- 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
- The structural stability of the spine remains intact.
- No neurologic deficits
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
- 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)
- Injury mode: axial force (e.g., swimming accident caused by jumping head-first into shallow water)
- 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
- X-ray of the spinal cord to discern an atlantoaxial dislocation CT or MRI
- Treatment: immobilization for stable fractures, surgery for dislocations
- 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
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
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
- Orotracheal intubation with rapid-sequence intubation is preferred for establishing an airway in an apneic patient with a cervical spine injury.
- Indication: stable fractures
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.