Sonographic Evaluation of the Lateral Femoral Cutaneous Nerve: Single-Institution Experience and Pictorial Review.

ABSTRACT: The location of the lateral femoral cutaneous nerve (LFCN) makes it susceptible to injury with trauma, external compression, and iatrogenic injury. The objectives of this study were to report the single-institution efficacy of LFCN visualization on ultrasound (US), define the clinical characteristics of patients with LFCN palsy, and describe sonographic appearances of LFCN abnormalities by pictorial review. A retrospective chart review of LFCN cases evaluated using US at a single institution was performed, documenting rate of visibility on US, mode of nerve injury, and US imaging findings. Nerve visibility rates on US were correlated with magnetic resonance imaging (MRI) when both modalities were used. Imaging findings were confirmed with clinical/surgical history and follow-up. Retrospective review found that 170 patients underwent US for LFCN evaluation in the last 10 years. Injury was associated with surgical intervention in 56% of cases, and perineural scarring was the most common pathology described using US. Lateral femoral cutaneous nerve was visible on US in 97% of cases; MRI visualized LFCN in 60%. Chart review showed US as an effective tool in evaluating LFCN pathology, with a higher visualization rate than MRI. Through pictorial review, the array of LFCN pathology sonographically detectable is demonstrated.

An Introductory Point-of-Care Ultrasound Curriculum for an Anesthesiology Residency Program.

Introduction: The use of point-of-care ultrasound (POCUS) is a growing trend in the field of anesthesiology. However, formal POCUS curriculums are still not widely implemented in residency programs. As the Accreditation Council for Graduate Medical Education and the American Board of Anesthesiology have both incorporated POCUS into their educational aims and expectations for graduates, we recognized the need for a formal POCUS curriculum for our residency program. We developed and implemented a comprehensive 3-week POCUS curriculum for our first-year anesthesiology residents (CA1s) in the latter half of their academic year. Methods: Twenty CA1s participated in this educational activity. The POCUS curriculum spanned seven topics and was given in weekly 2-hour sessions over the course of 3 weeks. Each session was designed with the first hour consisting of a traditional lecture-based presentation followed by live hands-on practice. A pretest on POCUS knowledge was given to every resident before the curriculum, and a posttest and survey were administered afterwards. Results: Every CA1 showed an improvement in their posttest scores. The median scores of the pretest and posttest were 49% and 75%, respectively. Survey results were positive, with all of the CA1s agreeing that the POCUS educational materials were appropriate to their level of training and that their POCUS knowledge and technical skills improved after the curriculum. Discussion: We have shown that our formal POCUS curriculum improved anesthesiology residents' knowledge as well as resulting in positive views on the implementation of this intervention.

Ultrasound features of traumatic digital nerve injuries of the hand with surgical confirmation.

OBJECTIVE: Characterize the appearance of digital nerve injuries in different ultrasound planes and correlate the presence and size of neuromas with time from injury. MATERIALS AND METHODS: Surgically confirmed nerve injuries were retrospectively evaluated. Appearances of the nerve injury in the available imaging planes were reviewed by two readers. Associations between presence and size of neuroma with time from injury were analyzed. RESULTS: Injuries of 29 digital nerves (3 incomplete lacerations, 17 complete lacerations, 6 with 7 stump neuromas, 3 neuromas-in-continuity) noted on ultrasound were surgically confirmed. Among the 20 lacerations, long-axis images were obtained in 15, of which 10 depicted the injury and 4 did not. Among the 10 depicting the injury in long axis, 2 showed a discrete gap, and 7 showed the nerve obscured by laceration tissue without a gap. In short axis, the nerve injury was visible in all 20, and nerve laceration was seen as a discrete gap in 2, and obscuration by laceration tissue in 14. Neuromas were hypoechoic and well-defined. There was a positive association between time and presence of neuroma (OR = 1.3, p = 0.002). Correlations between time and cross-sectional area (rs = 0.45) and volume (rs = 0.57) of neuromas were moderately positive. CONCLUSION: Ultrasound long axis may be less useful, and those short axis may be more reliable for assessing digital nerve injuries than previously reported. Neuromas are hypoechoic and well-defined, and their size can vary based on time from injury.

Osteomyelitis and septic arthritis after Mycobacterium Bovis BCG Therapy for Urinary Bladder Cancer.

Mycobacterium bovis (M. bovis) Bacillus Calmette-Guerin (BCG) - an attenuated strain of M. bovis - is closely related to Mycobacterium tuberculosis and may be used as a vaccine against tuberculosis as well as a treatment for urinary bladder cancer. Complications of M. bovis BCG administration, while rare, can occur. While a few cases of vertebral osteomyelitis secondary to BCG therapy exist in the literature, and while there are case reports of osteomyelitis and septic arthritis from BCG vaccination (Chen et al., 2017; Huang et al., 2019; Lin et al., 2015 [1-3]), there are no reported cases of osteomyelitis and septic arthritis involving the foot from BCG therapy for urinary bladder cancer. We present an unusual presentation of osteomyelitis and septic arthritis of the tarsometatarsal joints after M. bovis BCG therapy for urinary bladder cancer. We will describe MRI and ultrasound findings in our case of M. bovis BCG osteomyelitis and septic arthritis.

Etiology of Lumbosacral Radiculoplexopathy: Sacral Insufficiency Fracture on Magnetic Resonance Imaging.

BACKGROUND: Sacral insufficiency fracture (SIF) can cause lumbosacral radiculoplexopathy (LSRP) and is probably under-recognized. Symptoms may include nonspecific lumbar spine or buttock pain that is exacerbated by physical activity and alleviated with rest. The frequency of LSRP secondary to SIF has not been reported. QUESTIONS/PURPOSES: We aimed to determine the frequency of LSRP associated with SIF using magnetic resonance imaging (MRI) of the lumbar spine. METHODS: We searched a radiology database at our institution using the keywords "sacral insufficiency fracture" and "lumbar spine MRI" for patient records from January 2014 through December 2017. We assessed for the presence of LSRP, reflected by elevated T2-weighted or short tau inversion recovery (STIR) signal intensity and enlargement of the nerve on noncontrast lumbar spine MRI. An incompletely healed vertically oriented SIF was confirmed if there was a persistent bone marrow edema pattern adjacent to the fracture site; we did not include purely transverse SIFs. The final cohort comprised 57 patients (48 female; age range, 14 to 89 years). RESULTS: Abnormalities of the extraforaminal L5 nerve root or the combined L4 and L5 nerve roots (the lumbosacral trunk) were identified in 19 (33%) of 57 patients, with a total of 23 sites (bilateral involvement in four cases). Of the 23 abnormal nerves, 19 (82.6%) had corresponding, clinically documented radicular symptoms and 16 (69.6%) had no other explanation on MRI for their radicular symptoms other than SIF. CONCLUSIONS: LSRP caused by SIF is an entity all radiologists should be cognizant of, especially in cases of otherwise unexplained radicular symptoms. The diagnosis of SIF can be helpful in cases involving concomitant multilevel lumbar spondylosis and neural foraminal stenosis.

Identification of long thoracic nerve on high-resolution 3T MRI.

OBJECTIVE: Long thoracic neuropathy results in serratus anterior muscle denervation and presents with scapular winging. Previously published studies have been unable to identify the long thoracic nerve on MRI; instead, secondary imaging features of serratus anterior muscle denervation are used to infer nerve injury. Our study's purpose was to evaluate the ability of high-resolution MRI to depict the long thoracic nerve. MATERIALS AND METHODS: In this HIPAA-compliant, IRB-approved retrospective study, two musculoskeletal radiologists reviewed the brachial plexus MRI exans of 24 subjects performed for clinical suspicion of long thoracic neuropathy. The radiologists evaluated whether the long thoracic nerve could be identified and for the presence of serratus anterior denervation; when the nerve was seen, assessment for nerve enlargement, signal hyperintensity, and morphologic change was performed. Inter-observer reliability was estimated with Cohen's kappa (κ). Clinical presentation and electromyogram (EMG) were then reviewed. RESULTS: The long thoracic nerve was identified in 18 cases (75%), with high inter-observer reliability for nerve visualization. Kappa values of 1.0, 0.9, 1.0, and 0.9 were obtained for identification of the LTN on coronal sequences of the brachial plexus, identification of the LTN on proximal and mid segments of the nerve on oblique sagittal sequences, and identification of the distal segment of the LTN on axial sequences through the chest, respectively. The nerve was identified in 91% of patients with positive EMG findings for a long thoracic neuropathy. In patients with EMG features of long thoracic neuropathy, 70% had corresponding abnormal MRI features. When denervation edema was present, the nerve was identified 86% of the time. CONCLUSION: High-resolution MRI can be used to visualize segments of the long thoracic nerve.

Magnetic resonance imaging of the failed superior capsular reconstruction.

BACKGROUND: Superior capsular reconstruction (SCR) of the shoulder is an increasingly common procedure in the treatment of patients with massive, irreparable rotator cuff tears lacking significant osteoarthritis. Post-operatively, the appearance of failed grafts has only been described in isolated case reports and review articles. METHODS: From January 2016 through December 2017, surgical records at a single tertiary-care facility were queried to identify all patients undergoing SCR. Patient records were reviewed for patient demographic information, reason for post-operative MRI, and post-operative surgeon assessment. 74 patients underwent SCR, of whom 12 received a follow-up MRI post-operatively. One patient was excluded due to missing records; the remaining 11 patients comprise the study cohort. Post-operative MRIs were obtained at mean six months after surgery. RESULTS: On review of post-operative MRIs, three distinct locations of failure were identified. Four patients (40%) had midsubstance failure of the allograft with all glenoid and humeral head fixation remaining intact. One patient (10%) had complete detachment of the allograft from both glenoid and humeral head fixation. Five patients (50%) had detachment of the allograft from the glenoid. CONCLUSION: In this series of ten failed SCRs, the most common mode of failure was loss of fixation on the glenoid, followed closely by midsubstance rupture. We found no instances of isolated fixation failure on the humeral head. This series illustrates the need for careful imaging in patients whose post-operative course suggests clinical failure. These findings suggest that strengthening glenoid fixation may provide better clinical outcomes as this procedure becomes more common. LEVEL OF EVIDENCE: III - Retrospective study.

Fibreoptic Orotracheal Intubation of Obese Patients Using Parker Flex-Tip vs. Standard Endotracheal Tube.

OBJECTIVE: Advancement of the endotracheal tube through a fibreoptic scope can sometimes prove to be challenging in obese patients. The Parker Flex-Tip endotracheal tube was developed with a curved and tapered distal tip to facilitate easier placement in the trachea. This study examined the use of the Parker Flex-Tip tube as compared to standard endotracheal tubes in patients with a body mass index of 30 or greater. METHODS: Sixty patients undergoing surgery requiring general anaesthesia were randomised into two groups. Using the fibreoptic scope, one group was intubated with the Parker Flex-Tip tube and the other group with a standard polyvinyl Portex tube. The time for intubation and the number of attempts required to place the endotracheal tube were measured and recorded. RESULTS: Using the Mann-Whitney U rank sum test, the median time needed for intubation with the two types of endotracheal tubes did not show a significant difference. The chi-square analyses were conducted for the number of attempts needed to place the endotracheal tubes, which also did not demonstrate any significant difference. CONCLUSIONS: Parker Flex-Tip endotracheal tube was not superior to the standard endotracheal tubes for fibreoptic intubation in obese patients.

Evaluation of Osseous Morphology of the Hip Using Zero Echo Time Magnetic Resonance Imaging.

BACKGROUND: Femoroacetabular impingement syndrome (FAIS) is a common disorder of the hip resulting in groin pain and ultimately osteoarthritis. Radiologic assessment of FAI morphologies, which may present with overlapping radiologic features of hip dysplasia, often requires the use of computed tomography (CT) for evaluation of osseous abnormality, owing to the difficulty of direct visualization of cortical and subchondral bone with conventional magnetic resonance imaging (MRI). The use of a zero echo time (ZTE) MRI pulse sequence may obviate the need for CT by rendering bone directly from MRI. PURPOSE/HYPOTHESIS: The purpose was to explore the application of ZTE MRI to the assessment of osseous FAI and dysplasia morphologies of the hip. It was hypothesized that angular measurements from ZTE images would show significant agreement with measurements obtained from CT images. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 2. METHODS: Thirty-eight hips from 23 patients were imaged with ZTE MRI and CT. Clinically relevant angular measurements of hip morphology were made in both modalities and compared to assess agreement. Measurements included coronal and sagittal center-edge angles, femoral neck-shaft angle, acetabular version (at 1-, 2-, and 3-o'clock positions), Tönnis angle, alpha angle, and modified-beta angle. Interrater agreement was assessed for a subset of 10 hips by 2 raters. Intermodal agreement was assessed on the complete cohort and a single rater. RESULTS: Interrater agreement was demonstrated in both CT and ZTE, with intraclass correlation coefficient values ranging from 0.636 to 0.990 for ZTE and 0.747 to 0.983 for CT, indicating "good" to "excellent" agreement. Intermodal agreement was also shown to be significant, with intraclass correlation coefficients ranging from 0.618 to 0.904. CONCLUSION: Significant agreement of angular measurements for hip morphology exists between ZTE MRI and CT imaging. ZTE MRI may be an effective method to quantitatively evaluate osseous hip morphology.

Ultrasound-guided percutaneous treatment of volar radiocarpal ganglion cysts: Safety and efficacy.

PURPOSE: To determine the safety and efficacy of ultrasound (US)-guided percutaneous treatment of volar radiocarpal ganglion cysts. METHODS: The institutional review board approved the retrospective study of patients referred for US-guided percutaneous treatment of a volar radiocarpal ganglion cyst over a 5-year period. Treatment consisted of a combination of aspiration, lavage using anesthetic, wall fenestration, and steroid injection. Intraprocedural imaging and procedure notes were reviewed. Followup information was retrieved from postprocedure electronic medical records. RESULTS: Eighty-eight patients comprised our study group. Complete decompression of the ganglion cyst was achieved in 92% of cases immediately after treatment. There were no instances of hematoma or infection. Of 38 patients with available followup information, 66% had a ganglion cyst recurrence at a median time of 9 months, regardless of their initial size or the injection of steroids. Cysts with internal septa had a statistically significantly higher rate of recurrence (P = 0.033). CONCLUSIONS: US-guided percutaneous treatment of volar radiocarpal ganglion cysts is safe and ensures immediate decompression in most cases. However, cysts may recur, even after steroid injection or lavage.

Electronic tool helps anaesthesia trainee handovers.

BACKGROUND: Handovers in patient care are increasingly common occurrences in medicine and are highly susceptible to communication failures. Intraoperative anaesthesiology handovers are especially challenging because of concurrent management of the patient. Our goal was to develop and use an electronic handover checklist as an educational tool to teach anaesthesiology trainees a standardised method of handing over a case intraoperatively. We hypothesised that the use of the checklist would systematically enhance the transfer of accurate and complete information. METHODS: Thirty-four anaesthesia trainees were observed giving an intraoperative handover without the checklist, and then again with the checklist at a later time. An observational handover assessment tool was used by investigators to mark each item as either spontaneously relayed by the giver, elicited by the receiver, not discussed or not applicable to the case. After the use of the checklist, each handover giver filled out a survey related to his or her perceptions of the checklist. RESULTS: The proportion of items spontaneously relayed increased from 54% without the checklist to 98% when using the checklist (p < 0.0001). More than 90% of participants felt that the checklist increased handover efficiency and communication skills. All participants stated that the handovers were more thorough with the checklist and that they would incorporate it into their daily practice. Intraoperative anaesthesiology handovers are especially challenging because of concurrent management of the patient DISCUSSION: With the intervention of the checklist, our results show that the use of a standardised intraoperative checklist improved the transfer of important patient information among anaesthesia trainees.

Teaching Anesthesiology Residents How to Obtain Informed Consent.

BACKGROUND: Although obtaining medical consent is an important skill, many residents may have knowledge gaps in understanding key concepts of informed consent or may lack awareness of serious procedural risks. The objective of this study was to see if formal education makes a difference in anesthesiology residents' ability to obtain an informed consent. METHODS: Thirty-four first-year anesthesiology residents (CA1s) were randomized into either a control group or study group. The control group learned how to obtain consent for general anesthesia the current way, which is by observing senior residents or faculty. The study group received additional formal education, which included a video, a narrated lecture, and a quiz. Afterwards, both groups were observed obtaining informed consent on patients receiving general anesthesia. The investigators used a checklist consisting of 10 important items that the resident had to fulfill for a proper informed consent. To minimize bias, neither the control group nor the study group was shown the checklist. RESULTS: Overall, the study group did significantly better than the control group in fulfilling the 10 items on the checklist (median 0.90 vs 0.70; P < .001). There were statistical differences on 4 key components: identifying all persons on the anesthesia team (76.5% vs 5.9%, P < .0001), explaining why general anesthesia is necessary (82.4% vs 35.3%, P < .0134), explaining the risks and benefits of general anesthesia (94.1% vs 47.1%, P < .0066), and discussing the risks and benefits of blood transfusion (70.59% vs 29.4%, P < .0381). CONCLUSIONS: This study shows that formal instruction on informed consent enhances residents' ability to obtain an informed consent.

Prospective respiratory triggering improves high-resolution brachial plexus MRI quality.

BACKGROUND: Oblique sagittal MRI sequences, orthogonal to the longitudinal axis of the brachial plexus, can reliably depict morphologic and signal abnormalities. However, nerve visualization may be obscured by ghosting artifact from periodic respiratory motion. Respiratory triggering (RT) with a thoracoabdominal bellows can reduce ghosting artifact, but it is not routinely used for brachial plexus MRI. Furthermore, the efficacy of prospective RT for brachial plexus imaging has not yet been reported. PURPOSE: To compare brachial plexus MRI sequences acquired with and without respiratory triggering. STUDY TYPE: Prospective. SUBJECTS: Five volunteers and 20 patients were included. Each subject was imaged with and without RT during the same session. FIELD STRENGTH/SEQUENCE: Proton density or T2 -weighted Dixon fat suppressed sequences were obtained at 3.0T using receive-only 16-channel flexible array coils. ASSESSMENT: Three musculoskeletal radiologists blindly evaluated each sequence using subjective scoring criteria for ghosting artifact, nerve conspicuity, and diagnostic confidence. Nerve conspicuity scores at three distinct plexus levels were summed to calculate an overall image quality score. STATISTICAL TESTS: Marginal proportional odds logistic regression models were used to compare all scores between RT and non-RT. Gwet's agreement coefficient was used to assess interobserver and intraobserver reliability. RESULTS: Mean scan time per sequence increased from 4:25 minutes (95% confidence interval [CI], 4:02-4:49 min) with non-RT to 6:09 minutes (95% CI, 5:42-6:35 min) with RT. RT reduced ghosting artifact (odds ratio [OR] = 0.21, 95% CI: 0.09-0.46, P < 0.001), improved overall image quality (OR = 4.88, 95% CI: 2.18-10.95, P < 0.001), and increased diagnostic confidence (OR = 3.72, 95% CI: 1.61-8.63, P = 0.002) for all readers. Interobserver agreement for ghosting artifact and image quality was substantial to almost perfect (AC2 = 0.74-0.85). Interobserver agreement for all other scores was moderate to almost perfect (AC2 = 0.61-0.82). Intraobserver agreement was substantial to almost perfect for all parameters (AC2 = 0.76-1.0). DATA CONCLUSION: Prospective RT with bellows can effectively minimize ghosting artifact and improve image quality for brachial plexus MRI within clinically optimal acquisition times. LEVEL OF EVIDENCE: 1 Technical Efficacy: Stage 2.

The use of podcast videos for airway skills.

BACKGROUND: For a procedure-driven specialty such as anaesthesiology, hands-on training has always been the primary method of teaching airway skills. Although this method will always be a necessary component, the current generation of learners tend to gravitate toward media as educational sources. We propose that the addition of watching a series of podcast videos on airway management will further enhance the medical student's procedural skills. METHODS: A total of 34 medical students scheduled for an anaesthesia rotation were randomised into two groups. Both groups received the conventional one-to-one hands-on training on airway skills in the operating room; however, the study group received an additional series of podcast videos on airway equipment, mask ventilation and intubation. At the end of the rotation, all of the students were given an objective structured clinical examination (OSCE) on a mannequin. RESULTS: The study group who received the podcasts significantly out-performed the control group on the OSCE (p = 0.003). The mean score for the podcast video group was 94.4%, versus 76.5% in the control group. Commonly missed steps by the control group included checking the endotracheal tube balloon before intubation, taping the eyes and auscultation of the epigastrium and lungs. DISCUSSION: Our results showed that supplementing conventional hands-on training with contemporary channels such as podcast videos improved learners' procedural skills. The media format was relatable for these modern learners and provided the added benefit of self-paced learning. Overall, the podcast videos made a positive contribution to students learning airway techniques.

Brachial plexitis or neuritis? MRI features of lesion distribution in Parsonage-Turner syndrome.

INTRODUCTION: This study seeks to characterize lesion distribution in Parsonage-Turner Syndrome (PTS) using high-resolution MRI. METHODS: MRIs of 27 patients with clinically confirmed PTS were reviewed. Two radiologists independently evaluated the brachial plexus proper, side and terminal plexus branches, and more distal, upper extremity nerves. RESULTS: All patients had at least 1 clinically involved nerve. MRI revealed that the plexus appeared normal in 24 of 27 patients; in 3 other patients, signal hyperintensity was seen immediately proximal to the take-off of abnormal side or terminal branch nerves. Focal intrinsic constrictions were detected in 32 of 38 nerves. MRI interobserver agreement was high (Cohen's κ = 0.839). DISCUSSION: MRI findings, corroborated by electrodiagnostic testing, localized abnormalities to plexus branches and peripheral nerves, suggesting that PTS is characterized by 1 or more mononeuropathies rather than changes involving a portion of or the complete plexus proper. These results may improve diagnosis, prognostication, and management. Muscle Nerve 58: 359-366, 2018.

The Repaired Rotator Cuff: MRI and Ultrasound Evaluation.

PURPOSE OF REVIEW: The purposes of this review were to provide an overview of the current practice of evaluating the postoperative rotator cuff on imaging and to review the salient imaging findings of the normal and abnormal postoperative rotator cuff, as well as of postoperative complications. RECENT FINDINGS: The repaired rotator cuff frequently appears abnormal on magnetic resonance imaging (MRI) and ultrasound (US). Recent studies have shown that while the tendons typically normalize, they can demonstrate clinically insignificant abnormal imaging appearances for longer than 6 months. Features of capsular thickening or subacromial-subdeltoid bursal thickening and fluid distension were found to decrease substantially in the first 6-month postoperative period. MRI and US were found to be highly comparable in the postoperative assessment of the rotator cuff, although they had a lower sensitivity for partial thickness tears. Imaging evaluation of newer techniques such as patch augmentation and superior capsular reconstruction needs to be further investigated. MRI and US are useful in the postoperative assessment of the rotator cuff, not only for evaluation of the integrity of the rotator cuff, but also for detecting hardware complications and other etiologies of shoulder pain.

Imaging of Groin Pain: Magnetic Resonance and Ultrasound Imaging Features.

CONTEXT: Evaluation of groin pain in athletes may be challenging as pain is typically poorly localized and the pubic symphyseal region comprises closely approximated tendons and muscles. As such, magnetic resonance imaging (MRI) and ultrasound (US) may help determine the etiology of groin pain. EVIDENCE ACQUISITION: A PubMed search was performed using the following search terms: ultrasound, magnetic resonance imaging, sports hernia, athletic pubalgia, and groin pain. Date restrictions were not placed on the literature search. STUDY DESIGN: Clinical review. LEVEL OF EVIDENCE: Level 4. RESULTS: MRI is sensitive in diagnosing pathology in groin pain. Not only can MRI be used to image rectus abdominis/adductor longus aponeurosis and pubic bone pathology, but it can also evaluate other pathology within the hip and pelvis. MRI is especially helpful when groin pain is poorly localized. Real-time capability makes ultrasound useful in evaluating the pubic symphyseal region, as it can be used for evaluation and treatment. CONCLUSION: MRI and US are valuable in diagnosing pathology in athletes with groin pain, with the added utility of treatment using US-guided intervention. Strength-of Recommendation Taxonomy: C.

Magnetic resonance imaging patterns of mononeuropathic denervation in muscles with dual innervation.

Magnetic resonance imaging (MRI) of mononeuropathy in muscles with dual innervation depicts geographic denervation corresponding to the affected nerve. Knowledge of the normal distribution of a muscle's neural supply is clinically relevant as partial muscle denervation represents a potential imaging pitfall that can be confused with other pathology, such as muscle strain. This article reviews the normal innervation pattern of extremity muscles with dual supply, providing illustrative examples of mononeuropathy affecting such muscles.

Rhabdomyolysis resulting in concurrent Horner's syndrome and brachial plexopathy: a case report.

This case report describes a 29-year-old male who presented with immediate onset of Horner's syndrome and ipsilateral brachial plexopathy after sleeping with his arm dangling outside a car window for 8 h. Outside workup and imaging revealed rhabdomyolysis of the left neck musculature. Subsequent electrodiagnostic testing and high-resolution brachial plexus magnetic resonance imaging at the authors' institution attributed the Horner's syndrome and concurrent brachial plexopathy to rhabdomyolysis of the longus colli and scalene musculature, which had compressed-and consequently scar tethered-the cervical sympathetic trunk and brachial plexus. This case of co-existent Horner's syndrome and brachial plexopathy demonstrates the role of high-resolution brachial plexus MRI in diagnosing plexopathy and the importance of being familiar with plexus and paravertebral muscle anatomy.