Macyszyn Luke J, Gonzalez-Giraldo Ernesto, Aversano Michael, Heuer Gregory G, Zager Eric L, Schuster James M
Department of Neurosurgery, University of Pennsylvania Medical Center, Philadelphia, PA, USA.
Evid Based Spine Care J. 2010 Dec;1(3):51-4. doi: 10.1055/s-0030-1267068.
High-energy impact to the head, neck, and shoulder can result in cervical spine as well as brachial plexus injuries. Because cervical spine injuries are more common, this tends to be the initial focus for management. We present a case in which the initial magnetic resonance imaging (MRI) was somewhat misleading and a detailed neurological exam lead to the correct diagnosis.
A 19-year-old man presented to the hospital following a shoulder injury during football practice. The patient immediately complained of significant pain in his neck, shoulder, and right arm and the inability to move his right arm. He was stabilized in the field for a presumed cervical-spine injury and transported to the emergency department.
Initial radiographic assessment (C-spine CT, right shoulder x-ray) showed no bony abnormality. MRI of the cervical-spine showed T2 signal change and cord swelling thought to be consistent with a cord contusion. With adequate pain control, a detailed neurological examination was possible and was consistent with an upper brachial plexus avulsion injury that was confirmed by CT myelogram. The patient failed to make significant neurological recovery and he underwent spinal accessory nerve grafting to the suprascapular nerve to restore shoulder abduction and external rotation, while the phrenic nerve was grafted to the musculocutaneous nerve to restore elbow flexion.
Cervical spinal-cord injuries and brachial plexus injuries can occur by the same high energy mechanisms and can occur simultaneously. As in this case, MRI findings can be misleading and a detailed physical examination is the key to diagnosis. However, this can be difficult in polytrauma patients with upper extremity injuries, head injuries or concomitant spinal-cord injury. Finally, prompt diagnosis and early surgical renerveration have been associated with better long-term recovery with certain types of injury.
头部、颈部和肩部受到高能撞击可导致颈椎以及臂丛神经损伤。由于颈椎损伤更为常见，这往往成为治疗的初始重点。我们报告一例病例，其中最初的磁共振成像（MRI）有一定误导性，而详细的神经系统检查得出了正确诊断。
一名19岁男性在足球训练中肩部受伤后被送往医院。患者立即诉说颈部、肩部和右臂剧痛，且无法移动右臂。因推测有颈椎损伤，他在现场得到稳定处理后被送往急诊科。
最初的影像学评估（颈椎CT、右肩部X线）未显示骨骼异常。颈椎MRI显示T2信号改变和脊髓肿胀，认为与脊髓挫伤一致。在疼痛得到充分控制后，得以进行详细的神经系统检查，检查结果与上臂丛神经撕脱伤相符，CT脊髓造影证实了这一诊断。患者神经功能未能显著恢复，遂接受了副神经移植至肩胛上神经以恢复肩部外展和外旋，同时将膈神经移植至肌皮神经以恢复肘部屈曲。
颈椎脊髓损伤和臂丛神经损伤可由相同的高能机制引起，且可同时发生。如本病例所示，MRI表现可能具有误导性，详细的体格检查是诊断的关键。然而，对于伴有上肢损伤、头部损伤或合并脊髓损伤的多发伤患者，这可能具有难度。最后，对于某些类型的损伤，及时诊断和早期手术修复与更好的长期恢复相关。
