Tectorial membrane injury [Neurosurgery Wiki]

This page is read only. You can view the source, but not change it. Ask your administrator if you think this is wrong.
====== Tectorial membrane injury ======

The current knowledge base of [[craniocervical injury]] is very limited. A study of Child et al. showed that the key restraints to [[craniocervical instability]] are the [[alar ligament]]s, [[tectorial membrane]], and the [[atlantooccipital joint]] capsules. Dissociation requires the complete incompetence of all three. The craniocervical traction test reliably demonstrates instability and requires no more than 5-10 lb of traction to perform
((Child Z, Rau D, Lee MJ, Ching R, Bransford R, Chapman J, Bellabarba C. The
provocative radiographic traction test for diagnosing craniocervical
dissociation: a cadaveric biomechanical study and reappraisal of the pathogenesis
of instability. Spine J. 2016 Sep;16(9):1116-23. doi:
10.1016/j.spinee.2016.03.057. Epub 2016 Jun 6. PubMed PMID: 27283520.
)).
----


The [[tectorial membrane]] is the major [[craniocervical]] stabilizer and plays an essential role in the pathogenesis of [[retroclival epidural hematoma]] (REH)
((WERNE S. Studies in spontaneous atlas dislocation. Acta Orthop Scand Suppl.
1957;23:1-150. PubMed PMID: 13434893.
)).

It is a rare entity in the pediatric population. High-speed motor vehicle accidents (MVAs) are the predominant cause of injury
((Sun PP, Poffenbarger GJ, Durham S, Zimmerman RA. Spectrum of
occipitoatlantoaxial injury in young children. J Neurosurg. 2000 Jul;93(1
Suppl):28-39. PubMed PMID: 10879755.
)).

Abrupt acceleration/decelerations in combination with [[craniocervical junction]] [[hyperextension]]/[[hyperflexion]] (eg, in MVAs) is believed to be causative of pediatric tectorial membrane injury with REH
((Kwon TH, Joy H, Park YK, Chung HS. Traumatic retroclival epidural hematoma in 
a child: case report. Neurol Med Chir (Tokyo). 2008 Aug;48(8):347-50. PubMed
PMID: 18719324.
)).
----
The postulated mechanism for tectorial membrane injury is sagittal dislocation of the [[odontoid process]] associated with disruption of the [[transverse ligament]] that detaches the tectorial membrane from the [[clivus]]. In children, the dura matter and tectorial membrane are not firmly attached to the skull; stripping tectorial membrane injury could result in traction damage to the adjacent vascular structures such as the [[basilar venous plexus]] and dorsal meningeal branch of the [[meningohypophyseal trunk]]. This may result in the accumulation of blood in the [[retroclival]] epidural space
((Ratilal B, Castanho P, Vara Luiz C, et al. Traumatic clivus epidural hematoma: case report and review of the literature. Surg Neurol 2006;66:200–02))
((Kwon TH, Joy H, Park YK, et al. Traumatic retroclival epidural hematoma in a child: case report. Neurol Med Chir (Tokyo) 2008;48:347–50))
((Mizushima H, Kobayashi N, Sawabe Y, et al. Epidural hematoma of the clivus: case report. J Neurosurg 1998;88:590–93)).
----
Tubbs et al
((Tubbs RS, Griessenauer CJ, Hankinson T, Rozzelle C, Wellons JC 3rd, Blount JP,
Oakes WJ, Cohen-Gadol AA. Retroclival epidural hematomas: a clinical series.
Neurosurgery. 2010 Aug;67(2):404-6; discussion 406-7. doi:
10.1227/01.NEU.0000372085.70895.E7. PubMed PMID: 20644426.
))
had reported an association with [[craniocervical junction]] dislocation and [[spinal cord injury]]. This may be explained by the larger mobility and ligamentous flexibility of the craniocervical junction in children, which indirectly “protects” the osseous structures of the craniocervical junction but enhances ligamentous injuries. 

===== Diagnosis =====
Meoded et al. aimed to describe the neuroimaging findings in pediatric REHs, to summarize the mechanism of injury, and to correlate the imaging findings with the clinical presentation. 

They retrospectively evaluated CT and/or MR imaging studies of 10 children with traumatic REH. Most patients were involved in MVAs. The [[tectorial membrane]] was injured in 70% of patients, and REHs were medium to large in 80%. None of the patients had a focal spinal cord or brain stem injury, craniocervical junction dislocation, or vertebral fractures. Tectorial membrane disruption was diagnosed in most patients without craniocervical junction-related symptoms. Tectorial membrane lesions and REHs were seen in young children who sustained high-speed head and neck injuries. Clinical symptoms may be minimal or misleading. The radiologist should be aware of these injuries in children. MR imaging appears to be more sensitive than CT
((Meoded A, Singhi S, Poretti A, Eran A, Tekes A, Huisman TA. Tectorial membrane
injury: frequently overlooked in pediatric traumatic head injury. AJNR Am J
Neuroradiol. 2011 Nov-Dec;32(10):1806-11. doi: 10.3174/ajnr.A2606. Epub 2011 Aug 
18. PubMed PMID: 21852371.
)).

===== References =====