• HPI: 57-year-old man involved in a rollover ATV accident earlier; he was riding up a steep incline when the ATV flipped backwards and landed on top of him. He was not wearing a helmet and there was no LOC but he immediately had pain in his back and remained on the ground until he was picked up by emergency medical personnel. 

    ROS: The patient denies any headaches, weakness, numbness, tingling, or other neurological complaints. 

    PMH: Hypertension, CABG (10 years ago), CAD, seizures (no seizures for the past 20 years), ankylosing spondylitis. 

    ALLERGIES: NKDA 

    MEDICATIONS:
    1. Aspirin.
    2. Metoprolol.
    3. Lisinopril.
    4. Lipitor.
    5. Carbamazepine. 

    FAMILY HISTORY: Significant for headaches in the patient's mother. No other neurological disorders. 

    SOCIAL HISTORY: Retired; no tobacco use; rare ETOH use. 

    PHYSICAL EXAMINATION: 
    Vitals: normal. 
    Normal neuro exam (full strength, intact sensation, and normal reflexes in all four limbs) with intact rectal tone/sensation. 
    He has point tenderness in the mid thoracic spine with no palpable step-offs. 

    LABS: Normal. 

    Radiology: CT of C/T/L spine without IV contrast 
    C Spine: degenerative disk and facet disease in the mid and lower cervical spine with no acute fractures. 
    T Spine: Posterior rib fractures at almost all levels of the thoracic spine and comminuted scapular fractures bilaterally. 

    Anterior distraction injuries at T6/7 and T10/11. There is a superior endplate fracture at T7 that extends into the lamina and pedicle on the left. Impacted fracture of the right superior articular facet and T11 with fragments extending into the canal as well as blood in the central canal at this level. 
    L spine: multiple acute TP fractures on the left at L1, L2 and L3. No other acute fractures are seen.

    Figure 1. Serial sagittal reconstruction CT images through the thoracic spine.

    1. Would you obtain an MRI of the spine in this case to evaluate the ligaments and soft tissues?

    2. Are her symptoms likely related to her trauma?

    3. What is the next likely step in her management?

    4. You are suspicious she has a tumor and she is anxious to undergo open biopsy with resection. What approach should be taken for resection?

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