Emergency Neurological Assessment Required
This patient requires immediate emergency evaluation (call 911) due to the presence of hyperreflexia and clonus with compression fractures at T12 and L1, which suggests potential spinal cord compression or conus medullaris syndrome—a neurosurgical emergency.
Critical Neurological Red Flags Present
The combination of compression fractures at T12-L1 with hyperreflexia and clonus is highly concerning for:
- Spinal cord or conus medullaris compression: The conus medullaris typically terminates at L1, and compression fractures at T12-L1 can cause caudal displacement of the conus, leading to upper motor neuron signs including hyperreflexia and clonus 1
- Mixed upper and lower motor neuron findings: While cauda equina syndrome classically presents with lower motor neuron signs, compression at the thoracolumbar junction can produce atypical presentations with clonus, which should not delay diagnosis or treatment 2
- Progressive neurological deterioration risk: Vertebral fractures at this level with neurological signs indicate potential for rapid deterioration requiring urgent surgical intervention 1, 3
Immediate Actions Required
Call 911 immediately for emergency transport to a facility with neurosurgical capabilities because:
- Compressive myelopathy from retropulsion of fracture fragments is a relative contraindication to conservative management and requires urgent surgical evaluation 4
- Immediate surgical referral is mandatory for any neurological deficits with spinal instability or cord compression 5
- Corticosteroid therapy should be initiated immediately and surgery performed as soon as possible to prevent further deterioration in patients with neurological deficits 5
Why This Cannot Wait
- Time-critical nature: Neurological recovery correlates with timing of decompression; delays can result in permanent neurological sequelae 2
- Atypical presentation: The presence of upper motor neuron signs (hyperreflexia, clonus) with thoracolumbar fractures indicates cord-level involvement, not just nerve root compression 1, 2
- Fracture location: T12-L1 fractures are particularly dangerous as they occur at the conus medullaris level, where compression can produce varied neurological patterns including bladder dysfunction, motor weakness, and mixed upper/lower motor neuron signs 1, 3
Critical Pitfall to Avoid
Do not dismiss the diagnosis or delay treatment because of the presence of clonus—this upper motor neuron sign does not preclude spinal cord compression at the thoracolumbar junction and should heighten concern for urgent intervention 2. The clinicoradiological correlation must be made emergently with advanced imaging (MRI) and neurosurgical consultation 4, 2.