34 yo M BIBA s/p fall from 3 stories, suicidal attempt. Pt is AO3, CTA b/l, pelvis stable, able to lift all extremities off stretcher, sensation and peripheral pulses intact. Pt has right lateral heel/ankle deformity. +step off L1-L2 area, good rectal tone. Red trauma was activated. CT shows compression fracture of L1 with loss of vertebral height of 55%, kyphosis angle is 25 degrees. Is this fracture considered stable or unstable? What treatment may you consider?
Compression fractures of the spine usually occur at the bottom part of the thoracic spine (T11 and T12) and the first vertebra of the lumbar spine (L1). Compression fractures of the spine generally occur from too much pressure on the vertebral body. This usually results from a combination of bending forward and downward pressure on the spine. For example, falling from a chair in a sitting position on the floor usually causes your head to go forward at the same time your buttocks hit the floor. Compression fractures occur when the bone actually collapses and the front (anterior) part of the vertebral body forms a wedge shape. In burst fractures there is involvement of both the anterior and middle part of the vertebral body.
Factors indicative of instability
-progressive neurological deficit
-greater than 20 degrees of kyphosis
-greater than 50% loss of vertebral height
-canal comprimise >30%
-retropulsed bone fragments within the neural canal
Use of steroids in the setting of neurological loss in closed injuries remains controversial. The basis for this recommendation are the NASICS trials results, which are disputed by many. Many believe that there is no evidence to support the use of steroids in the managment of spinal cord injury, high dose steroids in trauma patients are associated with significant adverse effects or possibly a worse outcome in patients with penetrating injury.
The regimen for high dose steroids is below in case you, the neurosurgical team, and the trauma team decide to use it. Consider it more as a treatment option, for which there is weak clinical evidence (level II, III).
-methylprednisolone bolus of 30mg/kg over one hour followed by infusion of 5.4 mg/kg/hr
-if started within 3 hours continue infusion for a toral of 24 hours
-if started between 3 and 8 hours continue for 48 hours
Keep in mind that high dose steroids are not without side effects, and this issue is not completely resolved.