Vertebral fracture: Description
The spine consists of a total of seven cervical, twelve thoracic, five lumbar, five sacral and four to five coccygeal vertebrae. Together with a complex ligamentous and muscular apparatus as well as the intervertebral discs and their characteristic double-S shape, the spine is a functional elastic system that can absorb loads.
The vertebral bodies together form the spinal canal, in which the spinal cord (part of the central nervous system) runs with all its pathways. The so-called spinal nerves (peripheral nervous system), which protrude laterally between the vertebrae, branch off from the spinal cord.
If overloaded, the muscle-ligament apparatus can tear and/or a vertebral fracture can occur. This can injure the spinal cord and the spinal nerves.
A vertebra consists of a vertebral body, the spinous process and the two transverse processes. For this reason, vertebral fractures are subdivided according to their localization:
- vertebral body fracture
- spinous process fracture
- Transverse process fracture
Doctors also distinguish between three different types of fracture, which can occur in different directions. This is the classification according to Magerl, which corresponds to the AO classification (AO = Arbeitsgeminschaft für Osteosynthesefragen):
- Type A – compression injuries: In this case, the vertebra is compressed, resulting in an upper plate impression or impaction (collapse of the upper and base plates of the vertebral body). If the vertebra is compressed in the anterior region, a wedge fracture occurs.
- Type C – rotational injuries: They occur during rotation. Longitudinal ligaments and often intervertebral discs are also affected.
Vertebral fractures are also divided into stable and unstable fractures. This is important for subsequent treatment decisions.
Stable vertebral fracture
In a stable vertebral fracture, the soft tissues such as the surrounding ligaments remain undamaged. The spinal canal is therefore not constricted, meaning that no neurological symptoms occur. The affected person can usually be treated and mobilized at an early stage.
- Isolated disc injuries
- Isolated vertebral body fracture without disc injury, compression fractures
- Isolated vertebral arch fracture
- Vertebral body fracture with intervertebral disc injury
Unstable vertebral fracture
The following vertebral fractures are unstable:
- Dislocation fracture of the vertebrae (usually in the cervical spine)
- Comminuted fracture with damage to the intervertebral disc tissue and displaced fragments to the front and back
- Dislocation fractures with a bend of 25 degrees or more
- Fractures of the articular processes with gaping spinous processes
- Vertebral arch injuries
Vertebral fracture: symptoms
If a vertebra is fractured, localized pain typically occurs – regardless of whether the patient is resting, moving or performing weight-bearing movements. Due to the pain, the patient usually adopts a relieving posture. This can cause the surrounding muscles to tense up (muscle tension).
If the vertebral fracture is accompanied by nerve damage, it can cause sudden and severe pain (neuropathic pain) as well as painful burning or stinging (neurogenic pain). Sensory disturbances (paraesthesia) are also possible. In addition, mobility may be restricted in the segment corresponding to the level of the injury.
Vertebral fracture: causes and risk factors
A vertebral fracture can have various causes. They can be divided into two groups:
Traumatic vertebral fracture
In general, the transitions between the cervical spine and thoracic spine, between the thoracic spine and lumbar spine and between the lumbar spine and sacrum are particularly prone to injury. Around half of all vertebral fractures affect the transition between the thoracic spine and the lumbar spine. The following typical situations can lead to trauma to the spine:
- Seat belt injuries can cause a vertebral fracture together with injuries in the abdominal cavity.
- When falling from a great height, a heel bone fracture often occurs together with a fracture of the thoracic and lumbar spine.
- Intervertebral discs and ligament structures can rupture if a rapid body movement is stopped abruptly (deceleration trauma).
Spontaneous vertebral fracture
A vertebral fracture caused by osteoporosis is also known as a “sintering fracture”. The base and top plates collapse as a so-called fish vertebra or the front wall of the vertebral body collapses as a so-called wedge vertebra. This happens particularly often in the lower thoracic spine and the upper lumbar spine. In the event of a fall onto the face, older people often suffer a dens fracture – a form of neck fracture (dens = spine-like projection of the second cervical vertebra).
Apart from osteoporosis, the following diseases can also lead to an unexpected vertebral fracture in the event of minor trauma:
- Bone metastases, bone tumors
- Ankylosing spondylitis
- Plasmocytoma (multiple myeloma – a form of blood cancer)
- Vertebral body inflammation (spondylitis)
The specialist responsible for suspected vertebral fractures is a doctor of orthopaedics and trauma surgery. He will first ask you about a previous accident and your medical history (anamnesis). Possible questions include:
- Have you had an accident? What happened in it?
- Was there any direct or indirect trauma?
- Do you have pain? If so, in which area and with which movements?
- Were there any previous injuries or previous damage?
- Did you have any previous complaints?
- Do you have numbness in your arms or legs?
- Have you also experienced gastrointestinal complaints, difficulty urinating or difficulty swallowing?
Clinical examination
During the clinical examination, the doctor checks whether the patient is able to walk or stand. He also tests the patient’s general mobility. Next, cranial nerves, sensitivity and motor skills are checked to see if there are any neurological deficits. In addition, the doctor checks whether there is tension or hardening in the muscles (muscle stiffness) or torticollis.
Imaging procedures
Computed tomography (CT) is particularly suitable as an imaging procedure for areas that are difficult to see. This applies in particular to the transition area of the cervical spine to the thoracic spine. Injuries in this area can be precisely assessed using CT. If nerve damage is present, a CT scan is always performed.
Magnetic resonance imaging (MRI) is not usually necessary for acute injuries. It is only used if the spinal cord and intervertebral discs could also be injured.
Vertebral fracture: treatment
Treatment of vertebral fractures: Conservative
A stable fracture is usually treated conservatively. The patient is advised to take it easy and stay in bed until the pain has improved. However, in some cases, the spine may become curved due to the altered shape of the fractured vertebral body. A severe curvature can lead to permanent discomfort. Surgery is therefore usually performed for curvatures of 20 degrees or more in the thoracic and lumbar spine.
Conservative treatment of vertebral fractures in the thoracic and lumbar spine involves the use of a three-point corset or a plaster (plastic) corset.
Treatment of vertebral fractures: surgery
An unstable vertebral fracture is usually operated on, as there is always a risk that the spinal cord will be injured or is already injured. The aim of surgical treatment is to quickly realign and stabilize the spine in order to relieve the pressure on the nerves as quickly as possible. This also applies to complete paraplegia – even if it is not possible to estimate whether an improvement will occur after an operation. It is always difficult to predict to what extent the spinal cord of the affected person has been damaged.
In the case of spontaneous fractures caused by osteoporosis, for example, either a kyphoplasty or a vertebroplasty is performed.
In the case of traumatic fractures, two main procedures are used: osteosynthesis or spondylodesis.
Vertebral fracture surgery: kyphoplasty
Kyphoplasty is a minimally invasive method in which the collapsed vertebral body is straightened using a balloon. The surgeon then stabilizes the height of the vertebra by injecting cement.
Vertebral fracture surgery: vertebroplasty
Vertebroplasty is also a minimally invasive method of stabilizing the fractured vertebral body. Here too, cement is injected into the vertebral body.
Vertebral fracture surgery: Osteosynthesis
Vertebral fracture surgery: spondylodesis
In spondylodesis treatment (fusion surgery), two or more vertebrae are stiffened with a bone chip or plate. This procedure is usually considered for injuries to the ligaments and intervertebral discs of the cervical spine. Plates are attached to the cervical spine from the front and back.
If the spine is curved forward by more than 20 degrees due to a compression fracture in the thoracic and lumbar spine, the vertebral fracture is fused from the front and back. Distraction and torsion injuries of the thoracic and lumbar spine are also fused from both sides.
Vertebral fracture: course of the disease and prognosis
- Static disorder: After the vertebral fracture has healed, orthopaedic problems may arise with regard to statics.
- Spinal cord lesion: There is a risk of injury to the spinal cord or nerve roots in all vertebral injuries. In extreme cases, paraplegia may occur.
- Post-traumatic kyphosis: If the vertebrae collapse from the front, the convex curvature of the spine towards the rear can increase. In the thoracic spine, the deflection can increase in the thoracic region (“widow’s hump”) and decrease in the lumbar spine.
- Shipper’s disease: During heavy physical work such as “shoveling”, the spinous processes of vertebrae can break, especially of the seventh cervical or first thoracic vertebra. However, this does not cause any significant discomfort.
Vertebral fracture: healing time
The healing time for a vertebral fracture depends on how severe the injuries are. A stable vertebral fracture usually becomes bony firm again in a few weeks to months without further displacement. Depending on the pain, those affected can get up immediately or after about three weeks. However, an unstable vertebral fracture can continue to shift, with the risk of spinal cord compression and paraplegia as a result.
