Kummell's disease: delayed post-traumatic osteonecrosis of the vertebral body

Abstract

Delayed post-traumatic osteonecrosis, also known by its eponym Kummell's disease, is a rarely reported clinical entity that likely occurs with higher frequency than recognized. We highlight a case of a 75-year-old female household ambulator who presented with significant thoracolumbar pain and delayed T12 collapse after a ground-level fall. The patient had sustained a trivial fall at home 4 months prior to this presentation and had been hospitalized in our institution at that time for a general medical workup. Dedicated spine radiographs were not obtained during this visit. However, lateral chest radiograph demonstrated an intact T12 vertebral body. The patient was able to mobilize successfully with therapy and was discharged home. During the interim between the initial fall and subsequent presentation, she resumed physical activity including ambulating independently and performing various housework. Approximately 4 months following her initial injury, the patient returned to a local emergency department with vague complaints of abdominal pain without any history of recent fall or injury. After an unremarkable workup, the patient was sent home. Ten days later, she represented to our institution's emergency room with worsening pain. Radiographs and CT scan demonstrated interval collapse of the T12 vertebral body. A linear vacuum cleft was noted on X-rays and CT. An extensive workup to exclude other processes such as malignancy or infection, which was negative, ensued. Delayed post-traumatic vertebral collapse was diagnosed. A trial of medical management and therapy was attempted, but she continued to experience significant pain. A T12 vertebroplasty was therefore offered and performed to stabilize the injury and to relieve the pain. She was subsequently able to be discharged from the hospital and transitioned back to home life. At approximately 2 years following her injury, the patient was noted to be able to ambulate with a walking aid. Her final radiograph after her surgery demonstrated that the T12 vertebroplasty had maintained its height and sagittal alignment. This Grand Round case highlights the clinical presentation of Kummell's disease. Aspects of the clinical entity that will be discussed include a historical review of the disease, hallmark radiographic findings and treatment options.

Fig. 1

Lateral chest radiograph obtained during medical workup at the time of the initial injury. X-ray demonstrated the known old injury to the T11 vertebral body (triangle). Note the intact T12 vertebral body without obvious sign of collapse below (arrow)

Fig. 2

Repeat radiograph of the T12 vertebral body 4 months after the initial fall (arrow). There is significant collapse of the T12 vertebral body. Intravertebral air (vacuum cleft) can be seen on the AP and lateral projections (triangles). Note the linear shape of the vacuum cleft on the AP X-ray

Fig. 3

CT scan of the lumbar spine demonstrating the vacuum cleft phenomenon with anterior intraosseous air is identified within the vertebral body. There is minimal compromise of the spinal canal. A small amount of air can also be identified in the T12–L1 disc space

Fig. 4

MRI of the lumbar spine. The T12 vertebral segment is collapsed. Intraosseous air within the vertebral body can be seen (low signal on both weighted images). Note the intravertebral fluid collection often seen in osteonecrosis (low on T1-weighted images and high on T2-weighted images)

Fig. 5

Intraoperative fluoroscopic imaging demonstrating the vertebroplasty of T12

Fig. 6

Radiograph obtained after 2 years following vertebroplasty. Height of the T12 vertebral body is maintained along with sagittal alignment