• Clinical science

Vertebral fractures

Summary

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.

Epidemiology

References:[1]

Epidemiological data refers to the US, unless otherwise specified.

Etiology

References:[1][2]

Classification

Stability of vertebral fractures

A dorsal spine injury (vertebral arches, processes, and their ligaments) is always unstable and has a high probability of spinal cord injury.

Types of vertebral fractures

References:[2][3]

Clinical features

  • Local pain on pressure, percussion, and compression
  • Palpable unevenness or disruption of the vertebral process alignment
  • Paravertebral hematoma
  • Weakness or numbness/tingling
  • Neurogenic shock
  • Strong ventral compression with structural kyphosis
  • Depending on complications and any accompanying injuries, further symptoms, potentially as severe as paralysis, are possible.

References:[4][5]

Subtypes and variants

Atlas fracture

Dens fracture

  • Definition: fracture of the dens axis (second cervical vertebral body)
  • Epidemiology: 10–15% of all cervical fractures
  • Etiology
    • Head or neck injury as a result of a fall or blunt trauma
    • A contributing factor is loss of bone substance as a result of osteoporosis (mostly seen in elderly patients).
  • Symptoms
  • Specific forms: hangman's fracture
    • Definition: bilateral fracture of the axis arch
    • Etiology: trauma with hyperextension and distraction (e.g., car accident)
  • Diagnostics: x-ray of the spinal cord to discern an atlantoaxial dislocation , CT, or MRI
  • Treatment: immobilization for stable fractures, surgery for dislocations
Anderson and D'Alonzo dens fracture classification [6]
Type Characteristics Stability
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

References:[7][8][9]

Diagnostics

Physical exam

  • 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

Used 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.

References:[10]

Differential diagnoses

Cervical spine distortion (whiplash injury)

  • Etiology: often seen after car accidents due to abrupt flexion/extension movement of the neck
  • Symptoms
    • 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
  • Imaging
  • Treatment

References:[11][12]

The differential diagnoses listed here are not exhaustive.

Treatment

General

Conservative treatment

  • Indication: stable fractures
  • Procedures
    • Pain medication
    • Physical therapy
    • External bracing and orthotics to maintain spinal alignment, promote healing, and control pain through immobilization for about 8–12 weeks (e.g., rigid collar in cervical fracture, cervical-thoracic brace for thoracic fractures, and thoracolumbar-sacral orthosis for lower back fractures)

Surgical treatment

To minimize the risk of spinal cord lesions causing permanent neurological injury, treatment of unstable fractures should be initiated as soon as possible.

References:[13]

Complications

We list the most important complications. The selection is not exhaustive.