Vertebral fractures

Last updated: November 10, 2023

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

Common in older women (osteoporotic fractures) and young men (traumatic injuries)
Location: ∼ 50% in the cervical spine and ∼ 50% in the thoracic, lumbar, and sacral spine

References:^[1]

Epidemiological data refers to the US, unless otherwise specified.

Etiology

Trauma (e.g., car accidents, falls, gunshot wounds)
Pathological fractures
- Osteoporosis (most common)
- Malignancy (e.g., bone metastases)
- Infection (e.g., Pott disease)

References:^[1]^[2]

Classification

Stability of vertebral fractures

Stable vertebral fracture
- The structural stability of the spine remains intact.
- No neurologic deficits
- Fractures of the anterior column of the spine
Unstable vertebral fracture
- The structural stability of the spine is compromised.
- The spine can move as two or more independent units, which may cause spinal cord injury.
- Mid-column and posterior column 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

Vertebral compression fracture (most common type)
- Causes
  - Pathological fractures, e.g., due to osteoporosis (most common cause) or bone metastases
  - Trauma
- Clinical features
  - Usually stable
  - Often asymptomatic, but may cause acute back pain and point tenderness
  - Long-term findings after multiple vertebral compression fractures
    - Progressive thoracic kyphotic deformity if multiple vertebrae are affected (stooped posture with a “dowager's hump”)
    - Decreased height (loss of 2–3 cm with each fracture)
- Subtypes
  - Wedge fracture: characterized by a loss of height, predominantly of the anterior part of the vertebral body, which results in a wedge-shaped vertebra
  - Vertebra plana: advanced compression fracture with a loss of height of the entire vertebral body, both anteriorly and posteriorly
  - Codfish vertebra: characterized by loss of height of the central part of the vertebral body, resulting in a biconcave vertebral body
Burst fracture: fracture of the vertebra in multiple locations
- Result of compression trauma with severe axial loading
- Possible displacement of bone fragments into the spinal canal
Fracture-dislocation: fractured vertebra and disrupted ligaments; instability may cause spinal cord compression

$Compression fractures of the vertebra$ Anatomy of the vertebra Thoracic spine and costovertebral anatomy Costovertebral joints and ligaments

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]

Diagnostics

Physical exam

Detailed neurological 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.
The need for diagnostic imaging following cervical trauma should be evaluated to avoid unnecessary exposure to radiation, e.g., using the NEXUS criteria, which state that the absence of all of the following indicates a low risk for cervical spine injury and no need for imaging:
- Focal neurological deficit
- Posterior midline cervical spine tenderness
- Altered consciousness
- Intoxication
- Painful distracting injury

Imaging

Used to assess the stability of the fracture (see “Classification” above), spinal cord lesions

Anterior-posterior and lateral x-ray
- Discontinued cortex, bone fragments
- Loss of height in the vertebral bodies
CT: The axial image in particular helps localize the fracture and allows for an assessment of (posterior edge) stability.
MRI: most sensitive tool for detecting 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.

Chronic lumbar compression deformity $T12 burst fracture and L1 fracture$ $Burst fracture of T12 vertebral body$ $Vertebral compression fractures$ $Vertebral arch fracture deformity with spinal stenosis$ $Acute and chronic vertebral fractures$

References:^[6]

Differential diagnoses

Cervical facet dislocation ^[7]^[8]^[9]

Definition: an anterior displacement of one vertebral body over another; subclassified as unilateral or bilateral
Pathophysiology
- Excess flexion of the neck (e.g., due to a motor vehicle collision or contact sports injuries) → dislocation of the vertebral facet → cervical instability → potential spinal cord injury
- Most commonly involves C5–C7 junction ^[9]
- May include facet fracture (unilateral or bilateral)

		Unilateral facet dislocation	Bilateral facet dislocation
Clinical features		Neck pain
Clinical features		Monoradiculopathy (depending on the level of injury) C4/5: C5 radiculopathy C5/6: C6 radiculopathy C6/7: C7 radiculopathy	High risk for spinal cord injury Bilateral weakness of the upper and lower extremities Bilateral paresthesia of the lower extremities
Diagnostics	X-ray	Shows ∼ 25% subluxation of vertebral bodies ^[10]	Shows ∼ 50% subluxation of vertebral bodies ^[10]
	X-ray	Other findings include: Widening of the interspinous distance Hypolordosis at injury level Soft-tissue swelling Potentially, decreased disc height due to retropulsed disc in canal Flexion-extension radiographs to evaluate for instability
	CT	Shows malalignment or subtle subluxation of the vertebral facet; potentially facet fracture
	MRI	Should be obtained prior to surgical stabilization to exclude anterior space-occupying lesion (e.g., disc herniation) and other soft tissue lesions ^[9] Findings Disc herniations Posterior ligamentous injury (i.e., supraspinous and interspinous ligaments, posterior longitudinal ligament), posterior annulus disruption, and/or disruption of the posterior facet capsules Hematoma/compression of the spinal cord

Management: operative ^[8]^[9]
- Open anterior decompression (discectomy), reduction, and stabilization
- Open posterior reduction and stabilization
- Closed reduction

The differential diagnoses listed here are not exhaustive.

Treatment

General

Rescue from the field when there is concern for vertebral fractures.
- Place the patient on a long backboard ; move to stretcher once in the hospital.
- For possible injury of the cervical spine: immobilization with a rigid cervical collar
Orotracheal intubation with rapid-sequence intubation is preferred for establishing an airway in an apneic patient with a cervical spine injury.

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

Spondylodesis
- Indications: unstable fractures and/or neurological symptoms
- Approach: fusion of two or more vertebral bodies via internal fixation using plates, rods, screws, or cages
Minimally invasive procedures
- Indication: stable vertebral compression fractures with progressive pain or kyphosis despite conservative treatment
- Procedures
  - Vertebroplasty: injection of bone cement into the fractured vertebra for immediate stabilization
  - Kyphoplasty: reexpansion of the fracture through the insertion of an inflatable balloon into the vertebral body and injection of bone cement

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

Spondylodesis of C6/7 Vertebroplasty $Kyphoplasty in a vertebral compression fracture$ $Vertebral body compression fractures before and after kyphoplasty$ $Vertebral body fracture before and after kyphoplasty$

References:^[11]

Subtypes and variants

Atlas fracture

Definition: fracture of the atlas (first cervical vertebra)
- Injury mode: axial force (e.g., swimming accident caused by jumping head-first into shallow water)
- Jefferson fracture: combined fracture of the anterior and posterior arches
Symptoms
- Painful restriction of movement
- Neck ache, paravertebral hematoma with dysphagia
- Neurologic deficits, such as Horner syndrome
- An asymptomatic course is also possible.
Diagnostics
- Cervical spine x-ray: fractures and dislocations
- CT: best for Jefferson fractures
- Arteriography: in cases of vascular compromise
Treatment: immobilization for stable fractures; surgery for dislocations

$Jefferson fracture$

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
- Movement-induced pain
- Neurological problems ranging from local sensory loss to paralysis due to complete spinal cord injury
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 ^[12]
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

$Hangman's fracture$ $Hangman's fracture$ $Hangman's fracture$ $Dens fracture$ $Dens fracture$ Atlantoaxial dislocation following whiplash injury $Spondylolysis and cervical spine dislocation of C6/C7 in a right superior articular process of the vertebra fracture of C7 (1/4)$ $Facet fracture-dislocation$ $Spondylolysis and dislocation of C6/C7 in a right superior articular process of the vertebrae fracture of C7 (3/4)$ $Spondylolysis and dislocation of C6/C7 in a right superior articular process of the vertebra fracture of C7 (4/4)$ $Anderson's dens fracture classification$

References:^[13]^[14]^[15]

Complications

Spinal cord injury
- Severe injury of the spinal cord → respiratory depression
- Spinal contusion/concussion to spinal shock → neurological deficits
- Injuries of the cervical spine may result in a retropharyngeal hematoma → dysphagia
Vessel injury: dissection or thrombotic blockage of the vertebral artery
Posttraumatic deformation of the spine: loss of height, scoliosis, or kyphosis
Gibbus
- A hump or kyphotic deformity in the spine (usually thoracolumbar spine)
- Common causes include spinal fracture and spondylodiscitis (especially Pott's disease)

Stenosis of the vertebral artery at C1-C2 Transverse foramen (Foramen transversarium) Course and segments of the vertebral artery $Myelopathy following a C4 fracture$ $Myelopathy after a vertebral body fracture$ Gibbus deformity Tuberculous spondylitis (Pott disease) with gibbus deformity

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

References

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Alexandru D, So W. Evaluation and management of vertebral compression fractures. Perm J. 2012; 16 (4): p.46-51.
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.
McCarthy J, Davis A. Diagnosis and management of vertebral compression fractures. Am Fam Physician. 2016; 94 (1): p.44-50.
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
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
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
$Fracture, odontoid.
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
Saltzherr TP, Fung Kon Jin PH, Beenen LF, Vandertop WP, Goslings JC. Diagnostic imaging of cervical spine injuries following blunt trauma: a review of the literature and practical guideline.. Injury. 2009; 40 (8): p.795-800.doi: 10.1016/j.injury.2009.01.015 . | Open in Read by QxMD
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Fehlings M. Essentials of Spinal Cord Injury. Thieme Medical Publishers ; 2013
Vieweg U, Grochulla F. Manual of Spine Surgery. Springer Science & Business Media ; 2012
Spinal Fractures. https://neurosurgery.ufl.edu/patient-care/diseases-conditions/spinal-fractures/. Updated: March 9, 2017. Accessed: March 9, 2017.
Spinal fractures. http://www.mayfieldclinic.com/PE-SpineFract.HTM. Updated: April 1, 2016. Accessed: March 9, 2017.
Types of Spinal Fractures. https://www.spineuniverse.com/conditions/spinal-fractures/types-spinal-fractures. Updated: February 23, 2017. Accessed: March 9, 2017.
Vertebroplasty and Kyphoplasty Comparisons. http://www.spine-health.com/treatment/back-surgery/vertebroplasty-and-kyphoplasty-comparisons. Updated: February 5, 2014. Accessed: March 9, 2017.

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