SPINAL CORD HERNIATION INTO ASSOCIATED PSEUDOMENINGOCELE AFTER BRACHIAL PLEXUS AVULSION INJURY

Spinal Cord Herniation into a Pseudomeningocele-A Delayed Presentation following a Traumatic Cervical Root Avulsion Injury

Background  Spinal cord herniation into a traumatic pseudomeningocele is a rare clinical entity. We present the sixth known case and describe surgical management. Case Presentation  A 44-year-old male presented with Brown-Sequard syndrome three decades after a cervical nerve root avulsion injury. Imaging revealed hemicord herniation into a C7/T1 pseudomeningocele in addition to extra-axial cord compression from further pseudomeningoceles. Significant clinical improvement was achieved following surgical repair. The radiological findings and technique for operative repair are described. Conclusion  The case highlights this rare pathology and presentation, describes the surgical measures for repair of cord herniation, and provides evidence for the favorable outcome that can be achieved by surgical intervention.

Horner’s syndrome secondary to T1-T2 intervertebral disc prolapse

Background:

T1-T2 intervertebral disc prolapse (IVDP) is a rare clinical condition. Horner’s syndrome is an extremely rare clinical finding in these patients.

Case Description:

A 56-year-old man presented with the left C8 T1 radiculopathy, left hand grip weakness, and ipsilateral Horner’s syndrome. Magnetic resonance imaging of the spine showed a contrast-enhancing lesion in the left T1 foramen compressing the left T1 nerve root. He underwent left T1 hemilaminectomy, upper half of left T2 hemilaminectomy and removal of the left foraminal lesion. A biopsy of the lesion was sent for histopathological diagnosis which revealed tissue consistent with disc material. Postoperatively, he had near-complete recovery with residual minimal Horner’s syndrome.

Conclusion:

T1-T2 IVDP should be considered in the differential diagnosis when a patient presents with C8 T1 radiculopathy and Horner’s syndrome.

Radiological data of brachial plexus avulsion injury associated spinal cord herniation (BPAI-SCH) and comparison to anterior thoracic spinal cord herniation (ATSCH)

Spinal cord herniation (SCH) is a rare cause of myelopathy. When reported, SCH has most commonly been described as occurring spontaneously in the thoracic spine, and being idiopathic in nature (anterior thoracic spinal cord herniation, ATSCH) [1–3]. Several theories have been proposed to explain its occurrence, including congenital, inflammatory, and traumatic etiologies alike [1–4]. Even more rarely, SCH has been described to occur in the cervical spine in association with brachial plexus avulsion injuries (BPAI-SCH). In our accompanying article, “Late Cervical Spinal Cord Herniation Resulting from Post-Traumatic Brachial Plexus Avulsion Injury,” two cases of BPAI-SCH are presented and discussed in the context of the reviewed literature [5]. Here, pertinent accompanying follow-up data was collected and is presented for the cases, including postoperative radiographic outcome imaging. Furthermore, a table is presented comparing and contrasting ATSCH to BPAI-SCH. Although the two phenomena have been previously grouped together, this table highlights ATSCH and BPAI-SCH as distinct entities; more specifically, BPAI-SCH is a separate, long-term complicating feature of BPAI. This supplementary data helps treating physicians by increasing awareness and knowledge of BPAI-SCH as a distinct entity from ATSCH and cause of delayed neurological deterioration.

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Myelopathy due to spinal cord herniation (SCH) is rare.

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Brachial plexus avulsion injury associated SCH (BPAI-SCH) is a unique type of SCH.

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Follow-up data for a case of BPAI-SCH treatment is presented.

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BPAI-SCH is compared and contrasted with more common SCH subtypes.

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BPAI-SCH recognition and treatment is essential for patient improvement.

Late Cervical Spinal Cord Herniation Resulting from Post-Traumatic Brachial Plexus Avulsion Injury

BACKGROUND

Spinal cord herniation (SCH) is often described as occurring spontaneously in the thoracic spine, with few cases of cervical SCH reported as a late complication of traumatic brachial plexus avulsion. We present 2 cases of nerve root avulsion and pseudomeningocele formation, resulting in delayed cervical SCH and neurologic deterioration.

CASE DESCRIPTION

Case 1: A 37-year old man presented with progressive leg weakness 2 years after experiencing traumatic C8 and T1 root avulsions. Magnetic resonance imaging (MRI) showed previously documented C8-T1 nerve avulsions with new SCH in a T1 pseudomeningocele. A C7-T1 costotransversectomy and C4-T4 instrumented fusion were completed, allowing SCH reduction and patch graft repair of the dural defects without the need for adhesiolysis. At last follow-up, the patient's leg weakness had resolved. Case 2: A 32-year old man presented with progressive right arm numbness, weakness, and signs of myelopathy 9 years after experiencing C8 and T1 root avulsions. MRI showed previously documented root avulsions and new SCH with extensive and compressive pseudomeningocele formation. A C7 transpedicular approach with C5-T1 instrumented fusion was completed for dural repair. A large pseudomeningocele was found and drained on drilling the C7 pedicle, and adhesiolysis was required at the spinal cord avulsion site to reduce the SCH and allow patch graft repair. At last follow-up, the patient's right arm weakness was improving, although numbness persisted.

CONCLUSIONS

SCH is a rare cause of delayed neurologic deterioration after brachial plexus avulsion, with few case reports describing its occurrence. We present 2 cases of this complication and describe its successful surgical treatment through dural repair after instrumented fusion.

Challenges of Managing Patients with Symptomatic Large Traumatic Cervical Pseudomeningoceles

BACKGROUND

Traumatic cervical pseudomeningoceles (TCPs) occur secondary to traction of the cervical nerve roots resulting in violation of the dura. Surgical repair is not necessary in most cases because pseudomeningoceles have a high propensity to spontaneously resolve with conservative management alone. Currently, there are a limited number of cases of large TCPs (large is defined as ≥6 cm in greatest diameter), and there is no established guideline for the management of such lesions.

CASE DESCRIPTION

We describe the cases of 2 young men in their 20s who were involved in a motor vehicle accident. Both patients suffered a brachial plexus injury and developed large TCPs. Patient 1 was treated surgically for TCP using a combined intra-/extradural approach using a fascia lata graft. Patient 2 was ultimately treated nonsurgically because a spontaneous resolution of the pseudomeningocele was achieved over the period of 7 months after the accident. Both patients underwent brachial plexus repair surgery consisting of spinal accessory nerve transfer to the suprascapular nerve and intercostal nerve transfer to the musculocutaneous nerve.

CONCLUSIONS

Disease progression of TCPs is a dynamic process, and even large lesions may spontaneously resolve without surgical intervention. When surgery is indicated, a definitive dural repair using a fascia lata graft to cover the dural tear intra- and extradurally is an effective method. Surgery must be planned carefully on a case-by-case basis, and close follow-up with thorough physical examination and serial imaging is critical to monitor disease progression.

Spinal cord herniation after brachial plexus injury

Background

Spinal cord herniation (SCH) is an uncommon cause of myelopathy. Documented trauma is a rare cause, and most cases are idiopathic. One special type of trauma that may lead to SCH is a brachial plexus injury. We report a case of SCH with delayed neurological symptoms after a brachial plexus injury. We reviewed the literature and illustrated the closing technique as described by Batzdorf.

Case Description

Following a motor vehicle accident, a 27-year-old male sustained a brachial plexus injury and multiple left-sided nerve root avulsions (C6, C7, and C8) resulting into a full paralysis of the left arm. There was also a loss of pain and temperature sensation on the right side of the body. He underwent reconstructive surgery without any functional improvement. After 6 to 7 years his condition worsened. Magnetic resonance imaging revealed a left-sided SCH at the level of C7. He underwent a C6-C7 laminectomy which revealed a pseudomeningocele at C6-C7 accompanied by focal SCH at the location of the C7 root. The SCH was reduced intradurally and the dural defect of the meningocele was covered with a Neuropatch membrane wrapped around the spinal cord (between the spinal cord and the dura) according to the technique described by Batzdorf. Postoperatively, the neurological symptoms improved.

Conclusion

SCH should be surgically repaired utilizing the technique described by Batzdorf if further neurological deficits develop.

Large Compressive Pseudomeningocele Causing Early Major Neurologic Deficit After Spinal Surgery

STUDY DESIGN

Retrospective review.

OBJECTIVES

Large compressive pseudomeningocele causing a major neurologic deficit is a very rare complication that is not well described in the existing literature.

METHODS

Institutional review board consent was obtained to study 2552 consecutive extradural spinal surgical cases performed by a single senior spinal surgeon during a 10-year period. The surgeon's database for the decade was retrospectively reviewed and 3 cases involving postoperative major neurologic deficits caused by large compressive pseudomeningocele were identified.

RESULTS

The incidence of postoperative compressive pseudomeningocele causing major neurologic deficit was 0.12% (3/2552) per decade of spinal surgery with approximately 1.3% of cases incurring incidental durotomy. Average age of the patients was 57 years (range 45-78). One patient had posterior cervical spine surgery, and 2 patients had posterior lumbar surgery. All 3 patients had intraoperative incidental durotomy repaired during their index procedure. Large compressive pseudomeningocele causing major neurologic deficit occurred in the early 2-week postoperative period in all patients and was clearly identified on postoperative magnetic resonance imaging. All 3 patients were treated with emergent decompression and repair of the dural defect. All patients recovered neurologic function after revision surgery.

CONCLUSIONS

Incidental durotomy and repair causing a large compressive pseudomeningocele after spine surgery is a rare and potentially devastating event. Early postoperative magnetic resonance imaging assists in the diagnosis. Emergent decompression combined with revision dural repair surgery may result in improved outcomes. Surgeons should be cognizant of this rare cause of early postoperative major neurologic deficit in patients who had previous dural repair.

Spinal cord herniation following cervical meningioma excision: a rare clinical entity and review of literature

BACKGROUND

Spinal cord herniation following surgery is an extremely uncommon clinical condition with very few reports in published literature. This condition usually occurs as a spontaneous idiopathic phenomenon often in the thoracic spine or following a scenario of post traumatic spinal cord/nerve root injury. Rarely has it been reported following spinal cord tumor surgery.

PURPOSE

To document a case of cervical spinal cord herniation as a late onset complication following spinal cord tumor surgery with an atypical presentation of monoparesis.

DESIGN

Case report.

METHODS

We describe the clinical presentation, operative procedure, post operative outcome and review of literature of this rare clinical condition.

RESULTS

A 57-year-old man presented with right upper limb monoparesis due to a spinal cord herniation 6 years after a cervical intradural meningioma excision. The patients underwent surgery to reduce the herniation and duroplasty with subsequent complete resolution of symptoms.

CONCLUSIONS

Spinal cord herniation must be considered as differential diagnosis in scenarios of spinal cord tumor excision presenting with late onset neurological deficit. These cases may present as paraparesis, Brown-sequard syndrome and rarely as in our case as monoparesis.

Remote Paraparesis due to a Traumatic Extradural Arachnoid Cyst Developing 2 Years after Brachial Plexus Root Avulsion Injury: Case Report and Review of the Literature

Traumatic extradural arachnoid cyst is a rare entity. However, late appearance of paraparesis due to formation of an extradural arachnoid cyst as a sequel of brachial plexus injury is extremely rare and the literature regarding this issue is scarce revealing only 11 cases. Herein, we report a patient with delayed progressive spastic paraparesis appearing after a multilevel brachial plexus root avulsion injury where imaging revealed formation of a large traumatic extradural arachnoid cyst at the cervicothoracic region. Furthermore, to propose that a high-energy trauma might simultaneously result in delayed formation of an extradural arachnoid cyst. However, preganglionic root avulsion injury with pseudomeningocele formation in association with extradural arachnoid cyst is not reported previously. A case of a 36-year-old man with spastic paraparesis developing 2 years after a multilevel brachial plexus root avulsion injury is presented. Root avulsion had immediately resulted in complete paralysis of the left upper limb that had not ameliorated. Imaging studies of the cervicothoracic region disclosed left-sided multilevel pseudomeningoceles and a large extradural arachnoid cyst extending from C5 to T2. After appropriate en bloc laminotomy, the cyst was excised and the causative dural tear was closed. Subsequently, three large defects of pseudomeningoceles were obliterated with artificial dural patch for the prevention of cord herniation. This was followed with laminoplasty of the corresponding levels after dural closure. The postoperative course was uneventful and paraparesis recovered steadily within 2 months. Paraparesis even years after brachial plexus injury should be regarded as a serious event that deserves extensive imaging survey for the possibility of the formation of an extradural arachnoid cyst. Careful review of the literature disclosed that the current case is the 12th case that an extradural arachnoid cyst has developed after brachial plexus injury and the first example that the pathogenic factor that might be implicated in occurrence of this rare association could be clarified with review of the MRI features. Actually, the presence of posttraumatic pseudomeningoceles in association with an arachnoid cyst in the current case is in favor of the belief that only preganglionic root injuries that are in close proximity to the spinal canal had been the cause dural tear with remote formation of extradural arachnoid cyst.

Spinal cord herniation after resection of cervical spinal neurofibroma with a unique presentation

BACKGROUND CONTEXT

Spinal cord herniation (SCH) is a very rare condition. It was first reported in the lumbar spine in 1974. Thereafter, cases were reported in the thoracic and cervical spine occurring either spontaneously or after vertebral fracture, nerve root avulsion, and trauma surgery.

PURPOSE

There is only one recorded case of SCH after tumor surgery. In this article, we reported the second case.

STUDY DESIGN

We described the original surgical procedure, the clinical presentation, the operative repair, and the postoperative course.

METHODS

No funding was required for this case report.

RESULTS

The patient was a 56-years-old man, who presented with SCH 5 years after subtotal excision of a cervical neurofibroma. He presented with right upper monoparesis.

CONCLUSIONS

To our knowledge, this presentation has not been reported previously in literature.

Herniation of spinal cord into nerve root avulsion pseudomeningocele: A rare cause of delayed progressive neurological deficit

We present a patient with old traumatic right brachial plexus injury, who developed progressive neurological deterioration 4 years after the initial injury. On magnetic resonance imaging (MRI), herniation of the upper dorsal cord was noted into a post-traumatic pseudomeningocele. Though the herniation of cord into a post-traumatic pseudomeningocele is very rare, it should be suspected in cases of delayed progressive myelopathy. A three dimensional (3-D) T2-weighted sequence such as Sampling Perfection with Application optimized Contrasts using different flip angle Evolution (SPACE) or constructive interference in steady state (CISS) provides optimal visualization of the herniated cord and helps in surgical planning.

Tardy spinal cord tumor following avulsive brachial plexus injury: coincidental or causal?

OBJECTIVE

Late neurologic deterioration after brachial plexus injury (BPI) is uncommon and may be caused by multiple etiologies. An unusual, previously unreported, case of late neurologic deterioration after BPI is presented.

METHODS

A pediatric patient previously treated for a traumatic preganglionic BPI and presenting with neurologic deterioration 5 years after his injury is reviewed.

RESULTS

Magnetic resonance imaging and computed tomography myelogram revealed spinal cord herniation at the same level of the previous nerve root avulsions. Surgical open biopsy demonstrated a spinal cord anaplastic astrocytoma. Despite craniospinal radiotherapy and different regimens of chemotherapy, he died 4 years later from leptomeningeal spread.

CONCLUSION

This case illustrates a previously unreported cause of late neurologic deterioration following BPI. The probable coincidental versus possible causal interrelationship of these two processes (BPI and spinal cord tumor) is discussed, but no conclusions can be reached.

22. Traumatic plexus lesion

Pain, motor, and sensory deficits characterize patients with a traumatic lesion of the brachial plexus. Frequently, more severe injuries co-exist that require immediate surgical attention. Early rehabilitation and physical therapy are the cornerstones of treatment. Pharmacological management can be difficult. Surgical reconstruction is frequently advised when nerves are disrupted. The results, mostly from small historical reports, vary greatly. Neurostimulation may have an additional beneficial effect, especially if the pathophysiology of nociception and neuropathic pain becomes evident in these complex patients.

Cervicothoracic intraspinal pseudomeningocele with cord compression after a traumatic brachial plexus injury

BACKGROUND CONTEXT

Pseudomeningoceles are noted within the neural foramen after avulsion plexus injuries. We present the case of a cervicothoracic epidural pseudomeningocele with spinal cord compression 18 years after a brachial plexus injury.

PURPOSE

To present a case report of a patient and literature review on cases with epidural pseudomeningoceles.

STUDY DESIGN

Case report and review of the literature.

METHODS

Retrospective review of the medical records of a patient presenting with an epidural pseudomeningocele after a plexus injury.

RESULTS

A 37-year-old male presented with neurological decline 18 years after sustaining a brachial plexus injury. Magnetic resonance tomography revealed an epidural fluid collection from C5 to T7 with significant spinal cord compression. Surgical intervention initially involved fenestration of the cyst and then rhizotomies of the C7 and C8 roots resulting in resolution of his new symptoms.

CONCLUSIONS

Pseudomeningoceles are common after brachial plexus avulsion injury and are usually stable, causing no symptoms, other than plexus neuropathies. We are unaware of previous reports of a patient with a traumatic brachial plexus avulsion who developed a large cervicothoracic, symptomatic, spinal, epidural, intracanalicular pseudomeningocele with cord compression 18 years after the initial injury. Patients with prior trauma and known plexus injuries with development of new neurological symptoms should be evaluated for the rare case of intradural pseudomeningoceles. Preoperative imaging with computed tomography myelography is important to isolate and definitively treat the fistulous connection.

Traumatic spinal-cord herniation associated with pseudomeningocele after lower-thoracic nerve-root avulsion

BACKGROUND

Traumatic spinal-cord herniation after nerve root avulsion is rare. We report on the first patient with spinal-cord herniation associated with pseudomeningocele in the lower conus medullaris region after nerve avulsion.

CASE

This 72-year-old man presented with progressive pain in the left leg and motor weakness after two traumatic accidents. Constructive interference in steady-state (CISS) imaging showed the attachment of the spinal cord to the wall of a herniated pseudomeningocele and associated syringomyelia at the level of T12. At the time of surgery, a herniated pseudomeningocele was observed. The lateral portion of the spinal cord that had herniated into the pseudomeningocele was detached from its wall; this was followed by repair of the dural defect. A redundant nerve root was observed inside the pseudomeningocele, suggesting nerve root avulsion as the primary lesion. To facilitate cerebrospinal fluid drainage from the syringomyelia, we next performed dorsal root entry zone (DREZ)tomy to the pseudomeningocele. Postoperatively, he manifested significant clinical improvement.

CONCLUSIONS

This is the first report of spinal cord herniation after nerve root avulsion in the conus medullaris region. CISS imaging is highly useful for the demonstration of spinal cord herniation, syringomyelia and pseudomeningocele. To restore neurological function in patients with progressive symptoms, we recommend surgical treatment.

Spinal cord herniation into pseudomeningocele after traumatic nerve root avulsion: case report and review of the literature

We present an extremely rare case of traumatic spinal cord herniation due to a brachial plexus avulsion injury and provide a review of the literature of spinal cord herniation. Spinal cord herniation is an uncommon condition that can occur spontaneously or as a result of surgery or trauma. This condition often presents with symptoms and signs as Brown-Séquard syndrome. Traumatic pseudomeningoceles after a brachial plexus avulsion injury have been reported. But transdural herniation of the spinal cord into this pseudomeningocele is an extremely rare and poorly documented condition. There is only two reports of this condition in a thoracic case. The authors report the case of a 22-year-old man presented with a 2-year history of quadriplegia. He was involved in a motorcycle accident, 3 years prior to his presentation. Four years after the initial right brachial plexus injury, he was not able to walk independently. Magnetic resonance imaging (MRI) and computerized tomography (CT) myelography revealed a lateral pseudomeningocele arising from the right C6-7 and C7-T1 intervetebral foramen and cervical spinal cord herniation into this pseudomeningocele. The patient underwent primary closure of pseudomeningocele to prevent spinal cord reherniation. He can walk with cane and use left arm unrestrictedly at the 2-year follow-up examination. Spinal cord herniation following traumatic nerve root avulsion is extremely rare but it should be considered in the differential diagnosis of patients presenting with delayed myelopathy or Brown-Séquard syndrome.