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Spinal
Fractures
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Compression fractures of the spine are
one of the more common injuries sustained
by a vertebral structure. The vertebral
body itself is the largest single unit
of a vertebra. Its structural integrity
is similar to a cardboard box.
Imagine a cardboard box; big and sturdy
in appearance, but hollow on the inside.
Now, let's say a great deal of pressure
is placed on this box (vertebral body).
Perhaps a hyperflexion injury occurs.
In this case, hyperflexion means the neck
or low back is forced to bend too far
forward or sideways. The result? A crushing
effect causes the box (vertebral body)
to resemble a wedge. The amount of force
delivered to each vertebra is shared directly
with the surrounding spinal elements.
It might be assumed the smaller cervical
vertebrae would be more susceptible to
injury simply based on size. Injury of
this type generally does not occur often
in the lumbar region, due to the size
and density of the lumbar vertebrae.
Other fractures can occur from forces
that cause the body to torque (twist).
Even a direct blow to the spine can cause
a fracture. Other parts of the vertebra
such as the facet joints, or other bony
processes, can break possibly causing
dislocation of a vertebra and, perhaps,
paralysis to some body part.
Although bone is a hard material, it
can crack, split, or break away from the
parent bone. Spinal fractures require
immediate medical attention. An unstable
fracture may be a serious condition causing
one or more bone fragments to press against
the spinal cord or nerves.
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| Severe Pain |
A severe compression fracture may be
such that the spinal cord or nerve roots
are involved, as they are draped over
the sudden angulation of the spine. This
may cause severe pain, a hunched forward
deformity (kyphosis) and rarely neurologic
deficit from spinal cord compression.
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| Risks - Osteoporosis - Trauma |
The risk for spinal compression fracture
increases with age. Osteoporosis is the
most common risk facture for compression
fractures. Osteoporosis is a condition
in which there is thinning of the bones,
weakening them. This may be due to a lack
of calcium in the diet, certain medications,
old age, inactivity or genetic factors.
In general, some trauma occurs with
each compression fracture. In cases of
severe osteoporosis, the trauma may be
minimal, such as, stepping out of a bathtub
or lifting a heavy object. Moderate trauma
is usually required to create a fracture
in patients with mild to moderated osteoporosis.
This may range from falling off a chair
to an automobile accident. A normal spine
may also suffer from a compression fracture
when there is a severe forward bending
injury. This most commonly occurs from
a fall from a height or an automobile
accident.
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| Nerve Injury |
Neurologic injury is rare with
compression fractures. The degree of neurologic
injury is usually due to the amount of force
present at the time of injury. If there
is severe angulation of the spine secondary
to a wedge fracture, this may stretch the
spinal cord and create injury. This would
then lead to loss of strength and sensation,
as well as reflexes. In most patients with
osteoporotic compression fractures, there
is no neurologic injury but only pain from
the fracture. However, if left untreated
the fracture angulation may worsen and lead
to late paralogic injury.
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| Diagnosis |
A compression fracture is usually diagnosed
by the history, physical exam and x-rays. In
any patient over the age of 60 with the acute
onset of sudden low back pain, a compression
fracture should be suspected. Physical exam
will usually note tenderness directly over the
area of pain as well as mild kyphotic deformity
(e.g., a sudden angulation forward or hunched
over appearance). Plain x-rays will demonstrate
the wedge shape of the vertebral body on a lateral
view. A CAT scan is occasionally needed to help
differentiate a compression fracture from a
burst fracture.
Occasionally an MRI scan is obtained to rule
out disc herniation along with a compression
fracture. MRI scan may also help differentiate
pathologic compression fractures, that is, those
that involve a tumor, from a typical osteoporotic
compression fracture. In any patient with a
known history of cancer, a compression fracture
should tip off the physician to look for evidence
of a metastatic lesion and pathologic fracture.
If osteoporosis is suspected, a Bone Mineral
Density (BMD) test may be ordered. This test
helps determine the severity of the bone thinning.
In addition, laboratory tests to look at blood
count and thyroid function may be indicated
as well. A decision as to whether to treat osteoporosis
should be made by the patients' primary physician.
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| Treatment |
The majority of mild to moderate compression
fractures are treated with immobilization in
a brace or corset for a period of six to twelve
weeks. The duration of treatment is based on
symptoms and x-ray. As pain subsides and x-rays
show no change in the position of the spine
and healing of the fracture, the brace may be
discontinued.
The purpose of the brace is two-fold. Bracing
helps to reduce acute pain by immobilizing the
fracture. It also helps to reduce the eventual
loss in height and in angulation from the fracture.
Compression fractures treated in a brace tend
to have less deformity than those treated without
a brace. Occasionally, bracing beyond twelve
weeks is indicated in those patients with severe
osteoporosis.
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| Stabilization and Fusion |
In most cases, surgery consists of stabilization
of the affected portion of the spine. This can
be performed with rods and hooks placed from
the posterior (back) of the spine. Occasionally
the procedure may be performed anteriorly (from
the front) to remove the broken vertebra and
replace it with a plate, screws or cage.
Either of these approaches involves a spinal
fusion of the broken vertebra and its adjacent
segments.
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| Surgery |
Percutaneous Vertebroplasty is a new surgical
procedure that may be used to treat compression
fractures in senile patients. In this procedure,
the physician or surgeon advanced a catheter
into the compressed vertebra under an anesthetic.
This catheter is then used to inject the fractured
vertebrae with bone cement. This bone cement
hardens within the fractured vertebrae and gives
the initial stability to the vertebral body.
This procedure may be indicated in cases of
severe
Spinal surgery is rarely indicated for patients
with compression fracture. Indications would
include severe fracture with neurologic injury,
severe angulation, failure to heal with initial
bracing, increased angulation despite bracing
or late increasing neuologic deficit.
Specific details of indication and type of
surgery should be obtained from your personal
orthopaedic surgeon.
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| Recovery |
Most patients can expect to make a full recovery
from their compression fracture. Typically,
braces are worn for six to twelve weeks followed
by three to six weeks of physical therapy and
exercise. This is to help regain strength of
the trunk muscles and to increase endurance
of the trunk musculature. Overall strength,
aerobic capacity and flexibility are also helped
by physical therapy.
Most patients can return to a normal exercise
program six months after suffering their compression
fracture. Regular exercise is one of the activities
recommended to help prevent compression fractures
in the future. A well-balanced diet, calcium
supplement and occasionally other medications
prescribed by your personal physician may be
needed to help treat osteoporosis.
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| Reference Material |
1. Kao-Wha Chang. Anterior Decompression
and Fusion for old traumatic cervical cord
lesion. J orth Surg ROC 7 : 53-62, 1990.
2. Kao-Wha Chang. A Reduction-Fixation
system for Unstable Thoracolumbar Burst Fracture
spine. 17 : 879-86, 1992.
3. Kao-Wha Chang. Oligosegemental Correction
of post- traumatic Thoracolumbar angular kyphosis
spine. 18 : 1909-15, 1993.
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TAIWAN SPINE CENTER
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