ILLUSTRATIVE CASE

Comminuted Lumbar Vertebral Fracture With Spinal Cord

Compromise in an Adolescent Female After
a Minor Fall
Enoch Arhinful and Andrew Rosenthal, MD, MBA

She has no recollection of trauma, and she denies history of

Abstract: A 17-year-old adolescent girl with no past medical history physical abuse. She had no complaints of back pain before the
presented to the emergency department with a chief complaint of lower day of admission.
back pain after sustaining a minor fall several hours earlier. Physical Physical examination revealed a young adolescent girl in no
examination revealed mild to moderate back tenderness, and the result acute distress. She was normotensive and nontachycardic, and
of review of systems was negative. Laboratory evaluation was within her score in the Glasgow Coma Scale was 15. Moderate sacral
reference limits, and plain radiograph of the thoracolumbar spine tenderness was elicited by gentle palpation, but there was no
revealed mild scoliosis and irregularity at L1 vertebra. Subsequent costovertebral tenderness. Result of the rectal examination was
imaging studies revealed a comminuted, burst fracture of L1 with 90% normal. Musculoskeletal examination revealed no deformities.
spinal canal compromise. Her management consisted of early surgical Strength was 4 of 5 distally in lower extremities with intact deep
treatment, and she had a quick recovery. Her postoperative course was
unremarkable. We present this case to emphasize the importance of a
comprehensive history taking in young patients with complaints of back
pain and to highlight the role of imaging studies in the evaluation of back
pain and in the assessment for surgical or nonoperative management.
Key Words: comminuted, burst fracture, lumbar spine injuries, minor
fall, osteopenia, spinal canal compromise, trauma, pathologic fracture
(Pediatr Emer Care 2009;25: 764Y768)

A 17-year-old adolescent girl presented to the emergency

department with acute back pain and flank pain after a fall
3 hours earlier. She was attempting to fix her bedroom ceiling
fan while standing upright on the bed when she slipped off and
landed on her lower back. The pain in her lower back and right
flank was achy in nature, rated 8 of 10 in severity without
radiation and was aggravated with movement. There was no
associated motor or sensory complaint. The patient has no
history of previous falls or fractures. She denies dizziness,
syncope, and seizures in the past. Her past medical history was
significant for hemorrhagic fever at the age of 5 years that was
treated in the Philippines. She had no previous surgical history.
She took no medications or herbal supplements and has no
allergies.
Family history was positive for bone disease. Her mother
has congenital scoliosis, and her condition was diagnosed as
osteoporosis in her mid 40s. Her maternal family history is also
significant for multiple congenital vertebral abnormalities in-
cluding kyphosis and scoliosis. Further, her maternal aunt
sustained a hip fracture that required total hip arthroplasty at the
age of 15 years. Her 2 siblings are healthy. She was born at term
in the Philippines, and she met all developmental milestones.
Menarche occurred at the age of 10 years with regular cycles.

From the Division of Trauma Services, Memorial Regional Hospital, Holly-

wood, FL.
Reprints: Enoch Arhinful, Division of Trauma Services, Memorial Regional FIGURE 1. Plain radiograph of thoracic and lumbosacral spine:
Hospital, 3501 Johnson St, Hollywood, FL 33021 (e-mail: arhinful@ Inferior to the thoracic vertebra, this AP view of the spine
gmail.com). demonstrates a curvature compatible with scoliosis. Arrows
Copyright * 2009 by Lippincott Williams & Wilkins indicate the level of the defect, although the imaging does not
ISSN: 0749-5161 immediately reveal the fracture.

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Pediatric Emergency Care & Volume 25, Number 11, November 2009 Lumbar Vertebral Fracture After a Minor Fall

DISCUSSION
Back pain in the pediatric population presents mostly as
mild and nondebilitating pain that does not prevent daily ac-
tivities, and patients typically do not seek medical attention
immediately. In a study reported by Selbst et al,1 back pain
accounted for less than 1% of all pediatric emergency cases, half
of which was caused by musculoskeletal trauma. Other causes
of back in children and young adults are listed in Table 1.
In most back pain complaints in young adults, most patients
receive no definite diagnosis, and most back pains are broadly
categorized as nonspecific musculoskeletal back pain. Under
this category, a common known cause is muscle strain secondary
to weight bearing. It has been recommended by the American
Academy of Pediatrics that children and adolescents should
carry backpacks weighing no more than 20% of their body
weight. A small fraction of back pain in the young adult
population is attributable to large breasts, and others are found in

FIGURE 2. Transverse view of a computed tomographic scan of

the lumbar spine at the level of L1 demonstrating a burst fracture
of the L1 vertebral body with fragmented pieces found freely in
the right anterolateral prevertebral area (top arrow). There is also
a posteriorly displaced fragment indicated by the bottom arrow.

tendon reflexes and 5 of 5 in upper extremities. She responded

adequately to pin-prick, pain, and temperature, and her proprio-
ceptive sense was intact. No meningeal sign or focal neurologic
deficit was noted, and her cranial nerves were grossly intact.
Result of the routine laboratory evaluation was normal.
Spinal radiograph revealed vertebral compression fracture of L1
(Fig. 1). Computed tomography confirmed the L1 vertebral body
fracture (Figs. 2Y4).
Contrast-enhanced tomography of the lumbar spine with
sagittal and coronal reformatted images revealed a burst frac-
ture at the level of L1 vertebra with approximately 70% compres-
sion (Figs. 3 and 4). There was a large retropulsed bony fragment
in the spinal canal at the level of L1, which protrudes approx-
imately 1.4 cm into the spinal canal effacing the cord, and a tiny
anteropulsed fragment at this level (arrows on Fig. 3, sagittal
view). In addition, there was a fracture through the spinous pro-
cess at L1 with extension to the articular facet to the right of
midline. Magnetic resonance studies of the lumbar spine dem-
onstrated a comminuted fracture of L1Vburst typeVwith ap-
proximately 90% compromise of the spinal canal by a retropulsed
fragment (Fig. 5 and compare with Figs. 6 and 7). There was
edema in the L1 vertebral body with central stenosis below the
level of the conus medullaris, possibly compromising the cauda FIGURE 3. Sagittal view of a computed tomographic scan of
the thoracolumbar spine demonstrating an unstable fracture of
equina, which is displaced posteriorly (arrows in Figs. 5 and 8).
the L1 vertebra. There is an anteropulsed fragment shown by the
Vertical height loss of the burst fracture of L1 is 60% (Fig. 9). arrow on the left and a posteriorly displaced piece, which is pointed
On day 6 of hospitalization, the patient underwent left by the top arrow. As indicated by the arrow on the right, the
lateral thoracotomy with removal of the left 10th rib followed by spinous process at this level falls significantly out of alignment with
L1 corpectomy with fusion. A cage and plate construct was the spinous processes above and below, suggesting extension of
used. Her postoperative course was unremarkable. the L1 fracture to involve its spinous process.

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Arhinful and Rosenthal Pediatric Emergency Care & Volume 25, Number 11, November 2009

Spinal fractures are uncommon in young adults, constitut-

ing less than 3% of pediatric injuries. When they do occur, they
commonly affect the lower thoracic/upper lumbar spines, but the
cervical spine is most susceptible to injury in the pediatric pop-
ulation because of the relatively underdeveloped paraspinal
muscles, shallow and horizontal lie of the facet joints, and larger
head circumference in relation to trunk.8Y10 Traumatic injuries
including fractures are more common in the thoracic and lumbar
spines owing to their relative inflexibility.
The most common spinal fracture is asymptomatic com-
pression fracture of the vertebral body, and in children, they can
be caused by forceful sitting. The mechanism of this injury is
one of acceleration-deceleration, whereby fracture is a result of
momentum exerted on the involved bone by the sum of forces
located directly superior to this vertebral level. When the frac-
ture is of the burst type such as seen in this patient, retropulsion
or hematoma of the bone fragment may produce immediate
paraplegia or delayed symptoms of spinal cord injury.
Traumatic fractures involving the lumbar vertebral bodies
such as seen in this patient are a consequence of injuries that
produce anterior wedging or compression. Severe trauma can
cause fracture-dislocation or a Bburst[ fracture involving the
vertebral body and posterior elements.11 Traumatic vertebral
fractures are a result of fall from heights, vehicle collision, and
direct trauma and often present with neurologic compromise.
The young patient described here who presented with
moderate low back pain and virtually normal physical findings
save the 4 of 5 strength in bilateral lower extremities after sus-
taining a fall from a standard bed. There are no information on
history or workup to suggest neurocardiogenic etiology for her
fall, on history of seizure, or on visual impairment. She had no

FIGURE 4. Coronal view of a computed tomographic scan of

the lumbar spine, with an arrow showing a fracture that extends
through the full vertical height of the L1 vertebral body at its
midline. The kidneys and surrounding soft tissues including the
paraspinal muscles seem unaffected.

conjunction with mood disorder, anxiety, and psychological

distress.1Y5
An important cause of back pain is trauma involving the
vertebra.6 Traumatic and nontraumatic fractures are among the
most common manifestations of bone abnormalities. Fractures
are generally considered closed or open depending on the
integrity of the overlying skin. A fracture may be complete or
incomplete (eg, greenstick fracture); comminuted, referring to a
splintered bone; or displaced, when the apposing ends are
misaligned. Pathologic fracture refers to a fracture in a bone
with preexisting disease process7 such as neoplasm, and stress FIGURE 5. Transverse view of a magnetic resonance image
fracture slowly develops in bone that is predisposed to in- (without gadolinium) of the L1 vertebra demonstrating a
creased and repetitive workload, such as seen in athletes or comminuted burst fracture of the vertebral body with significant
heavy-duty labor. canal compromise (arrows).

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Pediatric Emergency Care & Volume 25, Number 11, November 2009
FIGURE 6. Transverse view of a magnetic resonance image
(without gadolinium) of T12 vertebra demonstrating intact canal
and spinal cord at this level. See arrows and compare this image
with Figure 6.
focal neurological deficits, and her back pain was moderate at
best. On initial presentation, she was able to turn from supine
position to lateral decubitus without great difficulty, and her pain
only worsened with twisting of the trunk and deep palpation over
the sacral area and right hip. Radiographic imaging revealed a
comminuted fracture of L1 vertebral body, burst type with
edema, cauda equina compression, and spinal stenosis. This
FIGURE 7. Transverse view of a magnetic resonance image
(without gadolinium) of L2 vertebra demonstrating an unaffected
spinal canal with intact cauda equine (arrows).
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Lumbar Vertebral Fracture After a Minor Fall
FIGURE 8. Sagittal view of a magnetic resonance image
(without gadolinium) of the thoracolumbar spine. This image
demonstrates a comminuted burst fracture of the L1 vertebral
body with retropulsed fragments that compress anteriorly on the
spinal cord at this level (arrows). There is a 90% compromise
of the spinal canal.
represents a case of traumatic fracture that falls out of proportion
with mechanism of injury and out of proportion with clinical
symptoms.
FIGURE 9. Lateral view of a plain radiograph of the thoracic and
lumbosacral spine: In this view, a depression in the height of the
L1 vertebral body is apparent. The irregularities of the vertebral
body in its anterior and posterior aspects suggest a fracture.
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Arhinful and Rosenthal Pediatric Emergency Care
TABLE 1. Causes of Low Back Pain in Children
Congenital Degenerative12 Neoplastic
Spondylolysis and Disc-osteophyte complex Metastatic (prostate, breast, etc) Vertebral osteomyelitis13
spondylolisthesis
Kyphoscoliosis Internal disc disruption Hematologic (multiple
myeloma, acute leukemias)
Spina bifida Spinal stenosis Primary bone tumors
Tethered spinal cord Atlantoaxial joint disease
Young healthy patients do not typically sustain commi-
nuted, burst fractures of the spine from mechanisms such as
described by this patient. In rare cases, pathologic fractures may
be the explanation. For instance, in osteogenesis imperfecta, a
congenital defect in collagen synthesis, patients have brittle
bones and are highly susceptible to pathologic fractures from
infancy. Minimal impact leaves these patients with deformities.
This condition, when diagnosed prenatally, is an indication for
cesarean delivery owing to the demands of traction and me-
chanical manipulation of abdominal delivery. Although there is
no history to suggest that this patient has osteogenesis im-
perfecta, the patient has a strong family history of bony abnor-
malities that partly explains her unusual fracture. Her mother
had a diagnosis of premenopausal osteoporosis. Her family
history is significant for multiple congenital kyphoscoliosis,
including a hip fracture that required total hip arthroplasty at
the age of 15 years. Given this history, the probability of this
patient’s fracture being a pathologic one cannot be ignored.
Perhaps there is some underlying pathologic process related to
kyphoscoliosis. Initial radiograph revealed scoliosis, although
it could not be ascertained whether this is secondary to the burst
fracture. There was no previous radiograph for comparison.
This 17-year-old adolescent girl with L1 burst fracture
presents several challenges. Her physical findings alone are
relatively unrevealing considering the extent of injury demon-
strated by imaging studies. Although the injury is out of pro-
portion with the history, it underscores the importance of careful
history taking including family history for benign complaints
that constitutes a significant fraction of office and emergency
department visits.
Radiographic studies play a vital role in the initial evalu-
ation of a patient with traumatic back pain. However, other or-
thopedic emergencies such as vertebral osteomyelitis must be
ruled out in the initial stages of evaluation. Magnetic resonance
imaging provides a detailed anatomy of gross bone abnormal-
ities including fractures, but this is only needed for the patient
who is currently being considered for surgical treatment or for
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& Volume 25, Number 11, November 2009
Infectious/Inflammatory Others
Trauma, vertebral artery
dissection
Spinal epidural abscess Osteosclerosis, osteoporosis
Meningitis Psychogenic, malingering,
chronic pain syndromes
Lumbar arachnoiditis
patients with systemic disease. Early surgical treatment should
be considered in burst fractures involving the vertebrae.
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