Spinal Fractures

If you'd like to support us, check out our awesome products:

Introduction

Spinal fractures are common injuries caused by trauma, osteoporosis, or other underlying medical conditions. The severity of the fracture can range from mild to severe, and treatment options will depend on the type and extent of the injury. 1

Ideal management involves immobilisation, imaging, and classification with early involvement from spinal surgeons. All unconscious patients, and those with distracting injuries elsewhere, must be assumed to have a spinal injury until proven otherwise.1

You might also be interested in our surgical flashcard collection which contains over 500 flashcards that cover key surgical topics.

Aetiology

Spinal fractures can result from various causes, including trauma, diseases, and degenerative changes.

Traumatic causes of spinal fractures and spinal cord injury include:

  • Road traffic collisions
  • Falls from height
  • Sports injuries
  • Violence or assault

Diseases and degenerative changes that can contribute to spinal fractures include:

  • Osteoporosis
  • Cancer
  • Infections
  • Arthritis

Anatomy

Understanding the clinically important anatomy of the spine can help understand the impact of spinal fractures. The spine is divided into three regions: cervical, thoracic and lumbar.

The spinal cord runs through the spinal canal, formed by the vertebrae. The spinal cord carries sensory and motor information between the brain and the rest of the body. Injuries to the spinal cord can disrupt this communication, leading to neurological deficits.

Injuries to the cervical spine can result in quadriplegia (paralysis of all four limbs). In contrast, thoracic or lumbar spine injuries can result in paraplegia (paralysis of the lower limbs). The location and severity of the damage determine the extent of neurological deficits and the overall prognosis.

For more information, see the Geeky Medics guides to the vertebral column and spinal cord.


Risk factors

Risk factors for sustaining a spinal fracture include:

  • Osteoporosis
  • Cancer
  • Trauma, such as a car accident or fall
  • Age
  • Tobacco use
  • Alcohol abuse
  • Chronic steroid use
  • Poor nutrition

Clinical features

The clinical features of spinal fractures and spinal cord injury can vary depending on the location and severity of the injury.

History

TypicalΒ symptoms of a spinal fracture may include:

  • Pain: in the back, neck or limbs
  • Paraesthesia: may indicate a spinal cord injury
  • Weakness/paralysis: may indicate a spinal cord injury

Other important areas to cover in the history include

  • Mechanism of injury: the cause and circumstances of the injury, including whether it was a high-impact trauma, fall, or sports-related injury
  • Bowel and bladder function: identify any changes in bowel or bladder function, as these can indicate spinal cord injury
  • Past medical history: pre-existing medical conditions, such as osteoporosis or cancer, may increase the risk of spinal fractures

Clinical examination

All patients should undergo a thorough examination, including inspection and palpation of the neck and spine for swelling, bruising or bony deformity.Β 

A neurological examination should be performed, including an assessment of motor function, sensory function, and reflexes. Patients with spinal cord injury may have weakness or paralysis in the affected limbs, loss of sensation, and altered reflexes.

Consider performing a rectal examination in patients with suspected spinal cord injury. Loss of anal tone can indicate spinal shock.


Initial assessment and acute management

Acute treatment for spinal fractures typically involves stabilising the spine to prevent further injury and manage pain. This may involve using a back brace or traction to immobilise the spine.1 Adequate analgesia should be provided.Β 

For more information on managing trauma patients, see the Geeky Medics guide to the acute management of major trauma.Β 

The initial assessment should define two aspects:

  • Is there a cord injury, and is it complete or incomplete?
  • Is there a significant spinal injury, and is it stable or unstable? The latter includes fracture–dislocations, burst fractures, and fractures of the atlas and axis.

Acute management

The following algorithm can guide the acute management of spinal fractures.3

Primary survey

Maintain cervical spine (C-spine) immobilisation with manual stabilisation or collar, sandbags and tape and log roll the patient. Do not attempt to remove a helmet unless trained to do so.

Identify and treat life-threatening injuries ((C)ABCDE approach). Assess neurological status and expose the patient to identify other injuries.

Secondary survey &Β removing the spinal board

Perform a ‘log roll’ examination of the back to assess the spine. Look for localised bruising and tenderness, as well as spinal deformities.Β 

Full neurological examination to assess the level and the extent of cord damage

This should include:

  • Pin-prick sensation (spinothalamic tracts)
  • Fine touch and joint position sense (posterior columns)
  • Power of muscle groups (corticospinal tracts)
  • Reflexes
  • Cranial nerves

The neurological examination should be repeated following the period of potential spinal shock.

Radiological investigation

A C-spine radiograph series comprises an AP, lateral and odontoid peg view. A CT neck should be requested if the C7/T1 junction is not easily visualised on a lateral radiograph.Β 

MRI may be utilised laterΒ (not in the acute management phase) to assess for any associated soft tissue injuries (including cord compression) or neurological deficits.

Analgesia

Provide adequate analgesia (e.g. NSAIDs or opioids).Β 

Spinal cord injury

Spinal cord injury (SCI) is a devastating condition that can result in partial or complete loss of motor and sensory function below the level of injury. SCI can be caused by traumatic or non-traumatic events and can lead to significant long-term disability.5

The severity and location of the spinal cord injury determine the clinical presentation and prognosis. The two main types of spinal cord injury are:

  • Complete spinal cord injury: results in the total loss of motor and sensory function below the level of the injury. The injury site is usually associated with a complete spinal cord disruption, leading to permanent paralysis and sensory loss.
  • Incomplete spinal cord injury: results in partial loss of motor and sensory function below the level of injury. The injury site is usually associated with partial spinal cord disruption, leading to varying patterns of paralysis and sensory loss.

Incomplete spinal cord injury types include:5

  • Anterior cord syndrome:Β sparing of the posterior column
  • Central cord syndrome: more common in elderly patients, results in relative sparing of motor supply to the legs
  • Brown-Séquard syndrome: hemitransection of the cord, preserving contralateral motor function, position and vibration sense, and preserved ipsilateral pain and temperature sensation
  • Mixed syndromes: a combination of the above

For more information, see the Geeky Medics guide to spinal cord lesions.


Cervical spine fractures

Atlas fractures

Atlas fractures are caused by vertical compression force breaking the ring into four pieces. These fractures are unstable. Management involves a halo vest to immobilise the cervical spine.

C1–C2 subluxation

This refers to displacement or misalignment of the first (C1) and second (C2) cervical vertebrae. It can result from trauma or degenerative changes, leading to spinal cord injury.

Managing C1-C2 subluxation involves immobilisation, traction, or surgical intervention depending on the degree of subluxation and associated clinical features.

Whiplash injury

A whiplash injury involves neck extension with sudden acceleration, after which deceleration causes forward flexion. Usually, this causes ligamentous and soft tissue damage only. However, patients may have pain and paraesthesia in the arms and hands.1Β 

Management involves rest, analgesia and physiotherapy.

Odontoid-peg fracture

An odontoid-peg fracture occurs at the base of the dens, a bony projection from the second cervical vertebra (C2). It is typically caused by trauma to the head or neck and can result in instability of the C1-C2 joint.

Management involves traction followed by a halo vest with posterior fusion for nonunion.

Anterior wedge fractures

These fractures typically involve the front portion of the vertebral body and can result in loss of height and kyphosis (forward curvature of the spine). They can occur in the cervical, thoracic, or lumbar spine.

Management involves pain management, bracing, or surgical intervention depending on the severity of the fracture.

Facet joint dislocations

Facet joint dislocations occur when the articulating surfaces of the vertebral facet joints become displaced, often due to a traumatic injury. This type of injury typically results in severe pain and spinal instability and can be associated with spinal cord or nerve root compression.

Management involves immobilisation, traction, or surgical intervention depending on the degree of dislocation and associated symptoms.

Conservative management may be attempted in mild cases, but more severe dislocations usually require surgical reduction and stabilisation to restore spinal alignment and stability.

Isolated spinous process avulsion

This type of fracture occurs when the spinous process, a bony projection on the posterior aspect of the vertebra, is pulled away from the vertebral body due to excessive traction or muscular forces. It typically occurs in the cervical or thoracic spine.

Management is conservative with rest and pain management.


Thoracic spine fractures

Fractures in the thoracic spine usually occur due to high-energy trauma, such as falls from heights, motor vehicle accidents, or sports injuries. These fractures are typically associated with severe neurological deficits and often require surgical intervention.1

Burst fractures

These are caused by axial compression and result in loss of vertebral body height. Burst fractures can be classified into three types:

  • Type A (anterior column injury)
  • Type B (middle column injury)
  • Type C (posterior column injury)

A halo jacket is used when these fractures are stable. If unstable, traction is used before applying a halo jacket. In certain circumstances, cord decompression may be necessary.

Flexion-distraction injuries

Also known as seatbelt fractures, these result from extreme spinal flexion, often seen in road traffic collisions. They are usually associated with spinal cord injury and require urgent surgical intervention.

Management involves immobilisation with a brace or cast, analgesia, and physical therapy to help with range of motion and strengthening. Surgery may be necessary in more severe cases, particularly in cases of spinal instability or spinal cord compression.

Fracture-dislocations

These are caused by high-energy trauma and involve displacement of the vertebral body. They are often associated with neurological deficits and require urgent surgical intervention.

Management involves stabilisation of the spine to prevent further damage, followed by surgical intervention to reduce the fracture and restore spinal alignment and stability. Spinal fusion may sometimes be necessary to promote healing and prevent recurrent injury. Analgesia, physical therapy, and rehabilitation are also important aspects of management.Β 


Lumbar spine fractures

Lumbar spine fractures are commonly caused by falls or road traffic collisions.4 They are usually classified based on the mechanism of injury and the fracture location.Β 

Compression fractures

These result from axial loading of the spine and are common in elderly patients with osteoporosis. They can also occur in younger patients with high-energy trauma, such as falls from heights or motor vehicle accidents.

Management includes analgesia, rest, and bracing to support the spine and allow for healing. In severe cases, surgery may be necessary to stabilise the spine and restore vertebral height.

Chance fractures

These are caused by flexion-distraction injuries and involve a horizontal fracture of the vertebral body. They are often associated with intra-abdominal injuries and require urgent surgical intervention.

Management includesΒ immobilisation with a brace or cast, analgesia, and physical therapy to help with range of motion and strengthening. In more severe cases, surgery may be necessary to reduce the fracture and restore spinal alignment and stability.

Fracture-dislocations

These are caused by high-energy trauma and involve displacement of the vertebral body. They are often associated with neurological deficits and require urgent surgical intervention.

Management includes stabilisation of the spine to prevent further damage, followed by surgical intervention to reduce the fracture and restore spinal alignment and stability. Spinal fusion may sometimes be necessary to promote healing and prevent recurrent injury. Analgesia, physical therapy, and rehabilitation are also important aspects of management.Β 

Transverse process fractures

Transverse process fractures are most common in the lumbar region, resulting from direct trauma in a crushing injury or violent muscular contraction. There is often severe soft tissue trauma and associated haematoma.4 Severe pain may occur. Fractures o L5 transverse processes are suggestive of pelvic trauma.

Management includes analgesia, rest, and immobilisation with a brace or cast to support the spine and allow for healing. In most cases, transverse process fractures can heal with conservative management.


Sacral & coccygeal fractures

Sacral fractures

Fractures of the sacrum are relatively rare and usually occur due to high-energy trauma, such as falls or motor vehicle accidents. They are typically classified based on the location and severity of the fracture.2

The most common types of sacral fractures are:

  • Vertical fractures: result from axial loading and can occur at any level of the sacrum
  • Transverse fractures: caused by lateral compression and usually involve the upper sacrum
  • Fracture-dislocations: rare and involve displacement of the sacrum from the pelvis, they are often associated with severe neurological deficits and require urgent surgical intervention

Management

Treatment typically involves stabilisation of the spine to prevent further damage, followed by surgical intervention to reduce the fracture and restore spinal alignment and stability. Spinal fusion may sometimes be necessary to promote healing and prevent recurrent injury. Analgesia, physical therapy, and rehabilitation are also important components of treatment for this type of injury.

Coccyx fractures

Coccyx fractures are usually caused by falls onto the buttocks and are more common in women due to their wider pelvic structure.4 They are often classified based on the degree of displacement and whether there is associated dislocation of the sacrococcygeal joint.

Management

Most coccyx fractures can be treated conservatively with analgesia and activity modification. Surgical intervention may be required in cases of severe displacement or instability.


Management

Surgical management

Surgical treatment for spinal fractures may be necessary for more severe injuries or fractures that are causing significant pain or neurological symptoms.1 Surgery aims to stabilise the spine and prevent further injury. SurgeryΒ may involve using metal plates, screws, and rods to hold the spine in place. Spinal fusion may sometimes be required to help stabilise the spine.

The following surgical options may be considered for the treatment of spinal fractures:

  • Vertebroplasty: a minimally invasive procedure in which bone cement is injected into the fractured vertebrae to stabilise the spine
  • Kyphoplasty: similar to vertebroplasty, a balloon creates a space in the fractured vertebrae before bone cement is injected
  • Spinal fusion: a surgical procedure in which two or more vertebrae are fused to stabilise the spine

Long-term management

Long-term treatment for spinal fractures will depend on the type and extent of the injury and the patient’s overall health and prognosis.

This may involve ongoing physiotherapy to help improve strength and mobility and medications to manage pain and other symptoms. In some cases, patients may also benefit from additional surgical intervention to help manage ongoing symptoms and complications.

Some patients may need admission to aΒ specialised spinal unitΒ for ongoing care. In patients with disability, it is essential to support the patient and their family. Occupational therapy can help maintain physical independence with activities of daily living.Β 

Management of spinal cord injury is complex and requires a multidisciplinary team of specialists, including neurosurgeons, rehabilitation medicine doctors, specialist nurses, physiotherapists, and psychologists.

The goal of management is to maximise functional recovery and prevent secondary complications.


Complications

Complications of spinal fractures include:1,2

  • Neurological: neuropathic pain, autonomic dysreflexia, spasticity, and loss of bowel and bladder function
  • Orthopaedic: pressure ulcers, osteoporosis, and joint contractures
  • Cardiovascular: deep vein thrombosis, pulmonary embolism, and autonomic dysfunction
  • Respiratory: respiratory muscle weakness, pneumonia, and respiratory failure. This may relate to partial phrenic nerve palsy, intercostal paralysis, poor cough, or a ventilation–perfusion disorder.

Prognosis

The prognosis of spinal fractures depends on the severity and location of the injury, as well as the patient’s age and overall health.

Most patients with spinal fractures generally have a good prognosis with appropriate treatment. However, patients with severe spinal fractures, such as those that involve complete spinal cord injury, may have a long-term disability and reduced quality of life.5

The following factors can affect the prognosis of spinal cord injury:

  • Level of injury: the higher the level of injury, the more severe the neurological deficits and the worse the prognosis
  • Severity of injury: patients with complete spinal cord injury have a worse prognosis than those with incomplete spinal cord injury
  • Age: younger patients generally have a better prognosis than older patients
  • Time to treatment: early intervention and prompt treatment can improve the prognosis
  • Comorbidities: patients with pre-existing medical conditions, such as diabetes, hypertension, or heart disease, may have a worse prognosis

Key points

  • Spinal fractures can be caused by trauma, osteoporosis, cancer, or other underlying medical conditions.
  • Risk factors for spinal fractures include age, osteoporosis, tobacco use, and chronic steroid use.
  • The severity of the fracture will determine the appropriate treatment, which may include conservative management, surgical stabilisation, or a combination of both.
  • Acute management of spinal fractures involves stabilisation of the spine and analgesia.Β 
  • Long-term management may include physiotherapy, pain management, and nutritional counselling.

Reviewer

Ms Rachel Psaila

Trauma and Orthopaedics Registrar


Editor

Dr Chris Jefferies


References

  1. Wang TY, Park C, Zhang H, Rahimpour S, Murphy KR, Goodwin CR, et al. Management of Acute Traumatic Spinal Cord Injury: A Review of the Literature. Front Surg. 2021 Dec 13;8:698736.
  2. Spinal Cord and Spinal Column Tumors: Principles and Practice. AJNR Am J Neuroradiol. 2007 Feb;28(2):394–5.
  3. Abu-Zidan FM. Advanced trauma life support training: How useful it is? World J Crit Care Med. 2016 Feb 4;5(1):12–6.
  4. Atlas Fractures & Transverse Ligament Injuries – Spine – Orthobullets [Internet]. Available from: [LINK]
  5. van Den Hauwe L, Sundgren PC, Flanders AE. Spinal Trauma and Spinal Cord Injury (SCI). In: Hodler J, Kubik-Huch RA, von Schulthess GK, editors. Diseases of the Brain, Head and Neck, Spine 2020–2023: Diagnostic Imaging [Internet]. Cham (CH): Springer; 2020. (IDKD Springer Series). Available from: [LINK]
  6. Bennett J, M Das J, Emmady PD. Spinal Cord Injuries. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022. Available from: [LINK]

 

Print Friendly, PDF & Email