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Vertebral fractures

Last updated: June 10, 2021

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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.

References:[1]

Epidemiological data refers to the US, unless otherwise specified.

References:[1][2]

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]

  • 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]

Atlas fracture

Dens fracture

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]

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]

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.

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]

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

  1. Parizel PM, Van der zijden T, Gaudino S, et al. Trauma of the spine and spinal cord: imaging strategies. Eur Spine J. 2009; 19 (Suppl 1): p.S8-17. doi: 10.1007/s00586-009-1123-5 . | Open in Read by QxMD
  2. Kaji A, Hockberger RS. Spinal Column Injuries in Adults: Definitions, Mechanisms, and Radiographs. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/spinal-column-injuries-in-adults-definitions-mechanisms-and-radiographs.Last updated: July 13, 2016. Accessed: March 9, 2017.
  3. Alexandru D, So W. Evaluation and management of vertebral compression fractures. Perm J. 2012; 16 (4): p.46-51.
  4. Kaji A, Hockberger RS. Evaluation of Thoracic and Lumbar Spinal Column Injury. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/evaluation-of-thoracic-and-lumbar-spinal-column-injury.Last updated: August 30, 2018. Accessed: October 31, 2018.
  5. McCarthy J, Davis A. Diagnosis and management of vertebral compression fractures. Am Fam Physician. 2016; 94 (1): p.44-50.
  6. Gonschorek O, Vordemvenne T, Blattert T, Katscher S, Schnake KJ, Spine Section of the German Society for Orthopaedics and Trauma.. Treatment of Odontoid Fractures: Recommendations of the Spine Section of the German Society for Orthopaedics and Trauma (DGOU).. Global spine journal. 2018; 8 (2 Suppl): p.12S-17S. doi: 10.1177/2192568218768227 . | Open in Read by QxMD
  7. Kandziora F, Scholz M, Pingel A, et al. Treatment of atlas fractures: Recommendations of the Spine Section of the German Society for Orthopaedics and Trauma (DGOU). Global Spine J. 2018; 8 (2): p.5S-11S. doi: 10.1177/2192568217726304 . | Open in Read by QxMD
  8. Bales CP, Chang I, Matheson G, Ouyang D, Dragoo JL. College football player with unstable C1 fracture. Am J Sports Med. 2009; 37 (1): p.195-198. doi: 10.1177/0363546508328594 . | Open in Read by QxMD
  9. Fracture, odontoid.
  10. Wong CC, McGirt MJ. Vertebral compression fractures: a review of current management and multimodal therapy. J Multidiscip Healthc. 2013; 6 : p.205-14. doi: 10.2147/JMDH.S31659 . | Open in Read by QxMD
  11. Rosenfeld M. Whiplash. Am J Med. 2001; 110 (8): p.667-668. doi: 10.1016/s0002-9343(01)00700-8 . | Open in Read by QxMD
  12. Tameem A, Kapur S, Mutagi H. Whiplash injury. Continuing Education in Anaesthesia, Critical Care & Pain. 2014; 14 (4): p.167-170. doi: 10.1093/bjaceaccp/mkt052 . | Open in Read by QxMD
  13. Vieweg U, Grochulla F. Manual of Spine Surgery. Springer Science & Business Media ; 2012
  14. Spinal Fractures. https://neurosurgery.ufl.edu/patient-care/diseases-conditions/spinal-fractures/. Updated: March 9, 2017. Accessed: March 9, 2017.
  15. Spinal fractures. http://www.mayfieldclinic.com/PE-SpineFract.HTM. Updated: April 1, 2016. Accessed: March 9, 2017.
  16. Types of Spinal Fractures. https://www.spineuniverse.com/conditions/spinal-fractures/types-spinal-fractures. Updated: February 23, 2017. Accessed: March 9, 2017.
  17. Vertebroplasty and Kyphoplasty Comparisons. http://www.spine-health.com/treatment/back-surgery/vertebroplasty-and-kyphoplasty-comparisons. Updated: February 5, 2014. Accessed: March 9, 2017.