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Isolated Bilateral Hypoglossal Palsy Secondary to Epidural Hematoma from Antlanto-occipital Dissociation 2006

General Spine

Jeremy B McCue, MD, Non ASSR Member
Patrick Turski, MD, Non ASSR Member
Garth Warren, BS, Non ASSR Member
Lindell R Gentry, MD, Non ASSR Member
Victor Haughton, MD, ASSR Member

Excerpta Extraordinaire

Excerpta

This case illustrates the utility of MR imaging in assessing ligamentous and neurologic injury in craniocervical trauma in a patient who developed isolated bilateral hypoglossal palsy after a farming accident.

Case:
10 Year old male presented with no gross neurological deficit after being crushed under a 700 pound hay bale. Patient complained of thoracic pain and was found to have mild compression fractures at T11-L1. Patient did not complain of neck pain. Routine imaging revealed severe cervical prevertebral soft tissue swelling with no fractures. CT cervical spine showed borderline widening of the basion-dens interspace with normal pre-dental space.

Several hours after admission the patient developed dysphonia and swallowing difficulty and was diagnosed clinically with bilateral hypoglossal nerve palsy. MRI of the cervico-occipital junction revealed severe ligamentous injury with complete disruption the apical ligament(Image 1), left alar ligament, and partial disruption of the right alar ligament and left tectorial membrane(Image 2/3). Additionally there was development of a large retroclival epidural hematoma extending to the hypoglossal canals bilaterally compressing the hypoglossal nerves (Image 4).

This case is an unusual presentation of a typically devastating injury. The patient presented neurologically intact, subsequently progressing to develop isolated hypoglossal palsy. Cranial nerve palsy been described as a rare complication in atlanto-occipital injury although typically associated with occipital condylar fractures.

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