Clavicular window for brachial plexus schwannoma removal

Schwannomas are benign nerve sheath tumors that can either be sporadic or part of neurofibromatosis type 2 (NF2). Tumors of the brachial plexus (BP) with both supra- and infraclavicular components are uncommon and represent a challenge to complete surgical resection. There are few reports on single clavicular osteotomies for BP exposure; however, there are currently no reports of utilization of a clavicular window for a large schwannoma resection.

We report a case of a patient with a schwannoma spanning the BP roots to the cords, with the majority involving the retro clavicular inferior trunk in the setting of NF2. The patient underwent previous subtotal resection and had postoperative enlargement of the residual mass. A gross total resection was made possible by the creation of a clavicular window to expose the BP. A 2 cm segment piece of the mid-clavicle was removed, allowing for roughly 6 cm of mediolateral exposure through clavicular distraction. This clavicular window facilitated complete exposure of the BP schwannoma underneath the clavicle as well as unobstructed exposure of supraclavicular and infraclavicular tumor. The segment was then refixed with a plate after resection of the tumor.

The use of a clavicular window allowed for extensive exposure of the trunks and divisions of the BP to achieve a gross total resection in this case. The clavicular window approach may provide a benefit for optimizing exposure in the setting of lesions involving the trunks and divisions that the clavicle would traditionally obstruct.