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.
- Common in elderly women (osteoporotic fractures) and young men (traumatic injuries)
- Location: ∼ 50% in the cervical spine and ∼ 50% in the thoracic, lumbar, and sacral spine
Epidemiological data refers to the US, unless otherwise specified.
- Trauma (e.g., car accidents, falls, gunshot wounds)
- Pathological fractures
- Stable vertebral fracture
- Unstable vertebral fracture
Vertebral compression fracture (most common type)
- (most common cause) or , e.g., due to
- Clinical features
- Usually stable
- Often asymptomatic, but may cause acute back pain and point tenderness
- Long-term findings after multiple vertebral compression fractures
- 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
- 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.
Subtypes and variants
- Definition: fracture of the atlas (first cervical vertebra)
- Treatment: immobilization for stable fractures; surgery for dislocations
- Definition: fracture of the dens axis (second cervical vertebral body)
- Epidemiology: 10–15% of all cervical fractures
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 |
|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|
- Detailed neurologic 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.
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.
Cervical spine distortion (whiplash injury)
- Etiology: often seen after car accidents due to abrupt flexion/extension movement of the neck
- Headache, neck ache, and/or pain radiating into the back of the head, the shoulders, or the arms
- Pain-based reduction in neck range of motion and palpable muscle tension of the shoulders and neck, as well as arm and hand paresthesia
- General symptoms such as dizziness, nausea, fatigue, insomnia, tinnitus, and problems with concentration
The differential diagnoses listed here are not exhaustive.
- Rescue from the field when there is concern for vertebral fractures.
- Orotracheal intubation with rapid-sequence intubation is preferred for establishing an airway in an apneic patient with a cervical spine injury.
- Indication: stable fractures
- 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)
Minimally invasive procedures
- Indication: stable vertebral compression fractures with progressive pain or kyphosis despite conservative treatment
- Spinal cord injury
- Vessel injury: dissection or thrombotic blockage of the vertebral artery
- Posttraumatic deformation of the spine: loss of height, scoliosis, or kyphosis
We list the most important complications. The selection is not exhaustive.