Conus Trauma

Failure to Surgically Intervene When Indicated
Failure to Use Steroids Following Spine Trauma

Case# MST201

33 year old male fell a distance of 20 feet to the ground from a tree landing on his legs and buttocks. He was transiently paraplegic. Upon examination in a local hospital Emergency Room he was in severe pain but grossly intact in his neurological examination.

Plain x-rays showed a compression fracture of the L1 vertebrae with a large retropulsed fragment occupying at least 50% of the spinal canal. This was confirmed by CT scan (below).

Scan also pointed out that laminar and pedicular fractures, indicating segmental instability, were present. Patient was treated with analgesics, but not steroids. He was then transferred to a regional Trauma Center. The Center examination, which continued to be sub-optimal because of the patient's severe pain, evidenced non-specific numbness and weakness.

At the trauma center pain medications (but not steroids) were again administered. A MRI examination, performed the same day (above with artist's interpretation to the right) showed severe compression of the conus medullaris and cauda equina primarily due to the retropulsed vertebral fragment as well as associated hematomas. In the saggital MRI view on the left the retropulsed bone fragment is shown with a yellow dot whereas the circumferential hematoma is indicated by anterior and posterior red dots.
Decompressive surgery with stabilization was not performed until the following day. Patient was left with a permanent sacral nerve syndrome and a intractable complex regional pain disorder.

This case represented poor medical judgment in a number of area including failure to use steroids early on and failure to surgically intervene in an expeditious manner. In clinical trials the timing of the introduction of therapeutic intervention was found to be of great importance with the critical "window of opportunity" being less than 8 hours post-injury. Neither the Frankel Grading Method (A-E) nor the American Spinal Injury Association (ASIA) Impairment Scale (A-E) were applied. Even if the patient did not qualify for a full NASCIS II methylprednisolone treatment protocol (loading dose of 30 mg/kg, 5.4 mg/kg hourly infusion, stop at 24 hours) failure to administer any steroid was considered to be poor medical practice. This case was settled out of court for a substantial amount.