- UCLA Department of Neurosurgery, University of California, Los Angeles, CA, USA
- Department of Orthopedic Surgery, University of California, Los Angeles, CA, USA
Correspondence Address:
Daniel C. Lu
UCLA Department of Neurosurgery, University of California, Los Angeles, CA, USA
Department of Orthopedic Surgery, University of California, Los Angeles, CA, USA
DOI:10.4103/2152-7806.113647
Copyright: © 2013 Li CH This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.How to cite this article: Li CH, Yew AY, Lu DC. Migration of traumatic intracranial subdural hematoma to lumbar spine causing radiculopathy. Surg Neurol Int 19-Jun-2013;4:81
How to cite this URL: Li CH, Yew AY, Lu DC. Migration of traumatic intracranial subdural hematoma to lumbar spine causing radiculopathy. Surg Neurol Int 19-Jun-2013;4:81. Available from: http://sni.wpengine.com/surgicalint_articles/migration-of-traumatic-intracranial-subdural-hematoma-to-lumbar-spine-causing-radiculopathy/
Abstract
Background:There have been rare reports of intracranial subdural hematoma (SDH) that migrated into the spine. All previous cases have been surgically managed and in this case report, we describe the first case of conservatively managed spinal hematoma secondary to migratory intracranial SDH.
Case Description:A 26-year-old male presented with a left tentorial SDH after blunt trauma. He was conservatively managed and discharged home. He presented 8 days later with worsening lower back pain that was found to be secondary to a spinal SDH.
Conclusion:Spinal hematomas can be a serious sequelae of migrated intracranial hematomas. Tentorial and other caudally located intracranial hematomas may be more prone to this phenomenon.
Keywords: Radiculopathy, subdural hematoma, trauma
INTRODUCTION
While the incidence of intracranial subdural hematoma (SDH) is estimated to constitute up to 11% of head trauma cases,[
CASE REPORT
History and examination
Our patient is a 26-year-old male who presented with a left tentorial SDH following blunt trauma to the head. The patient was brought to our Emergency department alert and oriented to person, place, and date and had no focal neurologic deficits. Noncontrast computed tomography (CT) imaging of the head revealed a 4 mm left tentorial SDH and 2 mm of pneumocephalus [
The patient returned on postinjury day 8 for follow up and discontinuation of his antiseizure prophylaxis. The patient noted that he was experiencing progressively worsening lower back pain that radiated into both lower extremities and had started one day after discharge. He also reported occasional ataxia and dizziness. He denied any changes in bowel or bladder function. The patient had 5/5 strength on confrontational motor testing in all lower extremity muscle groups.
The patient underwent contrast-enhanced magnetic resonance imaging (MRI) of the cervical, thoracic, and lumbar spine. Imaging of the cervical and thoracic spine revealed no abnormal enhancement and showed normal alignment. However, the MRI of the lumbar spine revealed a 6.84 mm SDH extending from the T4-T5 to the L5-S1 levels causing central displacement of the cauda equina. No cord deformity, compression, or edema was seen. There was a signal difference in the fluid of the thecal sac and moderate facet hypertrophy was observed at L4-L5 and L5-S1 [
Figure 2
(a) Sagittal T2 weighted MRI of the lumbar spine demonstrating anterior and posterior subdural hematomas that extend from the thoracic levels down to the level of the L5-S1 disc space, (b) Axial T2 weighted MRI of the lumbar spine redemonstrating both anterior and posterior components. There is displacement of the cauda equina nerve roots secondary to mass effect
DISCUSSION
We have described a rare case of radiculopathy developing secondary to migration of an intracranial SDH to the lumbar spine. In addition to blunt trauma, spinal SDH has also been reported in cases of epidural injections,[
Bortolotti et al. were the first to suggest that spinal SDHs may develop secondary to migration of an intracranial SDH. They described a 23-year-old woman who initially had blunt head trauma with a left frontal convexity intracranial SDH that subsequently migrated to the tentorium with tentorial layering. The patient developed sciatica and back pain 4 days after her head injury and MRI of the lumbar spine performed 10 days post-injury revealed a lumbar SDH. Operative decompression was performed and the patient's symptoms resolved.
Shimada et al. reported a case of a 68-year-old male who presented with severe low back pain secondary to a spinal SDH 2 weeks following conservative management of an intracranial SDH from blunt head trauma.[
The majority of spinal SDH secondary to migration of an intracranial SDH have required operative therapy. Ahn and Smith described the first case of a clivial SDH that presented simultaneously with cervical spinal SDH, which resolved with conservative treatment.[
Moscovici et al.[
Hung et al. proposed that as a result of increased intracranial pressure, there is an increase in shearing forces between the dura and arachnoid layers in the spinal column.[
While no authors have systematically assessed the position of the intracranial SDH and its relationship to likelihood of subsequent migration, our review of the literature reveals that four of the six case reports[
While two authors[
CONCLUSION
Traumatic spinal SDH is a rare phenomenon and subsequent migration into the spinal canal has been described in only a handful of cases. We report a patient who developed radiculopathy and lower back pain following cranial SDH that was found to be the result of a migratory spinal SDH. Our case illustrates the variability of the phenomenon of a migratory hematoma and we hypothesize that migration may be related to the location of the initial intracranial hematoma.
ACKNOWLEDGEMENT
This research was made possible through the generosity of J. Yang & Family Foundation.
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