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ECR 2019 / C-0081
Magna Cum Laude
Tectorial membrane injury in the acute trauma setting: examining disparities between the adult and paediatric populations
Congress: ECR 2019
Poster No.: C-0081
Type: Scientific Exhibit
Keywords: Neuroradiology spine, Paediatric, Trauma, MR, CT, Localisation
Authors: P. Fiester, E. Soule, P. Natter, D. Rao; Jacksonville, FL/US
DOI:10.26044/ecr2019/C-0081

Conclusion

A classification system for TM injuries is proposed based on this data: type 1 - retroclival stripping injury (more common in pediatric patients; associated with REH);

 

Fig. 4: Sagittal T2-weighted MRI of pediatric stripped tectorial membrane (type 1 TM injury) with retroclival location and REH
References: Neuroradiology, University of Florida Health Jacksonville, Shands hospital - Jacksonville/US

type 2a - subclival disruption at the basion (more common in adults);

Fig. 5: Sagittal T2-weighted MRI of adult disrupted tectorial membrane with clival location (type 2A TM injury)
References: Neuroradiology, University of Florida Health Jacksonville, Shands hospital - Jacksonville/US

type 2b - subclival disruption at the odontoid (more common in adults);

Fig. 6: Sagittal T2-weighted MRI of adult disrupted tectorial membrane with odontoid location (type 2B injury)
References: Neuroradiology, University of Florida Health Jacksonville, Shands hospital - Jacksonville/US

and type 3 - stretching injury of the TM.

Fig. 7: Sagittal T2-weighted MRI of pediatric stretched tectorial membrane (type 3 injury)
References: Neuroradiology, University of Florida Health Jacksonville, Shands hospital - Jacksonville/US

The nature, imaging, treatment, and prognosis of TM injury appears to differ between adult and pediatric patients. Adults tend to suffer type 2 injuries to the TM, or complete disruptions, and management is primarily surgical. In adults, persistent neurologic deficits are relatively common due to concomitant injuries. Meanwhile, pediatric patients tend to have type 1 injuries of the TM, or a stripping injury of the TM from the clivus. Management is primarily conservative and persistent neurologic deficits are relatively uncommon. Type 3 injuries may be a result of an unstable C2 fracture, resulting in mechanical loading of the TM and a 'stretched' appearance on imaging. They may also represent the milder end of the spectrum of TM injuries, where the force imparted to the membrane during trauma was insufficient to cause a full thickness rupture, but did cause a partial thickness 'fraying' tear.

 

The combination of increased ligamentous laxity and incomplete development/incorporation of the TM along the posterior clivus predisposes pediatric patients to a stripping of the TM and dura mater from the posterior clivus and development of a retroclival epidural hematoma. In adult patients, TM injuries were observed to be predominantly full thickness tears in either a subclival or an odontoid location. It has been suggested that a disruption of the TM is a critical determinant as to whether a CCJ injury is stable or unstable (3). None of the pediatric patients observed in this study suffered an overt disruption of the TM, and none underwent cervical spinal fusion. Preferentially suffering type 1 injury or separation of the TM from the clivus during acute trauma may allow children to recover with conservative management. Delayed maturation of ligamentous structures of the CCJ and especially the interface between the clivus and TM seems to protect children from TM rupture and unstable injury since children are more prone to cervical spine trauma (4). 

 

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