A 57-year-old male presented with complaints of back pain radiating to his right leg for 2 months following a fall. Physical examination found limited movement and muscle weakness in the right leg. X-ray revealed a compression fracture at lumbar vertebrae IV-V. The patient underwent laminectomy decompression and posterior stabilization surgery. He was treated medically and followed up, showing internal fixation attached from L3 to S1 on subsequent X-ray.

1. Compression Fracture of Vertebra Lumbar IV-V

2. Patient Identity
 Name : Mr. D. G
 Age : 57 years old
 Gender : Male
 Religion : Christian
 Address : Morowali Utara
 Examination Date : September 13, 2022

3. Main Complaint : Back Pain
History Taking

4. Current Medical History
A 57-year-old male patient with complaints of back pain since 2 months ago,
complained of back pain that was felt spread to the right leg and was
accompanied by cramps. The patient previously had a history of falling sitting
down due to slipping in the bathroom 2 months ago, where the patient fell from
the position of the right buttocks that became the focus. After falling, complaints
of back pain usually appeared since the patient woke up in the morning, the pain
felt reduced after the patient started to move in the morning, The patient also
has a history of did tophus excision surgery 1 month ago, complaints of
weakness in moving the right leg that were felt after undergoing surgery
accompanied by continuous back pain and aches.
History Taking

5. Past Medical History
History Taking
The patient has a history of hypertension and gout arthritis
Past Treatment History
The patient had previously undergone tophus excision surgery 1
month ago, the patient also often took anti-inflammatory drugs to
reduce swelling and pain in the joints.

6. • General Condition : Good
• Awareness : Compos mentist (GCS: E4V5M6)
Vital Sign :
Blood Pressure : 140/80 mmHg
Pulse : 85 x/minute
Breathing : 20 x/minute
Temperature : 37oC
SpO2 : 97%
VAS : 7
Physical Examination

7. • Head : Normocephal, hematoma(-)
• Eyes : Conjunctiva anemic (-/-), sclera icteric (-/-), pupil isochor(+/+)
• Nose : Secretions (-), septum deviation (-), Rhinorrhea (-)
• Ear : Ottorhea (-)
• Mouth : cyanosis (-), parrese (-)
• Throat : T1-T1, hyperemic pharynx (-).
Physical Examination

8. Pulmo
Inspection : Simetris bilateral
Palpation : Vocal fremitus (+/+)
Percussion : Sonor (+/+)
Auscultation : Vesicular (+/+), rhonki (-/-), whezzing (-/-)
Heart
Auscultation : Regular I-II heart sounds, gallops (-), murmurs (-)
Physical Examination

9. Abdominal Examination
• Inspection : Looks flat (+), lesions (-), hematoma (-), edema (-)
• Auscultation : Peristaltic (+)
• Palpation : Area tenderness of the abdomen (-)
• Percussion : Timpani (+), shifting dullnes (-)

10. Extremity Examination
• Superior Extremity : Edema (-/-), hematom (-/-), motion (+/+), cool (-/-),
Muscle Strength (5/5)
• Inferior Extremity : Edema (-/-), hematom (-/-), cool (-/-), Muscle Strength
(2/4)
- Motorik Dextra Sinistra
 Movement Limited Normal
 Strength 2 4
 Muscle tone Hypotonia Hypotonia
 Muscle
Appearance
Eutrofi Eutrofi
- Sensibility Dextra Sinistra
- Pain Normal Normal
- Temperature Normal Normal
- Rasa raba halus Normal Normal

11. Extremity Examination
Localist Status
Lumbar Region
Look :
- No open fracture seen
- Skin discoloration : no change in skin color, hematoma (-)
- Edema : (-)
- Deformity : (-)
- Wound : (-)
- Bleeding : (-)
Feel :
- Tenderness : (-)
- Crepitus : (-)
- Temperature : Normal
- Sensibility : feel/pain (+/+)
Move :
- Limited movement due to pain

12. Early Diagnosis :
Susp. Compression Fracture of Vertebral Lumbar IV-V

13. RESULT :
• Visible compression fracture
at lumbar IV – lumbar V
• Narrowed intervertebral
discs between vertebrae
lumbar IV-V.
• The anterior and posterior
lines of the lumbar IV-V spine
are not aligned with the
anterior lines of the other
vertebrae
X-Ray Imaging

15. Laboratory Finding
Examination Result Unit Normal Value
HGB 12.4 g/dL 14-18
WBC 12.1 103/uL 4.0-11.0
RBC 4.51 106/uL 4.1-5.1
HCT 33.2 % 36-47
PLT 394 103/uL 150-450
Ureum 37 mg/dl <50
Kreatinin 1.43 mg/dl 0.6-1.1
SGOT 49 U/L ≤45
SGPT 25 U/L ≤35
Na 136 mmol/l 136-146
K 4.3 mmol/l 3.5-5.0
Cl 91 mmol/l 98-106
HBsAg Non Reaktif - Non Reaktif

16. Resume
PowerPoint
Presentation
• A 57-year-old male patient came with complaints
of back pain since 2 months ago.
• The back pain that is felt radiates to the right leg
and is accompanied by cramps.
• The photo shows a compression fracture at lumbar
IV – lumbar V
• On physical examination, we found general
condition: good, awareness: compos mentis, and
vital signs within normal limits
• On lower extremity examination, edema (-/-),
hematoma (-/-), cold (-/-), limited movement (-/+),
muscle strength (2/4)

17. FINAL DIAGNOSIS:
Compression Fracture of Vertebra Lumbar IV-V

18. MEDICAL MANAGEMENT SURGICALMANAGEMENT
- Inj. Ranitidin 40 mg/8 hours
- Inj. Paracetamol drips/8 hours
- Inj. Anbacim1 gr/12 hours
- Inj. Omeprazole 40 mg/ 12 hours
- Pro Decompressive Laminectomy +
Posterior Stabilization
Decompressive Laminectomy + Posterior
Stabilization.
• Decompressive Laminectomy is a
surgical procedure used to treat spinal
stenosis, which occurs when spinal
nerves are pinched by narrowing at the
sides of the spinal column.
• Posterior means from the back side, so
posterior fixation means inserting
instruments on the back side of your
spine in order to stabilize it.
MANAGEMENT

19. 01 Content Here
Examination X- Ray (16/09/2022)
Result :
• Internal fixation attached CV L3-S1
• Intervertebral disc narrowed at CV L4-S1
Follow-Up

20. Anatomy of Vertebrae
Anatomical Sagittal View of the Bone Structure
and Soft Tissue of the Thoracolumbar Spine

21. Intervertebral Disc
Schematic of the intervertebral disc, which consists
of an outer circular layer of fibrous tissue called the
annulus fibrosis surrounding a hydrophilic core
known as the nucleus pulposus
Intervertebral disc
protrusion/herniation.

22. Discussion (History Taking)
• Patient with 57 years old complains of
back pain
• The patient had a history of falling down
due to slipping in the bathroom
Theory compression fracture of the vertebrae
• Compression fractures of the vertebrae occur
when the weight of the load exceeds the ability of
the vertebra to support the load, as in the case of
trauma.
• In osteoporosis, compression fractures can result
from simple movements such as falling in the
bathroom, sneezing, or lifting heavy weights.
• The main causes that cause fractures are trauma
such as direct or indirect trauma and pathological
events such as stress fractures or bone weakness.

23. Discussion (History Taking)
• the patient said that the patient also
frequently took glucocorticoid or
steroid drugs
Osteoporosis fractures in men under 60 years
of age should be suspected of an underlying
disorder such as: hypogonadism, metastatic
bone disease, multiple myeloma, liver disease,
alcohol abuse, malabsorption disorders,
malnutrition, glucocorticoid drug use or
antigonadal hormone treatment for prostate
cancer.

24. Discussion (History Taking)
• The patient has weakness in the
right lower extremity with limited
movement
Neurological evaluation to assess basic
function should be repeated to confirm further
damage. The presence of neurological injury
can be identified through motoric, sensory
and reflex tests.

25. Discussion
• The patient underwent X-Ray
and MRI examination
• X-Ray examination should be performed to detect
loss of vertebral height or presence of widening of
the vertebral bodies.
• CT scanning is a good option for identifying
posterior fractures that may be missed on x-rays.
• MRI is the “gold standard” for assessing soft tissue
injuries associated with thoracolumbar fractures

26. Classification
Historically, many classification systems were developed to describe
thoracolumbar spine injuries.
• In 1960 Holdsworth, Kelly and Whitesides described the two-column spinal
stability concept.
• This was replaced in 1983 by Denis' three-column theory which became the
most widely used spinal injury classification system.
• This classification has now been replaced by the AO/ASIF system
(Arbeitsgemeinschaft für Osteosynthesefragen/Association for the Study of
Internal Fixation) which reverts to the original two-column theory, namely
the anterior column and the posterior column.

27. Denis three-column spine model involving anterior (anterior half of vertebra/disc and
anterior longitudinal ligament), middle (posterior half of vertebra/disc and posterior
longitudinal ligament), and posterior (posterior elements including pedicle and facet
joints and remaining ligaments) column
Denis’ three-column classification

28. AO/ASIF (Association for the Study of Internal Fixation)
The AO/Magerl classification of thoracolumbar injuries categorizes these injuries into
three main types according to the vector forces applied to the spine: A, compression;
B, disruption; C. rotation.

29. Discussion
• patient was treated with
Laminectomy Decompression +
Posterior Stabilization
Surgical management is the treatment of choice.
The primary goal is stabilization and neurological
decompression as a secondary goal since the cord
injury is often already established. Surgery should
be on the next available theatre list where anterior
corpectomy, strut bone grafting (iliac crest) and
plate fixation is usually adequate. If there is severe
posterior disruption and the anterior reconstruction
is tenuous, posterior stabilization may be added.

30. Algorithm of TLICS Score

31. Basic of Surgical Therapy
In this patient, for the Severity Score of Thorocolumbar Injury
Classification in morphology, the fracture type was found to be a compression
type (point 1), on neurological status an "incomplete" type of spinal cord injury
was found (point 3) on the posterior ligamentous complex intact (point 0), so
that for the total score obtained (point 4).
The patient underwent operative action in the form of decompression
laminectomy and posterior stabilization because it was found on investigation
that there was bulging/compression towards the spinal cord which also caused a
neurological deficit during the examination.

32. Documentation

33. THANK YOU