Brachial plexopathy due to massive swelling of the neck associated with craniotomy in the park bench position

BackgroundDuring prolonged neurosurgical procedures, anesthetized patients are at risk for position-related complications. We report a rare combination of neck swelling and brachial plexopathy as operative position-related complications.Case DescriptionThis 56-year-old woman was placed in the left park bench position for removal of a tentorial meningioma in the right posterior fossa. At 2 hours after the 10-hour procedure, her left neck began to swell with progression during the next 10 hours to involve the face on the same side and the face and neck on the opposite side. Computed tomography showed swelling of the muscles and deep soft tissue primarily on the left. No brain edema was observed. She was conservatively treated with orotracheal intubation, placed in the head-up position, and received anticoagulants. Her swelling subsided by the 20th postoperative day; however, she manifested weakness in the proximal muscles of the left upper extremity. Magnetic resonance imaging revealed swelling of the brachial plexus on the left; electrophysiologic studies were compatible with damage to the upper trunk of the brachial plexus. She was discharged 2 months after surgery with improved weakness.ConclusionPossible pathologic mechanisms are kinking of the jugular vein due to extremely flexed neck position during surgery and associated delayed swelling of the neck and brachial plexus. The cerebral venous return may have been maintained by anastomosis between the internal jugular and the vertebral venous system. To prevent such complications, we must take great care of the anesthetized patients when placed in the forced neck position.