What is a Vertebral Fracture?
The vertebrae represent the 22 bones that make up the bony spine. Each vertebra is slightly different from the other. Most of them have a short cylindrical core called the “body” with 4 types of processes extending posteriorly and laterally from the cylinder. These include one spinous process, two transverse processes, two superior articular processes and two inferior processes. Any part of the vertebra can be fractured with different symptoms and complications.
Vertebral fractures can occur in the cervical spine, the thoracic spine or the lumbar spine. They represent a break in the cortex of the bone so the bone is in more than one piece. Most of the time, they are associated with major trauma and carry the risk of damage to the spinal cord, including neurological deficits.
Any part of the vertebra can be fractured. A patient can have a compression fracture of the body of the vertebra and any one of the processes can be fractured, leading to instability of the spine and the potential for spinal cord damage. Each vertebra is slightly different so they fracture in different patterns with different sequelae at the time of fracture.
The biggest risk of a vertebral fracture is a spinal cord injury. There are about 11,000 new cases of spinal cord injury in the US each year. About 250,000 persons are now living in the US from previous fractures. Half of the injuries are from the thoracic vertebrae down to the lumbar and sacral areas. The other half occurs in the cervical spine. The average age at time of injury is 32 years. More than half of all injured are between the ages of 16 and 30 years of age. A total of 80 percent of the victims are male.
A third of all vertebral fractures with spinal cord injury happen as a result of motor vehicle accidents. About twenty five percent are due to altercations and other violent acts. The remainder stems from recreational and sports injuries. Over the year, the incidence of accidents resulting in spinal injuries has been decreasing, while the rate of spinal injuries from violent acts has been increasing.
It is very costly to have a spinal cord injury. A paraplegic will spend $200,000 in the first year of the injury and about $21,000 per year after that. This means that the lifetime cost of caring for a person with paraplegia is about $730,000 if the victim was injured at the age of 25 and about $500,000 per lifetime if the patient was injured at age 50.
The lifespan of a person injured with a spinal cord injury is shortened by 15-20 years when compared to uninjured people. The main causes of death include pulmonary embolism, pneumonia, and sepsis.What are the Symptoms of a Vertebral Fracture?
If the patient simply has a compression fracture without spinal cord injury, there is only pain, muscle spasm and lack of mobility as major symptoms. The pain is located near the site of the fracture and does not radiate to other body areas.
Many vertebral fractures are unstable and can cause symptoms suggestive of an injury to a single nerve root, more than one nerve root, or the spinal cord. In such situations, the following symptoms can be noted:
- Back or neck pain
- Numbness below the level of the injury
- Tingling below the level of the injury
- Muscle spasm in the area of the injury
- Bowel or bladder difficulties
- Paralysis below the level of the injury
Remember that not all vertebral fractures will eventually result in an injury to the spinal cord and only on rare occasions is the spinal cord completely severed so the patient can have some residual function below the level of the fracture.Causes of a Vertebral Fracture
According to some statistics, the causes of a vertebral fracture include the following activities:
- Car accidents—45 percent
- Falls—20 percent
- Sports Injuries—15 percent
- Acts of violence/altercations—15 percent
- Miscellaneous actions—5 percent
Remember that conditions like osteoporosis and spinal tumors can weaken the bone and can contribute to vertebral fractures, sometimes without an obvious external injury.Risk Factors for Vertebral Fracture
Risk factors for vertebral fracture are very different for vertebral fractures that occur due to disease and vertebral fractures that are associated with trauma.
In vertebral fractures associated with disease, most patients are women and over the age of 70. Many have a small body mass index and are considered thin for their body stature. They can have fractures that occur spontaneously or that occur with even minor trauma. Patients with bony tumors are in the same category as those with osteoporosis in that they have weakened bones that fracture easily.
Alcohol consumption increased the risk of fracture in men. The use of estrogen supplementation seems to have had no effect on the risk of fracture of the vertebral bodies.
Risk factors for traumatic fractures of the spine include being a person who dives, motorcycle riders, those who drive recklessly, drive without seatbelts or speed while driving. In such cases, most of the victims are male and between the ages of 16-30 years.Diagnosing a Vertebral Fracture
There are several types of vertebral fractures that are diagnosed in various ways. With those fractures related to osteoporosis, it is important to diagnose a vertebral body fracture because there can be many adverse effects if the diagnosis is not picked up and the fracture not treated. Vertebral fractures, untreated, are associated with ongoing pain, physical deformity, loss of function and social isolation. Interestingly, women who have had a compression fracture of a vertebra have a fifteen percent higher mortality rate when compared to women who have not had a fracture.
Many fractures of the spine can be picked up on plain film x-ray. A simple anterior and lateral film can show whether or not the height and shape of the vertebral bodies are normal. Transverse fractures and fractures of the spinous process can be seen on a good plain film.
If plain film x-ray is not adequate, a CT scan of the spine can not only show a vertebral fracture, it can show the degree to which the fracture has damaged the spinal column. The spinal column shows up fairly well on CT scan so that it can be used when there are neurological signs suspicious for a fracture that has impinged on the spinal canal.
An MRI scan can also be done. It gives three-dimensional images of the bones of the spine and shows the structure of the spinal cord. It can be used instead of a CT scan of the spine in order to identify spinal fractures.
A myelogram does not show the actual fracture but can show if the spinal cord is being impinged upon by a fracture fragment. It involves injecting a dye into the intrathecal space. The dye travels up and down the spinal cord, revealing areas where the dye is not picked up because of a fracture.Treatment of a Vertebral Fracture
Treatment of a person injured with a vertebral body begins with the first responders. The patient suspected of having a vertebral fracture should have a c-spine immobilizer placed and should be placed on a backboard. First responders should use a log rolling technique when placing the patient on the backboard. The main idea is to transport the patient to the emergency department without making anything worse.
Even so, they should be removed from the spine board as soon as is feasible because patients can get sores and decubitus ulcers from being on a backboard too long.
In the emergency room, the initial focus should be on the ABCs of emergency care with attention to fractures and even neurological injuries placed on the back burner. Patients with vertebral fractures are often multiply injured and need attention on many different levels. One of these levels is “neurological”, which will tell the doctors what areas of the spinal cord to look for and which places to x-ray.
One of the first things to treat is spinal shock. This is a low blood pressure situation that happens when the spinal cord is injured. Usually the pulse is low as well and can be treated with atropine to keep the urine output to at least 30 ml/hr. Sometimes stronger blood pressure and heart rate medications need to be given to counteract this problem. The patient will need a Foley catheter in the bladder in order to carefully monitor the output. These are patients that are also at higher than average risk for low body temperature. They need to be warmed to a body temperature of at least 96 degrees core temperature.
All of the immobilizing devices must be kept in place until the x-rays are done. Even if the patient has a fracture, he can be removed from the spinal board and must be turned every hour or so in order to prevent decubiti.
High dose steroids are given when there are known neurological deficits. The initial dose is 30 mg/kg of methylprednisolone given over 15 minutes by intravenous line. Then a maintenance infusion is given for the first day. The idea is to shrink swelling of the spinal cord so as to minimize the degree of neurological injury.
Some patients will need surgery while others will not. Those who have minor fractures with stability of the spinal column can be treated without surgery. Major fractures with known instability of the spinal column need to be treated operatively.
Nonoperative treatment of unstable fractures of the spine involves using a spinal orthotic brace or vest. It prevents rotational movement and any kind of bending. The axial skeleton and upper body need to be completely supportive so the fracture can heal and the patient can receive proper rehabilitation.
The spinal orthoses used for stabilizing the spine can be a bit uncomfortable and are only partly effective in completely stabilizing the spine. For this reason, they can be considered only a reminder to the patient not to move very much. A better way of immobilizing the spine is the body cast, which is effective but extremely uncomfortable to wear.
High dose steroids are given as nonoperative ways to reduce swelling and inflammation in situations where the cord is impinged upon. It is usually given as IV methylprednisolone with the idea that the neurological outcome is better when the steroids are given than if they are not given.
Operative treatment is sometimes necessary. There are two major goals of treating the patient with an operation. The first is to decompress the spinal cord and the second is to stabilize the damaged vertebral column.
There are several operative approaches possible in this kind of treatment:
- The posterolateral approach
- The posterior approach
- The anterior approach
The actual approach used depends on where the spinal cord encroachment is located and exactly how the spine will be stabilized. The posterior approach is not commonly used unless there is a need for posterior bony stabilization and little need to mess with the spinal canal.
The anterior approach is considered the best approach because it gives the best access to the spinal cord and vertebral bodies. It is a good approach when there needs to be decompression of the spinal cord and whenever the spinal canal is compromised by fragments of the vertebral body.Complications of a Vertebral Fracture
Complications of a vertebral fracture include ongoing back pain, deformity of the back and decreased mobility of the back. If the fracture causes an injury to the spinal cord, the following complications can be seen:
- Numbness of the extremities
- Tingling of the extremities
- Bowel and bladder dysfunction
If you or a loved one has suffered a vertebral fracture as a result of someone else's negligence and would like to discuss your legal options with an experienced Sacramento Personal Injury Attorney, Contact Us Online or call us at 916.921.6400 to set up a FREE consultation.