Letter to the Director
Spinal fracture secondary to resuscitation procedures. Clinical and medicolegal issues
Fractura espinal secundaria a maniobras de resucitación. Implicaciones clínicas y medicolegales
a Instituto de Medicina Legal, Madrid, Spain, Sección de Antropología y Odontología, Madrid, Spain
b Servicio de Radiodiagnóstico, Hospital MAZ, Zaragoza, Spain
c Servicio de Traumatología y Cirugía Ortopédica, Hospital General de la Defensa. Zaragoza, Spain
d Servicio de Neurocirugía, Hospital MAZ. Zaragoza, Spain
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Implicaciones clínicas y medicolegales" "tienePdf" => "es" "tieneTextoCompleto" => "es" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "311" "paginaFinal" => "313" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Spinal fracture secondary to resuscitation procedures. Clinical and medicolegal issues" ] ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figura 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1120 "Ancho" => 2500 "Tamanyo" => 406367 ] ] "descripcion" => array:1 [ "es" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Examen externo: a) Se aprecian varias heridas por punturas intracardiacas (flechas), por encima de una placa apergaminada precordial (flechas largas), sugerente de aplicación enérgica de maniobras de masaje cardíaco. b, c) Se muestra la radiología <span class="elsevierStyleItalic">post mortem</span>. Se observa esclerosis focal en las esquinas de los cuerpos vertebrales (signo de la cuadratura vertebral) secundario a erosiones previas vertebrales (flechas negras). Se aprecian sindesmofitos finos al mismo nivel, formando puentes óseos intersomáticos (flechas finas blancas). Es patente la osificación del ligamento longitudinal anterior (flechas gruesas blancas), signo de la «caña de bambú». Los discos vertebrales muestran una altura normal. d, e) Corresponden a la pieza espinal tras digestión de partes blandas. Muestran una fusión raquídea en bloque, con osificación del ligamento longitudinal anterior (LLA). La fractura está señalada con flechas rojas en e). Se aprecia también un hemangioma vertebral en el soma de D7 (flecha amarilla en d). El asterisco en e) muestra un agujero nutricio dilatado en el contexto del angioma vertebral.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "E. Dorado Fernández, C. Sebastián Sebastián, A. Aso Vizán, J. 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"apellidos" => "Aso Escario" "email" => array:1 [ 0 => "jaso@maz.es" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "aff0020" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] ] "afiliaciones" => array:4 [ 0 => array:3 [ "entidad" => "Instituto de Medicina Legal, Madrid, Spain, Sección de Antropología y Odontología, Madrid, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Radiodiagnóstico, Hospital MAZ, Zaragoza, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Servicio de Traumatología y Cirugía Ortopédica, Hospital General de la Defensa. Zaragoza, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Servicio de Neurocirugía, Hospital MAZ. Zaragoza, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Fractura espinal secundaria a maniobras de resucitación. Implicaciones clínicas y medicolegales" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1120 "Ancho" => 2500 "Tamanyo" => 406367 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">External examination: a) Several intracardiac puncture wounds (arrows) can be seen above a precordial leathery plaque (long arrows), suggestive of forceful cardiac massage manoeuvres. b, c) Post mortem radiograph showing localised sclerosis on the corners of the vertebrae (vertebral body squaring) secondary to previous vertebral erosions (black arrows). Fine syndesmophytes can be seen at the same level, forming intervertebral bone bridges (thin white arrows). There is clear ossification of the anterior longitudinal ligament (thick white arrows), a sign of “bamboo spine”. The vertebral discs are normal in height. d, e) The spinal column after removal of soft tissue, showing spinal fusion with ossification of the anterior longitudinal ligament (ALL). The red arrows indicate the fracture e). A vertebral haemangioma can also be seen in D7 (yellow arrow in d). The asterisk in e) shows a large nutrient foramen in the vertebral angioma.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Spinal fractures associated with cardiopulmonary resuscitation (CPR) are interesting in both clinical and forensic medicine. Such fractures can be caused, or aggravated, by ankylosing spondylitis; hence the importance of this condition in the context of CPR.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Our patient was a 78-year old man. History: schizoaffective disorder, mild cognitive impairment and Parkinson’s disease.</p><p id="par0015" class="elsevierStylePara elsevierViewall">He was found sitting on the floor between the washbasin and the bathtub, leaning against the bathtub, unconscious, cyanotic and without a pulse. The electrocardiogram (ECG) showed pulseless electrical activity. CPR was performed per protocol, including cardiac massage, but the patient remained in asystole. Death was declared after 30<span class="elsevierStyleHsp" style=""></span>min of resuscitation.</p><p id="par0020" class="elsevierStylePara elsevierViewall">The autopsy showed: External examination: precordial leathery plaque, suggestive of chest compression manoeuvres. Skin wounds compatible with intracardiac punctures (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). Fracture of 3rd to 5th left anterior costal arch and fracture of the sternal manubrium. Internal examination: Haemorrhagic suffusions on the medial side of the rib cage at various levels. Bilateral haemothorax (100 cc). Transverse fracture line between T8 and T9, which crosses the intervertebral disc space and continues backwards, to the right and slightly upwards. Spinal fusion or “bamboo spine”. Ossification of the anterior longitudinal ligament (ALL) extending along the dorsal spine. Infiltration of blood in the epidural space (5.5<span class="elsevierStyleHsp" style=""></span>cm above the fracture). The spinal cord is unremarkable. Vertebral haemangioma at D7 (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>d, e).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">The post mortem radiograph showed syndesmophytes anterior to the vertebrae, with extensive, symmetrical bone bridges (vertebral ankylosis). Vertebral body squaring due to sclerosis of the anterior margins secondary to previous marginal erosions (Romanus lesions) and ALL ossification (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). Extensive histopathology, including autopsy of the heart and other organs, as well as toxicology, showed no abnormal findings. Death was classified as natural, primarily of cardiac origin (possible asystole due to bioelectrical phenomena), secondary fall without injuries, and spinal fracture caused by CPR.</p><p id="par0030" class="elsevierStylePara elsevierViewall">The fracture is a type B3A fracture according to the Schnake et al.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> classification. This system included for the first time the possibility of adding clinical modifiers, in this case, M2, which indicates comorbidity such as: ankylosing spondylitis, diffuse idiopathic hyperostosis, osteopenia, osteoporosis and other rheumatological diseases.</p><p id="par0035" class="elsevierStylePara elsevierViewall">The presence of fine, symmetrically distributed syndesmophytes and "bamboo spine" are characteristic of long-standing ankylosing spondylitis (AS). However, they are not specific. In diffuse idiopathic skeletal hyperostosis (DISH or Forestier's disease), the vertebral spaces are relatively well preserved<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>. Our case, therefore, is radiologically consistent with AS. However, there was no mention of rheumatological history in the patient’s medical record.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Spinal fractures due to CPR are rare and may account for 0.1% of lesions in autopsy series, the most common mechanism being hyperextension of the spine<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a>. There are also reports of a kickback effect during resuscitation manoeuvres, even in the absence of chest compression and defibrillation<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a>. Many spinal ankylosing diseases are accompanied by osteoporosis, which facilitates fractures, and by kyphosis, which lowers the body’s centre of gravity, thereby promoting falls and reducing automatic protection mechanisms<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a>. These factors increase the risk of vertebral fractures in AS, which occur in around 10% of patients<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a>. The B3A fracture is caused by hyperextension.</p><p id="par0045" class="elsevierStylePara elsevierViewall">The fracture mechanism, its appearance, the external signs of compression, and the concurrence of sternal and rib fractures indicate that it was caused by the CPR manoeuvres. The possibility of the fracture being caused by the fall was ruled out due to the absence of external trauma and the position the subject. The family did not report hearing any noise consistent with a fall or impact. The sternum fracture is also a marker of severe spinal dislocation, and suggests the presence of compression that tended to straighten the kyphosis.</p><p id="par0050" class="elsevierStylePara elsevierViewall">Despite the asystole, the presence of vital reactions (internal ecchymoses, bone bruising at the site of the fracture, infiltration of blood in the dura, and a certain amount of haemothorax) show the persistence of blood flow, perhaps due to the cardiac massage itself, and the injuries were therefore classified as perimortem rather than vital. As a result, the causal mechanism of the vertebral fracture was hyperextension caused by cardiac massage and/or intubation manoeuvres in a patient with structural kyphosis, ankylosis, and bone fragility.</p><p id="par0055" class="elsevierStylePara elsevierViewall">Our case highlights the importance of ruling out these risk factors. Some measures, such as placing the body and head to avoid straightening the spine and performing careful, gentle massage manoeuvres, could be appropriate. Time permitting, therefore, history collection protocols should indicate the need to investigate this type of morbidity (kyphosis, osteoporosis, vertebral ankylosing disease). Healthcare workers should also record these ankylosing symptoms in the patient’s clinical history, although their clinical significance may, at first glance, be relative.</p><p id="par0060" class="elsevierStylePara elsevierViewall">From a forensic point of view, a complete necropsy including an autopsy of the spinal cord is required, since the mechanism of death can be complex and include a combination of premorbid and morbid conditions together with injuries caused by resuscitation itself. This can determine whether the cause of death is classified as natural or violent, and avoid forensic problems in malpractice claims for spinal fractures during CPR.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Funding</span><p id="par0065" class="elsevierStylePara elsevierViewall">This study has not received funding from public or private institutions or individuals.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Conflict of interests</span><p id="par0070" class="elsevierStylePara elsevierViewall">The authors have no conflict to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Funding" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Conflict of interests" ] 2 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Dorado Fernández E, Sebastián Sebastián C, Aso Vizán A, Aso Escario J. Fractura espinal secundaria a maniobras de resucitación. Implicaciones clínicas y medicolegales, Rev Esp Anestesiol Reanim. 2022;69:311–313.</p>" ] ] "multimedia" => array:1 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1120 "Ancho" => 2500 "Tamanyo" => 406367 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">External examination: a) Several intracardiac puncture wounds (arrows) can be seen above a precordial leathery plaque (long arrows), suggestive of forceful cardiac massage manoeuvres. b, c) Post mortem radiograph showing localised sclerosis on the corners of the vertebrae (vertebral body squaring) secondary to previous vertebral erosions (black arrows). Fine syndesmophytes can be seen at the same level, forming intervertebral bone bridges (thin white arrows). There is clear ossification of the anterior longitudinal ligament (thick white arrows), a sign of “bamboo spine”. The vertebral discs are normal in height. d, e) The spinal column after removal of soft tissue, showing spinal fusion with ossification of the anterior longitudinal ligament (ALL). The red arrows indicate the fracture e). A vertebral haemangioma can also be seen in D7 (yellow arrow in d). The asterisk in e) shows a large nutrient foramen in the vertebral angioma.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:6 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "AO Spine Classification Systems (Subaxial, Thoracolumbar)" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "K.J. Schnake" 1 => "G.D. Schroeder" 2 => "A.R. Vaccaro" 3 => "C. 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