Traumatic lumbosacral meningocele Case report
Josl~ BARBERA, M.D., JAIME BROSETA, M.D., FRANCISCO ARGt~ELLES, M.D., AND JUAN L. BARCIA-SALORIO, M . D .
Departments of Neurosurgery and Traumatology. University Hospital, Valencia, Spain A case of traumatic avulsion of the L-5 and S-1 nerve roots is described. Surgical intervention was undertaken and long-term functional recovery obtained. KEY WORDS
9
nerve-root avulsion
T
RAUMATIC lumbosacral meningoceles are seldom described. We have found 16 well documented instances of this lesion :,8-6,8,ga2-t6 and present an additional case. Case Report
This 21-year-old man was riding a motorcycle on November 14, 1974, when he was struck by an automobile. He fell to the ground on his gluteal area, with the hip joints spread in abduction, and the left leg stretched with the hip and knee in extension. He was hospitalized immediately. He had a right inguinal h e m a t o m a and complained of aching sensations in the low back and pubic region. Examination. Neurological examination showed paralysis of the left ankle and foot. There was anesthesia in the L-5 and S-1 dermatomes on the left and hypesthesia in the S-2, S-3, and S-4 dermatomes. Thus, the left ankle jerk was abolished, while the patellar reflexes remained normal and symmetrical. Sphincters were intact. After the patient recovered from traumatic shock, radiographs 536
9 meningocele
9 trauma
showed right iliopubic and transverse sacral fractures. H e was treated with bed rest and right-leg traction. Electromyographic recordings 2 weeks after admission showed involvement o f the L-3 to S-3 nerve roots on the left. There was no change in his neurological status. One month after the injury a Pantopaque m y e l o g r a m (Fig. 1) showed a large meningocele at the level of the left L-5 and S-1 nerve roots. Other small diverticula a p p e a r e d above and below these roots. Lateral and oblique projections confirmed these findings. Operation. On December 28, 1974, an exploratory laminectomy was performed. At operation (Fig. 2), the meningoceles were visualized. The left L-5 root sheath was opened, revealing a normal nerve root in continuity with some swelling. The cyst of the left S-1 nerve root was also opened and a total nerve-root avulsion was found. Postoperative Course. At a follow-up examination 14 months postoperatively, the patient was markedly improved. He had begun work as a hairdresser. There was
J. Neurosurg. / Volume 46 / April, 1977
Traumatic lumbosacral meningocele residual paralysis of left ankle flexion. Sensation had improved with hypesthesia of the left S-1 d e r m a t o m e persisting.
Discussion Table 1 summarizes all 16 reported cases of this type o f lesion. This small number seems to suggest a low incidence of this lesion. However, Huittinen 11 found six intradural lesions of the lumbosacral nerve roots in 42 autopsied cases of trauma with pelvic fractures. It is likely that, if more patients survived violent trauma, a greater incidence of this lesion would be reported. In only 11 reported cases was a severe pelvic lesion with luxation or fracture-luxation of the sacroiliac joint found. 1,8,a2,15 Vertical sacral fractures can produce a radicular disruption by shearing but generally this lesion does not appear in the myelogram. 7 In the other five cases and in our own it was not possible to demonstrate a fracture that in itself would cause a radicular lesion. Thus, in three cases and in our case, m a x i m u m traction upon the sciatic
FIG. 1. Anteroposterior view of the myelogram, showing the L-5 and S-1 diverticula. Abnormal filling of the left radicular sheath can be seen.
FIG. 2. Two views of the operation. Left: The L-5 meningocele is opened, showing an intact nerve root. Right: The S-1 cyst is also opened, and appears empty without a nerve root.
J. Neurosurg. / Volume 46 / April, 1977
537
J. Barberfi,
et al.
TABLE 1
Summary of 16 eases of traumatic lumbosacral nerve root meningoeele* Author, Year Nosik, 1955
Age, Sex ?, M
Associated Lesions
Clinical Clin: Mechanism. . Myelogram Myelog ~ Follow-Up ~ymptomatology Relation surgery Results
none
possible increased CSF pressure
no neurological deficits; headache caused by lack of CSF
1.,-3meningocele, rt
none
none
well, 2 mos
Finney & Wulfman, 1960
19, M
laceration It buttock
sciatic traction
absent knee & ankle jerk on It; anterotibial paralysis; hypesthesia in It foot; delayed I.,-4 hyperalgesia
L-4 meningocele, It
none
none
residual footdrop, lyr
Goodell, 1966
22, M
separation pubic symphysis; sacroiliac joint
radicular traction
paralysis below rt knee; sphincter tone decreased; L5-$3 sensory loss, rt
L5-S1 meningocele, rt
none
operation: L5-S1 intact; $2--4 atrophic
neurologically unchanged 4 yrs
31, M
fracture rt radicular pubic ramus, traction ilium, & isehium; sacroiliac joint dislocated; separation I.,-2 superior facet; renal contusion
total motor and sensory loss, rt leg
L5-S1 meningocele, rt
none
lamiunchanged, nectomy 5 mos T12L3, all nerve roots intact
22, M
separation rt sacroiliac joint & pubic symphysis
paralysis rt toes; L-5 meninatrophy rt gocele, rt glutei, hamstrings, & biceps femoris; anesthesia rt foot, in dorsum, & posterior thigh
none
operation: no L-5 nerve root visualized
unchanged, 11 rues
19, M
separation both radicular sacroiliac traction joints, pubic fracture; fracture lower 3 sacral foramina on rt
paralysis anteL-5, S-1, rior compartS-2, ment rt leg; meninabsent ankle gocele, rt & knee jerks sensory loss I.A-S4
none
none
unchanged, 5 mos
Payne & 26, M Thompson, 1969
fracture of both radicular pubic rami, rt traction ilium, and sacroiliac joint; rt hip dislocation
weakness & atro- L-5, S-l, S-2 yes phy rt glutei meninquadriceps & gocele, rt calf muscles; foot drop; L5-S1 sensory loss, rt leg, foot, & bladder
none
intractable pain, cordotomy; gait and sphincter normal
Carlson & 24, M Hoffman, 1971
fracture both pubic rami, rt sacral wing, & L2--4 transverse process
paralysis It toe flexors; total It L5--$2 sensory loss
none
unchanged, 6 wks
Alker,
et al., 1967
radicular traction
sciatic traction
L5-S1 meningocele, It
none
*Our own ease is not included.
538
J. Neurosurg. / Volume 46 / April, 1977
Traumatic lumbosacral meningocele TABLE 1 (Continued)*
Author, Year
Age, Sex
Eisenberg,
33, M
et al., 1972
McLennan, 17, F
et al., 1973
Harris,
Associated Lesions
Mechanism
rt hip subluxa- sciatic tion; fracture traction posterior acetabulum
Clin: Clinical Myelog Surgery Follow-Up Symptomatology Myelogram Relation Results
paralysis of peroneal and posttibial nerves; sensory loss in rt foot, and lateral region of leg
none S-1 ex- pain, rhiplora- zotomy & tion:S-1 cordotomy, nerve amputation root below partially knee, 6 yrs lesioned
L5-S1 meningocele, rt
fracture It inradicular paralysis quadri- L-4 menferior pubic traction ceps, peroneal, ingocele, it ramus, sacro& tibial muscles; iliac joint & sensory loss in pubic symphysis 3 medial toes on It
none none
total
recovery,
6 mos
52, M
pubic diastasis; sciatic rt sacroiliac traction dislocation; rupture of urethra, & large bowel
weakness of rt L-5 menextensor halingocele, rt lucis longus & peroneal muscles; hypesthesia dorsum rt foot
yes
none
residual hypesthesia & aching sensation in rt foot 6yrs
33, M
pelvic and transverse process fractures
sciatic traction
weakness of rt L-3 mengluteus maxiingocele, rt mns & lateral hamstring; hypesthesia of rt S-1 dermatome
none
none
residual rt S-I hypesthesia, 18 mos
20, M
both pubic rami fractures, sacral fracture; rupture of bladder
sciatic traction
anterotibial muscular paralysis & weakness of all muscular groups of It leg distal to hip; hypexesthesia of It L-5 & S-1 dermatomes
L-4 and L-5 diverticula, It
yes, none partially
unchanged, with slight improvement of antexotibial paresis, 3yrs
20, M
multiple injuries sciatic of pelvis and traction extremities
paralysis of hip flexors, qnadriceps, foot dorsiflexors in the rt limb, weakness of hip extensors & hamstring, anesthesia L 2-5 dexmatomes, rt
L-2, L-3, and 1.,-5 meningocele, rt
yes, none partially
improved, 11 yrs
Barnett & 25, M Connolly, 1975
pubic diastasis, sciatic pubic rand traction fracture, rt dislocation of sacroiliac joint; amputation of both legs
intractable pain in It stump
meningoceles at different lumbar levels
none intrano pain dural dorsal column stimulation
Padberg & 6, M Coene, 1975
none
S-1 meningocele, It
none none
et al., 1973
hyperpres- none sure of CSF
total reeovery
*Our own case is not included.
J. Neurosurg. / Volume 46 / April, 1977
539
J. Barberfi,
et al.
d H
R
I
N
P
FIG. 3. Outlines of myelographic images in all similar cases, reported by the following authors: A = Nosik (1955); B = Finney and Wulfman (1960); C, D = Goodell (1966); E, F = Alker, et al. (1967); G = Payne and Thomson (1969); H = Carlson and Hoffman (1971); I = Eisenberg, et al. (1972); J, K, L, M = Harris, et al. (1973); N = McLennan, et al. (1973); O = Barnett and Connoily (1975); P = Padberg and Coene (1975).
nerve is assumed. '-6 The two remaining cases ls,~4 could be explained by a cerebrospinal fluid hyperpressure wave. Careful evaluation of anatomical lesions found during operations 5,8 sometimes shows nerve roots of normal a p p e a r a n c e at the level of the meningocele as well as in the dural sac. Not uncommonly, clinical improvement occurs in time in cases with clear myelographic findings),a2-~4 Outlines of the myelographic images found in all published cases are presented in Fig. 3. Even with large sheath disruptions 5,6,s,u,ls the suspected nerve root is not severed or may be only partially damaged, as later demonstrated by operation or clinical follow-up study. Thus, myelographic findings have no absolute value in demonstrating a nerve-root avulsion as has already been noted in brachial plexus injuries? ~ The surgical findings suggest that the junction between the radicular sheath proximal to the ganglion and the dural sac is a "locus 540
minor resistentiae" where traction can be centered, thus protecting the nerve root, which then suffers only a neuropraxis. Weakness at this junction point could explain the development of extradural sacral cysts, the surgical appearance of which is similar to the traumatic ones in our experience. The etiology of these cysts is not yet clear, but they are described with increasing frequency? This weakness of the radicular sheath can explain the extension of the subarachnoid space to the ganglion, giving the typical image of a perineural cyst at myelography. With persisting C S F pressure, gradual dilatation is facilitated. Surgery has not been generally advocated as treatment, but it should be considered in two contingencies: the arrest of clinical improvement and the existence of large pseudocysts whose size may increase by a ball-valve mechanism and could then compress adjacent nerve roots, as M c t e n n a n , el al., TM have suggested. J. Neurosurg. / Volume 46 / April, 1977
Traumatic lumbosacral meningocele References 1. Alker GJ Jr, Glasauer FE, Zoll JG, et al: Myelographic demonstration of lumbosacral nerve root avulsion. Radiology 89:101-104, 1967 2. Barberfi J, Barcia Salorio JL, Soler F, et ah Quistes intrasacros. Rev Esp Otoneurooftalm Ncurocir 31:1-19, 1973 3. Barnett HG, Connolly ES: Lumbosacral nerve root avulsion: report of a case and review of the literature. J Trauma 15:532-535, 1975 4. Carlson DH, Hoffman HB: Lumbosacral traumatic meningocele. Report of a case. Neurology 21:174-176, 1971 5. Eisenberg KS, Sheft D J, M u r r a y WR: Posterior dislocation of the hip producing lumbosacral nerve-root avulsion. A case report. J Bone Joint Surg 54A:1083-1086, 1972 6. Finney LA, Wulfman WA: Traumatic intradural lumbar nerve root avulsion with associated traction injury to the common peroneal nerve. Am J Roentgenol Radium Ther Nucl Med 84:952-957, 1960 7. Froman C, Stein A: Complicated crushing injuries of the pelvis. J Bone Joint Surg 49B:24-32, 1967 8. Goodell CL: Neurological deficits associated with pelvic fractures. J Neurosurg 24:837-842, 1966 9. Harris W R , Rathbun JR, Wortzman G, et al: Avulsion of lumbar roots complicating frac-
J. Neurosurg. / Volume 46 / April, 1977
10.
11.
12.
13. 14. 15. 16.
ture of the pelvis. J Bone Joint Surg 55A:1436-1442, 1973 H6on M: Myelogram: a questionable aid in diagnosis and prognosis in avulsion of brachial plexus components by traction injuries. Conn Med 29:260-262, 1965 Huittinen V-M: Lumbosacral nerve injury in fracture of the pelvis: a postmortem radiographic and patho-anatomical study. Acta Chir Scand (Suppl) 429:1-43, 1972 McLennan JE, McLaughlin WT, Skiilicorn SA: Traumatic lumbar nerve root meningocele. Case report. J Neurosurg 39:528-532, 1973 Nosik WA: Intracranial hypotension secondary to lumbar nerve sleeve tear. J A M A 157:1110-1111, 1955 Padberg G, Coene LNM: Traumatic disruption of the sacral root sheath. J Neuroi Neurosurg Psychiatry 38:819-821, 1975 Payne RF, Thomson JLG: Myeiography in lumbo-sacral plexus injury. Br J Radiol 42:840-845, 1969 Tarlov IM, Day R: Myelography to help localize traction lesions of the brachial plexus. Am J Surg 88:266-271, 1954
Address reprint requests to: Jos6 Barberd, M.D., Servicio de Neurocirugia, Hospital Clinico Universitario, Valencia, Spain.
541
Josl~ BARBERA, M.D., JAIME BROSETA, M.D., FRANCISCO ARGt~ELLES, M.D., AND JUAN L. BARCIA-SALORIO, M . D .
Departments of Neurosurgery and Traumatology. University Hospital, Valencia, Spain A case of traumatic avulsion of the L-5 and S-1 nerve roots is described. Surgical intervention was undertaken and long-term functional recovery obtained. KEY WORDS
9
nerve-root avulsion
T
RAUMATIC lumbosacral meningoceles are seldom described. We have found 16 well documented instances of this lesion :,8-6,8,ga2-t6 and present an additional case. Case Report
This 21-year-old man was riding a motorcycle on November 14, 1974, when he was struck by an automobile. He fell to the ground on his gluteal area, with the hip joints spread in abduction, and the left leg stretched with the hip and knee in extension. He was hospitalized immediately. He had a right inguinal h e m a t o m a and complained of aching sensations in the low back and pubic region. Examination. Neurological examination showed paralysis of the left ankle and foot. There was anesthesia in the L-5 and S-1 dermatomes on the left and hypesthesia in the S-2, S-3, and S-4 dermatomes. Thus, the left ankle jerk was abolished, while the patellar reflexes remained normal and symmetrical. Sphincters were intact. After the patient recovered from traumatic shock, radiographs 536
9 meningocele
9 trauma
showed right iliopubic and transverse sacral fractures. H e was treated with bed rest and right-leg traction. Electromyographic recordings 2 weeks after admission showed involvement o f the L-3 to S-3 nerve roots on the left. There was no change in his neurological status. One month after the injury a Pantopaque m y e l o g r a m (Fig. 1) showed a large meningocele at the level of the left L-5 and S-1 nerve roots. Other small diverticula a p p e a r e d above and below these roots. Lateral and oblique projections confirmed these findings. Operation. On December 28, 1974, an exploratory laminectomy was performed. At operation (Fig. 2), the meningoceles were visualized. The left L-5 root sheath was opened, revealing a normal nerve root in continuity with some swelling. The cyst of the left S-1 nerve root was also opened and a total nerve-root avulsion was found. Postoperative Course. At a follow-up examination 14 months postoperatively, the patient was markedly improved. He had begun work as a hairdresser. There was
J. Neurosurg. / Volume 46 / April, 1977
Traumatic lumbosacral meningocele residual paralysis of left ankle flexion. Sensation had improved with hypesthesia of the left S-1 d e r m a t o m e persisting.
Discussion Table 1 summarizes all 16 reported cases of this type o f lesion. This small number seems to suggest a low incidence of this lesion. However, Huittinen 11 found six intradural lesions of the lumbosacral nerve roots in 42 autopsied cases of trauma with pelvic fractures. It is likely that, if more patients survived violent trauma, a greater incidence of this lesion would be reported. In only 11 reported cases was a severe pelvic lesion with luxation or fracture-luxation of the sacroiliac joint found. 1,8,a2,15 Vertical sacral fractures can produce a radicular disruption by shearing but generally this lesion does not appear in the myelogram. 7 In the other five cases and in our own it was not possible to demonstrate a fracture that in itself would cause a radicular lesion. Thus, in three cases and in our case, m a x i m u m traction upon the sciatic
FIG. 1. Anteroposterior view of the myelogram, showing the L-5 and S-1 diverticula. Abnormal filling of the left radicular sheath can be seen.
FIG. 2. Two views of the operation. Left: The L-5 meningocele is opened, showing an intact nerve root. Right: The S-1 cyst is also opened, and appears empty without a nerve root.
J. Neurosurg. / Volume 46 / April, 1977
537
J. Barberfi,
et al.
TABLE 1
Summary of 16 eases of traumatic lumbosacral nerve root meningoeele* Author, Year Nosik, 1955
Age, Sex ?, M
Associated Lesions
Clinical Clin: Mechanism. . Myelogram Myelog ~ Follow-Up ~ymptomatology Relation surgery Results
none
possible increased CSF pressure
no neurological deficits; headache caused by lack of CSF
1.,-3meningocele, rt
none
none
well, 2 mos
Finney & Wulfman, 1960
19, M
laceration It buttock
sciatic traction
absent knee & ankle jerk on It; anterotibial paralysis; hypesthesia in It foot; delayed I.,-4 hyperalgesia
L-4 meningocele, It
none
none
residual footdrop, lyr
Goodell, 1966
22, M
separation pubic symphysis; sacroiliac joint
radicular traction
paralysis below rt knee; sphincter tone decreased; L5-$3 sensory loss, rt
L5-S1 meningocele, rt
none
operation: L5-S1 intact; $2--4 atrophic
neurologically unchanged 4 yrs
31, M
fracture rt radicular pubic ramus, traction ilium, & isehium; sacroiliac joint dislocated; separation I.,-2 superior facet; renal contusion
total motor and sensory loss, rt leg
L5-S1 meningocele, rt
none
lamiunchanged, nectomy 5 mos T12L3, all nerve roots intact
22, M
separation rt sacroiliac joint & pubic symphysis
paralysis rt toes; L-5 meninatrophy rt gocele, rt glutei, hamstrings, & biceps femoris; anesthesia rt foot, in dorsum, & posterior thigh
none
operation: no L-5 nerve root visualized
unchanged, 11 rues
19, M
separation both radicular sacroiliac traction joints, pubic fracture; fracture lower 3 sacral foramina on rt
paralysis anteL-5, S-1, rior compartS-2, ment rt leg; meninabsent ankle gocele, rt & knee jerks sensory loss I.A-S4
none
none
unchanged, 5 mos
Payne & 26, M Thompson, 1969
fracture of both radicular pubic rami, rt traction ilium, and sacroiliac joint; rt hip dislocation
weakness & atro- L-5, S-l, S-2 yes phy rt glutei meninquadriceps & gocele, rt calf muscles; foot drop; L5-S1 sensory loss, rt leg, foot, & bladder
none
intractable pain, cordotomy; gait and sphincter normal
Carlson & 24, M Hoffman, 1971
fracture both pubic rami, rt sacral wing, & L2--4 transverse process
paralysis It toe flexors; total It L5--$2 sensory loss
none
unchanged, 6 wks
Alker,
et al., 1967
radicular traction
sciatic traction
L5-S1 meningocele, It
none
*Our own ease is not included.
538
J. Neurosurg. / Volume 46 / April, 1977
Traumatic lumbosacral meningocele TABLE 1 (Continued)*
Author, Year
Age, Sex
Eisenberg,
33, M
et al., 1972
McLennan, 17, F
et al., 1973
Harris,
Associated Lesions
Mechanism
rt hip subluxa- sciatic tion; fracture traction posterior acetabulum
Clin: Clinical Myelog Surgery Follow-Up Symptomatology Myelogram Relation Results
paralysis of peroneal and posttibial nerves; sensory loss in rt foot, and lateral region of leg
none S-1 ex- pain, rhiplora- zotomy & tion:S-1 cordotomy, nerve amputation root below partially knee, 6 yrs lesioned
L5-S1 meningocele, rt
fracture It inradicular paralysis quadri- L-4 menferior pubic traction ceps, peroneal, ingocele, it ramus, sacro& tibial muscles; iliac joint & sensory loss in pubic symphysis 3 medial toes on It
none none
total
recovery,
6 mos
52, M
pubic diastasis; sciatic rt sacroiliac traction dislocation; rupture of urethra, & large bowel
weakness of rt L-5 menextensor halingocele, rt lucis longus & peroneal muscles; hypesthesia dorsum rt foot
yes
none
residual hypesthesia & aching sensation in rt foot 6yrs
33, M
pelvic and transverse process fractures
sciatic traction
weakness of rt L-3 mengluteus maxiingocele, rt mns & lateral hamstring; hypesthesia of rt S-1 dermatome
none
none
residual rt S-I hypesthesia, 18 mos
20, M
both pubic rami fractures, sacral fracture; rupture of bladder
sciatic traction
anterotibial muscular paralysis & weakness of all muscular groups of It leg distal to hip; hypexesthesia of It L-5 & S-1 dermatomes
L-4 and L-5 diverticula, It
yes, none partially
unchanged, with slight improvement of antexotibial paresis, 3yrs
20, M
multiple injuries sciatic of pelvis and traction extremities
paralysis of hip flexors, qnadriceps, foot dorsiflexors in the rt limb, weakness of hip extensors & hamstring, anesthesia L 2-5 dexmatomes, rt
L-2, L-3, and 1.,-5 meningocele, rt
yes, none partially
improved, 11 yrs
Barnett & 25, M Connolly, 1975
pubic diastasis, sciatic pubic rand traction fracture, rt dislocation of sacroiliac joint; amputation of both legs
intractable pain in It stump
meningoceles at different lumbar levels
none intrano pain dural dorsal column stimulation
Padberg & 6, M Coene, 1975
none
S-1 meningocele, It
none none
et al., 1973
hyperpres- none sure of CSF
total reeovery
*Our own case is not included.
J. Neurosurg. / Volume 46 / April, 1977
539
J. Barberfi,
et al.
d H
R
I
N
P
FIG. 3. Outlines of myelographic images in all similar cases, reported by the following authors: A = Nosik (1955); B = Finney and Wulfman (1960); C, D = Goodell (1966); E, F = Alker, et al. (1967); G = Payne and Thomson (1969); H = Carlson and Hoffman (1971); I = Eisenberg, et al. (1972); J, K, L, M = Harris, et al. (1973); N = McLennan, et al. (1973); O = Barnett and Connoily (1975); P = Padberg and Coene (1975).
nerve is assumed. '-6 The two remaining cases ls,~4 could be explained by a cerebrospinal fluid hyperpressure wave. Careful evaluation of anatomical lesions found during operations 5,8 sometimes shows nerve roots of normal a p p e a r a n c e at the level of the meningocele as well as in the dural sac. Not uncommonly, clinical improvement occurs in time in cases with clear myelographic findings),a2-~4 Outlines of the myelographic images found in all published cases are presented in Fig. 3. Even with large sheath disruptions 5,6,s,u,ls the suspected nerve root is not severed or may be only partially damaged, as later demonstrated by operation or clinical follow-up study. Thus, myelographic findings have no absolute value in demonstrating a nerve-root avulsion as has already been noted in brachial plexus injuries? ~ The surgical findings suggest that the junction between the radicular sheath proximal to the ganglion and the dural sac is a "locus 540
minor resistentiae" where traction can be centered, thus protecting the nerve root, which then suffers only a neuropraxis. Weakness at this junction point could explain the development of extradural sacral cysts, the surgical appearance of which is similar to the traumatic ones in our experience. The etiology of these cysts is not yet clear, but they are described with increasing frequency? This weakness of the radicular sheath can explain the extension of the subarachnoid space to the ganglion, giving the typical image of a perineural cyst at myelography. With persisting C S F pressure, gradual dilatation is facilitated. Surgery has not been generally advocated as treatment, but it should be considered in two contingencies: the arrest of clinical improvement and the existence of large pseudocysts whose size may increase by a ball-valve mechanism and could then compress adjacent nerve roots, as M c t e n n a n , el al., TM have suggested. J. Neurosurg. / Volume 46 / April, 1977
Traumatic lumbosacral meningocele References 1. Alker GJ Jr, Glasauer FE, Zoll JG, et al: Myelographic demonstration of lumbosacral nerve root avulsion. Radiology 89:101-104, 1967 2. Barberfi J, Barcia Salorio JL, Soler F, et ah Quistes intrasacros. Rev Esp Otoneurooftalm Ncurocir 31:1-19, 1973 3. Barnett HG, Connolly ES: Lumbosacral nerve root avulsion: report of a case and review of the literature. J Trauma 15:532-535, 1975 4. Carlson DH, Hoffman HB: Lumbosacral traumatic meningocele. Report of a case. Neurology 21:174-176, 1971 5. Eisenberg KS, Sheft D J, M u r r a y WR: Posterior dislocation of the hip producing lumbosacral nerve-root avulsion. A case report. J Bone Joint Surg 54A:1083-1086, 1972 6. Finney LA, Wulfman WA: Traumatic intradural lumbar nerve root avulsion with associated traction injury to the common peroneal nerve. Am J Roentgenol Radium Ther Nucl Med 84:952-957, 1960 7. Froman C, Stein A: Complicated crushing injuries of the pelvis. J Bone Joint Surg 49B:24-32, 1967 8. Goodell CL: Neurological deficits associated with pelvic fractures. J Neurosurg 24:837-842, 1966 9. Harris W R , Rathbun JR, Wortzman G, et al: Avulsion of lumbar roots complicating frac-
J. Neurosurg. / Volume 46 / April, 1977
10.
11.
12.
13. 14. 15. 16.
ture of the pelvis. J Bone Joint Surg 55A:1436-1442, 1973 H6on M: Myelogram: a questionable aid in diagnosis and prognosis in avulsion of brachial plexus components by traction injuries. Conn Med 29:260-262, 1965 Huittinen V-M: Lumbosacral nerve injury in fracture of the pelvis: a postmortem radiographic and patho-anatomical study. Acta Chir Scand (Suppl) 429:1-43, 1972 McLennan JE, McLaughlin WT, Skiilicorn SA: Traumatic lumbar nerve root meningocele. Case report. J Neurosurg 39:528-532, 1973 Nosik WA: Intracranial hypotension secondary to lumbar nerve sleeve tear. J A M A 157:1110-1111, 1955 Padberg G, Coene LNM: Traumatic disruption of the sacral root sheath. J Neuroi Neurosurg Psychiatry 38:819-821, 1975 Payne RF, Thomson JLG: Myeiography in lumbo-sacral plexus injury. Br J Radiol 42:840-845, 1969 Tarlov IM, Day R: Myelography to help localize traction lesions of the brachial plexus. Am J Surg 88:266-271, 1954
Address reprint requests to: Jos6 Barberd, M.D., Servicio de Neurocirugia, Hospital Clinico Universitario, Valencia, Spain.
541
