Consultant Mayo Clinic Rochester, Minnesota, United States
Case Diagnosis: Non-traumatic transverse L1 body fracture
Case Description: Case of a 68 year old male with medical history of hypertension, obstructive sleep apnea and chronic low back pain who underwent liver transplant secondary to nonalcoholic steatohepatitis-induced cirrhosis, and concomitant sleeve gastrectomy. Eight days after surgery, he developed acute cellular rejection requiring treatment with high dose steroids. Three weeks after his transplant, he reported worsening low back pain. Lumbar x-rays showed a stable superior endplate compression fracture on L2 and he was provided a soft corset for use when mobilizing. He was subsequently admitted to inpatient rehabilitation. At the time of admission he was severely limited by pain. Once pain control improved and mobilization was feasible, a significant thoraco-lumbar kyphosis was noted. A lumbo-sacral CT scan showed an unstable, oblique fracture on L1 that was not apparent on previous radiographs.
Discussions: An oblique burst-like fracture leading to an unstable spine is often associated with high-energy direct trauma seen in severe falls and motor-vehicle accidents. A limited number of cases have been reported where these fractures occur in the setting of high impact in contact sports. Despite this patient’s complex medical course and high dose steroid infusion, he did not experience a fall or traumatic event to justify this type of injury. He did not exhibit worsening neurological findings compared to baseline. Nonetheless, he showed sudden kyphotic posture and increased, constant back pain which led to further imaging of the spine. A possible explanation for this phenomenon is an acute steroid-induced osteoporosis.
Conclusions: This case highlights how a thorough physical examination and history can lead to early identification of occult, acute issues among complex post-transplant patients. It also reminds us the necessary precautions that need to be taken with these patients in order to improve outcomes in the inpatient rehabilitation setting.