Elsevier

Journal of Clinical Orthopaedics and Trauma

Volume 11, Issue 5, September–October 2020, Pages 952-955
Journal of Clinical Orthopaedics and Trauma

Case report
Delayed unrelated presentation of a lumbar burst fracture consequent to a remote episode of a single convulsive seizure: A diagnostic challenge

https://doi.org/10.1016/j.jcot.2020.06.043Get rights and content

Abstract

Non-traumatic vertebral fractures occurring as a sole consequence of the violent muscle forces generated during the first episode of a GTCS(generalized tonic clonic seizure) in a previously healthy non-epileptic individual are very rare. Being clinically asymptomatic they are easily overseen at the time of initial presentation due to their rarity of occurrence and the presence of potentially distracting factors in the post-ictal phase. We present a 52-year-old healthy non-epileptic male who presented with unrelenting back pain and neurodeficit secondary to a four-month-old unstable burst fracture of the first lumbar vertebra sustained during an isolated single episode of a witnessed GTCS. A detailed inquiry revealed no history of a significant traumatic event either during the convulsive episode or thereafter. A meticulous history taking, a thorough clinical and neurological examination combined with a comprehensive radiological evaluation established the unusual etiology of the fracture and the presence of a thoracolumbar kyphotic deformity with compression of conus medullaris. A detailed neurological, and laboratory work-up, confirmed no attributable organic or metabolic cause for the seizure. His BMD(Bone Mineral Density) was normal. Patient was managed with posterior instrumented deformity correction by a posterior column shortening osteotomy, neural decompression and fusion of D12-L1 facets. Patient had complete neurological recovery with good clinical and functional outcomes at 28-months follow-up. A few cases of seizure-induced non-traumatic spinal fractures have been published in literature. A majority of these fractures occurred in individuals with either seizure-provoking risk factors (epileptics with recurrent seizures, brain tumors, drug overdose/withdrawal, metabolic disorders, or electrolyte imbalance) or in those with an increased susceptibility to fracture due to decreased BMD. This case demonstrates the rare occurrence of a non-traumatic vertebral fracture during the first episode of a GTCS in an otherwise healthy non-epileptic individual with normal BMD and no seizure-provoking risk factors. This is the first case report of a delayed unrelated presentation of a non-traumatic lumbar vertebral fracture with complications (spinal deformity and neurodeficit) consequent to a remote episode of a single convulsive seizure. It emphasizes the need for a high index of clinical suspicion,a meticulous history taking, thorough musculoskeletal and neurological examination in any individual presenting with a seemingly benign back pain following a remote isolated episode of seizure, even in the absence of overt trauma. A detailed radiological evaluation guided by a meticulous history taking and detailed clinical examination is essential to rule out a fracture unless proven otherwise. It also shows that a single convulsive seizure can result in a potentially unstable fracture that when neglected, can result in devastating complications like spinal deformity and neurodeficit.

Level of evidence

Level IV.

Introduction

Non-traumatic spinal fractures occurring solely because of the violent paraspinal muscle contractions produced during a convulsive episode are very rare.1,2 The diagnosis is easily missed at initial presentation, leading to serious complications like neurodeficit or symptomatic spinal instability. A majority of seizure-induced non-traumatic spinal fractures occurred in individuals with seizure-provoking risk factors (known epileptics with recurrent seizures, brain tumors, drug overdose/withdrawal, metabolic disorders, or electrolyte imbalance) or in those with an increased susceptibility to fracture due to decreased BMD following prolonged anticonvulsant therapy.3, 4, 5, 6, 7 To our existing knowledge, there are no case reports of a delayed presentation of a seizure-induced non-traumatic spinal fracture, unrelated to a remote episode of a single convulsive seizure.

Section snippets

Case report

A 52-year-old otherwise healthy non-epileptic male, construction worker presented with complaints of unrelenting low back pain of four months duration, following the first episode of a witnessed GTCS (generalized tonic clonic seizure) which he sustained four months ago while sitting in a chair at his house. He also had progressive numbness and weakness in both the lower limbs for ten days. A detailed inquiry revealed no history of a significant traumatic event either during the convulsive

Discussion

The incidence of spinal fractures in seizures varies from 0.95% to 16%.8 These fractures occur commonly due to a significant traumatic event during the seizure episode. However, a non-traumatic vertebral fracture occurring as a sole consequence of the violent muscle forces generated during a convulsive seizure is a rare clinical entity. Published literature shows that they commonly occur in individuals with risk factors (known epileptics with recurrent seizures, brain tumors, drug overdose,

Institutional review board (IRB) approval

The study was approved by the IRB and Ethics committee of Madras Medical College, Chennai, India.

Source of funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

CRediT authorship contribution statement

Aju Bosco: Conceptualization, Methodology, Formal analysis, Writing - original draft, Writing - review & editing, Software. Nalli Ramanathan Uvaraj: Conceptualization, Writing - review & editing, Visualization, Supervision. Eswar Ramakrishnan: Writing - original draft, Writing - review & editing, Software, Formal analysis.

Declaration of competing interest

The authors have no potential conflicts of interest.

Acknowledgements

NIL.

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