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Case Reports
. 2007 Mar 19:2:7.
doi: 10.1186/1749-7221-2-7.

T1-nerve root neuroma presenting with apical mass and Horner's syndrome

Roman Bosnjak  1 , Urska Bacovnik, Simon Podnar, Mitja Benedicic
Affiliations
Case Reports

T1-nerve root neuroma presenting with apical mass and Horner's syndrome

Roman Bosnjak et al. J Brachial Plex Peripher Nerve Inj. .

Abstract

Background: The appearance of dumbbell neuroma of the first thoracic root is extremely rare. The extradural component of a T1-dumbbell neuroma may present as an apical mass. The diagnosis of hand weakness is complex and may be delayed in T1-neuroma because of absence of the palpable cervical mass. One-stage removal of a T1-root neuroma and its intrathoracic extension demanded an extended posterior midline approach in the sitting position.

Case presentation: A 51-year old man had suffered a traumatic partial tendon rupture of his wrist flexor muscles 6 years ago. Since the incident he occasionally felt fullness and tenderness in the affected forearm with some tingling in his fingers bilaterally. During the last two years the hand weakness was continuous and hypotrophy of the medial flexor and intrinsic hand muscles had become apparent. Electrophysiological studies revealed an ulnar neuropathy in addition to mild median and radial nerve dysfunction, including a mild contralateral carpal tunnel syndrome. The diagnostic work-up for multiple mononeuropathy in the upper extremity was negative. Repeated electrophysiological studies revealed fibrillations in the C7 paravertebral muscles on the affected side. Chest x-ray revealed a large round apical mass on the affected side. A Horner's syndrome was noted at this point of diagnostic work-up. MRI of the cervical and thoracic spine revealed a dumbbell T1 neuroma enlarging the intervertebral foramen at T1-2 and a 5 cm large extradural tumor with extension into the apex of the ipsilateral lung. The patient underwent surgery in sitting position using a left dorsal midline approach. Although the T1 root could not be preserved, the patient's neurological condition was unchanged after the surgery.

Conclusion: Extended posterior midline exposure described here using hemilaminectomy, unilateral facetectomy and costo-transversectomy is efficient and safe for one-stage removal of dumbbell tumors at the T1 level with a predominantly extraforaminal component in the apex of the lung extending up to 6-7 cm laterally. Horner's syndrome, if present and observed, may significantly narrow the differential diagnosis of hand weakness caused by T1-root tumors.

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Figures

Figure 1
Figure 1
Pre-operative chest X-ray demonstrating a round shadow of approx. 5 cm in diameter in the left pulmonary apex.
Figure 2
Figure 2
Left sided miosis due to T1 lesion – incomplete Horner's syndrome.
Figure 3
Figure 3
Coronal section of T1 weighted MRI demonstrating the left pulmonary apex tumor with extension into T1-2 intervertebral foramen.
Figure 4
Figure 4
Transverse section of T1 weighted MRI demonstrating protrusion of the tumor from the left T1-2 intervertebral foramen to the spinal cord.
Figure 5
Figure 5
A single curvilinear paramedian incision in the sitting position of the patient allowed for posterior midline approach and dorsal subscapular approach under the same skin flap if necessary.
Figure 6
Figure 6
Post-operative chest X-ray demonstrating removal of the T2 and T3 transverse processes, and proximal parts of the second and third ribs.
Figure 7
Figure 7
Coronal section of T1 weighted MRI demonstrating complete removal of the left-sided T1-neuroma from the T1-2 intervertebral foramen and from the pulmonary apex.
Figure 8
Figure 8
Transverse section of T2 weighted MRI demonstrating complete removal of the neuroma from the left T1-2 intervertebral foramen and the spinal canal.
See this image and copyright information in PMC

References

    1. Binder DK, Smith JS, Barbaro NM. Primary brachial plexus tumors: imaging, surgical, and pathological findings in 25 patients. Neurosurg Focus. 2004;2(5):E11. - PubMed
    1. Donner TR, Voorhies RM, Kline DG. Neural sheath tumors of major nerves. J Neurosurg. 1994;2(3):362–373. - PubMed
    1. Lusk MD, Kline DG, Garcia CA. Tumors of the brachial plexus. Neurosurgery. 1987;2(4):439–453. doi: 10.1097/00006123-198710000-00001. - DOI - PubMed
    1. Lot G, George B. Cervical neuromas with extradural components: surgical management in a series of 57 patients. Neurosurgery. 1997;2(4):813–20; discussion 820-2. doi: 10.1097/00006123-199710000-00010. - DOI - PubMed
    1. Morgan CJ, Lyons J, Ling BC, Maher PC, Bohinski RJ, Keller JT, Howington JA, Kuntz C. Video-assisted thoracoscopic dissection of the brachial plexus: cadaveric study and illustrative case. Neurosurgery. 2006;2(4 Suppl 2):ONS–287-90; discussion ONS-290-1. doi: 10.1227/01.NEU.0000204657.56274.86. - DOI - PubMed

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