The patient is a 28yo male who suffered a high-energy motocross crash in which he flipped forward over the handlebars and struck his thoracic spine. On arrival to the trauma center at 515pm, he was already paraplegic with a sensory level at the umbilicus. Initial CT imaging (within an hour of arrival) revealed an unstable three-column thoracic injury centered at T8 with burst fracture, T7–T8 translation, canal stenosis, and an associated paraspinal hematoma.
Additional injuries included multiple bilateral rib fractures, small pneumothoraces, and a subacute pubic ramus fracture. MRI performed later the same day (944pm) confirmed severe spinal cord compression with cord contusion spanning T6–T8 and an intramedullary hemorrhage at T7, consistent with a complete (ASIA A) spinal cord injury. The cervical spine CT also demonstrated a small acute C3 avulsion fracture.
Given the severity and instability of the fracture-dislocation, the patient underwent urgent salvage surgery the following morning (9am). This consisted of posterior segmental instrumentation from T6 through T10, posterolateral fusion, and decompressive laminectomies with open reduction of the fracture. Intraoperative and postoperative imaging confirmed satisfactory realignment, decompression, and hardware placement, with improved but not fully restored canal diameter. Despite surgical stabilization, the neurologic injury remained complete, remaining a full care paraplegic to date.
The question posed by the family concerns a possible delay in definitive treatment, and/or if any additional/more timely interventions would have made any impact on the subsequent outcome. MRI later that night? Intervention the following morning (cool-down period)?
For context, here is a clear outline of events:
Sat, Feb 22, 2025 — Mechanism & Initial Condition
Mechanism of injury: Motocross crash; flipped over the front of the bike, landed on upper thoracic spine; immediate paraplegia reported on scene.(approx 515pm)
On arrival (Level 1 trauma via flight): No loss of consciousness documented by ED HPI; cannot move toes or feel from umbilicus down; primary survey largely negative; sent for “complete trauma imaging.”
Sat, Feb 22, 2025 — First Imaging
Chest X-ray portable: 17:25 — shows paraspinal soft-tissue thickening and loss of height of a mid-thoracic vertebral body.
CT Head & CT Cervical Spine (non-contrast): 17:55 — Head CT negative. C-spine: acute C3 anteroinferior corner avulsion; no other acute C-spine fracture/subluxation.
CT Thoracic & Lumbar Spine (non-contrast): 17:55 — T7–T8 translation injury (5 mm), rightward subluxation (≈7 mm), T8 comminuted burst fracture with ≈50% anterior height loss, posterior element fractures (pedicles/lamina), fragments into L T7–8 foramen, focal kyphosis; canal stenosis at T7–8; multiple acute posterior rib fractures; long anterior paraspinal hematoma (T4–T11). No acute lumbar fracture.
CTA Neck (context): Signed 18:21 — no occlusion/dissection; included here to mark comprehensive early imaging; not directly altering thoracic management.
CT Chest/Abdomen/Pelvis (within trauma block): Signed 18:44 — trace bilateral pneumothoraces, trace pleural fluid, anterior thoracic paraspinal/posterior mediastinal hematoma, multiple acute bilateral rib fractures; abdomen/pelvis without acute injury; incidental subacute R inferior pubic ramus fracture (healing).
Sat, Feb 22, 2025 — MRI
MRI Thoracic Spine (non-contrast): 21:44 (report signed 22:26) — Cord compression at T7–T8, cord contusion T6–T8, small intramedullary hemorrhage at T7; confirms T8 burst fracture, T7–T8 anterolisthesis and kyphosis; also notes mild endplate compression fractures at T6 and T9.
Clinical Assessments
Neurosurgery diagnosis: ASIA A, SCI with T8 sensory level due to T8 burst fracture; C3 avulsion fracture.
Operative note pre-op diagnoses: T8 burst fracture; unstable three-column injury; ASIA A SCI.
Sun, Feb 23, 2025 — Salvage Decompression/Stabilization Surgery
Surgeon at bedside 07:42 (pre-op).
Incision/Procedure start: 09:09 — stop 13:42.
Procedure performed (posterior “salvage” operation): Posterior segmental instrumentation T6–T10; posterolateral arthrodesis T6–T10; decompressive laminectomies T7–T9 (brief note lists T7–8), open reduction of the thoracic burst fracture.
Brief post-procedure note timestamp: 14:50 — good kyphosis reduction; dura decompressed; acceptable hardware.
Intra-op/Immediate post-op imaging: Thoracic spine AP/Lateral portable 13:30 (fluoro time 57.6 s) for hardware positioning.
Post-op CT T-spine (non-contrast): 17:10 — shows T6–T10 screws/rods without failure; interval laminectomies at T7–T8; improved canal diameter at T7–T8; ~30% residual anterior T8 height loss; stable 5.5 mm anterolisthesis T7 on T8.
Feb 24–27, 2025 — Early Post-op Course (selected items for context)
Portable CXR 02:45 on 2/23 (comparison to prior day CT); routine postop/ICU monitoring.
Neurosurgery progress note 2/27: stable postop course, TLSO at bedside.
Files:
No questions yet!
Do you believe there might have been medical error?
The pt. Experienced a complete motor/sensory sci. He was seen /evaluated promptly by trauma team with ct/mri T-spine in a quick, expeditious fashion within hours of the injury. So far spot on. The radiographic and neurological exam findings correlated. The spinal cord decompression/ stabilization were completed less than 24 hours from the injury. As reported, within standard of care. That said, a few questions I would have. Was blood pressure “pushed” to maintain optimal spinal cord perfusion and conversely did it “drop” unnecessarily at any time in the peri-operative period? While not “mandatory” was there a reason the surgeon didn’t take the pt. To the OR the same evening once MRI t-spine completed and hemodynamically stable? As an aside were steroids utilized?
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
The complete sci was a result of the pt.’s trauma not medical error.
What makes you a good expert for this case?
I am neurosurgeon specializing in spine /trauma surgery for >20 years. The focus of my practice during this time was treating cases just like the one presented. Board certified by abns and spine fellowship trained (both at the barrow neurological institute: top rated) I was the director of clinical neurosciences and spine at honor health John c lincoln hospital in Az. I’m typically viewed as “down to earth” and relatable by colleagues, patients and staff.
How often do you encounter cases similar to this one in your practice?
Many times per year for 2+ decades.
Do you believe there might have been medical error?
The patient was treated appropriately with appropriate surgery with appropriate time frame
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
There is nothing in the summary to suggest that there was medical error causing worse prognosis. Patient unfortunately had a severe neurological injury
What makes you a good expert for this case?
I’m a spine neurosurgeon at level 1 trauma center
How often do you encounter cases similar to this one in your practice?
I see a couple of these a year
Do you believe there might have been medical error?
A credible argument can be made that surgery should have been performed emergently (same evening) rather than delayed until the next morning, and that the MRI caused avoidable delay. It is hard to prove damages because the patient already had a complete spinal cord injury (ASIA A) at arrival. It would be hard to find proof that earlier intervention would have changed the outcome. The outcome of permanent paraplegia was essentially predetermined. The delay may constitute a technical deviation from best practice, but not likely to be an actionable malpractice claim in my estimations, since causation would be hard to establish. The stronger malpractice cases in spine usually involve incomplete injuries (ASIA B–D) where delays led to permanent deficits.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Repeating the above I don't see causation as the patient arrived with a complete spinal cord injury which is always irreversible. It would be hard to find proof that earlier intervention would have changed the outcome. A trauma 1 center should have operated immediately on arrival and not delayed care by MRI or waiting overnight, but causation is weak.
What makes you a good expert for this case?
I am an academic neurosurgeon with active and ongoing neurotrauma experience having served as Director of Neurotrauma at two centers certified by the American College of Surgeons. I have experience with medicolegal documentation, depositions and court testimony, always as a treating physician. I have not worked as a plaintiff expert and I feel my testimony is highly credible.
How often do you encounter cases similar to this one in your practice?
I commonly perform similar operations on similar cases. I see a chance fracture (three-column fracture) at least twice a month, most recently last week.
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