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Vertebral Fracture

Practice Essentials

Cervical and thoracolumbar spine injuries are commonly encountered in trauma patients, with cervical spine injuries occurring in 3-4% and thoracolumbar fractures in 4-7% of blunt trauma patients presenting to the emergency department.
Vertebral fractures of the thoracic and lumbar spine are usually associated with major trauma and can cause spinal cord damage that results in neural deficits. Each vertebral region has unique anatomic and functional features that result in specific injuries. Certain risk factors predispose the thoracic spinal cord to injury. The thoracic cord is the longest component of the spinal cord (12 segments), which results in an increased probability of injury compared to other spinal areas. The spinal canal and vertebral bodies are proportionately smaller than those of the lumbar region. Finally, the vascular supply is more tentative, with few collateral vessels, small anterior spinal arteries, and small radicular arteries. All of these factors make the thoracic cord more vulnerable to injury.

By comparison, the lumbar cord has a better vascular supply, including the large radicular vessel (usually at L2) known as the artery of Adamkiewicz. The lumbosacral enlargement is rather compact (5 lumbar spinal segments) and terminates in the conus medullaris. With a proportionately more generous spinal canal, the lumbar cord is less susceptible to direct traumatic injury or vascular insult.

(See the image below.)

Anteroposterior and lateral radiographs of an L1 o

Anteroposterior and lateral radiographs of an L1 osteoporotic wedge compression fracture.

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Signs and symptoms

Symptoms of vertebral fracture can include pain or the development of neural deficits such as the following:

Weakness

Numbness

Tingling

Neurogenic shock – In neurogenic shock, hypotension is associated with relative bradycardia as a result of autonomic hyporeflexia

Spinal shock – Spinal shock is the temporary loss of spinal reflex activity that occurs below a total or near-total spinal cord injury; it initially results in hyporeflexia and flaccid paralysis; with time, the descending inhibitory influence is removed and hyperreflexive arches—even spasticity—may occur

An injury to the thoracic or lumbosacral cord would likely result in neural deficits at the trunk, genital area, and lower extremities. Specific syndromes, such as Brown-Séquard syndrome and anterior cord syndrome, may affect a major part of the spinal cord.

Diagnosis

Laboratory studies

Patients with vertebral or pelvic fractures resulting from a major trauma require serial hemoglobin determinations as an indicator of hemodynamic stability.

Other laboratory studies, including the following, aid in the evaluation of associated organ damage in patients with vertebral fracture:

Urinalysis or urine dip for blood – Can help to rule out associated kidney injury

Amylase and lipase levels – Elevated level of amylase or lipase may suggest pancreatic injury

Cardiac marker levels – Elevated levels in the setting of chest trauma may indicate a cardiac contusion

Urine myoglobin and serum creatine kinase levels – Elevated level of urine myoglobin or serum creatine kinase in the context of a crush injury may indicate evolving rhabdomyolysis

Serum calcium level – In patients with metastatic disease to the bone and resultant pathologic fractures, a serum calcium determination is necessary; these patients may have hypercalcemia that requires medical attention

Pregnancy test – Should be obtained in females of childbearing age

Imaging studies

Radiography – Plain radiographs are helpful in screening for fractures, but hairline fractures or nondisplaced fractures may be difficult to detect

Computed tomography (CT) scanning – CT scans can readily detect bony fractures and help with the assessment of the extent of fractures

Magnetic resonance imaging (MRI) – This is usually the study of choice for determining the extent of damage to the spinal cord; MRI is the most sensitive tool for detecting lesions of neural tissue and bone

Management

Nonsurgical fracture management

Minor fractures or those with column stability are treated without surgery. Nonoperative management of unstable spinal fractures involves the use of a spinal orthotic vest or brace to prevent rotational movement and bending.

Consideration should be given to the stabilization of patients with spinal cord injuries and paraplegia. These patients need to be stabilized sufficiently so that their upper body and axial skeleton are appropriately supported, which allows for effective rehabilitation.

Surgical fracture management

The goals of operative treatment are decompression of the spinal cord canal and stabilization of the disrupted vertebral column. The following basic approaches are used for surgical management of the thoracolumbar spine:

Posterior approach – Useful for stabilization procedures that involve fixation of the posterior bony elements; the posterior approach is used when early mobilization is considered and decompression of the spinal canal is not a major consideration

Posterolateral approach – Often used for high thoracic fractures such as T1 through T4; it may be combined with a posterior stabilization procedure when limited ventral exposure is needed

Anterior approach – Allows access to the vertebral bodies at multiple levels; the anterior approach is most useful for decompression of injuries and spinal canal compromise caused by vertebral body fractures

The 4 basic types of stabilization procedures are as follows:

Posterior lumbar interspinous fusion – Least-invasive method; involves the use of screws to achieve stability and promote fusion

Posterior rods – Effective in stabilizing multiple fractures or unstable fractures

Z-plate anterior thoracolumbar plating system – Has been used for the treatment of burst fractures

Cage

Hemodynamically unstable patients should not be taken for operative treatment of vertebral fractures until their condition has stabilized. Patients with advanced age and those with significant comorbid conditions (eg, significant coronary artery disease, peripheral vascular disease, advanced pulmonary disease) are poor candidates for any surgery, including vertebral fracture stabilization surgery. Patients with stable fractures can be observed for the development of deformity and then assessed for surgical treatment.

For patient education resources, see the patient education article Vertebral Compression Fracture.

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