Disclosures: Alexander S. Robitaille, DO: No financial relationships or conflicts of interest

Case Description: Patient presented with 2-year history of pain and weakness in her left shoulder. Initial symptom was pain with arm, shoulder, and neck movements. She developed weakness and atrophy in her shoulder and biceps. Additionally, she complained of numbness radiating to her left thumb. Prior work up included multiple electrodiagnostic (EMG) and MRI studies. EMG revealed a C5-6 radiculopathy and carpal tunnel syndrome. Subsequent carpal tunnel surgery minimally improved her hand symptoms. MRI of the shoulder revealed a rotator cuff tear and atrophy of the deltoid. Rotator cuff surgery was not helpful. Further imaging of cervical and brachial plexus revealed only spondylosis in cervical spine. Repeat EMG was concerning for a brachial plexus lesion, however considering lack of imaging findings she was recommended surgery for thoracic outlet syndrome. She then presented to our clinic for an additional opinion.

Setting: Tertiary care academic outpatient clinic

Patient: 47 year old female with left shoulder pain and weakness Assessment/

Results: History, exam, and EMG results were concerning for upper brachial plexopathy. Key exam findings included weakness and atrophy of C5 innervated muscles. We requested our radiologist to review her previous cervical spine and brachial plexus MRIs with close attention to the C5 nerve. A 1x1x2.5cm nerve sheath tumor along the C5 nerve root was observed. She was referred for surgical evaluation. Pathology was consistent with a neurofibroma.

Discussion: History and physical exam are essential for determining the location of brachial plexus lesions and guiding physician’s orders and interpretations of clinical data provided by diagnostic testing. Few studies have investigated the inter-reliability of physical examination, electrodiagnostics, and imaging in detecting brachial plexus lesions.

Conclusion: Clinicians need to understand the limitations of diagnostic tests in order to appropriately identify and treat brachial plexopathies. Relating clinical findings and suspected lesion location to radiologists and electrodiagnosticians may improve identification of lesions and prevent unneeded procedures.

Level of Evidence: Level V

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PM&R Meeting Abstracts - https://pmrjabstracts.org/abstract/missed-diagnosis-of-a-brachial-plexus-neurofibroma-a-case-report/