Cervico-thoracic Morel-Lavallée lesion

Abstract

Morel-Lavallée lesions (MLLs) result from high-energy trauma causing separation of subcutaneous tissue from the underlying tissue, most commonly in the gluteal region or thigh.

We report the case of a woman in her 40s with a fluctuant collection of the cervico-thoracic region following trauma. Further imaging identified an MLL. An orthoplastic approach resulted in non-operative management with a spinal brace. Three months from initial injury, the lesion completely resolved. She was symptom free at final follow-up and discharged.

We present the only recorded case of MLL developing in the cervico-thoracic region. Management posed difficultly as no literature currently exists. We demonstrated conservative management for cervico-thoracic MLL can be effective.

We have described the first documented case of cervico-thoracic MLL. MLL is not exclusive to pelvic injuries and can develop in the cervico-thoracic region. We have shown conservative management is a viable treatment of atypical MLL.

Background

Morel-Lavallée lesions (MLLs) are closed post-traumatic soft tissue injuries that involve degloving of superficial layers from deeper facial layers.^{1 2} MLLs were first described by the French physician Victor-Auguste-Francois Morel-Lavallée in 1853.³ MLLs are predominately caused from high-energy blunt trauma or crush injuries and are associated with pelvic and acetabula fractures. Motor vehicle accidents are the most common mechanism of injury.^{4 5}

The mechanism of injury is trauma that occurs tangential to the facial plane, which causes shearing forces to separate the facial planes. A seroma then forms in the cavity created.⁶ MLL commonly occurs over the greater trochanter with the thigh and pelvis also being common sites of injury.⁵

Case presentation

Here, we report the first case of cervico-thoracic MLL in a woman in her 40s who presented to the emergency department after a fall from a ladder about six feet heigh and further fall down a flight of stairs. At the time of presentation, the patient was tender in the midline over both cervical and thoracic regions; however, there was no focal neurology.

A CT scan identified an isolated T12 compression fracture. After discussion with the local spine team, management with a thoracolumbar sacral orthosis (TLSO) brace was advised. Ongoing pain and fluctuant swelling over the cervical/thoracic spine prompted an ultrasound scan (USS) of the area looking for a collection. USS suggested a MLL and an MRI was undertaken to confirm the diagnosis.

MRI confirmed the diagnosis of MLL extending from C7-T8 spinous process (figures 1 and 2). Specialist opinion was sought from plastic surgeons who advised to continue conservative management with sequential MRI for observation.

Figure 1.

(A) T1-weighted MRI sagittal view MLL cervico-thoracic spine. (B) T2-weighted MRI stir sagittal view MLL cervico-thoracic spine both at the time of injury.

Figure 2.

(A) T2-weighted MRI transverse view MLL cervico-thoracic spine and (B) T2 sagittal view MLL cervico-thoracic spine, both at the time of injury.

Outcome and follow-up

The patient was followed up in local fracture clinic at 1 month and 3 months post injury. Clinically, the patient had mild ongoing pain over the location of the MLL at the 1-month mark. Follow-up at 3 months found the patient was independently ambulatory and had no ongoing symptoms. An MRI was undertaken at this point, showing a complete resolution of the MLL and no recollection (figures 3 and 4). She was subsequently discharged with no ongoing problems.

Figure 3.

(A) T2-weighted MRI sagittal view MLL cervico-thoracic spine 3 months post injury and (B) T1-weighted MRI sagittal view 3 months post injury.

Figure 4.

(A) T1-weighted MRI axial view MLL cervico-thoracic spine and (B) T2-weighted MRI axial view. both taken at 3 months post injury.

Discussion

MLL is a closed post-traumatic lesion that most commonly occurs over the greater trochanter, elsewhere in the thigh, pelvis and knee.⁴ In a review of the literature, Vanhegan et al⁷ looked at 204 cases and documented the presenting area of injury. This breakdown can be seen in table 1. At the time of writing, not one case of a cervico-thoracic MLL has been recorded. In this report, we have documented the first known case of a MLL presenting in the cervico-thoracic spine.

Table 1.

Table from⁷ detailing site of Morel-Lavallée lesion (MLL) from literature

Site	Number
Greater trochanter/hip	62
Thigh	41
Pelvis	38
Knee	32
Gluteal	13
Lumbo-sacral	7
Abdominal	3
Calf/Lower leg	3
Head	1
Not specified	4

MRI is the imaging modality of choice when diagnosing MLL as one can more confidently identify the type of lesion and chronicity; however, USS can also be used. Mellado and Bencardino put forth a classification of MLLs according to T1- and T2-weighted MRI appearance, presence of a capsule and enhancement features. A summary of their classification can be found in table 2, with all MLLs being categorised into six types.⁴ Of the subtypes put forward by Mellado and Bencardino, the lesion we have detailed in this case report is best described as a MLL type I. MRIs taken at the time of injury shown in figure 1 display the characteristic hyperintense T2 image, hypointense T1 image without capsule formation.

Table 2.

Summary of Melland and Bencardino classification of Morel-Lavallée lesion (MLL)^{4 11}

	Type I Seroma	Type II Subacute haematoma	Type III Chronic organising haematoma	Type IV Closed lacerations	Type V Pseudonodular	Type VI Infected
Appearance T1-weighted images	Hypointense	Hyperintense	Hypointense	Hypointense	Variable	Variable
Appearance T2-weighted images	Hyperintense	Hyperintense	Hyperintense	Hypointense	Variable	Variable
Presence of capsule	Variable	Yes	Fibrous	No	Variable	Thick hyperintense

The management of MLL is dependent on multiple factors: (1) the stage at which the lesion is detected, (2) location and (3) patient factors. Options for the management of MLL include compression bandages, incision and evacuation and USS-guided drainage.^8–10 Conservative management in the treatment of MLL is not uncommon; but, in most cases described, this will be in the form of compression bandages and elevation. In the case presented, this was not possible due to the location of the lesion, the cervico-thoracic spine. After discussion with local spinal and plastic surgery teams, a ‘watchful wait’ approach was taken. As described, the patient had full resolution of symptoms and has now been discharged from local follow-up with no ongoing deficit. The findings of this report suggest that in MLL lesions developing in the cervico-thoracic region, conservative management can result in complete resolution of the lesion.

Learning points.

• Here, we have described the first documented case of a cervico-thoracic Morel-Lavallée lesion.

• The diagnosis of MLL must be considered for any traumatic injury where degloving could occur and not just in known areas.

• Conservative management is a viable option in the treatment of MLLs but we suggest further research is needed to correlate findings.

Ethics statements

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