Nocturnal spinal fracture--first manifestation of epilepsy

A 54-year-old patient suffered overnight a double thoracic burst-fracture. One week later during the investigation for a metabolic or endocrinological cause, a witnessed seizure led to an unstable fracture of the humerus and the scapula. The neurological work-up revealed a cerebral astrocytoma as the epileptogenic focus. Forces generated during a tonic-clonic seizure can result in axial skeletal trauma, including thoracic and lumbar burst fractures. Vertebral fractures unrelated to an exogenous trauma are therefore always suspicious of an underlying epileptic disease.     

Seizure-induced thoracic spine compression fracture: case report

BACKGROUND: Vertebral fracture caused solely by a convulsive seizure has rarely been reported in the neurosurgical literature. CASE DESCRIPTION: We describe a 34-year-old male with severe back pain from a thoracic fracture occurring in association with a seizure during hospitalization for treatment of temporal lobe epilepsy. Bone mineral densities in the lumbar spine and the femoral neck were decreased, possibly by long-term anti-epileptic medication. Muscle contractions during a seizure can result in vertebral fractures, especially at the thoracic levels. CONCLUSION: A complaint of back pain after a convulsive seizure should prompt radiologic investigation for vertebral fracture, even in the absence of external trauma.     

Multiple seizure-induced thoracic vertebral compression fractures: a case report

Background:Musculoskeletal injuries stemming from forceful muscular contractions during seizures have been documented in the literature. Reports of multiple seizure-induced spinal fractures, in the absence of external trauma and without risk factors for fracture, are rare.Discussion:This report highlights the importance of a complete history and examination of patients with a history of tonic-clonic seizures and back pain, especially when considering spinal adjustments.Summary:This case report presents an argument that a tonic-clonic seizure, in the absence of external trauma or significant risk factors for fracture, resulted in multiple vertebral compression fractures.     

Bilateral central dislocation of the hip. A case report

Bilateral posterior shoulder dislocations and vertebral fractures are well described complications of convulsive activity. A 72-year-old woman with osteoarthritis of both hips and knees centrally dislocated both hips during a tonic-clonic seizure. Bilateral central fracture dislocation of the hip, although rare, must be suspected in the postictal patient who complains of hip and knee pain.     

Delayed unrelated presentation of a lumbar burst fracture consequent to a remote episode of a single convulsive seizure: A diagnostic challenge

Non-traumatic vertebral fractures occurring as a sole consequence of the violent muscle forces generated during the first episode of a GTCS(generalized tonic clonic seizure) in a previously healthy non-epileptic individual are very rare. Being clinically asymptomatic they are easily overseen at the time of initial presentation due to their rarity of occurrence and the presence of potentially distracting factors in the post-ictal phase. We present a 52-year-old healthy non-epileptic male who presented with unrelenting back pain and neurodeficit secondary to a four-month-old unstable burst fracture of the first lumbar vertebra sustained during an isolated single episode of a witnessed GTCS. A detailed inquiry revealed no history of a significant traumatic event either during the convulsive episode or thereafter. A meticulous history taking, a thorough clinical and neurological examination combined with a comprehensive radiological evaluation established the unusual etiology of the fracture and the presence of a thoracolumbar kyphotic deformity with compression of conus medullaris. A detailed neurological, and laboratory work-up, confirmed no attributable organic or metabolic cause for the seizure. His BMD(Bone Mineral Density) was normal. Patient was managed with posterior instrumented deformity correction by a posterior column shortening osteotomy, neural decompression and fusion of D12-L1 facets. Patient had complete neurological recovery with good clinical and functional outcomes at 28-months follow-up. A few cases of seizure-induced non-traumatic spinal fractures have been published in literature. A majority of these fractures occurred in individuals with either seizure-provoking risk factors (epileptics with recurrent seizures, brain tumors, drug overdose/withdrawal, metabolic disorders, or electrolyte imbalance) or in those with an increased susceptibility to fracture due to decreased BMD. This case demonstrates the rare occurrence of a non-traumatic vertebral fracture during the first episode of a GTCS in an otherwise healthy non-epileptic individual with normal BMD and no seizure-provoking risk factors. This is the first case report of a delayed unrelated presentation of a non-traumatic lumbar vertebral fracture with complications (spinal deformity and neurodeficit) consequent to a remote episode of a single convulsive seizure. It emphasizes the need for a high index of clinical suspicion,a meticulous history taking, thorough musculoskeletal and neurological examination in any individual presenting with a seemingly benign back pain following a remote isolated episode of seizure, even in the absence of overt trauma. A detailed radiological evaluation guided by a meticulous history taking and detailed clinical examination is essential to rule out a fracture unless proven otherwise. It also shows that a single convulsive seizure can result in a potentially unstable fracture that when neglected, can result in devastating complications like spinal deformity and neurodeficit.Level of evidenceLevel IV.     

Non-traumatic compression fractures of the thoracic spine following a seizure -- treatment by percutaneous kyphoplasty.

A 26-year-old male presented with acute mid-thoracic back pain following a witnessed grand mal seizure. There was no trauma and the patient was on steroids for systemic lupus erythematosus. X-rays and CT scans of the thoracic spine revealed compression fractures at T5 and T6, with 50 % loss of vertebral height and kyphosis. He underwent percutaneous kyphoplasty of both vertebrae, with symptomatic improvement. Non-traumatic compression fractures of the thoracic spine following seizures are a rare injury. This may be related to the compressive forces exerted on the vertebral column by the contractions of the truncal muscles, during a seizure. These compression fractures are suitable for treatment by minimally invasive techniques, such as kyphoplasty.     

A case of posterior element fracture in Kummell's disease

Kummell's disease is a rare, delayed posttraumatic collapse of a vertebral body that can occur several months or even years after an osteoporotic compression fracture. However, there are few reports of posterior element fractures associated with Kummell's disease. A 72-year-old man who had sustained an L1 osteoporotic compression fracture 14 months prior was admitted to our institution with incapacitating back pain. Plain radiographs showed progressive collapse of the L1 vertebral body and severe kyphosis at the thoracolumbar junction. Magnetic resonance imaging revealed a posterior element fracture as well as osteonecrosis of the L1 vertebral body. An L1 percutaneous vertebroplasty was performed, followed by bone cement-augmented screw fixation to maintain stability and correct the kyphotic deformity. After surgery, pain relief was immediate, and the patient was able to walk unassisted. This case illustrates that continuous axial distraction stress caused by aggravated kyphosis secondary to Kummell's disease may result in posterior element fractures. Our discussion concludes with a literature review.     

Traumatic spondyloptosis resulting from high-energy trauma concurrent with a tonic-clonic seizure

Background contextTraumatic lumbosacral dislocation injuries are rare, high-energy injuries that are challenging to surgically manage.PurposeTo report a patient with a traumatic spondyloptosis of L5 on S1 as a result of bilateral pedicle fractures of L4 and L5 occurring during a motor vehicle accident, concurrent with a tonic-clonic seizure. The mechanism and treatment of the injury are discussed.Study designClinical case report and literature review.MethodsA staged circumferential fusion was performed with posterior reduction of L5 to the sacrum and instrumentation and fusion from L2 to the pelvis, followed 12 days later by anterior diskectomies and arthrodesis from L3 to S1.ResultsNear anatomic reduction and solid fusion were obtained and maintained at 3-year follow-up. The patient remained neurologically intact in all lumbosacral roots throughout the course of treatment.ConclusionsThe injury pattern described is quite rare. This case of multilevel, bilateral pedicle fracture with traumatic L5–S1 spondyloptosis was successfully treated by circumferential reduction and arthrodesis without neurological injury.     

Clavicle fracture with thoracic penetration and hemopneumothorax but without neurovascular compromise

Clavicle fractures are rarely associated with more severe neurologic or vascular injuries. When these associated injuries are encountered, prompt recognition and treatment are paramount to optimize outcome. The majority of fractures that result in neurovascular compromise are from high-energy trauma; however, a high index of suspicion should be present in all cases as low-energy trauma can also result in more catastrophic injury. This article describes a case of a low-energy clavicle fracture in a 28-year-old woman that resulted in intrathoracic penetration of the fracture fragment with hemopneumothorax. The patient underwent successful chest tube placement and open reduction and internal fixation of the fracture. A multidisciplinary team was used during surgery, including cardiothoracic, trauma, and orthopedic surgery. Two years postoperatively, the patient was back to normal activities with no neurologic, pulmonary, or vascular sequelae. This case highlights the importance of a comprehensive physical examination and inspection of all radiographs so that associated injuries are not missed.     

Secular trends in the incidence of postmenopausal vertebral fractures

Summary Several studies suggest secular increases in hip fracture incidence through this century, but little is known about such trends for vertebral fracture. We have examined changes in the incidence of clinically ascertained vertebral fractures among Rochester, Minnesota residents aged 35–69 years, that were first diagnosed between 1950 and 1989. Our results indicate no overall increase in incidence over the 40-year period. Categorization of fractures according to the level of preceding trauma, however, revealed a significant increase in the incidence of fractures following moderate trauma among women aged 60–69 years. This increase occurred between 1950 and 1964, and leveled off thereafter. Rates for severe trauma fractures among postmenopausal women, and for vertebral fractures from any cause among younger men and women, remained stable. The rise in moderate trauma fractures in postmenopausal women paralleled that for hip fractures in Rochester and began to plateau at around the same time. It might have resulted from increased diagnosis of vertebral fractures, but the increase in hip fracture incidence is inconsistent with this explanation. An increase in the prevalence of osteoporosis, however, might account for the trend in both types of fractures.     

Computed tomography of spinal and pelvic fractures

The value of computed tomography (CT) compared with conventional x-ray was assessed in 29 spinal and 9 pelvic fractures. In the so called bursting fractures of spinal vertebrae the position of bone fragments in the neural canal was shown better by CT. The neural canal was remarkably narrowed on several occasions without the patient having any clinical symptoms of root or medullary compression. In 2 patients a fracture of laminae was discernible only on CT. Vertical fractures of vertebral bodies were also difficult to distinguish on the conventional plain x-ray. CT was helpful for planning of the anterolateral decompression operation of L2 in one patient. In cases of pelvic trauma sacro iliac joint diastasis was readily shown by CT. CT was clearly better able to determine whether the fracture extended across the sacro iliac joint. Also in fractures of the iliac wings CT readily showed the internal and external surfaces which were difficult to evaluate on plain radiographic examination. In spinal and pelvic fractures CT can give useful additional information which can influence the treatment of the trauma patient.     

Bilateral femoral neck fracture following a convulsion in the presence of chronic kidney disease. A case report

Introduction and importanceBilateral femoral neck fractures in young adults are a rare entity. It is usually associated with pre-existing metabolic diseases, such as osteoporosis, renal osteodystrophy, or hypocalcemic seizures. Hence, it is essential in such cases to look for other associated injuries following a traumatic event. Missing associated injuries may lead to significant morbidities and poor functional outcomes.Case presentationA 37 years old male, who had chronic renal failure secondary to hypertension, and presented to the emergency room following a seizure episode, in which he developed a generalized tonic-clonic convulsion secondary to electrolyte imbalances with metabolic acidosis. As a result, he developed bilateral neck of femur fracture.Intervention and outcomeThe medical team optimized electrolytes imbalance and then the patient underwent surgical stabilization of both femur neck fracture, 1 year following the surgical fixation the patient had full range of motion of both hips with radiological evidence of complete healing of the fracture.ConclusionIn cases of fractures secondary to metabolic conditions, bilateral femoral neck fractures should be suspected and investigated; especially in young patients who develop a generalized tonic-clonic seizure. The etiology is multifactorial, and the treating surgeon should be aware of predisposing factors which may affect bone quality, thereby raising the risk of fractures even with low-energy atraumatic events. Hip preservation should always be the primary target when treating these patients.     

Spinal injury in major trauma: Epidemiology of 1104 cases from an Italian first level trauma center

IntroductionTraumatic spinal injuries are frequent and their management is debated, especially in major trauma patients. This study aims to describe a large population of major trauma patients with vertebral fractures to improve prevention measures and fracture management.Patients and methodsRetrospective analysis of 6274 trauma patients prospectively collected between October 2010 and October 2020. Collected data include demographics, mechanism of trauma, type of imaging, fracture morphology, associated injuries, injury severity score (ISS), survival, and death timing. The statistical analysis focused on mechanism of trauma and the search of predictive factors for critical fractures.ResultsPatients showed a mean age of 47 years and 72.5% were males. Trauma included 59.9% of road accidents and 35.1% of falls. 30.7% patients had at least a severe fracture, while 17.2% had fractures in multiple spinal regions. 13.7% fractures were complicated by spinal cord injury (SCI). The mean ISS of the total population was 26.4 (SD 16.3), with 70.7% patients having an ISS≥16. There is a higher rate of severe fractures in fall cases (40.1%) compared to RA (21.9% to 26.3%). The probability of a severe fracture increased by 164% in the case of fall and by 77% in presence of AIS≥3 associated injury of head/neck while reduced by 34% in presence of extremities associated injuries. Multiple level injuries increased with ISS rise and in the case of extremities associated injuries. The probability of a severe upper cervical fracture increased by 5.95 times in the presence of facial associated injuries. The mean length of stay was 24.7 days and 9.6% of patients died.ConclusionsIn Italy, road accidents are still the most frequent trauma mechanism and cause more cervico-thoracic fractures, while falls cause more lumbar fractures. Spinal cord injuries represent an indicator of more severe trauma. In motorcyclists or fallers/jumpers, there is a higher risk of severe fractures. When a spinal injury is diagnosed, the probability of a second vertebral fracture is consistent. These data could help the decisional workflow in the management of major trauma patients with vertebral injury.     

Vertebral body fracture after anterolateral instrumentation and interbody fusion in two osteoporotic patients

Background contextThe XLP plate is an anterolateral instrumentation system developed as a part of the eXtreme Lateral Interbody Fusion (XLIF) system for lateral transpsoas interbody fusion, an alternative to anterior interbody fusion.PurposeTo report two cases of atraumatic coronal plane vertebral body fractures in the early postoperative period after interbody fusion using XLIF cages, lateral plating using the XLP plate, and unilateral posterior pedicle screw instrumentation.Study designCase report.Methods/summariesBoth patients were septuagenarian women with normal body mass indices and osteoporosis. The patients underwent L4–L5 XLIF with anterolateral instrumentation followed by posterior decompression and fusion using unilateral pedicle screws. In the early postoperative period (≤6 weeks), the patients developed acute onset of severe low back pain without history of trauma. Imaging demonstrated coronal plane vertebral body fracture through the screw hole of the XLP plate in the superior vertebral body in one case and the inferior vertebral body in the other. One patient required kyphoplasty at the L4 level for pain relief. The other was treated conservatively. The nondisplaced fractures went on to union with pain resolution and successful fusion in both patients.ResultsCoronal plane fractures occurred in 2 of 13 patients treated by the senior author using XLIF, the XLP plate, and unilateral pedicle screw instrumentation. Osteoporosis was likely a contributing factor in both patients. One potential mechanism for this unusual fracture pattern is subsidence of the cage with resultant cut-through of the fixed-angle screws through the osteoporotic vertebral body. Alternately, the fracture could have resulted from the stress riser created by the screw hole traversing an area of relative stress concentration directly adjacent to the cage.ConclusionCoronal plane vertebral fracture may occur in osteoporotic patients treated with XLIF and XLP lateral instrumentation. Unilateral pedicle screw instrumentation does not prevent this complication.     

Zervikale Frakturen bei der Spondylitis ankylosans

In addition to general kyphoscoliosis, grotesque inclination and false positioning of the head are additional characteristics of Bekhterev's spondylitis. The causes of these changes are often fractures and are seldom of rheumatic nature. Although accidents can cause severe instability in the whole, stiffened vertebral column, minor trauma are not usually recognised. Even slight sintered fractures of the ventral vertebral area usually have a dorsal distraction component and can later increase to full dislocation. Severe deformation, which alone indicates the degree of damage, may not taken seriously until neurological changes occur. A definitive differentiation from an Anderson lesion is difficult, although this is of no relevance to the operative-therapeutic methods used. The earliest possible recognition of such a fracture or instability is of greatest prognostic significance to correct the situation without great difficulty, if necessary by using a Crutchfield clamp or a halo vest. If the fracture is found too late, such easy methods of correction are no longer possible and a more complex procedure is necessary. Whereas satisfactory stability can already be achieved via ventral access in the case of complete repositioning of the fracture, in the case of severe kyphosis and rigidity a combined dorsoventral approach involving several operations is necessary and the risk of complications is much higher.     

Simultane beidseitige Humeruskopfluxations- und Acetabulumfraktur

Seizures can cause severe musculoskeletal injuries and posterior shoulder dislocation is a typical result of a seizure. Bilateral posterior shoulder dislocation is rare and acetabular fractures caused by a seizure are also a rarity. We present the case of a 48-year-old man with simultaneous bilateral posterior shoulder fracture dislocations and bilateral acetabular fractures as a result of hypoglycemia-induced seizures.     

Acute and Long-Term Increase in Fracture Risk after Hospitalization for Vertebral Fracture

The aims of this study were to determine the magnitude of the increase in risk of further fracture following hospitalization for vertebral fracture, and in particular to determine the time course of this risk. The records of the Swedish Patient Register were examined from 1987 to 1994 to identify all patients who were admitted to hospital for thoracic or lumbar vertebral fractures. Vertebral fractures were characterized as due to high- or low-energy trauma. Patients were followed for subsequent hospitalizations for hip fracture, and for all fractures combined. A Poisson model was used to determine the absolute risk of subsequent nonvertebral fracture and compared with that of the general population. We analyzed 13.4 million hospital admissions from which 28.869 individuals with vertebral fracture were identified, of which 60% were associated with low-energy trauma. There was a marked increase in subsequent incidence of hip and all fractures within the first year following hospitalization for vertebral fracture in both men and women. Thereafter, fracture incidence declined toward, but did not attain, baseline risk. Increased risks were particularly marked in the young. The increase in fracture risk was more marked following low-energy vertebral fracture than in the case of high-eneergy trauma. We conclude that the high incidence of new fractures within a year of hospitalization for vertebral fractures, irrespective of the degree of trauma involved, indicates that such patients should be preferentially targeted for treatment. It is speculated that short courses of treatment at the time of first vertebral fracture could provide important therapeutic dividends. Received: 6 June 2000 / Accepted: 28 September 2000     

Prognostic utility of a semiquantitative spinal deformity index

The semiquantitative spinal deformity index (SDI) is a summary measure of the vertebral fracture status of the spine incorporating both the number and severity of vertebral fractures. For each vertebra, a visual semiquantitative grade of 0, 1, 2, or 3 is assigned for no fracture or mild, moderate, or severe fracture, respectively, and the SDI is calculated by summing the fracture grades of all vertebrae (T4 to L4). We investigated the effect of prevalent vertebral fracture number and severity, as integrated by the SDI, on 3-year vertebral fracture risk by performing logistic regression modeling with data from the MORE trial. There was a striking linear relationship between baseline SDI and the model-based vertebral fracture risk estimates, with a near-perfect correlation (r = 0.98, P < 0.001). However, the SDI may be overly simplistic, as a given SDI value can be attained through differing vertebral fracture scenarios (i.e., an SDI of 3 can be realized three ways), each corresponding to potentially different vertebral fracture risk. To address this issue, a second, more complex model was constructed that included individual predictor variables for number of mild, number of moderate, and number of severe prevalent vertebral fractures. The model-based risk estimates for vertebral fracture using the SDI and the more complex model were highly correlated (r = 0.91, P < 0.001), giving almost identical values up to an SDI of 5. Thus, for most clinical scenarios, it is not necessary to consider the particular fracture configuration that led to a given SDI score for predicting a patient's future vertebral fracture risk. These results validate the SDI as an accurate tool for assessing future vertebral fracture risk; patients with greater baseline SDI had greater future risk for vertebral fractures.     

Masking of vertebral artery dissection by severe trauma to the cervical spine

STUDY DESIGN: A prospective case study was performed. OBJECTIVES: To illustrate the association of cervical trauma with vertebral artery dissection, and to propose a diagnostic and therapeutic algorithm for suspected traumatic vertebral artery dissection. SUMMARY OF BACKGROUND DATA: Vertebral artery dissection is a recognized but underdiagnosed complication of trauma to the cervical spine. Symptoms of spinal cord injury, however, may obscure those of vertebral artery dissection, presumably causing gross underdiagnosis of this complication. METHODS: All patients with vertebral artery dissection admitted to the authors' facility between 1992 and 1997 were screened for cervical trauma. RESULTS: This article presents four patients with severe trauma to the cervical spine, defined as luxation, subluxation, or fracture, in whom symptoms of vertebral artery dissection developed after a delay ranging from several hours to weeks. The traumatic vertebral artery dissection typically was located at the site of vertebral injury or cranial to it. One patient with fracture of the odontoid process survived symptom free without ischemic brain infarctions. Another patient survived with traumatic quadriplegia in addition to large cerebellar and posterior cerebral artery infarctions. Two patients died as a result of fulminant vertebrobasilar infarctions, both with only moderate impairment from the primary spinal cord injury. CONCLUSIONS: Early signs of vertebral artery dissection include head and neck pain, often localized to the site of intimal disruption, which may be disguised by the signs of the spinal injury. Early Doppler ultrasound and duplex sonography as a noninvasive screening method should be performed for patients with severe trauma to the cervical spine. In cases of vertebral artery dissection, immediate anticoagulation should be initiated. Traumatologists should be aware of this complication in evaluating patients with severe trauma of the cervical spine, and also for a variety of forensic reasons.     

Severity of prevalent vertebral fractures and the risk of subsequent vertebral and nonvertebral fractures: results from the MORE trial

Prevalent vertebral fractures and baseline bone mineral density (BMD) predict subsequent fracture risk. The objective of this analysis is to examine whether baseline vertebral fracture severity can predict new vertebral and nonvertebral fracture risk. In the randomized, double-blind 3-year Multiple Outcomes of Raloxifene Evaluation (MORE) trial, 7705 postmenopausal women with osteoporosis (low BMD or prevalent vertebral fractures) were randomly assigned to placebo, raloxifene 60 mg/day, or raloxifene 120 mg/day. Post hoc analyses studied the association between baseline fracture severity and new fracture risk in the placebo group and the effects of placebo, raloxifene 60 mg/day, and raloxifene 120 mg/day on new fracture risk in women with the most severe prevalent vertebral fractures (n = 614). Vertebral fracture severity was visually assessed using semiquantitative analysis of radiographs and categorized by estimated decreases in vertebral heights. Reported new nonvertebral fractures were radiographically confirmed. Baseline vertebral fracture severity predicted vertebral and nonvertebral fracture risk at 3 years. In women without prevalent vertebral fractures, 4.3 and 5.5% had new vertebral and nonvertebral fractures, respectively. In women with mild, moderate, and severe prevalent vertebral fractures, 10.5, 23.6, and 38.1% respectively had new vertebral fractures, whereas 7.2, 7.7, and 13.8% respectively experienced new nonvertebral fractures. Number of prevalent vertebral fractures and baseline BMD also predicted vertebral fracture risk, but the severity of prevalent vertebral fractures was the only predictor of nonvertebral fracture risk and remained a significant predictor after adjustment for baseline characteristics, including baseline BMD. In patients with severe baseline vertebral fractures, raloxifene 60 mg/day decreased the risks of new vertebral [RR 0.74 (95% Cl 0.54, 0.99); P = 0.048] and nonvertebral (clavicle, humerus, wrist, pelvis, hip, and leg) fractures [RH 0.53 (95% CI 0.29, 0.99); P = 0.046] at 3 years. To prevent one new fracture at 3 years in women with severe baseline vertebral fractures with raloxifene 60 mg/day, the number needed to treat (NNT) was 10 for vertebral and 18 for nonvertebral fractures. Similar results were observed in women receiving raloxifene 120 mg/day. In summary, baseline vertebral fracture severity was the best independent predictor for new vertebral and nonvertebral fracture risk. Raloxifene decreased new vertebral and nonvertebral fracture risk in the subgroup of women with severe vertebral fractures at baseline. These fractures may reflect architectural deterioration, independent of BMD, leading to increased skeletal fragility.