- Clinical science
Vertebral fractures can be caused by direct or indirect trauma and are more likely to occur in patients with decreased bone density (osteoporosis, osseous metastases). Fractures may be stable or, if there is a risk of damage to the spinal cord, unstable. Diagnosis involves a detailed neurological exam and imaging (x-ray, CT, etc). Stable fractures can be treated conservatively with analgesics and physical therapy. Unstable fractures require surgical intervention such as spinal fusion (spondylodesis), which joins vertebrae through internal fixation. Due to the close proximity to essential anatomical structures (spinal cord, blood vessels), the vertebral fractures and their surgical treatment can cause serious complications.
Stability of vertebral fractures
Types of vertebral fractures
- Vertebral compression fracture (most common type)
Burst fracture: fracture of the vertebra in multiple locations
- Result of compression trauma with severe axial loading
- Possible displacement of bone fragments into the spinal canal
- Fracture-dislocation: : fractured vertebra and disrupted ligaments; instability may cause spinal cord compression
The degree of fracture stability is the most important feature of any spinal column injury.
Simplified Denis' three-column theory
|Affected Column||Affected Structures||Stability|
|Type A||Only anterior column|| || |
|Type B||Middle column also affected|| || |
|Type C||Posterior column affected|| |
A dorsal spine injury (vertebral arches, processes, and their ligaments) is always unstable!
A fracture of the vertebral body's posterior edge has a high probability of spinal cord injury and is therefore considered unstable!
Simplified AO classification (Magerl modification)
|Mode of injury||Acting force||Findings||Stability||Treatment|
|Type A||Compression injury||Flexion||Vertical|| || |
|Type B||Distraction injury||Flexion + Distraction||Vertical|| || || |
|Type C||Translation injury||Flexion + Distraction + Rotation||Vertical + Horizontal|| || |
- Local pain on pressure, percussion, and compression
- Palpable unevenness or disruption of the vertebral process alignment
- Strong ventral compression with structural kyphosis
- Paravertebral hematoma
- Weakness or numbness/tingling
- Depending on complications and any accompanying injuries, further symptoms, potentially as severe as paralysis, are possible.
- Neurogenic shock
- Definition: fracture of the atlas (first cervical vertebra)
- Painful restriction of movement
- Asymptomatic course is also possible
- Neck ache, paravertebral hematoma with dysphagia
- Neurologic deficits, such as
- Treatment: immobilization for stable fractures; surgery for dislocations
- Definition: fracture of the dens axis (second cervical vertebral body)
- Epidemiology: ∼ 10-15% of all cervical fractures
Specific forms: hangman's fracture
- Definition: bilateral fracture of the axis arch
- Etiology: trauma with hyperextension and distraction (e.g., car accident)
- X-ray of the spinal cord to discern an atlantoaxial dislocation CT or MRI
- Treatment: immobilization for stable fractures, surgery for dislocations
|Anderson's dens fracture classification|
|Type I||Oblique fracture through the cranial part of the dens (rare)||Stable|
|Type II||Fracture at the base of the dens (most common)||Frequently unstable|
|Type III||Dens fracture and affected corpus axis||Unstable|
- Detailed neurologic exam (cranial nerves, motor and sensory components, coordination, and reflexes)
- Rectal exam to assess sphincter activation
- In trauma scenarios, a secondary survey to assess for associated injuries should be done.
Imaging: to assess the stability of the fracture (see “Classification” above), spinal cord lesions
Anterior-posterior and lateral x-ray
- Discontinued cortex, bone fragments
- Loss of height in the vertebral bodies
- CT: The axial image in particular helps localize the fracture and allows for an assessment of (posterior edge) stability.
- MRI: most sensitive tool for detecting spinal cord lesions
- Anterior-posterior and lateral x-ray
Do not delay urgent interventions (e.g., intubation, fluid resuscitation) in favor of imaging in patients with suspected injury to the spine who are unconscious and/or show signs of hemodynamic or respiratory compromise.
- Etiology: Often seen after car accidents due to abrupt flexion/extension movement of the neck
- Headache, neck ache, and/or pain radiating into the back of the head, the shoulders, or the arms
- Pain-based reduction in neck range of motion and palpable muscle tension of the shoulders and neck, as well as arm and hand paresthesia
- General symptoms such as dizziness, nausea, fatigue, insomnia, tinnitus, and problems with concentration
X-ray of the cervical spine
- Cervical spine in two planes: Overlapping images at the height of CVB 7 can be avoided by pulling the arms downward or, alternatively, weighing down the hands.
- Odontoid view in transoral anterior-posterior position with mouth open
- CT on suspicion of changes in the spinal canal and neurologic deficits
- Doppler ultrasound if injury to vessels in the neck is suspected
- X-ray of the cervical spine
The differential diagnoses listed here are not exhaustive.
- Rescue from the field when there is concern for vertebral fractures
- Place the patient on a long back board → move to stretcher once in the hospital
For possible injury of the cervical spine: immobilization with a rigid cervical collar
- Duration of immobilization:
- Until reaching final stability (e.g., surgery)
- Or until cervical injury has been ruled out
- Duration of immobilization:
- Orotracheal intubation with rapid-sequence intubation is preferred for establishing an airway in an apneic patient with a cervical spine injury.
- Indication: stable fractures
- Indications: unstable fractures and/or neurological symptoms
- Approach: fusion of two or more vertebral bodies via internal fixation using plates, rods, screws, or cages
Minimally invasive procedures
- Indication: stable vertebral compression fractures with progressive pain or kyphosis despite conservative treatment
To minimize risk of spinal cord lesions causing permanent neurological injury, treatment of unstable fractures should be initiated as soon as possible.
Spinal cord injury
- Severe injury of the spinal cord → respiratory depression
- Spinal contusion/concussion to spinal shock → neurological deficits
- Injuries of the cervical spine may include a retropharyngeal hematoma → dysphagia
- Dissection or thrombotic blockage of the vertebral artery may lead to impaired vision.
- Posttraumatic deformation of the spine: loss of height, scoliosis, or kyphosis
We list the most important complications. The selection is not exhaustive.