Teaching Case

A 63-year-old man, post-fall, experienced severe mid-back pain, left leg and foot pain, and paraesthesia. He struggled to lift his legs due to back pain. No head, chest, or abdominal injuries were noted. Upon examination, he exhibited normal strength in the upper limbs but had reduced power (grade 4) in the left foot.

X-ray of the lumbosacral spine (Figures 1 and 2): Compression fracture of the T12 vertebra with reduced spinal canal diameter at the same level.

CT of the whole spine (Figures 3 and 4): Communited central compression fracture of T12 vertebral body with a retropulsed posterior fracture fragment narrowing spinal canal is noted; The fracture is seen extending to the lamina on the left side; The spinous process of T12 vertebra was also present (not shown in the images).

MRI of the lumbosacral spine (Figures 5, 6 and 7): T2WI shows comminuted fracture with central compression of the T12 vertebral body and the posterior elements, along with marrow oedema; The retropulsed posterior fragment of the vertebral body is compressing the thecal sac, causing swelling and a focal increased signal on T2WI of the conus; Sagittal STIR image shows oedema of the interspinous ligament is at T11–T12 level, along with oedema of adjacent subcutaneous tissue.

The conus medullaris is the tapered, cone-shaped end of the spinal cord, typically spanning T12 through L2 [2]. Causes of conus medullaris syndrome include disk herniation, trauma leading to compression or burst fractures, intramedullary tumours, infections (e.g., epidural abscess), spinal dural arteriovenous fistulas, and cord infarction. Clinically, conus medullari syndrome (CMS) manifests with severe back pain, lower-extremity weakness (a combination of upper and lower motor neuron deficits), saddle anaesthesia or hypoesthesia, early bladder and rectal sphincter dysfunction, and impotence.

Patients presenting with CMS symptoms post-trauma should undergo both computed tomography (CT) and magnetic resonance imaging (MRI). CT is essential for assessing bone injuries, providing a detailed view of fractures and retropulsed fragments causing cord compression. MRI is crucial for evaluating the spinal cord, discs, and soft tissues, aiding in the identification of intramedullary tumours or infections. The combined use of these modalities ensures a comprehensive assessment of the structural damage.

Early surgical intervention significantly enhances the prognosis for patients with CMS. Swift identification of the underlying cause through imaging, particularly CT and MR imaging, allows for timely decision-making regarding surgical approaches. Addressing compression, stabilising fractures, or removing tumours promptly can mitigate neurological deficits and improve long-term outcomes.

Our patient underwent titanium pedicle screw fixation of the spine in the dorsolumbar region and T12 laminectomy decompression of the conus epiconus region.