title: Giant intraspinal pseudomeningoceles cause delayed neurological dysfunction after brachial plexus injury: report of three cases.
abstract: OBJECTIVE
  Delayed neurological dysfunction after a brachial plexus injury is uncommon. We present the cases of three patients with a history of significant brachial plexus trauma and late neurological deterioration secondary to giant intraspinal extradural pseudomeningoceles.
  
  
  METHODS
  Three patients, each with a remote history of brachial plexus trauma, presented with slowly progressive upper-limb weakness. An examination revealed bilateral lower motor neuron weakness in the upper extremities in all patients and evidence of spastic paraparesis in one. Magnetic resonance imaging and postmyelogram computed tomographic scans demonstrated large anterior extradural cerebrospinal fluid collections extending from the upper cervical to lower thoracic and lumbar levels in each patient. Myelograms demonstrated a connection with the subarachnoid space in two patients.
  
  
  METHODS
  Direct obliteration of the connection between the cyst and the subarachnoid space was completed in two patients, and a cystoperitoneal shunt was placed in the third. Postoperative imaging demonstrated complete resolution of the extradural collections. Arrest of progression of upper-limb deterioration was observed in all patients, and dramatic improvement of long tract symptoms occurred in one.
  
  
  CONCLUSIONS
  Giant intraspinal pseudomeningoceles are a rare complication of brachial plexus root injuries or avulsion, capable of causing significant morbidity. Early intervention can improve symptoms related to long tract involvement and prevent further deterioration of lower motor neuron disease. The pathophysiology of neurological dysfunction caused by these giant collections is unclear; however, vascular and mechanical factors thought to be important in the pathogenesis of cervical myelopathy also may have a role.
authors.affiliation: Department of Surgery, University of British Columbia, Vancouver, Canada.
authors.forename: W J
authors.initials: WJ
authors.lastname: Hader
authors.forename: D
authors.initials: D
authors.lastname: Fairholm
mesh_terms: D000328:Adult; D001132:Arm / Q000294:innervation*; D001917:Brachial Plexus / Q000293:injuries*; D003952:Diagnostic Imaging; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008588:Meningocele / Q000175:diagnosis* / Q000601:surgery; D008875:Middle Aged; D016472:Motor Neuron Disease / Q000175:diagnosis* / Q000601:surgery; D009460:Neurologic Examination; D020336:Paraparesis, Spastic / Q000175:diagnosis* / Q000601:surgery; D011183:Postoperative Complications / Q000175:diagnosis; D013116:Spinal Cord / Q000473:pathology