Pitfalls in radiographic Dx of transverse processes fracture
Transverse process fractures of the lumbar spine are considered benign fractures which can be caused by the direct trauma or psoas muscle avulsion. A 40-year gentleman sustained injuries in a road traffic accident while overturning of the vehicle. There was history of loss of consciousness for 30 minutes. There was no history of vomiting, seizures or oral bleed.

Abdominal examination was soft and non-tender. Bowel sound was normal and there was no hepato-splenomegaly. The patient was conscious, alert and oriented to time, place and person. At the time of examination, the patient was conscious, alert and oriented (GCS-E4V5M6). Pupils were bilateral equal and reacting. Cranial nerves were normal.

Motor and sensory examination was normal. Vital signs and general examination was unremarkable. X-ray abdomen and pelvis was interpreted as normal. The patient was managed conservatively and was apparently well. However, he was complaining of low back pain, non-radiating and minimal relief with analgesics.

An MRI of the dorso-lumbar spine was performed and it was normal. Finally the patient underwent a CT scan of the dorso-lumbar spine and it showed the fractures of the L2 and L3 transverse processes. The patient was advised best rest and brace for 6 weeks. At follow-up he is doing well.

Key takeaways:-
- Plain radiographs is initial investigation provide and make the diagnosis of transverse processes fracture quite simple and straight-forward.

- However conventional radiography can be relatively insensitive in the diagnosis of transverse process fractures of the lumbar spine particularly in patient with multiple injuries, and where there are subtle fractures of the transverse processes.

- In cases where there is high index of suspicion and plain radiographs looks apparently normal, it may be supplemented by technicium 99 m bone scintigraphy and CT.

- As it was observed in present case the presence of bowel gas shadow made the initial detection of the fracture difficult, and the literature recommends the helical CT scan provided the greater details of the fractures.

- The MRI scan is very sensitive to detect stress fractures at an early stage.

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