High Yield Topics

Fracture, Compression

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Fracture, Compression
David E. J. Bazzo
Tara Robbins
Basics
Description
  • A compression fracture is defined as failure of the anterior vertebral column of the spine.
  • The thoracolumbar spine is divided into 3 columns:
    • Anterior column (anterior portion of vertebral body, anterior longitudinal ligament, and anterior annulus fibrosus)
    • Middle column (posterior longitudinal ligament, posterior annulus fibrosus, and posterior wall of vertebral body)
    • Posterior column (posterior arch and posterior ligamentous complex)
  • 2 subtypes: Anterior, caused by anterior flexion, and lateral, caused by lateral flexion
  • 3 locations: Cervical, thoracolumbar (transition between thoracic and lumbar from T10–L2), and lower lumbar vertebrae
  • If anterior AND middle columns are involved, the fracture is termed “burst.”
  • Synonym(s): Wedge fracture
Epidemiology
  • Spinal column injuries occur at 4–5.3 injuries per 100,000 households or ∼50,000 annually in the U.S.
  • ∼45% result from motor vehicle accidents, 20% from falls, 15% from sports-related activities, 15% from violence, and 6% from miscellaneous causes.
  • Spine injuries make up ∼10% of all athletic injuries.
  • Compression fractures make up ∼48% of thoracolumbar spinal fractures. L1 is the most commonly fractured vertebrae (1).
  • Most common cervical compression fracture is anterior wedge fracture, usually at C5, as a result of axial loading, as might occur in football or diving
  • ∼10% of cervical spine fractures have an associated, noncontiguous spinal column fracture.
  • 15% of female population >50 yrs will suffer a compression fracture secondary to osteoporosis, usually nontraumatic.
Risk Factors
Cervical spine injuries are most common in diving, American football (poor tackling technique), and wrestling.
Diagnosis
History
  • Hyperflexion and axial loading injuries, such as with “spear tackling” in football or striking the forehead on the bottom of the pool, typically cause cervical compression fractures. Hyperextension mechanism suggests a “teardrop” fracture or defect of posterior spinal elements or pars interarticularis.
  • Transient or permanent paralysis and/or sensory deficits can occur with compression fractures, but are rare. Neurologic deficits imply spinal cord injury due to retropulsion of disk material or the fracture fragment (ie, burst fracture).
Physical Exam
  • Sudden, localized pain immediately following direct trauma or axial loading injury
  • Palpate the spinal column for “step-off” defect or tenderness.
  • Careful neurologic examination, including sensation, motor function, and reflexes. Should be completely intact, but occasionally transient neurologic symptoms occur in an isolated compression fracture.
Diagnostic Tests & Interpretation
Imaging
  • Anteroposterior (AP) radiograph: Buckling of lateral vertebral cortex next to end-plate with decreased interspinous distance. May show lateral wedging with lateral flexion injury.
  • Lateral radiograph: Height of anterior vertebral body is decreased while posterior height is unchanged, causing increased density of vertebral body from bony impaction and prevertebral swelling. No subluxation of vertebral bodies.
  • Flexion-extension views: Evaluate cervical ligamentous instability (>3.5 mm horizontal or 11-degree angular displacement between adjacent vertebrae).
  • CT scan: To confirm intact vertebral ring (posterior wall, pedicles, and lamina). ∼25% of compression fractures identified on plain films will be reclassified as burst fractures after CT scanning.
  • Myelography: Rules out osseous protrusion into spinal canal and better evaluates neural compression than CT.
  • MRI: Recommended to evaluate spinal cord or nerve root compression and intrinsic spinal cord abnormalities if neurologic symptoms persist or plain films are abnormal.
Differential Diagnosis
  • Burst fracture (anterior and middle column disrupted, with or without posterior involvement)
  • Fracture-dislocation (anterior, middle, and posterior columns disrupted)
  • “Teardrop” fracture (triangular fracture of anteroinferior vertebral body)
  • Transverse process or spinous process fracture
  • Lumbar or cervical strain or sprain
  • Spondylolysis and/or spondylolisthesis
  • Scheuermann disease: Kyphosis >50 degrees, wedging of at least 3 vertebral bodies by at least 5 degrees, disk space narrowing, irregularity of end-plates
  • Spear tackler spine: Radiographic evidence of:
    • Developmental narrowing of the cervical spinal canal (<13-mm AP diameter of spinal canal on plain film or impedance of contrast medium on myelography)
    • Straightening or reversal of the normal cervical lordotic curve
    • Preexisting minor post-traumatic radiographic evidence of bony or ligamentous injury
    • History of repeated spear tackling. Some authors believe that these findings absolutely prohibit return to contact sports. Others believe that if normal cervical lordosis is restored by treatment and the athlete refrains from further spear tackling, then there is not a high risk of injury in returning to athletic activity.
  • Burning hands syndrome: A variant of central cord syndrome with characteristic complaint of burning paresthesia and dysesthesia in both arms or hands and occasionally legs. Associated with bony or ligamentous spine injury in 50% of cases.

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Treatment
Pre-Hospital
  • It is estimated that 3–25% of spinal cord injuries may result from improper stabilization of the spinal column during the transportation period.
  • Initial full spinal immobilization with a firm cervical orthosis and backboard are necessary in all cases of suspected spine injury until radiographs can confirm the extent of the injury.
  • If spinal cord injury is suspected, then management should be with advanced trauma life support procedures: Airway should be established and protected, breathing maintained, and circulation supported.
  • The possible administration of IV methylprednisolone (30 mg/kg) should be discussed with neurosurgical consultants prior to use.
  • If the player is wearing a helmet, it should not be removed.
ED Treatment
All suspected spinal cord injuries warrant emergency department evaluation as soon as possible. Radiographs should be obtained as soon as possible, and full neurological exam should be documented.
Medication
  • NSAIDs
  • Consider narcotics for acute treatment. If narcotics are used, then patient should also be put on a bowel movement program to prevent constipation.
Additional Treatment
  • Less severe injuries may be managed with bracing and serial imaging to evaluate healing and alignment.
  • Unstable injuries mandate urgent surgical treatment.
  • A portion of injuries may require delayed surgical intervention.
General Measures
  • Cervical compression fractures in the absence of subluxation are treated with a rigid brace for 8–12 wks with or without halo (2).
  • Thoracic fractures are relatively stable because of surrounding chest cage and strong costovertebral ligaments, and can be treated conservatively with relative rest.
  • Thoracolumbar injuries (T10–L2) are inherently more unstable and require a longer recumbency and possible immobilization in thoracolumbar spinal orthosis.
Surgery/Other Procedures
  • Isolated fractures with <25% anterior compression are considered stable and can be treated with thoracic lumbosacral orthosis brace immobilization.
  • A >50% loss of anterior vertebral height, multiple adjacent compression fractures, or angulation >20 degrees at the thoracolumbar junction are associated with segmental instability due to posterior ligamentous injury. This requires surgery to prevent formation of chronic instability and possible further kyphotic deformity. The procedure of choice is usually posterior short-segment pedicle screws or interspinous wiring and fusion.
  • Kyphotic deformities may be managed with a posterior approach with osteotomies or a combined anterior approach and posterior procedure, although anterior approaches are associated with higher morbidity and complications.
  • Vertebroplasty and kyphoplasty are routinely used for pain associated with osteoporotic and pathologic compression fractures. Recent study has shown that percutaneous vertebroplasty and kyphoplasty are 2 safe and effective techniques for treatment of thoracolumbar traumatic fractures and allow good pain control and return to normal working activity and social life.
Ongoing Care
Follow-Up Recommendations
Any patient with unstable radiographic abnormalities should be seen by an orthopedist or neurosurgeon for complete evaluation.
References
1. Denis F. The three column spine and its significance in the classification of acute thoracolumbar spinal injuries. Spine. 1983;8:817–831.
2. Khoueir P, Oh BC, Wang MY. Delayed posttraumatic thoracolumbar spinal deformities: diagnosis and management. Neurosurgery. 2008;63:117–124.
Additional Reading
Cantu RC, Bailes JE, Wilberger JE. Guidelines for return to contact or collision sport after a cervical spine injury. Clin Sports Med. 1998;17:137–146.
Costa F, Ortolina A, Cardia A, et al. Efficacy of treatment with percutaneous vertebroplasty and kyphoplastic for traumatic fracture of thoracolumbar junction. J Neurosurg Sci. 2009;53:13–17.
Maroon JC, Bailes JE. Athletes with cervical spine injury. Spine. 1996;21:2294–2299.
McGirt MJ, Parker SL, Wolinsky JP, et al. Vertebroplasty and kyphoplasty for the treatment of vertebral compression fractures: an evidenced-based review of the literature. Spine J. 2009.
Nicholas J, Nuber G, eds. The lower extremity and spine in sports medicine. St. Louis: Mosby, 1995.
Oner FC, Dhert WJ, Verlaan JJ. Less invasive anterior column reconstruction in thoracolumbar fractures. Injury. 2005;36 (Suppl 2):B82–B89.
Tatsumi RL, Hart RA. Cervical, thoracic and lumbar fractures. Current Therapy of Trauma and Surgical Critical Care. Philadelphia: Mosby; 2008:513–519.
Codes
ICD9
  • 733.13 Pathologic fracture of vertebrae
  • 805.00 Closed fracture of cervical vertebra, unspecified level
  • 805.10 Open fracture of cervical vertebra, unspecified level
Clinical Pearls
  • Compression fractures without neurologic injuries are considered stable and, once healed completely, should allow the player to return to action when neck pain is gone, range of motion is complete, muscle strength is normal, and fusion is solid (if done).
  • Athletes with significant vertebral injury requiring a halo brace or surgical stabilization are considered not to have adequate strength to return to contact sports.


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