The patient, a 14-year-old boy, was injured after he collided with a high-voltage power line, which led to his loss of consciousness and caused him to fall from a 20-meter-high steel tower. After being taken to a nearby hospital, he was flown by helicopter to our hospital for multidisciplinary treatment, where he was administered light sedation for pain relief.
His initial measurements were 112/68-mmHg blood pressure, 118-beats/min heartbeat, respiratory rate of 15 breaths/min, SpO2 of 100%, and body temperature of 38.0°C. His posterior neck, chest, and back were all severely burned (Fig. 1), and he had lost all motor and sensory function caudally from the Th10 level. He was diagnosed with an electric shock injury, a Th 10/11 dislocation fracture (AO type classification1); type C), and a complete thoracic spinal cord injury. Concomitant injuries included Th 7.8.9.12 fractures, right hemothorax, left hemothorax, and multiple rib fractures (Fig. 2A-D). MRI revealed a complete spinal cord tear at the Th10/11 level (Fig. 2E). The paraspinal muscles showed high signals on MRI T2 weighted imaging, respectively (Fig. 2F-G).
Figure 1.
Appearance at the time of transport to our hospital.
A) Extensive, severe burns can be seen on the patient’s back. B) Burn on the upper arm. C) Burn from the elbow to forearm.
Figure 2.
Findings at the time of transport to our hospital.
A) Spinal CT coronal image showed destruction of the Th 10/11 and fracture of the Th 7.8.9.12 vertebrae. B) CT sagittal image of the spine showing complete dislocation of Th 10/11. C) Chest CT showing multiple rib fractures and hemopneumothorax in both lungs. D) Neurological findings indicated that the patient had complete loss of motor and sensory function caudally from the Th10 level. E) Spinal MRI T2 weighted image, sagittal image. F) Spinal MRI T2 weighted image, para sagittal image, showing a signal change in the paraspinal muscles (orange arrow). G) Spinal MRI T2 weighted image, an axial image showing signal changes in the paraspinal muscles on both sides.
After confirming partial dislocation repair by manual traction under fluoroscopic guidance, we performed percutaneous posterior stabilization (Th5-L2) with percutaneous pedicle screws (PPS) without bone fusion. Relatively good realignment was achieved by intraoperative compression of the injured area in the supine position (Fig. 3A-D). On day 20 after injury, Th7-12 anterior intervertebral body fusion was performed via the extraperitoneal approach to reconstruct the anterior column (Fig. 3E-H).
Figure 3.
Pre- and postoperative imaging findings.
A) Appearance before initial surgery. A screw was inserted percutaneously to avoid damage to the soft tissue. B) Frontal X-ray image after the initial surgery; posterior fixation was performed at the Th5-L2 level. C) Lateral X-ray image after the initial surgery. D) CT sagittal view after the initial surgery. E) Frontal X-ray image after 2-stage surgery with anterior strut reconstruction at the Th7-12 level. F) Lateral X-ray image after two-stage surgery. G) Frontal CT image after two-stage surgery. H) Lateral CT image after two-stage surgery.
Debridement of burned skin was performed on the 5th, and skin grafting on the back was performed on the 35th day after the injury, respectively. The grafted skin survived well, and the wound healed completely on day 47 (Fig. 4). Rehabilitation, including wheelchair mobility training, could be started after two-stage spine surgery. On the 70th day after the injury, the wound was well-healed, and the patient was transferred to a nearby hospital.
Figure 4.
Progression of the condition of the soft tissue of the back.
A, B) Debridement was performed on the necrotic tissue five days after the initial injury. C, D) A skin graft was placed over the skin defect 35 days after injury. E) The dorsal area had become epithelialized with no signs of infection 70 days after injury.
Electric shock injuries may be accompanied by deep tissue injury to the nerves, blood vessels, muscles, and bones. To our knowledge, this is the first report of severe electroshock injury combined with spinal cord injury. Recently, the concept of spine damage control has been reported in the field of spine trauma injuries, often accompanied by complications caused by high-energy trauma, such as iliac and pelvic ring fractures2,3). Early stabilization of the spinal column promotes hemodynamic stability, respiratory failure, and systemic management and prevents complications. Initial stabilization with PPS and two-stage anterior strut reconstruction may be helpful in cases of high spinal instability and soft tissue damage. In this case, early surgery allowed good alignment without direct visual repair of the injured area. Electroshock wounds generally result in deep tissue damage, resulting in deep tissue necrosis. In particular, blood coagulation occurs after vascular injury, resulting in the progression of tissue necrosis due to hemodynamic irregularities for 8-10 days after injury4,5). In this case, MRI performed immediately after the injury showed signal changes in the paraspinal muscles; thus, the anterior column was reconstructed in two stages to prepare for potential posterior component infection, necessitating the removal of the pedicle screws. If the posterior muscle or implant developed an infection, we intended to immediately remove the implant and perform rigid anterior interbody fusion using autologous bone and rods. Fortunately, as no signs of posterior component infection were observed, interbody fusion was performed using a cage with autogenous bone alone.
Initial braking and two-stage PPS repair of the anterior column may be helpful in cases of excessive spinal instability and extensive soft tissue damage.
Conflicts of Interest: The authors declare that there are no relevant conflicts of interest.
Sources of Funding: None
Author Contributions: MC and RH performed two-staged spinal surgery. MO and TY treated back burns. HN managed the patient's general condition. RH and AT wrote the manuscript, and TY reviewed and edited it.
All authors read and approved the final manuscript.
Ethical Approval: This is a case report and does not require institutional ethical approval.
Informed Consent: Informed consent for publication was obtained from all participants in this study.
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