Clinical Practice and Cases in Emergency Medicine

Introduction: Hyperbaric oxygen therapy carries a risk of central nervous system oxygen toxicity, which can result in seizures. Seizure-induced spinal fractures are uncommon complications that occur during generalized convulsive activity. While often benign, lumbar vertebral body burst fractures may result in cauda equina syndrome. Additionally, patients with beta-thalassemia may have decreased bone mineral density due to ineffective erythropoiesis and bone marrow expansion increasing the risk for pathologic and traumatic fractures.

Case Report: A 35-year-old man with beta-thalassemia major presented to the emergency department after a witnessed, first-time generalized tonic-clonic seizure during hyperbaric oxygen therapy for chronic venous ulcers. Initial evaluation revealed severe low back pain and midline lumbar tenderness. Computed tomography revealed an acute third lumbar vertebra (L3) burst fracture with retropulsion. The patient rapidly developed progressive right lower-extremity weakness and acute urinary retention. Magnetic resonance imaging revealed 70% loss of height of L3, severe thecal sac stenosis at L2-L3 and L3-L4, and a ventral dural hematoma resulting in stenosis at L4-L5. The patient was diagnosed with cauda equina syndrome and underwent emergent neurosurgical decompression.

Conclusion: This case represents a rare convergence of multiple complications: central nervous system oxygen toxicity during hyperbaric oxygen therapy, seizure-induced lumbar burst fracture with retropulsion, and traumatic cauda equina syndrome in a patient with beta thalassemia. Physicians must maintain a high index of suspicion for vertebral fractures and monitor for evolving neurological deficits when managing the patient with acute back pain following seizure activity.