INTRODUCTION
Fracture of thoracolumbar spine may occur following high impact accidents. Cooper and colleagues stated that the incidence of thoracolumbar spinal fracture can be as high as 50% in blunt traumas (Cooper et al. 1995). Hsu and colleagues proposed radio imaging of the thoracolumbar spine in all victims of high impact accidents in the presence of midline tenderness, local signs of thoracolumbar injury, abnormal neurological signs, cervical spine fracture, GCS < 15, major distracting injury, and alcohol or drug intoxication (Hsu et al. 2003).
This was a case of an 18-yrs-old male, who presented with altered mental status and multiple abrasions wound over the face following a motor vehicle accident. Thoracolumbar spine fracture was missed during the first admission. This can be avoided by thorough primary and secondary examination followed by required radiological examination.
CASE REPORT
A previously well, 18-yrs-old male was involved in a motor vehicle vertebraaccident. He could not recall the exact mechanism of his injury. His Glasgow coma scale (GCS) was 14/15. He suffered multiple abrasion wounds over the maxillary area. Face computed tomography (CT) showed facial bone fracture with no intracranial bleeding. Following complete recovery of his GCS, he was discharged 6 hrs, later. Three days later, he presented to emergency department with severe epigastric pain. The pain was described as pricking in nature and radiated to the back. He was still able to walk, had no vomiting, chest pain or fever. Vital signs were stable. Tenderness was felt over T6-T8 vertebrae. There were no neurological abnormalities. Focussed Assessment using Sonography in Trauma (FAST) showed no positive findings. Due to raised suspicion of thoracic injury CT spine was done and showed burst fracture of T7 vertebral body with compression fracture of T6 and T8 (Figure 1). He was referred to orthopedic team and was admitted for surgical intervention. The patient underwent posterior instrumentation and fusion from level of T6-T10 four days after admission. Post-operative physiotherapy was done and he was able to self ambulate prior to discharge.
DISCUSSION
There are few case reports describing thoracic injury presenting as abdominal pain. Xiong et al. (2001) described a young lady who presented with abdominal pain and found to have a thoracolumbar fracture. We need to bear in mind that abdominal pain is an atypical presentation of thoracic injury. This should be suspected in patients complaining of abdominal pain where intra abdominal injury has been ruled out. The presentation of thoracic injury was similar to a previous case report in which radiculopathic pain resulted from nerve root compression (Xiong et al. 2001). Nerve root compression can produce poorly localized pain which may present as a non specific abdominal pain. Pain may be intermittent or constant and is usually described as electric, burning, or shooting in nature. As a result from dermatomal distribution, any compressing fracture between T7 and L1 can present as referred abdominal pain.
There are number of factors that contribute to delay in diagnosis. Substance intoxication, multiple injuries, altered level of consciousness and two level spinal cord injuries are among factors reported to cause delay in diagnosis (Reid et al. 1987). A trauma patient with concurrent low GCS and persistent complaint of abdominal pain should be suspected to have a possible thoracolumbar fracture if intra-abdominal injury has been ruled out. A screening criteria or tools similar as the NEXUS criteria in cervical spine clearance should be used in order to determine patients that require a CT of the thoracolumbar spine.
CONCLUSION
Thoracolumbar spinal injury may easily be missed in a trauma patient with altered mental status and distracting painful injury. Currently, there is no established guideline in ruling out thoracolumbar spine injury such as NEXUS or Canadian CT rule for cervical spine injury. We would advocate a thoracolumbar CT for any abdominal pain following trauma with normal abdomen CT.