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Traumatic Anterior Cervical Pseudomeningocele Successfully Treated With Blood Patch 2013

Category General Spine Laurence J. Eckel, Neuroradiologist/M.D.
Edwin Takahashi, Medical Student
Kara Schwartz, Neuroradiologist/M.D.
Felix E. Diehn, Neuroradiologist/M.D.
Christopher H. Hunt, Neuroradiologist
Daniels David, Neurosurgeon/M.D.
Purpose Describe a rare case of post-traumatic cervical pseudomeningocele, review the unusual clinical presentation, detail its imaging, and present the relatively noninvasive treatment which alleviated symptoms. Materials & Methods We present the case of a patient with a history of trauma to the spine following a motorcycle collision with a deer.  CT imaging revealed an isolated C6 spinous process fracture.  Approximately 24 hours post-injury, the patient complained of extreme neck pain when nursing staff attempted to sit him up. He also displayed progressively worsening episodes of bradycardia, oxygen desaturation, and mental status changes.  Subsequent MRI demonstrated an anterior cervical pseudomeningocele secondary to a dural tear.  The patient underwent an epidural blood patch the following day to treat his postural symptoms. He experienced almost immediate relief of his headache and neck pain. His heart rate and oxygen saturation also normalized. Results Traumatic anterior cervical pseudomeningoceles are extremely rare.  While the epidural blood patch procedure has been described for the treatment of spontaneous and postsurgical pseudomeningoceles that cause intracranial hypotensive symptoms, we report the first traumatic anterior cervical pseudomeningocele treated by this procedure.  In our patient, the pseudomeningocele was not identified at the time of presentation and pseudomeningoceles are most often asymptomatic. Patients may present with a variety of symptoms, but an orthostatic headache that is dramatically worse when upright and improved in recumbency is the most common symptom and is the hallmark of intracranial hypotension.  The preferred modality for investigating pseudomeningoceles is MRI, which reveals a region of low signal intensity on T1-weighted images and high signal intensity on T2-weighted images. CT myelography and fluoroscopic myelography may also identify pseudomeningoceles. Conclusion Anterior cervical pseudomeningocele is a rare complication of spinal trauma. Although usually asymptomatic, these lesions may cause orthostatic headache and neck pain, mental status changes, and cardiopulmonary compromise.  Therefore, pseudomeningocele should be included in the differential diagnosis for post-traumatic patients with these symptoms. MRI is the preferred modality to evaluate for these lesions. Our case demonstrates that an epidural blood patch may be an effective option for treating patients with intracranial hypotension symptoms due to anterior cervical pseudomeningocele. References
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