Acute traumatic cervical epidural hematoma associated with brachial plexus injury: a case report and literature review

Incluido en la revista Ocronos. Vol. VI. Nº 12–Diciembre 2023. Pág. Inicial: Vol. VI; nº 12: 392.6

Autor principal (primer firmante): Diana Lizeth Garfias Zavala

Fecha recepción: 14/12/2023

Fecha aceptación: 25/12/2023

Ref.: Ocronos. 2023;6(12): 392.6

https://doi.org/10.58842/URMY1816

Autores:

Ana Marisol Gutiérrez-Ortega 1

Edén Oceguera-Contreras 2

Karina Toledo-Villa 3

Diana Lizeth Garfias-Zavala 4

Cristian Javier Guerrero- Eraso 5

  1. Departamento de Terapia Intensiva, Hospital General Regional No. 1, IMSS Michoacán, Avenida Bosque de los Olivos 101, C.P., 61301, La Goleta, Mich., México.
  2. Centro Universitario de los Valles. Departamento de Ciencias de la Salud. Universidad de Guadalajara. Carretera Guadalajara-Ameca C.P. 44600, Ameca, Jalisco, México.
  3. Departamento de Neurocirugía Hospital General Regional No. 1 IMSS Michoacán, Avenida Bosque de los Olivos 101, C.P., 61301, La Goleta, Mich., México.
  4. Departamento de Medicina Interna Hospital General Regional No. 1 IMSS Michoacán, Avenida Bosque de los Olivos 101, C.P., 61301, La Goleta, Mich., México.
  5. Departamento de Anestesiología, Hospital de la Mujer de Morelia, SSA, Guillermo Roquet 250, Pob. Ocolusen, C.P., 58295, Morelia, Mich., México.

Keywords: Spinal epidural hematoma, cervical spine, trauma, cord compression, case report

Abstract

The term «post-traumatic spinal epidural cervical hematoma» refers to the accumulation of blood within the epidural space following a traumatic event.

This occurrence remains relatively uncommon. We present a case involving a 22-year-old patient who experienced a cervical epidural hematoma spanning from C2 to C4, following a motorcycle accident. The patient was admitted to the hospital two hours after the trauma.

A Computed Tomography (CT) scan revealed no evidence of contusions, hemorrhages, or intraparenchymal hematomas. After 24 hours from the event, a neurological assessment was performed, and the mechanical ventilation was successfully withdrawn. MRI was conducted at 72 hours.

Sagittal and axial T2-weighted images showed an area of epidural hyperintensity without mass effect, along with evidence of unilateral left C6-C7 facet subluxation without canal compression.

This was assessed by the neurosurgery service, which determined that it did not warrant surgical intervention.

This infrequent clinical condition demands urgent diagnosis and management, necessitating a collaborative effort between Intensive Care Unit (ICU) specialists, neurosurgeons, neuroradiologists, and physiotherapists to achieve favorable outcomes and ensure proper follow-up.

Introduction

The spinal epidural hematoma is the accumulation of blood in the epidural space, which generally occurs due to the rupture of the veins that make up Batson’s perivertebral venous plexus 1.

While it is true that its clinical presentation is not common, if it does occur, this condition brings along significant neurological sequelae due to the compression of the spinal cord or nerve roots, and even death 2,3.

That’s the reason detection and recognition of symptoms will allow us an early diagnosis and treatment, favoring the patient’s recovery 2

Furthermore, Kreppel et al., described that out of 613 patients with spinal epidural hematoma, trauma was the causal agent in 7.3% of the spinal hematomas, with 4.4% of these cases being associated with vertebral fractures 2.

It is worth noting that these hematomas do not become large enough to cause spinal cord compression.

In addition, Ricart et al., showed that out of 497 patients with cervical trauma, 2.5% had a post-traumatic cervical epidural hematoma, and of these, 59% had some degree of associated spinal cord compression, with the male population being predominantly affected by this condition, with motor vehicle accidents as the main causal mechanism of injury 3.

The brachial plexus is composed of ventral branches of the C5-T1 nerves, which may have some variations such as the inclusion of contributing nerves from C4 and T2. It is responsible for providing movement and sensitivity to the shoulder, arm, forearm, and hand 4.

Brachial plexus injuries are considered devastating injuries as they result in significant physical disability, stemming from penetrating injuries, falls, and motor vehicle accidents.

The incidence of these types of injuries is difficult to quantify due to the significant increase in extreme activities and sports, as well as motor vehicle accidents, but it is known that the majority of these occur in males aged 15 to 25 years old 5.

Case report

A 22-year-old male with no significant medical history. Admitted to the emergency department after a motorcycle accident at high speed, resulting in a frontal impact against a retaining wall without wearing a personal protective helmet.

Upon arrival to the emergency department, he presented with the following vital signs: blood pressure: 120/60 mmHg, heart rate: 111 bpm, breathing frequency: 23 bpm, arterial oxygen saturation: 90%, temperature: 36 ºC, and he exhibited neurological impairment, a Glasgow Coma Scale score of 6 points (ocular response one point, verbal response one point, motor response four points), requiring advanced airway management, the Injury Severity Score was calculated with a value of nine points.

He had multiple facial contusions, with isocoric pupils that were sluggish in response to light. His neck showed no apparent external injuries, and he had sinus tachycardia and hypotension, with no other relevant findings on physical examination. Imaging studies were initiated according to protocol. A plain skull CT scan showed no evidence of contusions, hemorrhages, or intraparenchymal hematomas.

The cervical spine CT scan revealed a spinal epidural hematoma extending from C2 to C4 (Fig. 1) with a volume of approximately 1.7 cms not associated with cervical vertebral fractures. The patient was transferred to the intensive care unit for life support and neuroprotective measures, without administering thromboprophylaxis.

After 24 hours from the event, a neurological assessment was performed, and the mechanical ventilation was successfully withdrawn. Upon reevaluation of the patient’s neurological condition, it was observed that the left upper limb had monoplegia, with involvement of dermatomes from C5 to T1, accompanied by loss of sensation in dermatomes C6-C8.

As part of the study protocol, a plain cervical spine MRI was conducted at 72 hours. Sagittal and axial T2-weighted images showed an area of epidural hyperintensity without mass effect, along with evidence of unilateral left C6-C7 facet subluxation without canal compression (Fig. 2 and 3).

This was assessed by the neurosurgery service, which determined that it did not warrant surgical intervention. Additionally, an MRI of the left brachial plexus was performed with FIESTA sequence, revealing neurotmesis (Fig. 4).

An electromyography was conducted, which reported motor conditions for the axillary, musculocutaneous, radial, median, and ulnar nerves as non-evocable. Denervation findings were noted in all muscles explored by terminal branches of the brachial plexus and in the cervical paravertebral muscles C5-T3.

Furthermore, It worth mentioning that severe axonotmesis was observed.

Discussion

Cervical epidural hematoma is a rare condition, occurring in 1 out of every 1,000,000 individuals per year 6. The space-occupying effect of the hematoma within the spinal canal leads to various clinical manifestations, predominantly sensory and motor déficits 7.

Being magnetic resonance imaging (MRI) the gold standard for assessing the location, extent, and degree of spinal cord compression 8.

Regarding post-traumatic cervical epidural hematoma, it predominantly affects male patients over 40 years of age 9,10.

Being falls and motor vehicle accidents the primary mechanisms associated with its occurrence.

Early and accurate diagnosis of cervical spine injuries is crucial. In this case, computed tomography revealed a spinal epidural hematoma from C2 to C4 initially, and the MRI performed at 72 hours revealed a cervical epidural hematoma from C4 to C6.

Harper 11, described that nerve root avulsions cannot be ruled out based on negative MRI studies. The epidural venous plexus has been speculated as a likely source of traumatic spinal epidural injury.

Although surgical decompression has been the standard management in most cases of spinal epidural hematoma, conservative management can be an alternative in cases with minimal neurological deficit and rapid recovery.

On the other hand, brachial plexus injury is a serious condition that predominantly affects young men in their productive years. This type of injury is found in 5% of polytrauma patients, primarily due to motorcycle accidents 12.

Two mechanisms are involved in plexus injury: traction, which causes avulsion or rupture of one or more cervical roots, and direct injury to the trunks, divisions, or fascicles that compose it 13.

The most common type of brachial plexus injury is described as a rupture or avulsion of the upper roots (C5-C6, and in some cases C7), with complete root avulsion being less common 14.

In more than 50% of cases, surgical reconstruction of the plexus elements is required 15.

In this case, the patient presents with two different injuries associated with the same etiology: traumatic non-surgical spinal epidural hematoma and brachial plexus avulsion.

It was the outmost importance to the neurosurgery service scheduled neurosurgical repair of the brachial plexus for increasing a better prognosis for the patient.

Conclusions

Spinal epidural hematoma associated with brachial plexus avulsion is a rare condition that requires timely diagnosis and multidisciplinary management involving specialties such as neurosurgery, intensive care, neuroradiology, to prevent significant neurological sequelae.

Additionally, modern surgical techniques and rehabilitative medicine play a fundamental role in achieving better prognosis.

Declaration of conflict of interest

The authors declare that they have no conflicts of interest.

Funding

The authors declare that they have not received funding for this study

Imágenes

Figure 1. Single cervical spine tomography, axial and sagittal sections, at the level of C4. Within the spinal canal, a hyperdense lesion adjacent to the left lamina is observed in the epidural space.

Figure 2. Magnetic resonance imaging of the cervical spine, axial and sagittal sections, T2 sequence. At the level of C6, a hyperintense intradural extradural (or epidural) lesion is observed adjacent to the left lamina and posterior wall, creating a mass effect with partial collapse of the cerebrospinal fluid column and displacement of the spinal cord towards the right.

Figure 3. Magnetic resonance imaging of the cervical spine, coronal section, T2 sequence. At the level of C6, a hyperintense intradural left-sided lesion is observed, causing displacement of the dural sac. The boundary between the sac and the lesion is clearly defined.

Figure 4. Coronal MRI, FIESTA sequence, delineates the nerve lesion with avulsion of the C6 root.

Anexos – Acute traumatic cervical epidural hematoma associated with brachial plexus injury.pdf

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