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Posttraumatic Cervical Nerve Root Avulsion with Epidural Hematoma
Accepted Manuscript Post Traumatic Cervical Nerve Root Avulsion with Epidural Hematoma William C. Newman, MD, Zachary J. Tempel, MD, Elizabeth C. Tyler-Kabara, MD, PhD PII:
S1878-8750(15)00798-6
DOI:
10.1016/j.wneu.2015.06.050
Reference:
WNEU 3002
To appear in:
World Neurosurgery
Received Date: 27 February 2015 Revised Date:
23 June 2015
Accepted Date: 23 June 2015
Please cite this article as: Newman WC, Tempel ZJ, Tyler-Kabara EC, Post Traumatic Cervical Nerve Root Avulsion with Epidural Hematoma, World Neurosurgery (2015), doi: 10.1016/j.wneu.2015.06.050. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Title: Post Traumatic Cervical Nerve Root Avulsion with Epidural Hematoma William C. Newman, MDa Zachary J. Tempel, MDa
RI PT
Elizabeth C. Tyler-Kabara, MD, PhDb
a. Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
Pennsylvania, USA
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Correspondence: William C. Newman, MD
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b. Children’s Hospital of Pittsburgh, Division of Pediatric Neurosurgery, Pittsburgh,
200 Lothrop Street, Suite B-400. Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15217. Phone: 412-647-6777 Fax: 412-692-5921
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E-mail: [email protected]
Running Title: Traumatic Cervical Root Avulsion with Epidural Hematoma Abbreviations: CSF (Cerebrospinal Fluid), CT (Computed Tomography), GCS
Collision)
EP
(Glasgow Coma Scale), MRI (Magnetic Resonance Imaging), MVC (Motor Vehicle
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Word Count: 112 (Title Page); 1359 (Entire Manuscript)
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Abstract
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Background Cervical nerve root avulsion after trauma is a well-known occurrence. It is associated with traction injuries to the brachial plexus, commonly after high-speed motor vehicle collisions (MVCs). Traumatic nerve root avulsion occurs when traction forces pull the nerve root sleeve into the intervertebral foramen with associated tearing of the meninges. The proximal nerve root retracts, and the neural foramen fills with cerebrospinal fluid and eventually forms a pseudomeningocele. While imaging characteristics often include nerve root edema and pseudomeningoceles, there has only been one description of associated epidural hematoma in the literature.
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Case Description 3 year-old female restrained passenger in rear car seat presented to the Emergency Department after high-speed MVC. The patient was found lying unconscious on the floor of the front passenger side. On arrival, she was flaccid with absent sensation in her left upper extremity, 3/5 strength in her right upper extremity, and full strength in her lower extremities. CT cervical spine was negative for acute fractures. MRI cervical spine demonstrated a noncompressive epidural hematoma from C5-T10 and MRI brachial plexus demonstrated diffuse left cervical nerve root edema and C5-T1 nerve root avulsion with pseudomeningoceles, which were not seen on the MRI cervical spine. The patient was managed conservatively for her brachial plexus injury.
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Conclusions Although pseudomeningocele formation after cervical nerve root avulsion is commonly cited, associated epidural hematomas are not well described. It is important to consider this etiology in patients with asymmetric examinations and epidural hematomas prior to surgical evacuation.
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Key Words: Cervical Spine, Epidural Hematoma, Nerve Root Avulsion, Pediatrics, Trauma
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Background Cervical nerve root avulsion after trauma is a well-known occurrence with a prevalence of 0.1%.1 It is associated with traction injuries to the brachial plexus, commonly after high-speed motor vehicle collisions (MVCs). Traumatic nerve root avulsion occurs when traction forces pull the nerve root sleeve into the intervertebral foramen with associated tearing of the meninges.2 The proximal nerve root retracts, and the neural foramen fills with cerebrospinal fluid (CSF) and eventually forms a pseudomeningocele. While imaging characteristics often include nerve root edema and pseudomeningoceles, there are few case reports of associated epidural hematomas and none in the pediatric literature. Arriving at the diagnosis of epidural hematoma caused by brachial plexus injury as opposed to isolated epidural hematoma is important as the short and long term management of each is different. Symptomatic epidural hematomas are managed with emergent decompression. Brachial plexus injuries, however, are often managed with aggressive physical therapy, delayed neurophysiologic testing, and possible surgical intervention depending on the patient’s functional gains during the observational period. The reason for delayed intervention in these patients is the possibility of spontaneous improvement in patients with neurapraxia or axonotmesis due to incomplete injury to the nerve that allows for regeneration. Conversely, observation does not negatively impact the outcome of those patients with neurotmesis where spontaneous recovery is not possible.
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Case Description 3 year-old female restrained passenger in a rear car seat presented to the Emergency Department after high-speed MVC. The car seat was found turned over in the front seat. She was intubated for altered mental status with negative CT of the Head and transferred to Children’s Hospital of Pittsburgh. On arrival, she had a GCS 10T. After extubation, physical examination revealed pupils that were equally round and reactive to light, a flaccid left upper extremity, and a right upper extremity with 3/5 strength in the deltoid, wrist extensors, and intrinsic hand muscles. She maintained her elbows in flexion due to bilateral fractures. She was full strength in her lower extremities. CT Cervical spine was negative for acute fractures. MRI Cervical spine demonstrated ligamentous injury and noncompressive epidural hematoma from C5T10 (Figure 1) and MRI brachial plexus demonstrated diffuse nerve root edema with possible nerve root avulsions versus extraforaminal rupture proximally at C5 and C6 and distally at C7 and T1 (Figure 2). The epidural hematoma was deemed asymptomatic given the patient’s intact lower extremity exam. Her brachial plexus injury accounted for her left arm flaccidity. She was managed conservatively for her noncompressive epidural hematoma with close observation in an intensive care unit. During her hospitalization, she had improvement in her right arm strength to full strength, her lower extremities remained full strength, and her left arm remained flaccid and insensate. Her brachial plexus injury was managed conservatively with aggressive physical therapy.
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At her 6 week follow up, the patient continued to be flaccid and insensate in her left upper extremity, findings consistent with complete nerve root avulsion or extraforaminal rupture with failed spontaneous recovery. At this point, the family declined an eletromyogram and pursued surgical intervention at a different medical facility.
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Discussion Brachial plexus injuries with associated nerve root avulsions or extraforaminal rupture are known sequelae of upper extremity traction injuries. However, the literature makes very little reference to associated epidural hematomas and their management, especially in pediatric patients. Following nerve root avulsion or rupture, tearing of the meninges from nerve root retraction causes CSF leakage and the formation of pseudomeningoceles. The trauma also can cause bleeding and associated epidural hematoma formation.3 Zubair et al. reported on a pair of adult patients with Brown-Sequard syndrome secondary to a compressive epidural hematoma after brachial plexus avulsion injuries.4 In their case report, both patients had acute neurologic declines with compressive epidural lesions seen on MRI. They were treated with emergent laminectomies for decompression and evacuation of hematoma with improvement in neurologic function. In our patient, the epidural hematoma was noncompressive and inconsistent with the patient’s clinical examination. Because the patient was clinically asymptomatic from the epidural hematoma, clinical observation was pursued without adverse consequence. Were the lesion to become symptomatic, emergent decompression would have been undertaken. While the finding of an epidural hematoma associated with nerve root avulsions in adults has been demonstrated in the literature, our case report demonstrates several unique points. First, our case demonstrates the need for consideration of brachial plexus injuries in patients with asymmetric examinations, epidural hematomas, and appropriate traumatic mechanisms. Second, our case demonstrates the role of nonoperative management for these clinically asymptomatic epidural hematomas with close serial examinations in an intensive care unit. Third, our case highlights the need for a detailed pediatric examination to guide decision making; however, this is often made difficult by patient age and their ability to participate consistently, making diagnosis and conservative management more difficult. The importance of recognizing epidural hematomas associated with nerve root avulsions stems from its ability to change clinical management. Our case report demonstrates the importance of considering brachial plexus injuries as the etiology of asymmetric weakness following trauma as this diagnosis alters short and longterm management. Conclusions Although pseudomeningocele formation after cervical nerve root avulsion is commonly cited, associated epidural hematomas are not well described. It is important to consider this etiology for epidural hematomas in patients with non-
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penetrating spine trauma and asymmetric examinations prior to surgical evacuation. Citations
RI PT
1. Dorsey MJ, Hsu W, Belzberg AJ. Epidemiology of brachial plexus injury in the pediatric multitrauma population in the United States. J Neurosurg. 2010;5:573-77. 2. Finney LA, Wulfman WA. Traumatic intradural lumbar nerve root avulsion with
SC
associated traction injury to the common peroneal nerve. AJR Am J Roentgenol 1960;84:952–57
M AN U
3. Kaiser MC, Capesius P, Ohanna F, Roilgen A. Computed tomography of acute spinal epidural hematoma associated with cervical root avulsion. J Comput Assist Tomogr 1984;8(2):322-3.
4. Zubair M, Ravindran T, Chan CYW, Saw LB, Kwan MK. Acute Brown-Sequard
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syndrome following brachial plexus avulsion injury. A report of two cases. Hong
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EP
Kong Journal of Emergency Medicine 2011;18:347-351.
ACCEPTED MANUSCRIPT
RI PT
Figure 1: Sagittal (A) and axial (C) T1 and sagittal (B) T2 weighted MRI Cervical Spine without contrast demonstrating noncompressive epidural hematoma (arrows) extending from C5 to the upper thoracic spine. Also seen is prevertebral fluid edema extending from the odontoid tip down to C3 with anterior displacement of the anterior longitudinal ligament.
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Figure 2: Left MRI Brachial Plexus 3D reconstruction demonstrating proximal nerve root avulsions at C6 and C7 and distally at T1 (arrows).
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Case of pediatric patient with brachial plexus avulsion and epidural hematoma Imaging findings in brachial plexus avulsion Role for conservative management of epidural hematoma Role of delayed surgical intervention for brachial plexus injury
S1878-8750(15)00798-6
DOI:
10.1016/j.wneu.2015.06.050
Reference:
WNEU 3002
To appear in:
World Neurosurgery
Received Date: 27 February 2015 Revised Date:
23 June 2015
Accepted Date: 23 June 2015
Please cite this article as: Newman WC, Tempel ZJ, Tyler-Kabara EC, Post Traumatic Cervical Nerve Root Avulsion with Epidural Hematoma, World Neurosurgery (2015), doi: 10.1016/j.wneu.2015.06.050. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Title: Post Traumatic Cervical Nerve Root Avulsion with Epidural Hematoma William C. Newman, MDa Zachary J. Tempel, MDa
RI PT
Elizabeth C. Tyler-Kabara, MD, PhDb
a. Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
Pennsylvania, USA
M AN U
Correspondence: William C. Newman, MD
SC
b. Children’s Hospital of Pittsburgh, Division of Pediatric Neurosurgery, Pittsburgh,
200 Lothrop Street, Suite B-400. Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15217. Phone: 412-647-6777 Fax: 412-692-5921
TE D
E-mail: [email protected]
Running Title: Traumatic Cervical Root Avulsion with Epidural Hematoma Abbreviations: CSF (Cerebrospinal Fluid), CT (Computed Tomography), GCS
Collision)
EP
(Glasgow Coma Scale), MRI (Magnetic Resonance Imaging), MVC (Motor Vehicle
AC C
Word Count: 112 (Title Page); 1359 (Entire Manuscript)
ACCEPTED MANUSCRIPT
Abstract
SC
RI PT
Background Cervical nerve root avulsion after trauma is a well-known occurrence. It is associated with traction injuries to the brachial plexus, commonly after high-speed motor vehicle collisions (MVCs). Traumatic nerve root avulsion occurs when traction forces pull the nerve root sleeve into the intervertebral foramen with associated tearing of the meninges. The proximal nerve root retracts, and the neural foramen fills with cerebrospinal fluid and eventually forms a pseudomeningocele. While imaging characteristics often include nerve root edema and pseudomeningoceles, there has only been one description of associated epidural hematoma in the literature.
TE D
M AN U
Case Description 3 year-old female restrained passenger in rear car seat presented to the Emergency Department after high-speed MVC. The patient was found lying unconscious on the floor of the front passenger side. On arrival, she was flaccid with absent sensation in her left upper extremity, 3/5 strength in her right upper extremity, and full strength in her lower extremities. CT cervical spine was negative for acute fractures. MRI cervical spine demonstrated a noncompressive epidural hematoma from C5-T10 and MRI brachial plexus demonstrated diffuse left cervical nerve root edema and C5-T1 nerve root avulsion with pseudomeningoceles, which were not seen on the MRI cervical spine. The patient was managed conservatively for her brachial plexus injury.
EP
Conclusions Although pseudomeningocele formation after cervical nerve root avulsion is commonly cited, associated epidural hematomas are not well described. It is important to consider this etiology in patients with asymmetric examinations and epidural hematomas prior to surgical evacuation.
AC C
Key Words: Cervical Spine, Epidural Hematoma, Nerve Root Avulsion, Pediatrics, Trauma
ACCEPTED MANUSCRIPT
M AN U
SC
RI PT
Background Cervical nerve root avulsion after trauma is a well-known occurrence with a prevalence of 0.1%.1 It is associated with traction injuries to the brachial plexus, commonly after high-speed motor vehicle collisions (MVCs). Traumatic nerve root avulsion occurs when traction forces pull the nerve root sleeve into the intervertebral foramen with associated tearing of the meninges.2 The proximal nerve root retracts, and the neural foramen fills with cerebrospinal fluid (CSF) and eventually forms a pseudomeningocele. While imaging characteristics often include nerve root edema and pseudomeningoceles, there are few case reports of associated epidural hematomas and none in the pediatric literature. Arriving at the diagnosis of epidural hematoma caused by brachial plexus injury as opposed to isolated epidural hematoma is important as the short and long term management of each is different. Symptomatic epidural hematomas are managed with emergent decompression. Brachial plexus injuries, however, are often managed with aggressive physical therapy, delayed neurophysiologic testing, and possible surgical intervention depending on the patient’s functional gains during the observational period. The reason for delayed intervention in these patients is the possibility of spontaneous improvement in patients with neurapraxia or axonotmesis due to incomplete injury to the nerve that allows for regeneration. Conversely, observation does not negatively impact the outcome of those patients with neurotmesis where spontaneous recovery is not possible.
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EP
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Case Description 3 year-old female restrained passenger in a rear car seat presented to the Emergency Department after high-speed MVC. The car seat was found turned over in the front seat. She was intubated for altered mental status with negative CT of the Head and transferred to Children’s Hospital of Pittsburgh. On arrival, she had a GCS 10T. After extubation, physical examination revealed pupils that were equally round and reactive to light, a flaccid left upper extremity, and a right upper extremity with 3/5 strength in the deltoid, wrist extensors, and intrinsic hand muscles. She maintained her elbows in flexion due to bilateral fractures. She was full strength in her lower extremities. CT Cervical spine was negative for acute fractures. MRI Cervical spine demonstrated ligamentous injury and noncompressive epidural hematoma from C5T10 (Figure 1) and MRI brachial plexus demonstrated diffuse nerve root edema with possible nerve root avulsions versus extraforaminal rupture proximally at C5 and C6 and distally at C7 and T1 (Figure 2). The epidural hematoma was deemed asymptomatic given the patient’s intact lower extremity exam. Her brachial plexus injury accounted for her left arm flaccidity. She was managed conservatively for her noncompressive epidural hematoma with close observation in an intensive care unit. During her hospitalization, she had improvement in her right arm strength to full strength, her lower extremities remained full strength, and her left arm remained flaccid and insensate. Her brachial plexus injury was managed conservatively with aggressive physical therapy.
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At her 6 week follow up, the patient continued to be flaccid and insensate in her left upper extremity, findings consistent with complete nerve root avulsion or extraforaminal rupture with failed spontaneous recovery. At this point, the family declined an eletromyogram and pursued surgical intervention at a different medical facility.
AC C
EP
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M AN U
SC
RI PT
Discussion Brachial plexus injuries with associated nerve root avulsions or extraforaminal rupture are known sequelae of upper extremity traction injuries. However, the literature makes very little reference to associated epidural hematomas and their management, especially in pediatric patients. Following nerve root avulsion or rupture, tearing of the meninges from nerve root retraction causes CSF leakage and the formation of pseudomeningoceles. The trauma also can cause bleeding and associated epidural hematoma formation.3 Zubair et al. reported on a pair of adult patients with Brown-Sequard syndrome secondary to a compressive epidural hematoma after brachial plexus avulsion injuries.4 In their case report, both patients had acute neurologic declines with compressive epidural lesions seen on MRI. They were treated with emergent laminectomies for decompression and evacuation of hematoma with improvement in neurologic function. In our patient, the epidural hematoma was noncompressive and inconsistent with the patient’s clinical examination. Because the patient was clinically asymptomatic from the epidural hematoma, clinical observation was pursued without adverse consequence. Were the lesion to become symptomatic, emergent decompression would have been undertaken. While the finding of an epidural hematoma associated with nerve root avulsions in adults has been demonstrated in the literature, our case report demonstrates several unique points. First, our case demonstrates the need for consideration of brachial plexus injuries in patients with asymmetric examinations, epidural hematomas, and appropriate traumatic mechanisms. Second, our case demonstrates the role of nonoperative management for these clinically asymptomatic epidural hematomas with close serial examinations in an intensive care unit. Third, our case highlights the need for a detailed pediatric examination to guide decision making; however, this is often made difficult by patient age and their ability to participate consistently, making diagnosis and conservative management more difficult. The importance of recognizing epidural hematomas associated with nerve root avulsions stems from its ability to change clinical management. Our case report demonstrates the importance of considering brachial plexus injuries as the etiology of asymmetric weakness following trauma as this diagnosis alters short and longterm management. Conclusions Although pseudomeningocele formation after cervical nerve root avulsion is commonly cited, associated epidural hematomas are not well described. It is important to consider this etiology for epidural hematomas in patients with non-
ACCEPTED MANUSCRIPT
penetrating spine trauma and asymmetric examinations prior to surgical evacuation. Citations
RI PT
1. Dorsey MJ, Hsu W, Belzberg AJ. Epidemiology of brachial plexus injury in the pediatric multitrauma population in the United States. J Neurosurg. 2010;5:573-77. 2. Finney LA, Wulfman WA. Traumatic intradural lumbar nerve root avulsion with
SC
associated traction injury to the common peroneal nerve. AJR Am J Roentgenol 1960;84:952–57
M AN U
3. Kaiser MC, Capesius P, Ohanna F, Roilgen A. Computed tomography of acute spinal epidural hematoma associated with cervical root avulsion. J Comput Assist Tomogr 1984;8(2):322-3.
4. Zubair M, Ravindran T, Chan CYW, Saw LB, Kwan MK. Acute Brown-Sequard
TE D
syndrome following brachial plexus avulsion injury. A report of two cases. Hong
AC C
EP
Kong Journal of Emergency Medicine 2011;18:347-351.
ACCEPTED MANUSCRIPT
RI PT
Figure 1: Sagittal (A) and axial (C) T1 and sagittal (B) T2 weighted MRI Cervical Spine without contrast demonstrating noncompressive epidural hematoma (arrows) extending from C5 to the upper thoracic spine. Also seen is prevertebral fluid edema extending from the odontoid tip down to C3 with anterior displacement of the anterior longitudinal ligament.
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EP
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M AN U
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Figure 2: Left MRI Brachial Plexus 3D reconstruction demonstrating proximal nerve root avulsions at C6 and C7 and distally at T1 (arrows).
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Case of pediatric patient with brachial plexus avulsion and epidural hematoma Imaging findings in brachial plexus avulsion Role for conservative management of epidural hematoma Role of delayed surgical intervention for brachial plexus injury