Case Report 2

back to June 09 Issue

Vertebral Compression Fractures Resulting from Hypoglycemic Convulsions in a Patient with Type 1 Diabetes Mellitus: A Case Study

David M. Swensen, DC, FACO*

* Corresponding author
Address: 40 West Foster Street Melrose, MA 02176
Email: dosdc@aol.com

Published: June, 2009
Journal of the Academy of Chiropractic Orthopedists
June 2009, Volume 6, Issue 2
Received: 11 May 2009
Accepted: 12 July 2009

This article is available from: http://www.dcorthoacademy.com © 2009 Swensen and the Academy of Chiropractic Orthopedists
This is an Open Access article which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract
The chiropractic orthopedist often encounters patients who present with either diagnosed or undiagnosed Type 1 Diabetes Mellitus (DM1).  This condition may contribute to musculoskeletal conditions. This case study presents a rarely reported case of vertebral compression fractures in a seemingly healthy, physically active, well conditioned male adult, resulting from nocturnal hypoglycemic convulsions. It behooves the chiropractic orthopedist to become familiar with the ‘tight’ control of glucose levels in patients with DM1 in order to recognize possible symptoms and give proper counsel regarding avoiding hypoglycemic events.

Introduction
Diabetes Mellitus (DM) affects 20 million children and adults in the United States [1]. Persons with DM may present to the chiropractic orthopedist with musculoskeletal complaints [2]. The chiropractic orthopedist should therefore be aware of the array of musculoskeletal symptoms which may be associated with DM. This case presents a rarely reported occurrence of vertebral compression fractures which resulted from hypoglycemic convulsions, on two occasions in the same patient with Type 1 Diabetes Mellitus (DM1). The purpose of this case presentation is to create awareness of the occurrence of this injury in the population of DM patients, and to encourage chiropractic physicians to further their knowledge of DM1 so that they may appropriately counsel and refer patients when necessary.

Case Study
A 41 year old, well nourished, athletic male presented with a complaint of moderate to severe thoracic pain centered between the shoulder blades. He reported that the onset of pain was the day of his presentation for evaluation, in the morning when he woke up, which was somewhat earlier than usual. He also noted that he had bitten his tongue and there was blood on his sheets and pillow. Earlier that day, he had been seen in a different chiropractic office where x-rays had been taken. The patient was told the x-rays were normal. The doctor applied ice and recommended adjustments to the thoracic spine. The patient opted for another opinion.

The patient’s score on the Visual Analogue Scale [3] was 10.The patient reported that he had been very busy working a desk job for 50 – 60 hours per week. He reported that he had still managed to exercise regularly, lifting weights, swimming, and running, for a total average of 4-5 days per week. He also played ice hockey on occasion.  He denied any history of epilepsy or other seizure disorders. He had been diagnosed four years earlier with DM1. He had been monitoring his blood sugar level 4 or 5 times per day. He reported that he was taking Humalog (fast acting insulin analog) with meals. He denied any other medications. Previous medical history also included left latissimus dorsi strain several years earlier.

Inspection revealed a guarded posture of the trunk, and stiffness with motion. Gait was otherwise normal. He was afebrile. Palpation revealed spasm in the thoracic paravertebral musculature, with pain on palpation from T5-9. Cervical flexion created increased pain in the middle thoracic region at 30 degrees. Other cervical motions were normal and did not increase pain in the thoracic region. Pain was significantly increased at 5 degrees of thoracic flexion. Thoracic extension was 0 degrees with noticeably less pain than with flexion. Thoracic rotation was minimal and painful. Soto Hall maneuver was positive, causing increased middle thoracic pain. No neurological deficits were detected upon evaluation of motor strength, sensation to pinprick, and deep tendon reflexes in the C5-T2, and L4-S1 spinal levels bilaterally. No abnormality was detected upon evaluation of sensation to pinprick in the thoracic dermatomes. Abdominal reflex was normal in all quadrants.

An initial working diagnosis of thoracic disc herniation was described to the patient, and an MRI of the thoracic spine was obtained. The study demonstrated wedging of T4 and T5 vertebral bodies (Fig.1) with abnormal marrow signals on T1 and T2 weighted images, consistent with compression fractures. Ten percent loss of height of the T4 vertebral body, and twenty percent loss of height of the T5 vertebral body was noted. No evidence of pre-existing bony pathology was present. The initial X-ray studies were later obtained from the first chiropractic office which the patient had sought care. It was found that cervical and lumbar films were taken, but not thoracic films.

Figure 1. Sagital image showing compression of T4 and T5.

A diagnosis of compression of bi-level thoracic compression fracture secondary to nocturnal hypoglycemic convulsion was made. Conservative treatment consisting of cryotherapy, interferential current at a submuscular threshold, and effleurage was applied to the thoracic region, with the patient’s consent, in order to decrease pain and spasm.  He was treated on 5 occasions over 6 weeks, with the goal of decreasing pain and spasm and educating on home care. At the 6 week follow-up he was not yet able to run because of the pain, but he had ice skated. He was seen the following year for an unrelated complaint, and reported no sequelae.

Six years later, the patient returned with a similar complaint, however on this occasion, he did not injure his tongue. Again, he woke up with mid back pain which he rated at a 10 on a Numerical Rating Scale (NRS) [3], and did not recall any unusual event. He reported that he had been undergoing an extended period of physical activity, specifically several 10-12 hour days of performing finish carpentry. His mealtime and sleep schedules had been deviating from his usual routine, and he reported that he was exhausted during the day before this second event occurred. Examination findings were very similar to the first event. There was pain and limitation with all thoracic motions, especially flexion. Palpation was positive for pain and tenderness in the middle thoracic levels over the paraspinal muscles. Percussion of the spinous processes was painful at T6 and 7. No neurological deficits were noted in the upper or lower extremities, or over the abdominal region. MRI revealed vertebral body compression fractures at T6 and T7 (Fig. 2), with increased signal on the STIR sequence, indicating an acute process. The loss of vertebral body height at T4 and T5 was evident, present from the previous injury. 

Figure 2. T1 sagital image demonstrating compression of T6 and T7 as well as old compression of T4 and T5.

The patient had indicated that after the first episode his medication was changed to NPH insulin, which is similar to Humalog, but longer acting. He was currently taking Lantus, a 24 hour ‘background’ insulin, which is designed to mimic the low level of insulin that is present in non-diabetic individuals. He reported that he had been trying to keep his blood glucose levels as close to normal as possible and indicated that, other than fatigue, he had not experienced any symptoms associated with hypoglycemia, such as dizziness or confusion. He reported that his HbA1c, a measure of mean glycosylated hemoglobin, had been in the target rate of under seven.

The patient was treated nine times over a twelve week period, with treatment consisting of therapeutic modalities, and manual and instrument assisted soft tissue mobilization to the paraspinal musculature in order to decrease pain and spasm. The patient had expressed concern over developing a forward stooped posture because of the multiple levels of anterior wedging. Beginning with the fourth treatment, which was four weeks post injury, the patient was instructed on performing postural exercises, including: pectoral, scalene, SCM, and suboccipital stretching exercises; scapular retraction and paraspinal extensor strengthening exercises. These were demonstrated and performed in the office and as home exercises. The patient was compliant throughout because he was very motivated to get back to his usual activities, which included working as a contractor, running, weight lifting, and playing ice hockey.

At this time spinal manipulation was performed to the levels above and below the area of injury, as tolerated by the patient. At 12 weeks, the patient continued to have a complaint of ache and stiffness in the mid thoracic region which he rated at a 3-4 on a scale of 0-10. Motion palpation revealed restriction from T4 – T9. The patient was adjusted using an anterior to posterior and inferior to superior line of drive in a supine position, with arms crossed, with the doctor contact of one hand under the T9 vertebrae, acting as a fulcrum, and the other forearm on the patient’s crossed forearms. This adjustment was only performed after a pre-manipulative stress test was tolerated by the patient. This pre-manipulative test consisted of placing the patient in the same position as described, and applying light pressure to determine if pain or discomfort was noted by the patient. The patient reported that the pain subsided immediately after the adjustment. He was advised to continue with home exercises and to gradually increase his activity level, to his tolerance. He was advised to return as needed.

Discussion
Chiropractic orthopedists evaluate and treat many patients for musculoskeletal complaints. Several musculoskeletal complaints have been associated with DM [4, 5, 2]. In the United States, 14.6 million persons have been diagnosed with DM and a suspected 6.2 million have the condition but have yet to be diagnosed. With this considerable number, there is a strong likelihood of a diabetic patient presenting to a chiropractic orthopedic practice with musculoskeletal complaints. DM patients, whether Type 1 or Type 2, have a greater incidence than the general population of several musculoskeletal conditions. These include muscle cramps, muscle infarction, loss of deep tendon reflexes, peripheral neuropathy, complex regional pain syndrome, stiff hands syndrome, neuropathic joints, carpal tunnel syndrome, adhesive capsulitis of the glenohumeral joint, tenosynovitis, diffuse idiopathic skeletal hyperostosis, and  Dupuytren’s contracture [2].  This case study reports two incidents of bi-level vertebral compression fractures in the same patient which occurred slightly greater than six years apart. There have been few reports of vertebral compression fracture resulting from hypoglycemic convulsions in the English language [4,5].  These have been attributed to inappropriate self management. Of the six cases of musculoskeletal injuries from hypoglycemic convulsions reported by Hepburn et al, two sustained vertebral compression fractures, one suffered a tibial and fibular fracture from a fall when she became unconscious, one sustained bilateral humeral neck fractures, and two suffered glenohumeral dislocation. In four of the six cases intervention of either intravenous dextrose or intramuscular glucagon was necessary to restore consciousness.   Nabarro reported on four cases of vertebral compression fracture resulting from hypoglycemic convulsions. He suggested that the greater emphasis on ‘good control’ may be an etiological factor in these events.

Tight control of glucose levels in DM1 patients has been advocated in order to delay and minimize complications, especially microvascular complications such as retinopathy, neuropathy, and nephropathy. The effect of this disease on the microvasculature may also be a contributing factor to some of the musculoskeletal conditions previously discussed .  However, along with the benefits of maintaining ‘tight’ control, there is also a risk of becoming hypoglycemic. For this reason, it is important for healthcare practitioners to be aware of and to ensure the patient realizes the importance of monitoring their blood glucose levels several times throughout the day, and before bedtime. It is equally important for the patient to understand the hazard of hypoglycemia occurring at night, while the patient is asleep and not able to recognize symptoms, possibly leading to convulsions or coma. For this reason, if a bedtime glucose reading is low or borderline, an appropriately sized snack should be eaten.

Optimal blood glucose control is defined by a target HbA1c , the mean glycosylated hemoglobin level over the previous two to three month period, of less than 7 percent, and meter readings of preprandial glucose level of 80 to120 mg per dL  and a bedtime glucose level of 100 to140 mg per dL  [6].    Havas reports that clinical trials have provided a strong scientific basis in support of the potential benefits of tight glucose control.  Frequent monitoring is necessary in order to maintain the target zone and to avoid the onset of hypoglycemic events.

In this case, the patient had been taking measures to maintain tight control of glucose levels, including proper nutrition, glucose monitoring, and regular exercise. On both occasions leading to hypoglycemic convulsions, his stress level and number of hours at work had increased for an extended period. Although he had reported not having any symptoms associated with hypoglycemia, in retrospect, the extreme fatigue he had experienced was most likely a symptom. Failure to recognize this as a symptom led to excessively low blood glucose and convulsions. The occurrence of compression fractures is attributed to the strength of the thoracic extensors being less than the cervical and lumbar extensors, and the mechanical advantage of the trunk flexors, which work from the pelvis and the rib cage [5]

Because of the growing number of persons affected by DM, the chiropractic orthopedist should be aware of the possibility of a patient presenting with spinal pain that may be associated with a hypoglycemic event. As promoters of wellness and as musculoskeletal specialists, chiropractic orthopedists should be aware of testing procedures used to monitor blood glucose levels, and target levels for those tests (Table 1). With adequate knowledge of this condition, the chiropractic orthopedist will be able to ask pertinent questions to determine if the patient is properly managing their condition, and realize when a referral to their primary care physician or endocrinologist is appropriate. Additional information about testing and management of diabetes is available on the American Diabetes Association web site www.diabetes.org.

Consent
Written informed consent was obtained from the patient for publication of this Case Report, and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.

Competing interests
The author declares that he has no competing interests.

References

1. About Diabetes.   http://www.diabetes.org/about-diabetes.jsp.
2. Wyatt LH, Ferrance RJ: The musculoskeletal effects of diabetes mellitus. J Can Chiro Assoc 2006, 50, 43-50.
3. Bolton JE, Wilkinson RC: responsiveness of pain scales: a comparison of three pain intensity measures in chiropractic patients. J Manipulative Physiol Ther 1998, 21, 1-7
4. Hepburn DA, Steel JM, Frier BM: Hypogycemic convulsions cause serious muskuloskeletal injuries in patients with IDDM. Diabetes Care 1989, 12, 32-34.
5. Nabarro J: Compression fractures of the dorsal spine in hypoglycemic fits in diabetes. [Case report]. BMJ 1985, 291, 1320.
6. Havas, S: Educational guidelines for achieving tight control and minimizing complications of type 1 diabetes. American Family Physician  1999,60, 1985-1998.

Table 1.