Recovery of brachial plexus injury after bronchopleural fistula closure surgery based on electrodiagnostic study: A case report and review of literature.

BACKGROUND: Axillary thoracotomy and muscle flap are muscle- and nerve-sparing methods among the surgical approaches to bronchopleural fistula (BPF). However, in patients who are vulnerable to a nerve compression injury, nerve injury may occur. In this report, we present a unique case in which the brachial plexus (division level), suprascapular, and long thoracic nerve injury occurred after BPF closure surgery in a patient with ankylosing spondylitis and concomitant multiple joint contractures. CASE SUMMARY: A 52-year-old man with a history of ankylosing spondylitis with shoulder joint contractures presented with right arm weakness and sensory impairment immediately after axillary thoracotomy and latissimus dorsi muscle flap surgery for BPF closure. During the surgery, the patient was positioned in a lateral decubitus position with the right arm hyper-abducted for approximately 6 h. Magnetic resonance imaging and ultrasound revealed subclavius muscle injury or myositis with brachial plexus (BP) compression and related neuropathy. An electrodiagnostic study confirmed the presence of BP injury involving the whole-division level, long thoracic, and suprascapular nerve injuries. He was treated with medication, physical therapy, and ultrasound-guided injections. Ultrasound-guided steroid injection at the BP, hydrodissection with 5% dextrose water at the BP and suprascapular nerve, and intra-articular steroid and hyaluronidase injection at the glenohumeral joint were performed. On postoperative day 194, the pain and arm weakness were resolved, and a follow-up electrodiagnostic study showed marked improvement. CONCLUSION: Clinicians should consider the possibilities of multiple nerve injuries in patients with joint contracture, and treat each specific therapeutic target.

Aggravation of dysphagia after surgical removal of anterior cervical osteophytes: a case report.

Dysphagia induced by anterior cervical osteophytes (ACOs) is frequently reported in older individuals. Surgical resection of ACOs is considered when conservative treatment fails, but its effectiveness is controversial owing to side effects after surgery. We present the case of a 78-year-old man who complained of progressive dysphagia that started 10 months previously. A videofluoroscopic swallow study (VFSS) showed prominent ACOs along C2-C6, which translocated the upper hypopharynx anteriorly, impinging the lumen and impairing epiglottic folding and laryngeal closure. Aspiration of a soft diet was observed. Despite conservative therapy, the symptoms persisted, and ACO resection surgery was performed. Unexpectedly, the patient's dysphagia worsened immediately post-surgery. A VFSS on postoperative day (POD) 2 showed improvement in epiglottic folding. However, prevertebral soft tissue swelling and dysfunction of opening of the upper esophageal sphincter newly arose. Laryngeal aspiration was observed during 5 cc and a large amount of liquid swallowing trials. The patient was provided a modified diet and rehabilitative dysphagia therapy. A VFSS on PODs 6 and 14 showed a gradual improvement in the prevertebral soft tissue swelling. This report suggests that a serial VFSS is effective for evaluating the different mechanisms of dysphagia and for devising an appropriate treatment plan.

Bilateral multifocal muscular hemorrhage in the triceps surae during antiplatelet therapy: a case report.

Hemorrhagic complications are often reported following antiplatelet therapy; however, simultaneous multifocal hemorrhages in both legs are uncommon. The patient was a 75-year-old man diagnosed with ST elevation myocardial infarction who underwent percutaneous coronary intervention in the right coronary artery. He was prescribed oral acetylsalicylic acid and ticagrelor. Three days after initial drug treatment, he complained of bilateral leg pain that was aggravated by walking and moving his ankle across a broad range of motion. No deep vein thrombosis was detected on Doppler ultrasonography; however, muscular hemorrhage was suspected according to musculoskeletal ultrasonography. Multifocal muscular hemorrhage was confirmed in the soleus and gastrocnemius muscles on magnetic resonance imaging. To reduce the risk of bleeding, we changed the medication from ticagrelor to clopidogrel. The patient performed leg elevation exercises, compression, and applied an ice pack. He also performed range of motion exercises and gait training in addition to receiving drug treatment. With these therapies, his pain score improved from 5 to 3 on a visual analog scale, without further complications. Multifocal muscular hemorrhage rarely occurs bilaterally; however, when it does occur, an appropriate treatment plan can be developed based on musculoskeletal ultrasonography.