A 45 y.o. man died of sepsis secondary to quadriplegia due to complex multiple fractures of the lower cervical column (C4-C7) after a 3-weeks hospitalization in the intensive care unit. The family interviewed before performing autopsy declared that he was arrested for an alleged fight with a neighbor of the day before. They told that during the statement taken in the police station the police officer noticed a strange, irascible behavior and a neuropsychiatric consultation was requested. The medical documentation shows that the man was hospitalized in the psychiatric unit and suddenly some neurological signs appeared. Then the patient was moved to the orthopedic unit and checked radiologically with positive result – instable C5 fracture – and a Philadelphia collar stabilizer was applied. His condition was rapidly worsen and he was transferred to the intensive care unit with respiratory arrest, peripheral and central cyanosis, fixed and unreactive pupils (GCS=3). The blood pressure and oxygen’s saturation were undetectable and the pulse was 40 bpm. He was reanimated, intubated and a cardiotonic was administered; the patient recovered cardio-respiratory function (pulse 120-130bpm). It follows a complex monitoring, sedation and algotherapy with morphine. After some days an extensive CT scan of the head and neck was performed and no pathological or traumatic signs were found in the head, but multiple fractures from C4 to C7 (fractures of the spinous process of C4 and C5; fractures of the vertebral bodies of C5 (type III), C6 (type I), C7 (type I) were detected. After ten days of admission in intensive care unit the patient presented convulsion and fever (BT: 38.7 °C). During hospitalization the patient received fluid supply, human albumin 20%, mannitol 20%, antibiotic therapy according to antibiogram, antiaggregant, barbituric, analgesics, sedatives, antiacid and vitamins. Despite of this intensive treatment his hemodynamic state was instable and the fever rose up till 40.9 °C and biochemical signs of a multiple organ failure appeared (leukocytosis 15x109/L, AST 249 IU/L, ALT 580 IU/L, hypoalbuminemia, urea 11.2mmol/L, glucose 36 mmol/L). The patient died after 23 days of intensive care with diagnose of sepsis. At autopsy, the external examination revealed two decubitus area, in the occipital and sacral area with skin necrosis, marks of defibrillation and no signs of trauma. The classical autopsy opening procedure was completed with a complete posterior neck dissection discovering a minimal, insignificant paravertebral blood infiltration on the C4-C5 area and the cervical column was taken away for further bones and spinal cord evaluation. The internal organs showed macroscopically signs of failure and sepsis. The spinal cord, fixed in formalin, presented macroscopically an external, light brownish discoloration investigated microscopically. The cervical vertebrae were prepared in order to observe the localization, type and the state of fracture’s repair process. The forensic evaluation of the case confirmed a linear correlation between the vertebral-medullar injuries and the death. The CT-images revealed clear, multiple complex fractures in the cervical area that could be only the result of a relevant neck trauma. The localization of the multiple vertebral fractures, in the lower cervical spine, allows the existence of a free interval of neurological signs and the instability due to the complexity of the fractures (C5) can explain the suddenly deterioration of the neurological condition as the result of small, ordinarily neck’s movements. The big forensic questions to answer are the moment and the mechanism of the vertebral trauma, because many different situations and persons could be involved in this case (the discussion/fight with the neighbor, abuse of force by the police, event happened in the psychiatric unit (fall, use of restraints, altercation with another person) or a traumatic event before the arrest.
Schillaci, D., Barbu, C., Gashi, M., Gerxhaliu, A. (2013). Vertebral-medullary trauma death: when, where and how was the trauma?. In Proceedings of the American Academy of Forensic Sciences (pp.369-370). Colorado Springs (CO, USA) : American Academy of Forensic Sciences (AAFS).
Vertebral-medullary trauma death: when, where and how was the trauma?
SCHILLACI, DANIELA ROBERTA;
2013
Abstract
A 45 y.o. man died of sepsis secondary to quadriplegia due to complex multiple fractures of the lower cervical column (C4-C7) after a 3-weeks hospitalization in the intensive care unit. The family interviewed before performing autopsy declared that he was arrested for an alleged fight with a neighbor of the day before. They told that during the statement taken in the police station the police officer noticed a strange, irascible behavior and a neuropsychiatric consultation was requested. The medical documentation shows that the man was hospitalized in the psychiatric unit and suddenly some neurological signs appeared. Then the patient was moved to the orthopedic unit and checked radiologically with positive result – instable C5 fracture – and a Philadelphia collar stabilizer was applied. His condition was rapidly worsen and he was transferred to the intensive care unit with respiratory arrest, peripheral and central cyanosis, fixed and unreactive pupils (GCS=3). The blood pressure and oxygen’s saturation were undetectable and the pulse was 40 bpm. He was reanimated, intubated and a cardiotonic was administered; the patient recovered cardio-respiratory function (pulse 120-130bpm). It follows a complex monitoring, sedation and algotherapy with morphine. After some days an extensive CT scan of the head and neck was performed and no pathological or traumatic signs were found in the head, but multiple fractures from C4 to C7 (fractures of the spinous process of C4 and C5; fractures of the vertebral bodies of C5 (type III), C6 (type I), C7 (type I) were detected. After ten days of admission in intensive care unit the patient presented convulsion and fever (BT: 38.7 °C). During hospitalization the patient received fluid supply, human albumin 20%, mannitol 20%, antibiotic therapy according to antibiogram, antiaggregant, barbituric, analgesics, sedatives, antiacid and vitamins. Despite of this intensive treatment his hemodynamic state was instable and the fever rose up till 40.9 °C and biochemical signs of a multiple organ failure appeared (leukocytosis 15x109/L, AST 249 IU/L, ALT 580 IU/L, hypoalbuminemia, urea 11.2mmol/L, glucose 36 mmol/L). The patient died after 23 days of intensive care with diagnose of sepsis. At autopsy, the external examination revealed two decubitus area, in the occipital and sacral area with skin necrosis, marks of defibrillation and no signs of trauma. The classical autopsy opening procedure was completed with a complete posterior neck dissection discovering a minimal, insignificant paravertebral blood infiltration on the C4-C5 area and the cervical column was taken away for further bones and spinal cord evaluation. The internal organs showed macroscopically signs of failure and sepsis. The spinal cord, fixed in formalin, presented macroscopically an external, light brownish discoloration investigated microscopically. The cervical vertebrae were prepared in order to observe the localization, type and the state of fracture’s repair process. The forensic evaluation of the case confirmed a linear correlation between the vertebral-medullar injuries and the death. The CT-images revealed clear, multiple complex fractures in the cervical area that could be only the result of a relevant neck trauma. The localization of the multiple vertebral fractures, in the lower cervical spine, allows the existence of a free interval of neurological signs and the instability due to the complexity of the fractures (C5) can explain the suddenly deterioration of the neurological condition as the result of small, ordinarily neck’s movements. The big forensic questions to answer are the moment and the mechanism of the vertebral trauma, because many different situations and persons could be involved in this case (the discussion/fight with the neighbor, abuse of force by the police, event happened in the psychiatric unit (fall, use of restraints, altercation with another person) or a traumatic event before the arrest.
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