An 80-year-old female, height 155 cm, weight 45 kg, was admitted to our department with chief complaint of "lower back pain and limited mobility for more than 10 days". The patient had lower restricted movement and back pain for unobvious reasons. The pain aggravated while she was turning over or waking up, but it was not relieved after conservative treatment. The patient had a history of pulmonary tuberculosis healed after regular anti-tuberculosis treatment, and had not taken medicine for a long time. Besides, the patient had no history of blood system disease or long-term anticoagulation therapy. She had a history of osteoporosis and multiple old spinal fractures. In recent years, the patient gradually appeared hunchback. Physical examination revealed slight kyphosis of the thoracolumbar spine and restricted range of motion. There was tenderness and percussion pain in the back. Both Lasegue's signs and Babinski's signs were negative. No edema was in the lower limbs and the peripheral blood supply was normal. Magnetic resonance imaging (MRI) revealed OVCFs in the 5th and 12th thoracic vertebrae and the 1st and 4th lumbar vertebrae, with multiple old vertebral fractures. Besides, radiographies illustrated compression of spinal vertebrae (Figures 1A,B). Laboratory examinations showed that white blood cell (WBC) was 8.02 x 109/L, red blood cell (RBC) 3.78 x 1012/L, hemoglobin (HB) 115 g/L, platelet (PLT) 205 x 109/L, erythrocyte sedimentation rate (ESR) 28 mm/h, C-reactive protein (CRP) 55.00 mg/L. Thromboelastography results showed that coagulation factor level, fibrinogen function, platelet function and fibrinolysis system were normal, with R value at 5.8 min, K value at 1.6 min, Angle value at 67.8 degree, MA value at 61.5 mm, LY30 value at 0%, EPL value at 0% and CI value at 0.5. These suggested that the coagulation function were normal. Bence-Jones protein qualitative test result was negative. T-SPOT (tuberculosis) test result was negative. Our initial diagnosis included 1. OVCF (T5/T12/L1/L4), 2. Old spinal fracture, and 3. A history of pulmonary tuberculosis.
The patient received anti-inflammatory treatment due to the high inflammatory index before operation. There were 4 OVCF requiring surgical treatment, and they were divided into two operations. The first surgical plan including three OVCFs (T12/L1/L4) was successfully completed, and the postoperative vital signs were stable. A symptomatic treatment was conducted, including infection prevention, analgesia, local ice bag compression and so on. There was no swelling or hematoma at the surgical sites. PVP for the OVCF (T5) was performed on the 2nd day after the initial surgery before postoperative radiographies were taken (Figures 1C,D). During the operation, a mild local swelling was found at the operation site, with minor bleeding. Therefore, an local ice bag compression was applied to stop the bleeding for 30 min, and the bleeding was successfully stopped, with blood pressure at 98/60 mmHg. However, about 90 min after surgery, the patient developed shock. She fainted for a few seconds, and the blood pressure gradually dropped to 62/36 mmHg, accompanied by obvious swelling of his back. She was immediately given a rapid infusion of liquid to raise her blood pressure, and at the same time, 400 ml of blood including 2 units of red blood cells was transfused. Meanwhile, local ice bag compression was applied to stop the bleeding and detumescence. The emergency blood tests indicated that WBC was 11.26 x 109/L, RBC 2.95 x 1012/L, HB 84 g/L, PLT 262 x 109/L, CRP 11.00 mg/L, prothrombin time (PT) 12.00 s, activated partial thromboplastin time (APTT) 31.20 s, thrombin time (TT) 20.07 s, fibrin/fibrinogen degradation products (FDP) 12.67 microg/ml, potassium (K+) 3.20 mmol/L, sodium (Na+) 138 mmol/L, and chloride (Cl-) 106 mmol/L. Additionally, an emergency computed tomography (CT) scan revealed that an irregular soft tissue mass with uneven density on the left chest wall, with a subcutaneous hemorrhage amounted to approximately 1500 ml, and without evidence of bone destruction or hematoma in ribs adjacent to the 5th thoracic vertebra (Figure 2).
The patient was in hemorrhagic shock. After the emergency consultation, a symptomatic treatment was given, which including 400 ml of blood transfusion (containing 2 units of red blood cells), 500 ml of glucose and sodium chloride rehydration (containing 25 g glucose and 4.5 g sodium chloride) and 30 ml of oral potassium chloride supplement (containing 3 g potassium chloride). Meanwhile, patient's vital signs were monitored by electrocardiography. After 800 ml of blood were transfused, the blood pressure increased to 110/70 mmHg. The blood tests (5 h after the first tests) showed that WBC was 7.93 x 109/L, RBC 3.19 x 1012/L, HB 93 g/L, PLT 214 x 109/L, and CRP 10.00 mg/L. On the 2nd day, besides the same volume of glucose and sodium chloride rehydration, antibiotics and analgesics, the patient was given infusion with 500 ml of multiple electrolytes rehydration (containing 2.63 g sodium chloride, 2.51 g sodium gluconate, 1.84 g sodium acetate, 0.185 g potassium chloride and 0.15 g magnesium chloride) and 100 ml of oral potassium chloride supplementation (containing 10 g potassium chloride). The 2nd day blood tests showed that WBC was 9.92 x 109/L, RBC 3.43 x 1012/L, HB 106 g/L, PLT 192 x 109/L, CRP 5.00 mg/L, K+ 3.90 mmol/L, Na+ 141 mmol/L, Cl- 105 mmol/L. The 3rd day blood tests showed that WBC was 10.57 x 109/L, RBC 3.22 x 1012/L, HB 102 g/L, PLT 212 x 109/L, CRP 4.00 mg/L, K+ 4.70 mmol/L, Na+ 141 mmol/L, Cl- 106 mmol/L. After about 2 weeks of treatment, the swelling of the patient's back obviously subsided and the ecchymosis area faded. Therefore, the treatment was effective and confirmed by CT examination on the 12th day after operation (Figure 3).
An OVCF of the 3rd lumbar vertebra happened without visible reasons, on the 16th day after the 2nd surgery. PVP was performed again smoothly without any complications. Therefore, she was discharged on the next day. A follow-up of chest CT showed that there was no residual hematoma at 12th and 17th months postoperatively (Figures 4, 5). There was no recurrence during the follow-up.