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Evaluation of a Patient with Klumpke's Palsy: A Case Report

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The Neuroradiology Journal 23: 325-328, 2010 www.centauro.it

Evaluation of a Patient with Klumpke’s Palsy

A Case Report

A. D’AMORE¹, G. CONTE¹, A. VIGLIANESI², R. CHIARAMONTE³, G. PERO¹, I. CHIARAMONTE¹

¹Department of Neurosciences, University of Catania; Catania, Italy
²Department of Radiology, University of Catania; Catania, Italy
³Department of Otorhinolaryngology, University of Catania; Catania, Italy

Key words: Klumpke’s palsy, pseudomeningocele, MRI

SUMMARY – Klumpke’s palsy is a rare form of paralysis involving the muscles of the forearm and
hand, resulting from a brachial plexus injury in which the eighth cervical (C8) and first thoracic
(Th1) nerves are injured either before or after they have joined to form the lower trunk. We report a
case of a 45 years-old woman with post-traumatic left cervical-brachial pain afflicted by obstetric
brachial plexus palsy on the right side. Magnetic Resonance Imaging (MRI) examination of the cer-
vical spine revealed a meningeal stretch in the left side at C7-Th1 level, responsible for pain, and
also multiple intraforaminal pseudomeningoceles at C5-C6, C6-C7 and C7-Th1 intersomatic spaces
in the right side, due to the perinatal trauma that had determined the obstetric brachial plexus
palsy. Spinal pseudomeningocele is an extradural collection of CSF in the surrounding soft tissues
due to a dural breach and can represent a predictive finding of injury of the brachial plexus. We ob-
tained clinical and electrophysiological findings of Klumpke’s palsy, but MRI examination showed
the lack of visualization of C8 and the integrity of Th1 nerve roots and to our knowledge there is no
evidence in literature about the possibility to have a partial Klumpke’s palsy without Th1 avulsion.
The aim of this article was to underline that for the correct assessment of patients with brachial
plexus palsy the only use of MRI is insufficient: it is necessary an integration of the information
obtained from clinical, electromyographic and MRI study.

Introduction tool to evaluate subjects with brachial plexus

Spinal pseudomeningocele is an extradural
collection of CSF in the surrounding soft tissues
due to a dural breach 1. Iatrogenic causes of spi-
nal pseudomeningocele represent the most fre-
quent ones, especially after lumbar or cervical
spinal procedures that can determine a dural
defect, while congenital and traumatic causes
are less common 1,6. An association between
pseudomeningoceles and nerve root injury has
been reported and it is probable that these le-
sions are determined by nerve avulsion 9. Ob-
stetric brachial plexus palsy may determine
the formation of spinal pseudomeningocele
through nerve root avulsion 2,7-9. The frequency
of brachial plexus palsy is approximately 0.3 to
3.6 in 1000 births 9,11.
Spine Magnetic Resonance Imaging (MRI)
examination represents an useful diagnostic
birth palsy, because may allow to depict the
presence of the injured nerves, of the pseudo-
meningoceles and of other associated patholo-
gies 9,11. It shows the extension of injury, al-
though is not always able to detect the related
avulsion of the nerve roots. For this reason it
is important to evidence that only by combin-
ing clinical, electrophysiological and radiologic
findings a correct diagnosis and assessment of
patients with Klumpke’s palsy becomes possi-
ble.
Case Report
A 45-year-old woman presented in the Neu-
roscience Department of our hospital with
post-traumatic left cervical-brachial pain. Ra-
diographs of the cervical spine and shoulder

325
Evaluation of a Patient with Klumpke’s Palsy
Figure 1 Axial 3D FIESTA image at C7-Th1 level shows the
spinal pseudomeningocele. Note that the right C8 nerve root
was not identified and presumed to be avulsed. At the same lev-
el, on the left side, there is a meningeal stretch due to trauma.
Figure 2 Coronal T2-weighted image shows the pseudomenin-
goceles (from C5 to Th1 level).
showed no injury. The patient also had an ob-
stetric brachial plexus palsy of the right side.
Her physical examination showed paralysis of
intrinsic muscles of the right hand with hy-
potrophy of thenar, hypothenar and interros-
seus muscles, hypotrophy of muscles situated
in the anterior part of the forarm, abduction
and adduction deficiency of fingers, proximal
phalanges flexion, pinkie-thumb opposition and
ulnar side sensory impairment. No other defi-
cits or neurological symptoms were detected.
To support our clinical diagnosis and exclude
other diseases, an MRI scan and electrophysi-
ological study were performed.
MRI examination of the cervical spine was
performed with a 1.5 T MRI unit. To study the
cervical region we obtained sagittal and axial
T2-weighted and T1-weighted sequences and
axial 3D fast imaging with steady state ac-
quisition (FIESTA) sequences. The images ob-
tained by the 3D FIESTA sequences were fur-
ther reformatted in MIP (maximum intensity
projection) and orthogonal, oblique and curved
planes with MPR (multiplanar reconstruction).
The 3D FIESTA sequences demonstrated a
meningeal stretch of left nerve roots at C7-Th1
level; the right C8 nerve root was not visual-
ized and presumed to be avulsed (Figure 1).
The electrophysiological study disclosed no le-
sions involving nerves of the traumatized arm.
The MRI study demonstrated two small intra-
326
A. D’Amore
foraminal pseudomeningoceles at C5-C6 and
C6-C7 intersomatic spaces on the right side
and a larger one at C7-Th1 level that appeared
as a lobulated lesion of CSF signal (Figure 2).
3D FIESTA images demonstrated the integrity
of nerve roots at C5-C6, C6-C7 and Th1-Th2
intesomatic spaces (Figures 3-5). Electromy-
ography (EMG) revealed a chronic neurogenic
sufferance of muscles innervated by C8-Th1
nerve roots. There was no electric conduction
by ulnar nerve and a lower conduction by me-
dian nerve in neurography examination.
Discussion
Spinal pseudomeningocele is an extradural
collection of CSF in the soft tissues due to a
dural breach 1. Because of the absence of a lin-
ing membrane, pseudomeningoceles tend to
expand gradually into the surrounding tissues,
eventually forming a fibrous capsule.
Iatrogenic causes of pseudomeningoceles are
the most frequent, especially after lumbar or
cervical spinal procedures that can cause a du-
ral defect, such as laminectomy and lumbar
puncture. Congenital and traumatic causes are
less common 1. Congenital pseudomeningoce-
les can be due to neurofibromatosis type 1 and
Marfan’s Disease 6.
Various conditions can be involved in the for-
www.centauro.it The Neuroradiology Journal 23: 325-328, 2010

mation of traumatic pseudomeningoceles, such

as spinal nerve root injury (often due to the
birth palsy or motorcycle accidents), vertebral
fracture and joint dislocation 1-3,9. All these con-
ditions can determine a dural breach that facili-
tates CSF outflow to surrounding soft tissues.
Pseudomeningoceles are associated with
nerve root injury and it is probable that these
lesions are determined by nerve avulsion 9,11.
Obstetric brachial plexus palsy may determine
the formation of spinal pseudomeningocele
through nerve root avulsion caused by traction
of the neck and shoulder during birth 2,7-9. As
reported by some authors, pseudomeningocele
is found in 53-63% of subjects with brachial
plexus palsy and is predictive of a severe nerve
root injury 9,11.
Clinical, electrophysiological and radiological Figure 3 Axial 3D FIESTA at C5-C6 level.
examinations are useful to the assessment of
patients with obstetric brachial plexus palsy.
In our case the pseudomeningoceles were
correlated with obstetric palsy and might have
been due to the traction mechanism. Clinical
examination disclosed a sensory and motor im-
pairment of the structures innervated by ulnar
and median nerves arising from the inferior
lower trunks of the brachial plexus (C8-Th1).
The clinical findings of obstetric brachial
plexus palsies may differ depending on the level
of the spinal cord lesion: Erb’s palsy affects
nerves arising from C5 and C6; upper-middle
trunk brachial plexus palsy involves nerve
fibers from C5, C6, and C7 levels; Klumpke’s
palsy is a rare form of paralysis involving
the muscles of the forearm and hand, result- Figure 4 Axial 3D FIESTA at C6-C7 level.
ing from a brachial plexus injury in which the
eighth cervical (C8) and the first thoracic (Th1)
nerves are injured either before or after they
have joined to form the lower trunk, (although
many clinicians agree that pure C8-Th1 inju-
ries do not occur in infants and may be indica-
tive of spinal cord injury); total obstetric palsy
affects nerves at all levels (C5-Th1).
Electromyography (EMG) is an important
diagnostic tool in root avulsion because it can
demonstrate denervational changes 4,5. EMG ex-
amination of our patient revealed a neurogenic
sufferance compatible with avulsion of C8-Th1
nerve roots. These findings were confirmed by
the neurographic study which showed no con-
duction by the ulnar nerve and a lower con-
duction by the median nerve: this is possible
because some of the fibers, whose the median
nerve is composed, originates from the upper
trunk of the brachial plexus.
Physical examination alone and EMG are Figure 5 Axial 3D FIESTA at Th1-Th2 level.

327
 Evaluation of a Patient with Klumpke’s Palsy
usually insufficient to evaluate patients with
obstetric brachial plexus palsies due to a lack
of information on the extent of the disease and
the anatomic structures involved 9.
MRI of the spine, especially with 3D FIESTA
sequences, is helpful to identify the pseudo-
meningocele and to evaluate the course and in-
tegrity of sensory and motor nerve roots 4. MRI
can also be useful for surgical planning 9.
On MRI, spinal pseudomeningoceles show
typically low signal intensity on T1-weighted
images and high signal intensity on T2-weighted
images of the same consistency as CSF.
In our case MRI examination showed three
pseudomeningoceles from C5 to Th1 levels:
the largest lesion was localized at the C7-Th1
intersomatic space where the C8 nerve roots
arise. 3D FIESTA sequences showed the C6
and C7 nerve roots, but at the level of the larg-
est pseudomeningocele the right C8-nerve roots
were not visualized, probably because of the
perinatal trauma which caused their avulsion.
The visualization on MRI of nerve roots at the
same level as pseudomeningoceles (C5-C6 and
C6-C7 intersomatic spaces) was a demonstra-
tion of their integrity. At this level, pseudo-
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328
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A. D’Amore
meningoceles were determined by a dural tear
in the absence of nerve root avulsion. Accord-
ing to clinical and instrumental evidence we
supposed that our patient had Klumpke’s palsy
(C8-Th1). However MRI showed that Th1 nerve
roots were present and oriented normally. At
the same level no pseudomeningocele was de-
picted and this finding is strongly correlated
with intact nerve roots 7. To our knowledge
there is no evidence in the literature of partial
Klumpke’s palsy without Th1 nerve root avul-
sion. It is possible that Th1 nerve roots were
present and that the damage was localized in
the lower trunk of the brachial plexus after C8
and Th1 nerve roots had joined. In addition, it
was suggested that intraforaminal root avul-
sion can develop without any tearing of the
dura mater and so without formation of pseu-
domeningocele 10.
In conclusion, we suppose that the exclu-
sive use of MRI examination of the spine does
not always disclose nerve root injury. There-
fore, the correct assessment of patients with
brachial plexus palsy can be obtained only by
combining the information from clinical, elec-
tromyographic and MRI evaluation.
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avulsion: case report and review of the literature. Eur
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Adriano Viglianesi, MD
Department of Radiology
University Hospital
Catania, Italy
Tel. +393897897806
E-mail: a.viglianesi@hotmail.it