Epidural Space Research Articles

Determining the epidural space by loss of resistance technique with lidocaine 2% in comparing to normal saline 0.9% and effectiveness on onset of action and outcome of block

Determining the epidural space by loss of resistance technique with lidocaine 2% in comparing to normal saline 0.9% and effectiveness on onset of action and outcome of block

Predicting clinical entry point for thoracic epidural catheter insertion during paramedian approach: A prospective observational study.

Thoracic epidural insertion has high failure rates in the mid-thoracic region due to steep angulation of oblique bending of spinous processes. The preferred skin puncture point for epidural needle insertion in the paramedian sagittal plane with respect to the superior/inferior tip of spinous process or inter-spinous cleft in the mid-thoracic region (T5-8) is not standard. The primary objective of this prospective observational study was to find the skin puncture point which had the best success rate for a successful epidural catheterization. Secondary objectives were to study the number of attempts and passes required to locate epidural space, incidence of failed epidural, and its relationship with patient characteristics and demographics. After informed consent, 155 patients planned for general anesthesia with epidural analgesia in the mid-thoracic region were included in the trial. Patient demographics, the details of epidural attempts with respect to anatomical landmarks, distance from the midline, and number of passes in each attempt were noted. Epidural catheterization was considered successful after demonstrating dermatomal band of sensory blockade. The success rate at different skin puncture sites was not statistically significant (P = 0.58). We found a failure rate of 12.9%. Failed epidural catheterization was significantly high in the age group >56 years (n = 62 and P = 0.007). In our study, none of the skin puncture points had a significant association with successful epidural insertion in mid-thoracic segments using a para-median approach.

Spinal Cord Stimulator Paddle Lead Revision and Replacement for Misplaced or Displaced Electrodes

ObjectivesSpinal cord stimulators (SCS) are commonly implanted via a laminotomy or laminectomy. Revision surgery may be necessary in instances of hardware failure or loss of efficacy. It is uncommon for leads to have been initially misplaced in a suboptimal position, and revision in these cases necessitates additional dissection for appropriate repositioning. Accordingly, there is concern with a more extensive revision for a potentially higher risk of associated complications. This study aims to describe a series of patients with failed paddle SCS electrodes due to misplacement who underwent revision and replacement. MethodsPatients who underwent SCS paddle replacement for misplaced paddles between 2021 and 2023 were identified. Medical charts were reviewed for demographic data, operative details, and incidence of complications. ResultsSixteen patients underwent thoracic SCS paddle revision and replacement. The mean age was 59.6±12.6 years, with 11 females and 5 males. Misplaced paddles were too lateral (n=12), too high (n=2), or incompletely within the epidural space (n=2). The mean duration from initial implantation to revision surgery was 44.8±47.5 months. The mean operative duration was 126.1±26.9 minutes, and all patients required a “skip” laminectomy or laminotomy. No complications were encountered. The mean length of follow-up was 18.4±7.3 months. Mean preoperative pain intensity was 7.9±1.5, and at last follow-up was 3.6±1.7 (p<0.001). All but one patient continued to use their device in follow-up. ConclusionThe revision and replacement of misplaced paddle SCS electrodes is a feasible and durable revision strategy, even in long-term implants with extensive scarring.

Postoperative Epidural Fibrosis: Challenges and Opportunities - A Review.

Postoperative epidural fibrosis (EF) is still a major limitation to the success of spine surgery. Fibrotic adhesions in the epidural space, initiated via local trauma and inflammation, can induce difficult-to-treat pain and constitute the main cause of failed back surgery syndrome, which not uncommonly requires operative revision. Manifold agents and methods have been tested for EF relief in order to mitigate this longstanding health burden and its socioeconomic consequences. Although several promising strategies could be identified, few have thus far overcome the high translational hurdle, and there has been little change in standard clinical practice. Nonetheless, notable research progress in the field has put new exciting avenues on the horizon. In this review, we outline the etiology and pathogenesis of EF, portray its clinical and surgical presentation, and critically appraise current efforts and novel approaches toward enhanced prevention and treatment.

Intrathecal hematoma following epidural blood patch: An alternative mechanism to intrathecal puncture.

Intrathecal blood after a percutaneous epidural blood patch is a known complication, one that has been previously attributed to inadvertent needle tip position in the subarachnoid space. We present two cases with imaging confirmation of an alternative mechanism, one that includes blood transferring from the epidural space to the subarachnoid space through a pre-existing dural defect.

Vertebral Hemangiomas: Yucesoy-Yilmaz Classification System with Corresponding Therapeutic Options

Vertebral hemangiomas (VHs) are relatively common, symptomatic benign tumors of the spine with a reported estimated incidence up to 11%. They usually appear in the body of the vertebrae; however, they can extend into pedicles, laminae, and epidural space. They may cause pain, neurologic deficits. and fractures. In this retrospective, single-center study, we reviewed our cases with VH and we propose the novel classification system that evaluates these lesions per their views on magnetic resonance imaging and clinical findings under 4 main categories. Our novel classification system proposes that grade I lesions occupy less than 50% of the vertebral body, whereas grade II lesions occupy more than 50% and grade III lesions occupy the whole corpus. Grade IV lesions show an epidural and pedicular extension. We propose that grade I lesions may not be worthwhile for follow-up, whereas asymptomatic grade II (a) lesions to be worthy for a biannual imaging and symptomatic thoracolumbar grade II (b) and thoracolumbar grade III lesions to be considered for percutaneous vertebroplasty. We imply that decompression, posterior spinal instrumentation, and open vertebroplasty may be performed for thoracolumbar grade IV lesions. We further consider cervical grade IIb, III, and grade IV lesions as operable because of the disadvantages of percutaneous vertebroplasty. We suggest that our novel classification system may be useful for the determination of diagnostic and therapeutic procedures in the management of VH. Further multicentric trials on larger series are warranted to validate this system and popularize its utility in larger populations.

Massive spinal epidural infantile hemangioma, image findings, and treatment: a case report and review of literature

Spinal involvement of infantile hemangiomas is rare with the predilection to involve the epidural space. A proper diagnosis might be challenging due to the atypical location and variable/inconsistent use of the International Society for the Study of Vascular Anomalies (ISSVA) classification by radiologists, pathologists, and clinicians. A proper diagnosis of epidural infantile hemangioma is key due to the different aggressiveness of the treatment options with inconstant literature regarding the best available treatment. Herein, we present a case of a massive epidural infantile hemangioma successfully treated with only beta-blocker. We discuss the clinical, MRI, CT, ultrasound, and histological features of this lesion as we review the literature with the objective of addressing some of the confusion surrounding the subject.

First evidence of a biomarker-based dose-response relationship in chronic pain using physiological closed-loop spinal cord stimulation

Background and objectivesIn spinal cord stimulation (SCS) therapy, electricity is the medication delivered to the spinal cord for pain relief. In contrast to conventional medication where dose is determined by...

Interventional Management of Low Back Pain: A Comprehensive Review of Epidural Steroid Injections and Related Techniques

Lower back pain (LBP) represents a significant global health burden, impacting individuals’ quality of life, productivity, and financial stability. While acute episodes may resolve spontaneously, chronic LBP persists beyond 12 weeks, necessitating a multidisciplinary approach to management. This comprehensive review examines the interventional management of LBP, with a focus on Epidural Steroid Injections (ESIs) and related techniques. ESIs, administered into the epidural space surrounding spinal nerves, aim to alleviate inflammation and nerve compressioninduced pain. However, they carry inherent risks, including infection, nerve damage, and allergic reactions. Comparative effectiveness studies highlight varying outcomes associated with different interventions, emphasizing the need for individualized treatment plans. Guidelines from professional organizations advocate for a patient-centered approach, prioritizing non-pharmacologic therapies as first-line treatments. Integrating evidence-based practices and considering patient preferences and clinical circumstances are crucial in optimizing outcomes. This review also discusses patient selection criteria, safety considerations, and long-term outcomes associated with interventional management techniques. By adhering to established guidelines and integrating a range of therapeutic options, clinicians can effectively address the multifaceted challenges posed by LBP, ultimately enhancing patient well-being, and improving treatment outcomes. A holistic approach, encompassing both conservative and interventional modalities, is essential in the comprehensive management of LBP

Comparative Study of Dexmedetomidine versus Fentanyl as an adjuvant to Ropivacaine (0.75%) in Epidural Anaesthesia in Lower Limb Orthopaedic Surgery

Background: Dexmedetomidine and Fentanyl both possess hypnotic, sedative, analgesic properties and have been utilised as an additive in epidural anaesthesia. The purpose of this study is to compare the sedative and analgesic effects of Dexmedetomidine and Fentanyl when added epidurally with Ropivacaine (0.75%) during lower limb orthopaedic surgery.&#x0D; Methods: The study comprised of 60 patients, both male and female, aged 18 to 60, who had ASA classification I or II for tibia fibula surgery. Two groups of patients were split up at random: Group RD contains– Ropivacaine (0.75%) 15ml + Dexmedetomidine (1microgm/kg) 0.5ml + 0.5ml sterile water (Total volume-16ml) and Group RF - Ropivacaine 15ml (0.75%) + 1ml Fentanyl (1microgm/kg) (Total volume-16 ml). The epidural space was maintained 4 cm within and situated between L3 and L4 space. Investigations were conducted on parameters such as sensory and motor block features, sedation score, hemodynamic factors and pain assessment. Using the student `t` test, statistical analysis was performed using STATAIC13 software.&#x0D; Results: Onset of sensory analgesia at L1 and Complete sensory and motor blockage occurred much earlier in the RD group. Higher sedation scores and significantly prolonged postoperative analgesia was observed in RD group.&#x0D; Conclusion: Dexmedetomidine is a safer and more effective epidural adjuvant than fentanyl because it provides stable hemodynamics, extended post-operative analgesia, early onset and development of sensory and motor effects and sedation.

Does Early Initiation of Labor Epidural Analgesia Affect Labor Outcomes? A Randomized Clinical Trial

Background: Although epidural analgesia (EA) is a popular and effective method for pain relief during labor, significant controversy exists in terms of the impact of EA on labor outcomes and the best time for initiation of EA. Here, we aim to explore the effects of early initiation EA on the labor process in nulliparous at-term pregnant women.&#x0D; Methods: A total of 240 nulliparous women enrolled in this study. The early epidural (EE) group (n=120) consisted of women in the latent phase of labor and the late epidural (LE) group (n=120) were in the active phase of labor. Each group received 16 ml of 0.125% preservative-free isobaric bupivacaine with 50 µg fentanyl (total: 17 ml) as a primary bolus dose in the epidural space for labor analgesia and an intermittent bolus of 5-10 ml of the primary solution was administered via a catheter. The length of labor, rate of cesarean section (CS), neonatal well-being, and infant Apgar scores were recorded.&#x0D; Results: There were no statistically significant differences between the two groups regarding the duration of the first (p=.43) and second (p=.54) phases of labor. No statistically significant differences were observed between the two groups in terms of the rate of CS (p=.21), causes for CS (p=.24), and neonatal Apgar scores (p=0.84).&#x0D; Conclusion: Initiation of EA during early labor did not result in increased CS or instrumental vaginal deliveries, and did not prolong labor duration.

Delayed neurological dysfunction following posterior laminectomy with lateral mass screw fixation: A case report and review of literature

BACKGROUND While most complications of cervical surgery are reversible, some, such as symptomatic postoperative spinal epidural hematoma (SEH), which generally occurs within 24 h, are associated with increased morbidity and mortality. Delayed neurological dysfunction is diagnosed in cases when symptoms present &gt; 3 d postoperatively. Owing to its rarity, the risk factors for delayed neurological dysfunction are unclear. Consequently, this condition can result in irreversible neurological deficits and serious consequences. In this paper, we present a case of postoperative SEH that developed three days after hematoma evacuation. CASE SUMMARY A 68-year-old man with an American Spinal Injury Association (ASIA) grade C injury was admitted to our hospital with neck pain and tetraplegia following a fall. The C3-C7 posterior laminectomy and the lateral mass screw fixation surgery were performed on the tenth day. Postoperatively, the patient showed no changes in muscle strength or ASIA grade. The patient experienced neck pain and subcutaneous swelling on the third day postoperatively, his muscle strength decreased, and his ASIA score was grade A. Magnetic resonance imaging showed hypointense signals on T1 weighted image (T1WI) and T2WI located behind the epidural space, with spinal cord compression. Emergency surgical intervention for the hematoma was performed 12 h after onset. Although hypoproteinemia and pleural effusion did not improve in the perioperative period, the patient recovered to ASIA grade C on day 30 after surgery, and was transferred to a functional rehabilitation exercise unit. CONCLUSION This case shows that amelioration of low blood albumin and pleural effusion is an important aspect of the perioperative management of cervical surgery. Surgery to relieve the pressure on the spinal cord should be performed as soon as possible to decrease neurological disabilities.

Supraclavicular Artery Island Flap for Treatment of Cervical Wound Defects and Persistent Cerebrospinal Fluid Leaks: A Technical Note and Systematic Review of the Literature

BackgroundSoft tissue defects and persistent cerebrospinal fluid (CSF) leaks can create complications after cervical spinal surgery. The supraclavicular artery island (SAI) flap is useful in closing tissue defects, particularly in these complex surgeries and multiple reinterventions. However, technical reports in this context are scarce. We describe application of the SAI flap technique to control persistent CSF leak in the first documented instance (to our knowledge) of a low-grade fibromyxoid sarcoma (LGFMS) in the cervical epidural space. Additionally, we conducted a comprehensive review of PubMed, Embase, and Google Scholar from their earliest records through December 17, 2023 using combined terms, “supraclavicular artery island flap AND spine” and “supraclavicular AND flap AND spine”. Technical NoteA 56-year-old woman with arm pain and weakness presented with a cervical epidural mass extending from C4–C6 and associated spinal cord compression. She underwent a 3-level corpectomy and tumor resection. Primary dural closure was impossible due to the dural invasion, and reintervention with an SAI flap and definitive lumboperitoneal shunting were required to control and seal the CSF leak. Systematic Literature ReviewSeven case reports describing SAI flap for spinal surgery complications were identified. The indications in those cases were correcting esophageal and hypopharyngeal perforations after cervical fusion and discectomy and persistent soft tissue coverage after cervical instrumentation. ConclusionThe SAI flap technique provided wound defect coverage in this case and is suitable for addressing issues such as persistent CSF leaks or soft tissue coverage after cervical spine surgery.

Sciatica caused by spinal epidural abscess as the initial clinical presentation of colon cancer: a rare case report and review of literature

BackgroundColorectal cancer is one of the most frequently diagnosed forms of cancer, and it is associated with several common symptoms and signs such as rectal bleeding, altered bowel habits, abdominal pain, anemia, and unintentional weight loss. Sciatica, a debilitating condition in which the patient experiences paresthesia and pain in the dermatome of associated lumbosacral nerve roots or sciatic nerve distribution, is not considered one of these. Here we present a case of colorectal cancer manifesting symptoms of sciatica alone.Case presentationA 68-year-old male presented with progressive lower back pain radiating to his left thigh and calf over L5/S1 dermatome. Sciatica was suspected and initially underwent conservative treatment with analgesics. However, the symptoms progressed and MRI revealed an epidural abscess surprisingly. Surgical debridement was performed and pus culture isolated Streptococcus gallolyticus. Based on the strong association of S. gallolyticus with colorectal cancer, the presence of this pathogen prompted further tumor evaluation, even in the absence of the typical symptoms and signs. This investigation ultimately leads to the diagnosis of sigmoid adenocarcinoma.ConclusionsAlthough rare, sciatica caused by S. gallolyticus infection of the spinal epidural space may serve as the initial presentation of colorectal cancer. Physicians should be aware of the strong association between S. gallolyticus and colorectal cancer. Based on what we currently know about the condition; a thorough systematic assessment of occult neoplasia for patients with S. gallolyticus infection is recommended.

Cadaveric study of the ultrasound-guided erector spinae plane block over the transverse process of the twelfth thoracic vertebra in dogs: Transversal vs longitudinal approach

This study describes a transversal (TV) ultrasound-guided erector spinae plane (ESP) block technique over the transverse process of T12. And evaluates the distribution of the dye and affected nerves branches compared to a longitudinal (LNG) approach over the transverse process of T12 in canine cadavers. Secondly, it also compares de anatomy and dimensions of the transverse processes of T12 with T9 and T5. For this double-masked, cadaveric experimental study, 12 adult Beagle cadavers were injected with 0.6 mL/kg of dye/contrast. Spread was evaluated by computed tomography (CT) and dissection.Mean bodyweight was 9.76 (±0.59) kg. The TV and LNG approaches stained a median (range) of four (2–6) and three (1–6) medial branches of the dorsal rami of the spinal nerves, three (2–6) and three (2–5) lateral branches, and one (0−3) and one (0−4) ventral branches, respectively. Dye was detected in the epidural space in 55.6% and 66.7% of cases for the TV and LNG approaches, respectively (P=0.63). And in the ventral paravertebral compartment in 22.2% and lymphatics in 88.8% in both approaches. There were no statistical differences for the spread. The dorsolateral edge of the transverse process (TP) was not visible with CT at T12. The mean (±SD) length of the TP was significantly shorter at T12 [3.34 (±0.22)] mm, compared to T9 [6.08 (±0.47)] mm and T5 [5.93 (±0.62)] mm (P <0.001). This study showed similar distribution whether using a TV or LNG approach and differences in the anatomy and length of the T12 TP.

Mapping lumbar efferent and afferent spinal circuitries via paddle array in a porcine model

BackgroundPreclinical models are essential for identifying changes occurring after neurologic injury and assessing therapeutic interventions. Yucatan miniature pigs (minipigs) have brain and spinal cord dimensions like humans and are useful for laboratory-to-clinic studies. Yet, little work has been done to map spinal sensorimotor distributions and identify similarities and differences between the porcine and human spinal cords. New methodsTo characterize efferent and afferent signaling, we implanted a conventional 32-contact, four-column array into the dorsal epidural space over the lumbosacral spinal cord, spanning the L5–L6 vertebrae, in two Yucatan minipigs. Spinally evoked motor potentials were recorded bilaterally in four hindlimb muscles during stimulation delivered from different array locations. Then, cord dorsum potentials were recorded via the array by stimulating the left and right tibial nerves. ResultsUtilizing epidural spinal stimulation, we achieved selective left, right, proximal, and distal activation in the hindlimb muscles. We then determined the selectivity of each muscle as a function of stimulation location which relates to the distribution of the lumbar motor pools. Comparison with existing methodsMapping motoneuron distribution to hindlimb muscles and recording responses to peripheral nerve stimulation in the dorsal epidural space reveals insights into ascending and descending signal propagation in the lumbar spinal cord. Clinical-grade arrays have not been utilized in a porcine model. ConclusionsThese results indicate that efferent and afferent spinal sensorimotor networks are spatially distinct, provide information about the organization of motor pools in the lumbar enlargement, and demonstrate the feasibility of using clinical-grade devices in large animal research.

Cerebrospinal fluid in the epidural space accidental finding in spontaneous intracranial hypo-tension headache cured by epi-dural blood patch - case report

&lt;p&gt;自發性顱內低血壓頭痛(SIH)是一種體位性(姿勢性)頭痛，大多因腦脊髓液(CSF)在脊椎段發生滲漏造成，通常在核磁共振成像(MRI)可發現滲漏。本病例報告一名自發性顱內低血壓頭痛患者，在MRI上發現於胸部脊柱椎體(T1)以下後硬膜外腔腦脊髓液滲漏，並接受了腰椎穿刺以排除腦膜炎。此病患經過保守治療之後無效、在核磁共振檢查之後第5天，患者在腰椎硬膜外血液貼片(LEBP)治療時，於腰椎硬膜外腔(L3-4)中發現了一些腦脊髓液並接受腰椎硬膜外血貼片治療改善病情。我們討論了自發性低顱內壓頭痛的病理生理學、提出的病因和治療方法、腰椎硬膜外血液貼片治療的安全性以及一位在脊椎目標滲漏區間遠處發現硬脊膜外腦脊髓液滲漏之罕見病例。&lt;/p&gt; &lt;p&gt;&amp;nbsp;&lt;/p&gt;&lt;p&gt;Spontaneous intracranial hypotension headache (SIH) is a phenomenon com-bined with postural headaches, cerebrospinal fluid (CSF) leakage often at spine level on magnetic resonance imaging (MRI). We present a patient with SIH with CSF leakage blow thoracic (T1) spine vertebral level presence of posterior epidural space CSF on MRI and received lumbar puncture to excluded meningitis. The patient re-ceived conservative treatments but in vain. Some CSF was found in lumbar epidural space (L3-4) during aempiric lumbar epidural blood patch (LEBP) treatment 5 days later. The patient was pain relief immediately. We discuss the pathophysiology, pro-posed etiologies and treatments, and safety of LEBP anesthesia in spontaneous in-tracranial hypotension, and a rare case is found CSF far away to the target CSF leakage site.&lt;/p&gt; &lt;p&gt;&amp;nbsp;&lt;/p&gt;

Pneumocephalus after ankle surgery: A Case Report

Introduction: Pneumocephalus, or air in the cranial cavity, can have various causes. Traumatic brain injury is the most common cause of pneumocephalus, accounting for 75% of all cases, particularly in those with skull base fractures. Spinal trauma-related pneumocephalus is rare but has been reported, and patients with this condition are usually treated conservatively. Tumors, infections, and iatrogenic causes are responsible for the remaining 25% of cases. Proper management and a high index of suspicion are critical when considering pneumocephalus as a possible complication, as it can result in significant morbidity and potentially life-threatening consequences. Accidental puncture of the dura mater is a common cause of pneumocephalus secondary to epidural anesthesia, and air entry into the intrathecal space is another known cause. Case presentation: This is a 64-year-old female patient who underwent elective ankle surgery, the anesthetic technique was epidural-spinal block needle on needle, no complications during procedure. She was discharged from the Traumatology and Orthopedics service the next morning, 24 hours after her hospital discharge, she was brought back, in the emergency area, she was found with psychomotor agitation, disorientation, no auditory hallucinations, paresthesias were denied, no mentation disorder, with a score on the Glasgow Coma Scale of 14: Eye opening 4 points, Verbal response 4 points, Motor response 6 points. After 48 hours the CT brain scan revealed absortion of pneumocephalus. Clinical discussion: The causes of neumocephalus resulting from epidural or spinal anesthesia procedures are not entirely understood. However, it is believed to occur due to the introduction of air or gas into the subarachnoid or epidural spaces during the puncture, accidental or not . Given the potential severity of this condition, early diagnosis and appropriate management are crucial, even if the symptoms differ from the most common. Conclusion: This research paper highlights the importance of anesthesiologists being aware of the potential risks associated with epidural or spinal block. Future research could investigate the long-term outcomes of patients who experience pneumocephalus during anesthesia procedures and identify strategies for preventing and managing this complication.

Cochlear aqueduct revisited: A histological study using human fetuses

Background and aimThe cochlear aqueduct (CA) connects between the perilymphatic space of the cochlea and the subarachnoid space in the posterior cranial fossa. The study aimed to examine 1) whether cavitation of the CA occurs on the subarachnoid side or the cochlear side and 2) the growth and/or degeneration of the CA and its concomitant vein. MethodsWe examined paraffin-embedded histological sections from human fetuses: 15 midterm fetuses (crown-rump length or CRL, 39–115 mm) and 12 near-term fetuses (CRL, 225–328 mm). ResultsA linear mesenchymal condensation, i.e., a likely candidate of the CA anlage, was observed without the accompanying vein at 9–10 weeks. The vein appeared until 15 weeks, but it was sometimes distant from the CA. At 10–12 weeks, the subarachnoid space (or the epidural space) near the glossopharyngeal nerve rapidly protruded into the CA anlage and reached the scala tympani, in which cavitation was gradually on-going but without epithelial lining. However, CA cavitation did not to occur in the anlage. At the opening to the scala, the epithelial-like lining of the CA lost its meningeal structure. At near-term, the CA was often narrowed and obliterated. ConclusionThe CA develops from meningeal tissues when the cavitation of the scala begins. The latter cavitation seemed to reduce tissue stiffness leading, to meningeal protrusion. The so-called anlage of CA might be a phylogenetic remnant of the glossopharyngeal nerve branch. A course of cochlear veins appears to be determined by a rule different from the CA development.

How a broken vertebra can lead to a fatal hemorrhage: a case report

BackgroundUnintentional falls are common among the elderly and given the expected increase of the aging population, these falls contribute to a high number of admissions to the emergency department. Relatively low-energy trauma mechanisms can lead to serious injuries in the elderly, with contributing factors being comorbidities, medication use and degenerative abnormalities.Case presentationA 94-year-old female suffered an unintentional fall at home. Upon arrival of the ambulance at her house she was hemodynamically stable and mobilized to the gurney with assistance. During primary survey at the emergency department, her blood pressure and oxygen saturation decreased, she was not able to move her legs anymore and lost consciousness. A full-body CTA was performed, which showed a fracture through the vertebral body of L2 with significant dislocation and a large active bleeding of the corpus, extending to the retroperitoneum and the epidural space. Despite resuscitation, her vital signs deteriorated and given the severe abnormalities on CTA, it was decided to discontinue further treatment, after which she deceased. The performed CTA and an x-ray from 2016 suggested diffuse idiopathic skeletal hyperostosis, which might have contributed to the severity and instability of the vertebral fracture. Mobilization after the fall might have increased the dislocation of the fracture. The use of oral anticoagulants worsened the subsequent bleeding and the extension to the epidural space caused the paralysis of the legs.ConclusionsIt is important to be aware of the possible serious consequences of unintentional falls in the elderly population and to provide strict immobilization of the spinal column until proper imaging.