A 33-year-old man is brought to the emergency department after being involved in a major motor vehicle accident. He is unable to move his legs and complains of severe pain in his mid to lower back. On physical examination, he is found to have exquisite tenderness over some of the bony prominence of his lower back, but no gross physical deformity can be appreciated. On neurologic examination, flaccid paralysis of both lower extremities and complete anesthesia to all sensory modalities below approximately the L3 dermatome are noted. Catheterization of his bladder yields approximately 700 mL of urine. Plain radiographs of the spine reveal compression fracture in the body of L3 with greater than 50% of loss in its height. A computed tomography (CT) scan through this area reveals a burst fracture of the body of L3. There are large fragments of bone driven dorsally with an 80% canal compromise. What is the cause of weakness?
This patient has suffered a traumatic fracture of L3 in which bony fragments were displaced dorsally to compress the cauda equina at that level. It is important to remember that the spinal cord does not extend along the entire length of the spine. The conus medullaris, the most caudal tip of the spinal cord, ends in 98% of people at or above L2 vertebrae. Thus, it is highly unlikely for an L3 fracture to cause compression of the spinal cord or conus medullaris.
Compression of the conus medullaris
Compression of the spinal cord at the level of L3
Compression of the cauda equina
Rupture of the anterior spinal ligament
Nervous System