A 40-year-old man presented at our Emergency Department in a deeply drunken state. Initially, he did not complain of any pain or neurologic symptoms because he was inebriated. His initial vital signs were within normal limits (blood pressure, 108/69 mm Hg; heart rate, 117 beats/min; respiratory rate, 30 breaths/min; temperature, 36.0
; 94% oxygen saturation breathing room air), and the examination was not remarkable for any deformity or tenderness.
After he was awake, we redid the physical examination, and included sensory and motor deficits. He complained of tenderness over the lumbosacral spine. Neurologically, he presented with paresthesia over the left whole foot and had left foot drop. Motor power was about grade 4/5 strength of knee flexion, 3/5 of knee extension, 4/5 of ankle plantarflexion, 1/5 of ankle dorsiflexion. But, grade 5/5 strength presented through right lower extremity and deep tendon reflexes were 2+ throughout.
A coagulation panel was normal with an international normalized ratio of 0.96 and a platelet count of 590,000. There were no specific abnormal laboratory findings.
A plain X-ray revealed fractures involving the left inferior and bilateral superior pubic ramus, left sacral ala and spinous process of thoracic spines 2-8 level. An magnetic resonance imaging (MRI) revealed a fracture with bone marrow edema involving the left side of body and ala of the sacrum (S1-2), and hematoma in the spinal canal at the L5-S1 level ( and ).
Preoperative lumbar magnetic resonance imaging (saggital plane) showing a hematoma in the spinal canal at the L5-S1 level.
Preoperative lumbar magnetic resonance imaging (axial plane) showing the hematoma in the left aspect of the spinal canal.
The patient was had surgery (partial laminectomy) on post-trauma day 7. L5/S1 and epidural hematoma evacuation was done. After the partial laminectomy at L5/S1, a massive hematoma with fluid was drained (). Operative findings included enlargement of fat tissue and ligaments in the spinal canal and hematoma formation due to posterior internal vertebral vein rupture.
After partial laminectomy at L5/S1, the massive hematoma (with a fluid-feature) was drained.
Postoperatively, we put the patient on a regimen of bed rest, serial neurological examinations, muscle strengthening exercises and pain control with nonsteroidal anti-inflammatory drugs. He remained in the orthopedic general ward unit with foot drop. A repeat MRI done on postoperative day 11 revealed removal of the hematoma in the spinal canal (). After postoperative day 18, motor power of left ankle was about grade 1/5 but the foot drop remained. At postoperative day 19, ankle movement in the horizontal plane was checked and at day 21, ankle movement was checked against gravity. At day 24, he started ambulation exercise. At day 27, the patient was discharged home on convalescent leave. On follow-up at 1-year and 10-months, he was able to engage in strenuous physical activity without neurologic sequelae.
Postoperative lumbar magnetic resonance imaging (saggital plane) showing removal of the hematoma in the spinal canal.