Transient paraplegia in an elderly due to lightning injury: An unusual cause

Sir,

Lightning injuries may present with a wide spectrum of manifestations which may range from simple burns to fatal death. They have been reported to cause a wide spectrum of neurological injuries. A 75-year-old male farmer was brought to the emergency department with complaints of inability to move both his lower limbs following a lightning injury. There was also a brief period of loss consciousness following the fall. On examination, his Glasgow Coma Scale was 15/15, and there was a ‘fern pattern’ [Figure 1] burn injury marks on the skin over his abdomen. Neurologically, he had complete paraplegia American Spinal Injury Association (ASIA) A in his lower limbs, with complete loss of sensations below D12 spinal level. Per rectal examination revealed absence of anal tone, perianal sensation, and voluntary anal contraction with normal bulbocavernosus reflex.

Figure 1.

Clinical photograph of the patient showing ‘fern pattern’ seen over the left side of the abdomen extending from the left subcoastal to left inguinal region

Plain radiograph and agnetic resonance imaging (MRI) of thoracolumbar and lumbosacral spine was normal [Figures 2 and 3]. He gradually started demonstrating improvement in sensation and motor power in his lower limbs within 24 h period from injury and later completely normal neurology. He was able to ambulate normally and had no residual disability at 1 year follow-up.

Figure 2.

Lateral view of plain radiograph lumbosacral spine with no obvious fractures/malalignment

Figure 3.

Magnetic resonance imaging (MRI) T2-weighted sagittal view of lumbosacral spine with no mechanical compression of the cord or any significant signal changes in the spinal cord

Charcot defined ‘keraunoparalysis’ as a clinical state specific to lightning injury where the patient develops a brief paralytic state with loss of sensation and motor power affecting the lower limbs, with both sensory and motor modalities returning to normal within a few hours.[1] Different injury patterns have been described based on the pathway of the electric force through the body.[2] The above case most probably would be “step-voltage” type, as he was working outdoors during the lightning strike, he also presented with characteristic dermal changes in the trunk, as well as transient paraplegia with sparing of heart and brain. He had the transient dermal fern-pattern markings (Lichtenberg's figures) that have been considered to be pathognomonic features of the lightning injury.[3]

Complete history, clinical examination, and radiographs are warranted in patients that present with a history of a fall or being thrown away as a result of the lightning strike causing direct/indirect injuries. Cervical spine imaging should be obtained if there is evidence of loss of consciousness, confusion, spinal tenderness, or other mechanistic considerations like having been thrown or a fall. The unconscious, confused, or neurologically deteriorating patient may require a Computed Tomography (CT) or MRI to rule out associated vertebral column and/or spinal cord injuries.[4] We suggest that lightning injuries in a conscious patient with normal plain radiograph features usually do not warrant further imaging like MRI or CT scan unless there is suspicion of secondary injury.

We report this case to create awareness among orthopedic surgeons, spine surgeons, and emergency physicians about the clinical presentation of such injuries. Although many of these may present with profound neurological deficits, the majority of them will resolve fairly rapidly, and required only supportive treatment. Secondary injuries should be carefully excluded by clinical examination, with advanced radiological investigations such as CT and MRI scans being ordered in selected patients.