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��ࡱ�>��	eh����d�������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������]�	���6bjbjz�z�4b�1\�1\�.)�������tt���������8D|�4�,��pdzzzUkw�,�,�,�,�,�,�,�/��2`�,�UU�,��zz��,� � � �z�z�,� �,� � ��*h,z����p��G;������=+�,�,0�,M+��2� �2 ,,�2�%,\� �,�,� �,���������������������������������������������������������������������2tJ�:Traumatic lumbar fracture associated with a thoracic spinal cord injury without radiologic abnormality. Case report and literature review.


Firass El Hajj (MD)1, Guillaume Riouallon (MD)1, Hugues Pascal-Moussellard (MD / PHD)1

(1)�:Department of Orthopaedic Surgery, Piti�-Salp�tri�re Hospital, Assistance Pubique � H�pitaux de Paris.
Corresponding Author�:
Firass El Hajj, MD, 
Department of Orthopaedic Surgery, Piti� � Salp�tri�re Hospital, 
47-83, Boulevard de l�h�pital
75013 	PARIS ;
FRANCE
Tel : +33 (0)1 42 17 70 52
Fax : +33 (0)1 42 17 74 15
E - m a i l :  HYPERLINK "mailto:firass_elhajj@hotmail.com" firass_elhajj@hotmail.com
Running title�: Thoracic SCIWORA associated with a lumbar fracture








Traumatic lumbar fracture associated with a thoracic spinal cord injury without radiologic abnormality. Case report and literature review.



Abstract:
A case of complete paraplegia due to a T8 spinal cord injury without radiologic abnormality (SCIWORA) associated with a L3 vertebral fracture is presented. 
 SCIWORA is a rare injury, most frequently seen in the pediatric age group. Some cases have been published on SCIWORA of the adult cervical spine but cases of adult thoracic spine are extremely rare and very few cases have been published.
An association of a spinal cord section with a distant fracture has been described in the cervical spine but not in the thoracic and lumbar spine. This article discusses a rare case of a lumbar fracture associated with an adult thoracic SCIWORA. The mechanism is most probably a traction injury due to hyperflexion of the spine.


Key words: Vertebral fracture; paraplegia; thoracic spine; spinal cord section







Case Description: 
An 18 years old female had a high velocity motor vehicle accident and was transferred to our hospital. In the emergency department, the Glasgow score was 15, systolic and diastolic blood pressures were 110/53 mmHg and heart rate was 110 bpm.
The initial examination showed flaccid paraplegia with a sensitive level at T10. Lower limbs reflexes were absent and superior limbs reflexes were present. There was no Babinski sign. There were perineal anesthesia and loss of the anal sphincter tone. 
Thoracic and pelvic X-rays were normal. A total body computed tomography (CT) scanning showed:
L3 vertebral fracture with posterior distraction (Magerl�B2) (Fig. 1)
L2 spinous process fracture
Hepatic contusion in segments V and VI
Aortic dissection at the level of the iliac bifurcation with permeability of the iliac vessels
Pneumoperitoneum with hematic collection and suspicion of caecum perforation
She had an urgent laparotomy and multiple intestinal resection and anastomosis were done. 
Since the complete paraplegia and the sensitive level could not be explained by the L3 fracture an MRI was done after the abdominal surgery. MRI showed a medullar laceration at the level of T8 without ligamentous or disc injuries at this level. It was a complete spinal cord section. No tethered cord was noted (Fig 2).
The patient had an L1-L5 posterolateral arthrodesis. The fracture was reduced and autologous bone grafts were used (Fig.3). We choose to perform a long fusion for tow main reasons: in this context of paraplegia, it is necessary to obtain a good stability and the implants will probably not removed. Furthermore, given the fact the patient had previously a laparotomy, it was not envisaged to perform an additional anterior arthrodesis.
The patient did not have motor or sensitive recovery and at the last follow-up (2 years after the accident) she still have complete paraplegia with a T10 sensitive level and sphincter incontinence. Intermittent bladder auto catheterizations are done in the sitting position. CT-scan at the last follow-up showed complete healing of the L3 fracture (Fig 4). MRI at the last follow-up showed the T8 lesion, which is equivalent to a spinal cord rupture (Fig. 5). 
Discussion:
Spinal cord injury without radiographic abnormality (SCIWORA) is seen most frequently in the pediatric age group [1, 2], and it is rarely seen in skeletally mature patients [1]. To our knowledge, a case of thoracic SCIWORA associated with a lumbar vertebral fracture in adults was not described in literature previously.

Pediatric thoracic SCIWORA is not unusual. Dickman et al. have speculated that up to 50% of pediatric SCIWORA cases may involve the thoracic spine [3]. 
Due to the stability and stiffness of the thoracic spine in the adult population, SCIWORA is rarely seen in adults. The mechanical properties of the spinal column are such that fractures of the body or neural arch or locking of facets have to take place before the neural structures can be injured [4]. Different mechanisms including cord traction injury caused by hyperflexion of the spine, extrinsic cord damage from spinal hyperextension, direct spinal trauma, and delayed cord damage resulting from vascular injury have been proposed to explain adult SCIWORA [4].
Some cases have been published on SCIWORA of adult cervical spine [5, 6]. Cases of SCIWORA of adult thoracic spine are extremely rare and very few cases have been published [1, 2]. Samsani et al. reported a case of disruption of the spinal cord from T10 downward with patchy high signal in the cord and loss of normal architecture without evidence of ligamentous damage to the spine. The absence of ligamentous damage excludes local spinal hyperflexion injury in this case [1]. The postulated mechanism of injury was a sudden violent traction injury to the lower limb sciatic nerves resulting from major bilateral lower limb injuries. These traction forces thus were transferred proximally via the relatively mobile and elastic cauda equina to be expressed in the relatively more fixed segments proximal to the conus medullaris [1]. Hirsh et al�reported a case of partial transection of spinal cord at the T6-T7 level [2]. In this case, SCIWORA is most likely due to spinal hyperflexion with spinal cord distraction. The interspinous ligament hyperintensity visible on MRI scanning is consistent with a hyperflexion injury and ligamentous tearing [2]. In the case described by Van Buul et al, MRI showed focal spinal cord contusion at level T4 with some extension to T3 and T5 in T2-weighted images. There were no signs of posterior ligamentous complex injury. In this case, the presence of multiple rib fractures and a scapula fracture on the left side in combination with an ipsilateral traumatic avulsion of the nerve root T4 suggests focal violent transverse traction injury to the spinal cord causing a contusion of the whole spinal cord at this level [4].

Many articles have discussed multiple injuries of the thoracic and lumbar spine but these injuries were noncontiguous fractures with or without spinal cord injuries at the same levels [7, 8, 9]. Multiple-level noncontiguous spinal fractures may occur as a result of a major trauma such as a traffic accident. The increase in the incidence of these lesions has been attributed to an increase in motor vehicle accidents and improved diagnostic techniques [10]. Vaccaro et al. reported a series of 39 patients with noncontiguous fractures of the spine. These fractures were at the cervical, cervicothoracic, thoracic, thoracolumbar or lumbar levels. Only one patient had 3 noncontiguous fractures [7]. 71 patients with noncontiguous spinal fractures and 20 multiple contiguous fractures were described by Gupta el al [8]. The regions most commonly involved were the lower cervical and thoracocervical regions [8]. In the study of Wang et al. the most common combination was thoracic and lumbar fractures [10].
The importance of noncontiguous fractures of the spine lies in the potential for additional neurologic damage to the spinal cord and roots due to inadequate immobilization as a result of missed injury [7]. Early recognition of these injuries is essential to treat appropriately and to minimize the extent of neurologic deficit [9].
We have presented a rare case of a patient who had a traumatic lumbar fracture associated with a thoracic SCIWORA. More than a spinal cord contusion, it was a real complete anatomical spinal cord section. This kind of lesion is very rare. Only two cases have been described in the literature with such a specific trauma [1, 2]. The thoracic injury was suspected due to the inconsistency between the initial radiological examination of the spine and clinical findings. MRI was of great importance in this case and it showed the T8 medullar lesion without thoracic discoligamentous injuries.
To our knowledge, this association is extremely rare and no other cases were published in literature. In fact, the combination of a vertebral fracture with a non-contiguous spinal cord injury was evoked in the cervical spine but not in the thoracic and lumbar spine [5, 11]. 
The way the cord injury was produced in this case is open to discussion. We think that this spinal laceration is a traction injury of the cord caused by traumatic hyperflexion of the spine. The Magerl B2 fracture of the L3 vertebra is in favor of this hypothesis: it is as if the spinal cord was fixed at the L3 level and stretched by a rotational movement around a horizontal axis at the L3 level. The associated abdominal lesions and particularly the aortic dissection at the level of the iliac bifurcation seem to confirm this hypothesis.

Conclusion:
An extremely rare case of complete paraplegia due to a T8 SCIWORA associated with a L3 vertebral fracture was presented. Such associations were described in the cervical spine but never in the thoracic and lumbar spine.


Conflict of interest�: None HYPERLINK "mailto:g.riouallon@gmail.com" 



References:
Samsani SR, Calthorpe D, Geutjens G (2003) Thoracic spinal cord injury without radiographic abnormality in a skeletally mature patient: a case report. Spine (Phila Pa 1976) 28(4):E78-E80.
Hirsh LF, Duarte L, Wolfson EH (1993) Thoracic spinal cord injury without spine fracture in an adult: case report and literature review. Surg Neurol 40(1):35-38.
Dickman CA, Zabramski JM, Hadley MN, Rekate HL, Sonntag VKH (1991) Pediatric spinal cord injury without radiographic abnormalities: report of 26 cases and review of the literature. J Spinal Disord 4:296-305.
Van Buul G, �ner FC (2009) Thoracic spinal cord injury without radiographic abnormality in an adult patient. Spine J 9(3):e5-e8.
Pointillart V, Mousselard H, Vital JM, S�n�gas J (1992) Traumatic spondylolisthesis of the axis associated with a spinal cord rupture in T1. Eur Spine J 1(3):200-201.
Kothari P, Freeman B, Grevitt M, et al. (2000) Injury to the spinal cord without radiological abnormality (SCIWORA) in adults. J Bone Joint Surg [Br] 82:1034�7.
Vaccaro A R, An HS, Lin S, Sun S, Balderston RA, Cotler JM (1992) Noncontiguous injuries of the spine. J spinal disord 5(3):320-329.
Gupta A, El Masri WS (1989) Multilevel spinal injuries. Incidence, distribution and neurological patterns. J Bone Joint Surg Br 71(4):692-695.
Calenoff L, Chessare JW, Rogers LF, Toerge J, Rosen JS (1978) Multiple level spinal injuries: importance of early recognition. AJR Am J Roentgenol 130(4):665-669.
HYPERLINK "http://www.ncbi.nlm.nih.gov/pubmed?term=Wang%20H%5BAuthor%5D&cauthor=true&cauthor_uid=23511651"Wang H, HYPERLINK "http://www.ncbi.nlm.nih.gov/pubmed?term=Xiang%20Q%5BAuthor%5D&cauthor=true&cauthor_uid=23511651"Xiang Q, HYPERLINK "http://www.ncbi.nlm.nih.gov/pubmed?term=Li%20C%5BAuthor%5D&cauthor=true&cauthor_uid=23511651"Li C, HYPERLINK "http://www.ncbi.nlm.nih.gov/pubmed?term=Zhou%20Y%5BAuthor%5D&cauthor=true&cauthor_uid=23511651"Zhou Y (2013) Multiple-level noncontiguous spinal fractures: difference between the young and the elderly. J Spinal Disord Tech 26(7):E272-6.
Choi SJ, Shin MJ, Kim SM, Bae SJ (2004) Non-contiguous spinal injury in cervical spinal trauma: evaluation with cervical spine MRI. Korean J Radiol 5(4):219-224.










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