Case ReportPosttraumatic Cervical Nerve Root Avulsion with Epidural Hematoma
Introduction
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. 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 and eventually forms a pseudomeningocele. Although 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, because the short- and long-term management of each is different. Symptomatic epidural hematomas are managed with emergent decompression. Brachial plexus injuries, however, often are 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 as the result of 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.
Section snippets
Case Description
A 3-year-old girl restrained in a passenger-side rear car seat presented to the emergency department after high-speed motor vehicle collision. The car seat was found turned over in the front seat. She was intubated for altered mental status with negative computed tomography of the head and transferred to Children's Hospital of Pittsburgh. On arrival, she had a Glasgow Coma Scale score 10T. After extubation, physical examination revealed pupils that were equally round and reactive to light, a
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.
After nerve root avulsion or rupture, tearing of the meninges from nerve root retraction causes cerebrospinal fluid leakage and the formation of pseudomeningoceles. The trauma also can cause bleeding and associated
Conclusion
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 nonpenetrating spine trauma and asymmetric examinations before surgical evacuation.
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Traumatic intradural lumbar nerve root avulsion with associated traction injury to the common peroneal nerve
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Cited by (4)
Pediatric spine trauma: A comprehensive review
2022, Clinical ImagingCitation Excerpt :Therefore, patients demonstrating neurological deficits in context of negative CT or radiographs should undergo MRI for evaluation of soft tissue injury within 72 h, otherwise, the resorption of hemorrhage and/or edema reduces the sensitivity of the exam.74,76 Tearing of the nerve root and surrounding meninges can occur secondary to traction injury.77,78 Brachial plexus injuries account for 0.1% of all pediatric polytrauma patients, most commonly due to motor vehicle accidents.79
A pentavalent approach for the evaluation of traumatic brachial plexopathy on MRI: Correlation of macropattern and micropattern
2023, British Journal of RadiologyAn Unusual Case of Traumatic Cervical Epidural Hematoma in an Infant
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2018, American Journal of Roentgenology
Conflict of interest statement: The author declares that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.