A thirty-nine-year-old woman who was seventeen weeks pregnant fell from a standing height on the day prior to presentation after she had been consuming alcohol and marijuana. She presented to the emergency department the following day because of wrist and back pain. The medical and surgical history was notable for paranoid schizophrenia and a previous cesarean delivery. She denied taking any prescription medications or having any allergies.
At the time of the initial presentation, the patient had a distal radial fracture and back pain. The back pain was not further evaluated, given the low level of trauma and the pregnant status of the patient. The distal radial fracture was reduced, and a cast was applied. She was discharged with instructions to return for follow-up of the wrist. The patient returned to the emergency department the next day with worsening back pain and new complaints of lower extremity weakness as well as urinary and fecal incontinence. At that time, a magnetic resonance imaging scan of the thoracic and lumbar spine was acquired and confirmed a burst fracture at the twelfth thoracic vertebral body with retropulsion of an osseous fragment into the spinal canal (Figs. 1 and 2).
The risks and benefits of both operative and nonoperative intervention were explained in a thorough discussion with the patient. Counseling was provided by the obstetrics service regarding issues related to the pregnancy, as well as by social services, given the concerning circumstances of this case. Corticosteroid therapy was not considered because of the delayed presentation. The patient ultimately elected to undergo surgical decompression and stabilization. Although fetal heart monitoring is able to detect heart tones as early as ten weeks of gestation, it was not used during the procedure.
The patient was taken to the operating room and placed into the right lateral decubitus position. A lead drape was placed over the pelvis of the patient, and the operative field was prepared and draped in the normal sterile manner. A single-shot fluoroscopic image was acquired to localize the incisional site, which was made over the tenth rib, and the rib was excised. A retroperitoneal approach exposed the fractured vertebra. A second single-shot fluoroscopic image was acquired to confirm the location of the fractured vertebra. The segmental arteries of the eleventh thoracic, twelfth thoracic, and first lumbar segments were ligated. A twelfth vertebral body corpectomy and spinal canal decompression was performed; the space was reconstructed with a carbon fiber cage, local bone graft, and Kaneda anterior instrumentation. A final pair of anteroposterior and lateral fluoroscopic images was acquired to confirm the position of the instrumentation and the alignment of the spine. The total estimated blood loss was <150 mL. No further radiographs were made. The patient was mobilized without a thoracolumbar brace and was eventually discharged to home without complication.
A little over four months later, she delivered a healthy, full-term infant by means of a repeat cesarean section. At the time of follow-up at five months after the delivery of her child, the patient was walking without assistive devices, had no pain, had recovered full strength in the lower extremities, and denied any fecal incontinence. She continued to have some difficulty with urinary incontinence although this had improved. Radiographs made at that time revealed excellent position of the instrumentation and early healing of the bone graft (Figs. 3-A and 3-B).