Article, Traumatology

Traumatic cervical spinal epidural hematoma mimics brachial plexus injury

Case Report

Traumatic cervical spinal epidural hematoma mimics brachial plexus injury

Abstract

Cervical spinal epidural hematoma is rare, and most cases are reported sporadically as caused by spontaneous bleeding. Traumatic cervical epidural spinal hematoma is extremely rare, and mimicking the symptoms of brachial plexus injury has never been reported. We describe a 32- year-old man who sustained a Motorcycle accident and had multiple trauma with bilateral lung contusion and spleen laceration. He had left clavicle bone fracture and was diagnosed to have brachial plexus injury with the symptoms of weakness and paresthesia of left upper limb. Brachial plexus injury was suspected, and cervical spinal computer tomography was obtained to rule out the cervical Spinal injury. He was admitted to the trauma intensive care unit for the polytrauma. Cervical spinal epidural hematoma was further confirmed after obtaining magnetic resonance imaging. He received Surgical decompression to evacuate the hematoma due to persisting weakness and severe paresthesia. However, his symptoms did not have significant improvement after surgical decompression, and he received long-term rehabilitation thereafter. Herein, we present this rare injury with an unusual manifestation.

A 32-year-old drunk man who had a motorcycle accident was transferred to our emergency department (ED) with multiple trauma over face, thorax, abdomen, and 4 limbs. The patient was treated under the advanced trauma life support protocol. On the primary survey, the patient was irritated but oriented with patent airway. His respiratory rate was 14 breaths/min, pulse rate was 103 beats/min, and blood pressure was 123/78 mm Hg. focused assessment with sonography for trauma was performed and revealed intraabdominal bleeding. His Glasgow Coma Scale was E3V5M6, and both pupils reacted to light. The patient also presented with pain over the neck and shoulder. He felt his left upper Extremity weakness and paresthesias. However, no diminishing of pulse was found. Clavicle fracture was palpable with swelling over the shoulder. With intoxication by alcohol and the impression of intraabdominal bleeding and brachial plexus injury, he received brain, cervical, and thoracoAbdominal computed tomography (CT) scans to

survey the potential injuries. A hematoma over the C3 to C5 level of spine was found (Fig. 1A-1 to A-5). The boney structure of cervical spine was relatively intact without obvious lesions (Fig. 1C). abdominal CT scans revealed spleen laceration, and he was admitted to our surgical intensive care unit for further observation. Cervical spinal epidural hematoma was also confirmed by following the arrangement of magnetic resonance imaging (MRI) later after transferal to ordinary ward (Fig. 1B). Brachial plexus injury was ruled out by somatosensory-evoked potential test. Due to persisting muscle weakness and paresthesias, he received laminectomy and the hematoma was evacuated. However, his symptoms did not show significant improve- ment after the operation, and he received persistent long-term rehabilitation in our hospital after surgical intervention.

Traumatic cervical spinal epidural hematoma is extremely rare [1-4], and the exact incidence ranges from 0.5% to 7.5% as reported in different series [5,6]. Diagnosis may be missed due to unfamiliarity and inexperience of the injury. Although high doses of steroid have been found to have a significant effect in delayed diagnosis patients [7,8], early emergency laminectomy for Hematoma evacuation has been reported to have Good neurologic outcome [5,9,10]. In our patient, this rare injury was thought to be brachial plexus injury due to the presentation of the similar symptoms combined with clavicle bone fracture. Although the hematoma was evacuated later, the neurologic function of patient did not fully recover.

In the Emergency care setting, differential diagnosis between brachial plexus injury and cervical spinal injury is difficult, especially when their symptoms are similar. Although the diagnosis of spinal hematoma was confirmed by CT scans in the ED, brachial plexus still could not be ruled out and was further evaluated by MRI and somato- sensory-evoked potential test. However, due to the Liver laceration and bilateral lung contusion, the survey of the brachial plexus injury and spinal hematoma was delayed until the patient became more stable.

Most patients who present to the ED with traumatic spinal injury are Neurologically intact, active, and alert [10]. Patients usually have a high rate of concomitant injuries like our patient that may underscore the need for a high index of suspicion and careful assessment of their spinal injury. In spinal epidural hematoma, cervical spinal injury predominates over other locations [9,11], and most patients have reported falling, sport injury, violence, or a motor vehicle crash

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Fig. 1 A-1 to A-5, A cervical spinal CT shows evidence of spinal epidural hematoma (black arrow) from C3 to C5. B, Sagittal T1-weighted magnetic resonance scan shows high signal intensity in the dorsal epidural space from the C3 to the level of C5 consistent with acute hemorrhage. C, A cervical spinal reconstructed CT shows some small osteophytes (white arrows).

[5,12-16]. Therefore, when a patient has trauma with the risk factors combined with neurologic deficit, early evaluation of the peripheral nerves and central nerve injury should be performed to exclude the need for surgical intervention.

People who sustain cervical spinal epidural hematoma may have a variety of symptoms including neck pain, muscle weakness, paresthesia, and even quadriplegia. However, we present a patient who had a traffic accident with traumatic cervical spinal epidural hematoma with the symptoms mimicking brachial plexus injury, and to our knowledge, this has never been observed in previous reports.

In this patient, we highlight the difficulty of differential diagnosis between the spinal epidural hematoma and brachial plexus injury. Early evacuation of the hematoma to decompress the pressure was found to have better results as suggested by previous studies. Therefore, soon after stabiliz- ing polytrauma patients with the neurologic deficient in the primary management, central nerve injury including epidural hematoma should be considered and further evaluated by CT

or MRI, whereas the Peripheral nerve injury test should also be arranged without delay for surgical decompression.

Hsing-Lin Lin MD, MS

Department of Trauma Kaohsiung Medical university hospital Kaohsiung Medical University

Kaohsiung, Taiwan Department of Emergency Medicine Kaohsiung Medical University Hospital Kaohsiung Medical University

Kaohsiung, Taiwan Department of Surgery

Kaohsiung Medical University Hospital Kaohsiung Medical University

Kaohsiung, Taiwan Graduate Institute of Healthcare Administration

Kaohsiung Medical University

Kaohsiung, Taiwan

Case Report

Liang-Chi Kuo MD, MS Yuan-Chia Cheng MD

References

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Department of Trauma Kaohsiung Medical University Hospital Kaohsiung Medical University

Kaohsiung, Taiwan Department of Emergency Medicine Kaohsiung Medical University Hospital Kaohsiung Medical University

Kaohsiung, Taiwan Department of Surgery

Kaohsiung Medical University Hospital Kaohsiung Medical University

Kaohsiung, Taiwan

Jiun-Nong Lin MD Division of Infectious Diseases Department of Internal Medicine E-Da Hospital/I-Shou University

Kaohsiung, Taiwan

Shing-Ghi Lin MD

Department of Trauma Kaohsiung Medical University Hospital Kaohsiung Medical University

Kaohsiung, Taiwan

Tsung-Ying Lin MD Wei-Che Lee MD,MS Department of Trauma

Kaohsiung Medical University Hospital Kaohsiung Medical University

Kaohsiung, Taiwan Department of Emergency Medicine Kaohsiung Medical University Hospital Kaohsiung Medical University

Kaohsiung, Taiwan Department of Surgery

Kaohsiung Medical University Hospital Kaohsiung Medical University

Kaohsiung, Taiwan E-mail address: [email protected]

doi:10.1016/j.ajem.2010.01.012

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