Fractures of the spine are not as common as fractures in other areas of the body. However, there are many different types of fractures classified according to the level of fracture, the involved bone, complexity, neurologic injury, and other associated factors. The major concern of spinal fractures is associated neurologic injury, development of deformity, and pain.
Two broad categories must be recognized prior to discussion of spinal fractures. The young patient who sustains a fracture of the spine as a result of a high energy trauma (like a fall from heights or a motor vehicle accident) also called a Burst Fracture and the elderly who sustains the very common Compression fracture of the vertebral segment due to low density of bone. The latter is usually the result of a very minor force applied to the spine.
Since the fractures of the spine in the elderly are much more common, we will begin the discussion with this type of fractures. As our bodies age, bone mineral density decreases which is also referred to as Osteoporosis. This is a universal phenomenon and occurs in all individuals. However, some individuals loose more bone that other which places them at higher risk. The patients that are at higher risk for greater bone loss include women who are post-menopausal, white in color, thin, alcohol users, and smokers. In general African American males who are heavy in weight will have higher bone density. An easy way to remember this phenomenon is that a bone which is placed under higher stress will produce more bone to resist and withstand the applied forces. This results in a much stronger bone density and strength. In persons predisposed to these osteoporotic fractures, also called Compression Fractures, the bone literally collapses in front of the spine. Some patients may have several of these fractures in adjacent levels and eventually their height may actually decrease. They may also have a change in their posture which is the usual hump back seen in some elderly individuals. Usually, the event leading to this type of fracture is very minor and could be the lifting of a grocery bag. The picture to the left depicts such a fracture. In general, these fractures are not associated with any neurologic injury. They are however associated with pain, and the onset of deformity. The pain is intense at the onset of the fracture and will usually decrease over days or weeks. Function may be limited in the first few days but they are generally regarded to be very common in the elderly population and are treated conservatively in most cases. In patients that are diagnosed in the early period after the fracture, an extension brace can be prescribed to hold the spine in a corrected and rigid position. This may help control pain and could theoretically decrease the potential for increase in deformity. Pain medications can also be prescribed to control symptoms. Long term bed rest should be avoided as it will lead to a set of complications like respiratory infections and initiation of blood clots in the lower extremities. Diagnostic studies that help in diagnosis include the plain X-ray as the first modality. To evaluate the fracture in more detail and asses the spinal canal size, a CT scan may be a better option. In cases where neurologic injury is suspected an MRI scan may be more helpful since it delineates neurologic structures in much greater detail. In most cases, a brace is all that is needed for the patient with a compression fracture. In small subset of patients, pain will continue leading to dysfunction and change in lifestyle. These patients may seek other alternative treatment options. Rarely fusion will be recommended in patients with this kind of fracture since most are elderly with multiple medical conditions. Furthermore, the benefits may not out weight the benefits. If surgical correction is contemplated, the spine can be approached from the front or the back and standard fusion techniques can be utilized.
In recent years two new techniques were introduced that are minimally invasive with decreased morbidity. The two procedures are called Vertebroplasty and Kyphoplasty. Vertebroplasty include the insertion of a cannula through a skin puncture into the collapsed bone. Then through the cannula, a special liquid material, called surgical cement is injected into the bone. This cement quickly hardens and stabilizes the fracture. Patients often have good pain relief with fast recovery from the procedure. The major risk to this procedure is the inadvertent injection of the cement into the spinal canal which may have catastrophic results. Most surgeons will perform this procedure under Fluoroscopic guidance (similar to a live x-ray machine) to avoid this possible complications. The procedure called Kyphoplasty is similar the Vertebroplasty. However, prior to injection of the cement into the fracture site, a balloon is placed and inflated in the bone. This can potentially elevate the collapse bone, enhance the patient’s posture, and create space necessary for injection of the liquid cement. Some surgeons believe Kyphoplasty is safer since it creates a space (with inflation of the balloon) and the injection of the liquid cement is performed under lower pressures. This fact theoretically leads to less risk of the cement ending up in the spinal canal next to neural tissues.
The other major type of fracture is called a Burst Fracture and occurs in younger individuals as a result of high energy trauma like falls from heights and motor vehicle accidents. Different classifications exist to evaluate these fractures but these are too detailed for discussion in this relatively short page. The most common area of the spine involved is usually the area called the Thoraco-lumbar junction. This area is the junction between the low back area (lumbar) and the chest area (thoracic spine). This area is less rigid and has more mobility which predisposes it to these fractures. A burst fracture can be simplified if described as explosion of the bony vertebrae. In sever cases the bony fragments retropulse (push back) backward into the spinal canal pushing on the nerves and possibly the spinal cord. Patients suspected of having Burst fractures will initially have an x-ray followed up with a CT Scan. The CT scan delineates the bony details of the fracture. The top left CT scan is a good example of such a fracture without any penetration into the central spinal canal. The fracture can be clearly identified. However, the lower image reveals a fracture with bony fragments pushing back into the spinal canal impinging neural structures. CT scan can also be reconstructed in other views to show the details of the fracture from different perspectives as well. Coupled with a detailed physical examination and treatment plan is set to allow maximal possible recovery. The treatment options for these fractures are very complicated and involved. Neurologically injured patients will routinely receive high doses of steroids to preserve any possible functions. However, some patients may not have any neurologic deficit and they may be treated non-operatively. If operative treatment is contemplated, the spine can be approached from the back or the front. Some surgeons will approach the spine from the front as well as the back in a combined procedure to enhance chance of healing. The details of surgical decision making are extremely involved and beyond the scope of discussion in this page.
This picture is an example of operative treatment in such a fracture (Burst fracture). In this case the spine was approached from the back only. Pedicle screws and rods were used to stabilize the spine. Furthermore, correction of the deformity across the fracture forces the bony fragments that were pushed back into the spinal canal, to be displaced back into their proper position and in turn relieves the pressure from the neural structures. Bone graft is placed along side the spinal implants to expedite fusion of the fracture site. The goal of any surgical procedure is to expedite mobilization. This is usually performed by a rehabilitation team which includes physical therapist, occupational therapist, rehabilitation physicians, and specialized nurses.
As with any treatment plan, risks, benefits, alternatives should be reviewed with you physician. The information provided in this page are only basic concepts used in the treatment of patients with spinal fractures. Discuss specific situations with your surgeon to arrive at a logical treatment option which fits your own situation.
