How a broken vertebra can lead to a fatal hemorrhage: a case report

Abstract

Background: Unintentional falls are common among the elderly and given the expected increase of the aging population, these falls contribute to a high number of admissions to the emergency department. Relatively low-energy trauma mechanisms can lead to serious injuries in the elderly, with contributing factors being comorbidities, medication use and degenerative abnormalities.

Case presentation: A 94-year-old female suffered an unintentional fall at home. Upon arrival of the ambulance at her house she was hemodynamically stable and mobilized to the gurney with assistance. During primary survey at the emergency department, her blood pressure and oxygen saturation decreased, she was not able to move her legs anymore and lost consciousness. A full-body CTA was performed, which showed a fracture through the vertebral body of L2 with significant dislocation and a large active bleeding of the corpus, extending to the retroperitoneum and the epidural space. Despite resuscitation, her vital signs deteriorated and given the severe abnormalities on CTA, it was decided to discontinue further treatment, after which she deceased. The performed CTA and an x-ray from 2016 suggested diffuse idiopathic skeletal hyperostosis, which might have contributed to the severity and instability of the vertebral fracture. Mobilization after the fall might have increased the dislocation of the fracture. The use of oral anticoagulants worsened the subsequent bleeding and the extension to the epidural space caused the paralysis of the legs.

Conclusions: It is important to be aware of the possible serious consequences of unintentional falls in the elderly population and to provide strict immobilization of the spinal column until proper imaging.

Keywords: Diffuse idiopathic skeletal hyperostosis; Elderly; Emergency medicine; Hemorrhage; Spinal fracture.

Fig. 1

Transverse (A), coronal (B), and sagittal (C, D) plane CT slices of the vertebral bleeding. A, B Active bleeding toward the retroperitoneum with a larger hematoma on the right side, but active contrast extravasation on both sides. C Active bleeding extending to the epidural space. D CT slice with bone window setting showing substantial dislocation of the fracture and extensive calcification of the anterior ligament of the spine

Fig. 2

Transverse (A), coronal (B), and sagittal (C) plane CT slices of the extension of the vertebral bleeding into the retroperitoneum with mass effect causing a ventral displacement of the right kidney

Fig. 3

Global timeline of events, diagnostics and treatment. BP blood pressure, ATLS advanced trauma life support, O₂ oxygen, NRM non-rebreathing mask, Hb hemoglobin, INR international normalized ratio, CTA computed tomography angiography

Fig. 4

Lumbar spine X-ray in 2016, showing severe degenerative changes and calcification of the anterior ligament, suggesting DISH