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EeroHirvensalo

Fractures of the Spine

Essentials

  • Injuries to the spine are most often associated with falling from a height, traffic accidents or a simple fall from a standing position. Note particularly the at-risk groups that may suffer a fracture of the spine even after a low-energy trauma (such as whiplash injury, or a direct or indirect blow to the neck or to the thoracic/lumbar spine):
    • elderly persons, especially if an accidental fall is associated with head or back injury or if the person falls on the buttocks
    • patients with ankylosing spondylitis or osteoporotic changes in the spine.
  • Falls from a height and similar injuries affecting the spine area (including simple falls from a standing position in the elderly) must always be carefully assessed. The diagnostics and planning of treatment should take place in specialized care, excluding minor strains and similar situations.
  • The patient must be moved in a supine position, and if a cervical spine injury is suspected the patient's neck must be supported with a collar. If the patient has ankylosing spondylitis or some other known condition that causes the spine to be permanently forward stooped, sufficient elevation pillows have to be used in order to maintain the natural curvature, or the patient has to be placed to a supported lateral position.
  • Always remember the possibility of spinal injury in an unconscious trauma patient.
  • If cervical spine injury is suspected, a CT scan is the primary investigation. If a blood vessel injury is suspected, a CT scan with contrast medium is performed. X-ray examination is indicated in primary care as a part of the primary examination of thoracic and lumbar spine injuries. An x-ray may also be taken of the cervical spine if CT scanning is unavailable early during the diagnostic workup (e.g. diagnostic assessment in a surgery with a possibility to perform imaging).

Fracture of the cervical spine

  • If cervical spine injury is suspected, the patient should be referred to specialized care.
  • When taking the patient history, information about any direct or indirect neck injury (e.g. in association with a fall or falling from a height) is important.
  • A painful neck or spine in an elderly patient who has fallen over or hit their head on a wall in a stairwell, for example, always requires further examination, and a fracture must be considered probable.
  • All fractures should be considered unstable until the diagnosis has been confirmed.
  • Monitor and record the patient's neurological status, especially that of the upper limbs, and any changes to it.
  • The likelihood of cervical spine fracture is very small in healthy children and young adults if the head region has suffered no more than low-energy injury. Imaging is usually unnecessary in such cases, particularly in patients who have not even the slightest localized tenderness in the neck or shoulder region, no neurological symptoms and no co-existing diseases that could interfere with the diagnosis.
  • In unclear cases, a CT scan is indicated if injury to the cervical spine area is suspected.
    • If the patient has multiple injuries or is intoxicated, or if he/she may be suffering from brain injury or if the patient's cooperation is otherwise impaired, the patient's sensation and reporting of pain cannot be relied on when evaluating the injuries.

Diagnosis

  • Careful history taking is important.
  • In the clinical picture, occipital, neck, shoulder or upper limb pain suggests significant injury to the cervical spine area with nerve root irritation/injury (radiation of pain depending on the level of injury).
  • In the initial phase, local pain in the cervical spine cannot be reliably detected by palpation.
  • The neurological status of all limbs should be examined.
  • The possibility of brain injury should be taken into account
  • Clinical examination should be complemented by a CT scan if symptoms suggesting cervical spine injury appear and it is known that there is a head or neck injury or if blood vessel injury in the neck (carotid or vertebral artery) is suspected. If this is not possible, the cervical spine can be x-rayed during the initial workup to exclude most distinct injuries.
    • Examine the lateral projection for displacement of the vertebrae; ensure that vertebrae C1-C7 are shown on the x-ray (pictures 1 3). Check that the anterior and posterior edges of the vertebral bodies form even lines, that the facet joints are in right position, that the apices of the spinous processes curve evenly and that the distances between the apices are even.
    • Check the outline of the odontoid process carefully for intactness in both lateral and AP projections.
    • In an AP projection, check that the arch of C1 (atlas) is not abnormally wide (evident as lateral displacement of the lateral masses from their expected alignment in relation to the outline of C2 [epistropheus]). In the AP projection, also check the regularity of the spinous processes as in the lateral projection; note irregularities to either side.
    • If injury to the cervical spine is suspected, x-raying is insufficient to exclude the injury (small fracture fragments cannot be seen clearly, and the lower part of the spine cannot be seen sufficiently).

Treatment

  • Fractures of the cervical spine require assessment in specialized care and most often also hospitalization in the initial phase. Assessment of stability is sometimes difficult. Repeating imaging during the next few days is warranted in unclear situations. A cervical collar must be applied before the patient is moved.
  • Unstable fractures are treated surgically. A cervical collar or traction may be applied in the initial phase only. In the case of dislocation, skull traction should be applied at the treating unit (1 kg/vertebra, i.e. a fracture of C3 will require 3 kg) to achieve closed reduction.
  • Injury of carotid or vertebral artery may necessitate anticoagulant therapy or vascular surgical treatment.

Fracture of the thoracic and lumbar spine, the sacrum and the coccygeal bone

  • Fractures of the thoracic and lumbar spine are usually classified by their stability.
    • In a stable compression fracture, only the anterior edge of the vertebral body is collapsed (one-column fracture).
    • In a partially unstable vertebral fracture the posterior edge of the vertebral body is also injured (two-column fracture).
    • In a completely unstable vertebral fracture the area around the facet joints and spinous processes and the attached ligaments are also injured (three-column fracture).
      • An unstable fracture may extend horizontally across the bone or ligament structure (so-called chance fracture). The bony injury may be hard to recognize in such fractures.
  • Partially and completely unstable vertebral fractures involve a risk of injury to neurological structures. Unstable fractures are typically associated with high-energy falls but even a minor fall may be sufficient to cause a fracture in an osteoporotic spine or one that has lost its suppleness (ankylosing spondylitis).

Stable vertebral compression fracture

  • The most common fracture is a compression fracture in the junctional area (Th10-L2) of the thoracic or lumbar spine (one-column fracture) in an elderly person, caused by relatively insignificant vertical force. Sometimes no specific trauma can be established.
  • The injury may occur in any area of the spine, including the sacrum (see Fractures of the Ribs and Pelvis).
  • Falling from a standing position or from sitting in a chair may be enough to cause a fracture in osteoporotic vertebrae. Fractures may also occur elsewhere in the area of the thoracic or lumbar spine. Higher-energy injury (falling from a greater height) is typically required to fracture healthy vertebrae.

Diagnosis

  • Local tenderness at the fracture site and often also in the long back muscles around and below the level of the injury
  • In x-ray films, attention should be paid on the preservation of the height of the vertebral bodies, integrity of the posterior edge of the vertebral body, any vertebral transposition, and maintenance of interpedicular distances virtually in the same range as between the adjacent vertebrae.
  • A CT scan (picture 5) is indicated in two- and three-column fractures for more accurate diagnosis and assessment of stability.
  • Fractures of the sacral area are typically accompanied by a haematoma in the area of the intergluteal cleft.

Treatment

  • If the height of a vertebral body is decreased anteriorly by more than 50% (compare with an adjacent vertebra) and the fracture is stable, surgical treatment may be warranted, but the need should be individually assessed. The fracture can often be treated conservatively.
    • In elderly patients and those with severe osteoporosis, it is acceptable to treat fractures with an even greater decrease in vertebral body height conservatively. Sufficient pain control is important
    • Vertebroplasty and kyphoplasty (using an inflatable balloon) are minimally invasive surgical methods for the treatment of collapsed vertebral fractures. Their indications should be weighed up individually. These methods are not established in common therapeutic practice. Evidence of their long-term benefits is limited and the methods are not without risks.
  • Pain may persist for a long time after the injury. It may be accompanied by other degeneration of the spine and development of radicular symptoms on different levels which makes assessing the cause of the pain more difficult.
  • Osteoporotic compression fractures (picture 6) usually occur without particular trauma or in association with slight jolts (e.g. falling down from a chair). They are generally sufficiently stable to be treated conservatively even if the collapse of the vertebral body is significant (more than 50% of the height of the vertebra).
    • An osteoporotic compression fracture in an elderly patient may be treated in the initial phase with pain medication on a community hospital ward. The patient may be mobilized as pain allows.
  • Starting of osteoporosis medication should be considered in patients with osteoporotic fractures Osteoporosis.

Unstable vertebral fracture

  • Compression fractures of other than the anterior parts of vertebrae (one-column fractures) are unstable.
  • Unstable fractures are usually treated surgically.
  • In two-column fractures, fragments of the posterior edge of the vertebral body may penetrate the vertebral canal. In three-column fractures, the whole vertebra is injured and the spine is unstable on the level of that vertebra. The injury may consist of a comminuted (burst) fracture of one or several vertebrae or of a horizontal fracture line running through the vertebral structures (chance fracture). Three-column injuries may also involve dislocated vertebrae.

Diagnosis

  • The mechanism of injury described in the patient history is usually of a higher energy level than in vertebral compression fractures but in an osteoporotic spine or in patients with ankylosing spondylitis even minor excessive force may cause a significant injury and complete instability at the level of the injury. This involves a fundamental risk of further damage to neural structures, which should be considered when transporting patients.
    • It is important to examine and repeatedly record the neurological status of the lower limbs and the caudal area.
    • It should be ascertained whether spontaneous urination is possible.
    • Residual urine should be measured if neurological injury is suspected.
  • A CT scan is the primary imaging study. MRI can be used as a complementary study if penetration of an intervertebral disk into the vertebral canal or haematoma (neurological finding atypical for the type of injury) is suspected.

Treatment

  • The treatment is surgical. Stabilization of the spine (surgery to correct spine position, and arthrodesis) should be used to prevent excess movement and (further) injury to neural structures.
  • The degree of severity of the neural injuries is decisive for choosing further treatment. It is important to provide guidance for physical activity and muscle training. Assistance with activities of daily life should initially be provided on the ward.
  • The patient should be referred for special rehabilitation through an outpatient clinic for patients with spinal cord injury, as necessary.

Fracture of the sacrum

  • A sacral fracture may occur in injuries caused by a fall from a height, in the elderly also in low-energy injuries, resulting e.g. from falling into a sitting position. It is also often an associated injury in other injuries of the pelvic girdle. It may be associated with a malposition and damage to neural structures.
  • The fracture may be a transverse fracture breaking the sacrum, but it is often accompanied by vertical fractures as well (so-called H type fracture). Urinary retention may be the only symptom suggesting neurological damage in a situation when the sacral canal is narrowed as a consequence of fracture shift.

Diagnosis

  • Tenderness and haematoma on the midline and gluteal region, urinary retention, lowered sphincter tone
  • Functioning of the bladder and rectum as well as perianal sensation should always be checked.
  • If neural dysfunction is found, injury in the sacral region should be excluded when other possible injuries of the spine are investigated.
  • Transverse fracture of the sacrum is revealed by lateral radiograph of the sacrum. From it, a possible malposition can be assessed.
  • Vertical fracture line can be seen in a postero-anterior radiograph of the pelvis, but these fracture lines are not always discernible.
  • CT scan is therefore necessary for diagnosis, assessing the nature of the fracture and the state of the vertebral canal, and especially if neurological deficits are found.

Treatment

  • Surgical treatment is in most cases warranted if the roots of the sacral nerves are narrowed (significant displacement or bend in the fracture).
  • Assessment in specialized care is always required.

Fracture of the coccygeal bone

  • Falling to the ground on sitting position may lead to a fracture of the coccygeal area.
  • The fracture causes local pain which is provoked especially in sitting position. Regional tenderness on palpation is typical.
  • The fracture can be confirmed by a lateral-projection x-ray of the sacrum and coccyx. From the viewpoint of differential diagnosis, such imaging may also make it possible to rule out a more significant fracture of the sacral area.
  • First-line treatment is conservative: analgesic medication and, for sitting, a coccyx cushion (doughnut cushion).
  • Healing of the fracture may remain incomplete. In prolonged painful situations, where bone union has failed, removal of the distal fragment is a reasonable treatment option.

Fracture of a transverse process

  • Injury from falling or, in some cases, maximum muscle contraction (an epileptic fit, for example) may cause a fracture of a transverse process in the lumbar spine.
  • In high-energy injuries, other injuries to the trunk area should be excluded (by CT of the chest, abdomen and pelvis).
  • Lower back pain that may last several weeks is a characteristic symptom. Analgesics without restrictions on moving suffice for treatment. Urine should be tested for blood after the injury. If there are copious erythrocytes in the urine, moving should be restricted to what is unavoidable, and pain allowing, during the first 24 hours.