• History & Physical: The patient is a 35 y.o. male roofer with a history of cocaine and marijuana abuse who fell 14 ft while at work. He complained of excruciating low back pain. He denies radiating pain, lower extremity weakness or sensory changes, or bowel / bladder changes. On exam his strength is 5/5 in all muscle groups bilaterally, sensation is intact to light touch and pin prick, reflexes are normal, and toes are down-going bilaterally. Plain x-rays in the emergency department reveal a L4 compression fracture(Figure 1 below).

    The patient was treated with bracing for three months with no progression of compression or angulation. He continued to complain of severe low back pain while sitting or standing which improved with lying. Neurologic exam remained stable. Lumbar flexion / extension films were obtained (Figure 2 below).

    Figure 1A.

    Figure 1B.

    Figure 2A. Extension

    Figure 2B. Extension

    1. Do you agree with the initial management of this patient (bracing for 3 months)?

    2. What is the appropriate next step in the management of this patient?

    3. Would you offer surgery to this patient at the initial presentation?

    4. If you would offer surgery would your operate now?

    5. If you were to offer surgery what would you offer?

    6. Please add any suggestions or comments regarding this case:

    the pt mentioned above maybe manganed by 2 to 3 weeks bracing and phsiotillall investigation compelete o9r ready and then stabilization and decompression eor s- thankyouvery much

    Diagnosis based on images incomplete. We need to see a CT scan and MRI to make a decision for the first treatment. Maybe the patient has an istmic or pedicle fracture and it could be the reason of his persistent pain. This patient has a rotational instability and he nneds surgery in order to control the pain.

    Further workup should to be carried out to rule out the possibility of other underlying disease causing persistent low back pain. Spinal MRI would be appreciated.

    Further workup should to be carried out to rule out the possibility of other underlying disease causing persistent low back pain. Spinal MRI would be appreciated prior to surgical exploration and decompression if indicated.

    Neither of the above answers from question #5. This pt seems like the ideal patient for kyphoplasty which is designed to relieve the acute pain caused by acute vertebral body compression fracture of the lumbar or thoracic spine.

    Plain Xrays are not sufficient for decision making in this patient.We should see CTScan or MRI, but even without these, I think it is a burst fx(potentially unstable),and surgery should be done in the begining.

    Would also do a vertebroplasty.

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