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Injury Extra 42 (2011) 25–28

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Injury Extra

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Case report Lumbar spine burst fracture as a result of hypoglycaemia induced seizure

S.A. Malik *, A. Mitra, K. Bashir, A. Mahapatra

Trauma and Orthopaedic Department, Our Lady of Lourdes Hospital, Drogheda, Ireland

Her American Spinal Injury Association (ASIA) examination was ARTICLE INFO normal with no signs of cord compression. She had full control over Article history: her bowel and bladder function. She had reduced power in the Accepted 10 November 2010 lower limbs bilaterally which was attributed to pain. The focal tenderness was confirmed, with no other obvious tender points over the spinous processes. Computer tomogram demonstrated an 1. Introduction isolated burst fracture at the level of L2 involving the anterior and middle column with retropulsion into the spinal canal. The canal It has been reported in literature that vertebral fractures can was reduced to 8 mm diameter. Her case was discussed with the occur as a consequence of seizures. Muscle forces alone during specialist spinal unit for second opinion and treatment was by tonic–clonic seizures can result in severe musculo-skeletal injuries conservative management. She was fitted with a lumbar spine which include vertebral fractures, neck of femur fractures, support brace (C37) and mobilised next day with analgesic support proximal humeral fractures and dislocations of shoulder. and physiotherapy guidance. She made good recovery and was We report the case of a 42 years old lady, who sustained burst discharged in two days with adequate independent mobilisation fracture of second lumbar vertebra with mild retropulsion as a with analgesic control for her pain. consequence of hypoglycaemia induced seizure. 3. Discussion 2. Case Various collateral injuries have been reported as a result of A 42-year-old lady presented to accident and emergency seizures, including fractures of the vertebrae, femoral neck, pelvis 1,4 department with a history of five days of low back pain. Significant and dislocation of shoulder. These fractures usually result from 3 past medical history included poorly controlled insulin dependent fall or accident caused by the seizure. But in our case, fracture diabetes mellitus, celiac disease. She is a non-smoker and worked occurred as a consequence of hypoglycaemia induced seizure in as a shop assistant until recently, independently mobile, managing bed, without any evidence of fall or trauma. In literature, the activities of daily living without support. incidence of vertebral fracture associated with convulsive seizures 5,7 Questioning revealed a hypoglycaemia induced seizure five varies from 0.95 to 16%, although it is difficult to identify purely days ago. The seizure was not related with any obvious trauma to atraumatic fractures, as seizures are frequently unwitnessed. the back or fall during the episode. She had attended the The fracture incidence has been reported as 2.4% in patients 5 department on the same day for treatment of her hypoglycaemia undergoing electroconvulsive therapy. Vertebral fractures oc- induced seizure which was controlled with dextrose infusion and curred in 0.95% of cases and thoracic compression fractures [T3– 5 better control of her insulin regime. She had complained of T8] were quantitatively the most common fractures sustained. difficulty in breathing at the same time on presentation. A chest The seizure-induced vertebral fractures appear to occur more radiograph was taken, but no obvious cause for her respiratory frequently in male patients, suggesting a direct relationship 7 distress was identified. The lung fields were clear and no rib injury between the risk of vertebral fractures and muscle bulk. During or pneumothorax identified. She was discharged home with seizure tonic–clonic muscle activity can cause fractures that are analgesia for her back pain and advice on insulin regime. associated with only mild pain, 15% of primary asymptomatic 11 The second presentation five days later was due to persistent fractures are attributed to seizure. low back pain. At this point she had a thorough clinical This emphasises the importance of a critical musculo-skeletal examination of her spine which revealed a tender L2 spine. Plain examination of patients admitted after tonic–clonic seizures even radiograph revealed a 50% L2 anterior wedge compression fracture. if an event of fall or trauma is not reported in the history. Special She was then transferred to the regional orthopaedic unit for emphasis should be made towards spine or limbs as well as major further management. joints. In case of doubt, radiographic assessment should be performed to rule out skeletal involvement like fractures or dislocations. * Corresponding author. Tel.: +44 (0)7530880944. There are mainly two hypotheses suggesting the mechanism of E-mail address: [email protected] (S.A. Malik). fracture:

1572-3461 ß 2010 Elsevier Ltd. Open access under the Elsevier OA license. doi:10.1016/j.injury.2010.11.008 26 S.A. Malik et al. / Injury Extra 42 (2011) 25–28

1. In the absence of external trauma, the mechanism of seizure- disease component. This was not investigated as she did not fit the induced vertebral burst fractures appears to involve a violent criteria other than the single risk factor of diabetes, there was no muscle contraction producing either simple axial compression other obvious site involvement to suggest generalised mineral or flexion–compression. This theory has been put to the bone disease. question with equivocal answers.6 The treatment of neurologically intact patients with thoraco- 2. A decrease in measured internal pressure from slow to high lumbar burst fractures is still contentious. However, there is a speed loading groups suggests that the nucleus entering the growing body of evidence suggesting that operative management vertebral body may act as a wedge thereby splitting the of burst fractures in the absence of abnormal neurological findings vertebral body and enabling the retropulsion which is com- provide no major long-term advantage compared with non- monly noted in these fractures by pushing the bony fragments operative treatment.13,8 to enter the canal.6 For the same energy and direction of impact, Conservative management of thoraco-lumbar burst fracture is a high loading rate produces fractures with significant canal followed by marked degree of spontaneous redevelopment of the encroachment (47.6%)6 which would explain the high incidence deformed spinal canal, providing further argument in favour of in these fractures due to the high volume of forces produced non-operative management.2 This patient was managed non- during seizure. Conversely, minimal encroachment (6.8%) into operatively and achieved excellent symptomatic recovery. There the canal was noted at low loading rates.6 was no neurological deficit noted at further follow-up.

Spinal canal impingement of over 50% cases of seizures have been noted in literature.12 In order to produce spinal canal 4. Conclusion impingement, seizure has to generate a high loading rate. There has been one more case which has been reported previously for In conclusion we can say that tonic–clonic seizures produce a atraumatic lumbar burst fracture9,12 and proximal humeral high rate of loading to cause an atraumatic burst fracture in a fracture caused by nocturnal seizure precipitated most likely by vertebral body leading to retropulsion in majority of cases. hypoglycaemia in an insulin dependent diabetic patient. There is a need for high degree of clinical suspicion in post- Vertebral fractures caused without the presence of trauma seizure patients with subtle symptoms to diagnose musculo- related to seizures follow a different fracture pattern in compari- skeletal injury. If in doubt a radiological investigation is always son to spinal fracture following direct trauma. Seizure induced advocated to rule out potential bony injury, especially in the atraumatic vertebral fractures are usually located in mid-thoracic presence of symptoms. region between T3 to T8. Traumatic injury to the spine leading to The presence of diabetes in this patient, the aetiology for the fracture is usually located in the cervical spine, thoraco-lumbar or seizure, could be a potential underlying cause for mineral bone lumbo-sacral junction.12 disease. Without radiological investigation, it is impossible to Mid lumbar fracture is a very rare entity specially made rarer in diagnose and treat patients in this category. the absence of trauma. Conservative management in a lumbar burst fracture led to Diabetes and iron overload are associated with mineral bone good symptom relief and full recovery of function, further adding disease.10 There could have been an underlying mineral bone to the evidence of good recovery from conservative management.

Appendix 1

[()TD$FIG] Roentgenogram of lumbar spine of a burst fracture of the second lumbar vertebra of a patient with hypoglycaemia induced seizure. S.A. Malik et al. / Injury Extra 42 (2011) 25–28 27

[()TD$FIG] CT views of L2 burst fracture of a patient with hypoglycaemic-induced seizures.

[()TD$FIG] 28 S.A. Malik et al. / Injury Extra 42 (2011) 25–28

Appendix 2

[()TD$FIG] Follow-up roentgenogram of lumbar spine at six months.

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