Myelographic Demonstration of Lumbosacral Nerve Root Avulsion

Abstract

Avulsion of cervical nerve roots by A traction injury to the shoulder girdle is well known (1, 7, 12), but, on the other hand, traumatic avulsion of lumbosacral nerve roots is exceedingly rare. A search of the literature revealed only 3 reported cases to date of this condition with myelographic demonstration. The first was described by Finney and Wulfman in 1960 (3), and 2 more were reported recently by Goodell (4). The 2 case reports which form the basis of this communication describe the characteristic radiographic and clinical features of lumbar or sacral nerve root avulsion. Case I: F. H., a 22-year-old man, was admitted to a local hospital on Oct. 9, 1962, following an auto accident in which he sustained cerebral concussion and fractures of the right upper and lower extremities. The pelvic fractures included separation of the right sacroiliac joint and of the pubic symphysis with marked deformity (Fig. 1). Due to the numerous fractures, a complete neurological examination could not be carried out. It was noted on admission, however, that the patient could not move his right toes and he appeared to have anesthesia over the right foot and the posterior aspect of the right thigh. As his condition improved, these findings persisted. In time, weakness and wasting of the right glutei, hamstrings, and biceps femoris developed. Several months after discharge, the patient was admitted to the Edward J. Meyer Memorial Hospital, Buffalo, N. Y. Myelography showed clear Spinal fluid with normal dynamics (Fig. 2). In September 1963, eleven months after the injury, a laminectomy of L4 and L5 was performed, and the area explored. The cyst-like structure, which had been demonstrated by myelography, was found to lie laterally along the course of the L5 nerve root sheath. The dura was then opened in midline and revealed thickening of the arachnoid with adhesions, pocketing, and matting of nerves of the cauda equina. The cyst on the right at the L4–5 level appeared to consist mainly of dura rather than arachnoid but communicated with the subarachnoid space. The surgeon could not definitely distinguish a nerve passing through this particular cyst. The patient's neurological deficit extended over the distribution of L4 and all sacral nerves on the right. It was believed that, in addition to the avulsion of the L5 nerve root, he had also suffered damage to the lumbosacral plexus. His neurological status did not improve. Case II. D. S., a 19-year-old college student, was admitted in the early morning of Oct. 21, 1965, after the car which he was driving hit a telephone pole. The exact mode of injury is not known. On admission, he was found to have multiple facial injuries, comminuted open fracture of the left femur, separation of both sacroiliac joints, fracture of the symphysis pubis and fracture of the lower three sacral foraminae on the right (Fig. 3). Because of cerebral injury, he was markedly belligerent and disoriented.