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Authors: Dr Amie Jade Ford, Dr Maninder Bhambra, Dr Hossam Ghazzawi, Worcester Royal Hospital

We, the authors, have no conflict of interest.

Introduction

We present an unusual case of vertebral compression in a paediatric patient which did not warrant surgical intervention and was instead managed conservatively.

 

Background:

Fractures of the spine in children and adolescents are rare and cause 0.2% of all fractures in the pediatric population whereas structural lesions account for 0.6-3% of all spinal damages (1). Diagnosis of vertebral fractures in growing individuals still remains a challenging task since among others the late calcification of the epiphyseal plate makes radiologic diagnosis complicated (2). A study by Saul et al. (2018) found that 3.7% of cases required operative management and the most common of these was in the lumbar spine. All conservatively treated patients required no subsequent operative procedures because of missing fracture healing (3).

Case Report:

A fourteen year old girl attended accident and emergency with back pain and a head injury. The patient was in a stable with a horse which attempted to bite her causing the patient to hit her back and head against a concrete wall behind her. There was no history of LOC, seizure, vomiting, reduced GCS at any time or weakness.

She was recently discharged from a tertiary centre for previous compression fracture of L1 vertebrae after being thrown from a horse 8 months ago. She was not on any regular medication.

On assessment the patient was mobilising independently in the department, observations were stable, GCS 15 and Abbey pain score 2.

There were no signs of significant head injury, C-spine was cleared with full range of movement and no midline tenderness noted. No changes in vision or focal neurology found on examination. A paediatric head injury proforma was completed identifying that no further investigation or treatment was required.

On examination of the spine, tenderness was noted over L1 with no visible signs of injury; no bruising or lacerations and no para spinal tenderness in this region. No saddle anaesthesia was noted and the patient was able to pass urine and open bowels normally. Due to the previous compression fracture and bony tenderness an X-Ray T-L (thoracic and lumbar) spine was requested.

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Figures 1 and 2: T-L spine AP (March 2019) vs. T-L spine AP (Nov 2019)

 

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Figures 3 and 4: T-L spine X-Ray Lateral views (March 2019 vs. Nov 2019)

X-Rays revealed no further compression to the existing fracture. This patient was treated conservatively and discharged with head injury advice; understanding of red flags regarding cauda equina were checked with patient and mother prior to discharge.

 

Key Learning Points:

 

References:

  1. Weinberg A, Tscherne H, Henkel R. Tscherne Unfallchirurgie: Untere Extremität, Wirbelsäule, des kindlichen Skelettes (German Edition). Dordrecht: Springer; 2006.
  2. Taylor JAM, Resnick D. Skeletal imaging: Atlas of the spine and extremities. 2nd ed. Philadelphia: Elsevier Saunders; 2010.
  3. Saul D, Dresing K. Epidemiology of vertebral fractures in pediatric and adolescent patients. Pediatr Rep. 2018;10(1):7232. Published 2018 Mar 29. doi:10.4081/pr.2018.7232