A 28-year-old male who was admitted to the emergency department of a regional hospital presented, as a result of a car accident, multiple trauma with a 6° fracture costal arch and right-sided adrenal hematoma right-sided ligament luxation, right-sided renal injury right-sided, right-sided renal injury left adrenal mass with polytrauma.
The patient required orotracheal intubation and ventilation assisted by respiratory failure, and blood transfusions for acute anemia, admitted to the ICU.
Extubated 48 hours later without incidents, the patient was transferred to the hospital ward 24 hours later, where she remained ten days, with placement of a plaster in the right lower limb.
From hospital discharge, 13 days after the trauma, the patient presents back-lumbar pain, initially found to have renal trauma, which in the last 7 days is associated with subjective sensation of constipation plus lower extremities discomfort for paresthesia.
One month after the trauma, the patient came to the regional hospital with thoracic and lumbar spine x-rays. An increase in lateral interspinous distance was observed, with a minimum anterior vertebral body dislocation, above and above the T11.
MRI was performed in the area in which the presence of hematomas in the canal was ruled out, confirming the X-ray findings, and with a doubtful image of spinal cord contusion.
Blood is also present at the level of the interspinous ligament.
The patient is admitted to our service.
1.
On admission, the patient had mild paraparesis (4+/5) predominantly proximal, with no sensory deficits, mild bilateral symmetrical hyperreflexia, without signs of pyramidal release.
CT is performed, which in the axial sections shows the existence of an abnormal disposition of the facets T11-T12, with stenosis of the canal at this level, and the existence of a sign of the fractured sagittal facet T12.
1.
The patient was operated on by means of an ex posterior approach, performing a curettectomy for a complete magtraction - autologous fixation quasi-graft at the level of both, curettage of the superior vena cava - T12, reduction.
The patient evolved favorably, his neurological symptoms disappeared in the first week, being discharged without pain and walking normally.
