Lipomas as an Extremely Rare Cause for Brachial Plexus Compression: A Case Series and Systematic Review

The Utility of Intraoperative Neuromonitoring in Pediatric Surgical Oncology

BACKGROUND

Intraoperative nerve monitoring (IONM) is a technique used to decrease the possibility of nerve-associated morbidity and damage to nearby neural structures during complex surgical procedures. The use and potential benefits of IONM in pediatric surgical oncology are not well-described.

METHODS

An overview of the current literature was performed to elucidate the various techniques that may be useful to pediatric surgeons for resection of solid tumors in children.

RESULTS

The physiology and common types of IONM relevant to the pediatric surgeon are described. Important anesthetic considerations are reviewed. Specific applications for IONM that may be useful in pediatric surgical oncology are then summarized, including its use for monitoring the recurrent laryngeal nerve, the facial nerve, the brachial plexus, spinal nerves, and lower extremity nerves. Troubleshooting techniques regarding common pitfalls are then proposed.

CONCLUSION

IONM is a technique that may be beneficial in pediatric surgical oncology to minimize nerve injury during extensive tumor resections. This review aimed to elucidate the various techniques available. IONM should be considered as an adjunct for the safe resection of solid tumors in children in the proper setting with the appropriate level of expertise. A multidisciplinary approach is advised. Additional studies are necessary to further clarify the optimal use and outcomes in this patient population.

LEVELS OF EVIDENCE

Level III.

Upper extremity mass with lipomatous axillary involvement and multiple level encasement of the brachial plexus

A 40-year-old female presented for surgical consultation of an upper extremity soft tissue mass. Initial ultrasound report recorded a 5.5 cm mass, consistent with a subcutaneous lipoma. Intra-operative visualization revealed an intramuscular lipoma emerging from brachialis muscle. Post-excision MRI was ordered for continued axillary fullness which revealed lipomatous extension into axilla and posterior arm with multiple level encasement of the brachial plexus. Lipomas with brachial plexus involvement are rare and can present with a range of symptoms and distortion of local anatomy. Surgical debulking is challenging requiring microsurgical expertise for adequate removal and to minimize long-term neurological deficits.