for neuropsychiatric illness. We suggest specific studies to resolve the uncertainty.