OrthoNeuroSpine & Pain Institute
Spinal fractures are different than a broken arm or leg. A fracture or dislocation of a vertebra can cause bone fragments to pinch and damage the spinal nerves or spinal cord. Most spinal fractures occur from car accidents, falls, gunshot, or sports. Injuries can range from relatively mild ligament and muscle strains, to fractures and dislocations of the bony vertebrae, to debilitating spinal cord damage. Depending on how severe your injury is, you may experience pain, difficulty walking, or be unable to move your arms or legs (paralysis). Many fractures heal with conservative treatment; however severe fractures may require surgery to realign the bones.
To understand spinal fractures, it is helpful to understand how your spine works. Your spine is made of 33 bones called vertebrae that provide the main support for your body, allowing you to stand upright, bend, and twist. In the middle of each vertebra is a hollow space called the spinal canal, which provides a protective space for the spinal cord (Fig. 1). The spinal cord serves as an information super-highway, relaying messages between the brain and the body. Spinal nerves branch off the spinal cord, pass between the vertebrae, to innervate all parts of your body.
What are spinal fractures?
Spinal injuries can range from relatively mild ligament and muscle strains (such as whiplash), to fractures and dislocations of the bony vertebrae, to debilitating spinal cord injuries. Spinal fractures and dislocations can pinch, compress, and even tear the spinal cord. Treatment of spinal fractures depends on the type of fracture and the degree of instability.
Fractures can occur anywhere along the spine. Five to ten percent occur in the cervical (neck) region. Sixty four percent occur in the thoracolumbar (low back) region, often at T12-L1.
There are numerous classifications for fractures. In general, spine fractures fall into three categories:
Fractures: when more pressure is put on a bone than it can stand, it will break. The most common type of spine fracture is a vertebral body compression fracture . Sudden downward force shatters and collapses the body of the vertebrae. If the force is great enough, it may send bone fragments into the spinal canal, called a burst fracture.
People affected by osteoporosis, tumors, and certain forms of cancer that weaken bone are prone to vertebral compression fractures (VCF). The fracture appears as a wedge-shaped collapse of the vertebra. Multiple VCFs can cause a forward hunch of the spine called kyphosis.
Dislocations: when the ligaments and/or discs connecting two vertebrae together are stretched or torn, the bones may come out of alignment. For example, when the rapid forward motion of the upper body against a seat belt pulls apart the vertebra and stretches the ligaments. A dislocated vertebra can cause instability and spinal cord compression. They usually require stabilization surgery or a brace.
Fracture-dislocations: occur when bone is broken and the ligaments are torn. These fractures are usually unstable, tend to be very debilitating, and are often surgically repaired.
What are the symptoms?
Symptoms of a spinal fracture vary depending on the severity and location of the injury. They include back or neck pain, numbness, tingling, muscle spasm, weakness, bowel/bladder changes, and paralysis. Paralysis is a loss of movement in the arms or legs and may indicate a spinal cord injury. Not all fractures cause spinal cord injury and rarely is the spinal cord completely severed.
What are the causes?
Car accidents (45%), falls (20%), sports (15%), acts of violence (15%), and miscellaneous activities (5%) are the primary causes of spinal fractures. Diseases such as osteoporosis and spine tumors also contribute to fractures.
Who is affected?
- 80% of patients are aged 18-25 years
- Men are 4 times more likely to have a traumatic spinal fracture than women
How is a diagnosis made?
In most cases of a spinal injury, paramedics will take you to an emergency room (ER). The first doctor to see you in the ER is an Emergency Medicine specialist who is a member of the trauma team. Depending on your injuries, other specialists will be called to assess your condition. The doctors will assess your breathing and perform a physical exam of the spine. The spine is kept in a neck or back brace until appropriate diagnostic tests are completed.
X ray test uses x-rays to view the bony vertebrae in your spine and can tell your doctor if any of them show fractures. Special flexion and extension x-rays may be taken to detect any abnormal movement.
Computed Tomography (CT) scan is a safe, noninvasive test that uses an X-ray beam and a computer to make 2-dimensional images of your spine. It may or may not be performed with a dye (contrast agent) injected into your bloodstream. It is especially useful for viewing changes in bony structures.
Magnetic Resonance Imaging (MRI) scan is a noninvasive test that uses a magnetic field and radiofrequency waves to give a detailed view of the soft tissues of your spine. Unlike an X-ray, nerves and discs are clearly visible. It may or may not be performed with a dye (contrast agent) injected into your bloodstream. MRI is useful in evaluating soft tissue damage to the ligaments and discs, and assessing spinal cord injury.
What treatments are available?
Treatment of a fracture begins with pain management and stabilization to prevent further injury. Other body injuries (e.g., to the chest) may be present and need treatment as well. Depending on the type of fracture and its stability, bracing and/or surgery may be necessary.
Braces & Orthotics do three things, 1) maintains spinal alignment; 2) immobilizes your spine during healing; and 3) controls pain by restricting movement. Stable fractures may only require stabilization with a brace, such as a rigid collar (Miami J) for cervical fractures, a cervical-thoracic brace (Minerva) for upper back fractures, or a thoracolumbar-sacral orthosis (TLSO) for lower back fractures. After 8 to 12 weeks the brace is usually discontinued. Unstable neck fractures or dislocations may require traction to realign the spine into its correct position. A halo ring and vest brace may be required.
Instrumentation & Fusion are surgical procedures to treat unstable fractures. Fusion is the joining of two vertebrae with a bone graft held together with hardware such as plates, rods, hooks, pedicle screws, or cages. The goal of the bone graft is to join the vertebrae above and below to form one solid piece of bone. It may take several months or longer to create a solid fusion.
Vertebroplasty & Kyphoplasty are minimally invasive procedures performed to treat compression fractures commonly caused by osteoporosis and spinal tumors. In vertebroplasty, bone cement is injected through a hollow needle into the fractured vertebral body. In kyphoplasty, a balloon is first inserted and inflated to expand the compressed vertebra before filling the space with bone cement.
Q: What is a spinal fracture?
A: Fractures of the bones that make up the spinal column are called spinal fractures or vertebral compression fractures. Mistakenly considered a ''normal'' part of aging, the stooped posture that occurs with multiple fractures contributes to chronic pain, reduced quality of life and an increased risk for more fractures.
Q: Are spinal fractures difficult to diagnose?
A: Not really, although they do tend to be under-recognized by physicians and patients alike. About two-thirds of all osteoporosis-related spinal fractures are not diagnosed primarily because:
- Patients with spinal fractures may have mild, or very little discomfort
- Patients may consider back pain a normal part of aging
- Patients and physicians may not realize the importance of obtaining a proper diagnosis
- A complete physical exam, together with an X-ray and/or Magnetic Resonance Imaging (MRI), can help your physician differentiate between pain caused by a spinal fracture or pain caused by other disorders.
Q: Why should I be concerned about spinal fractures?
A: After just one spinal fracture, your risk for having another fracture is 3-5 times greater than before because the broken bone affects the distribution of weight along the spinal column. Misalignment brought on by a fractured vertebral body places more stress on adjacent vertebrae; the front of the spine is forced to withstand more stress or weight with fewer functioning parts, resulting in a structure that is now weakened and more vulnerable to additional fracture.
Q: What are the symptoms of a spinal fracture?
A: Most spinal fractures have a gradual onset unrelated to specific injury. Fractures can occur as a result of normal activity; i.e., bending over or reaching for something. In some cases, patients experience sudden and severe back pain without engaging in activity at all. The fact that a spinal fracture can be easily confused with other back problems underscores the importance of obtaining a correct diagnosis and receiving treatment. Complicating the issue of spinal fracture diagnosis is the fact that patients can have pain from a fracture and the fracture may not show up on X-ray for several weeks. If your doctor does not find a fracture on the initial X-ray, but you have persistent back pain with no clear cause, consider asking for a second X-ray. Sometimes an MRI may be appropriate.
Q: Can spinal fractures affect my overall health?
A: Multiple spinal fractures can cause a forward curvature of the spine (kyphosis). This increases your risk for future fracture and can reduce your quality of life. With each additional fracture, the spinal curvature can become more pronounced, painful and debilitating. Severe kyphosis has a "compression effect" on your organs, making it progressively difficult to breathe, walk, eat or sleep. Lung capacity is reduced and mobility can become limited. Early satiety (a feeling of fullness after having eaten only a small amount) can cause you to lose weight and become malnourished. Finally, sleep disorders are common with pronounced kyphosis.
Q: What are the psychosocial effects of spinal fractures?
A: In addition to medical complications, patients with spinal fractures can experience depression, anxiety and lowered self-esteem. The alterations in lifestyle that accompany severe kyphosis can profoundly affect well-being and cause feelings of isolation and sadness.
Q: What is osteoporosis?
A: Osteoporosis is a disease in which bones become fragile and weak, causing them to break more easily than normal bone. Often referred to as the “silent thief”, osteoporosis usually progresses without obvious signs or symptoms until the first fracture occurs. According to a large-scale epidemiologic follow-up study, approximately 1.4 million vertebral fractures due to osteoporosis occur annually in Europe.
Q: Who is at risk for an osteoporosis-related fracture?
A: The International Osteoporosis Foundation estimates that 40% of women and 15% of men over the age of 50 will have one or more osteoporosis-related fractures in their lifetime; however, changes that weaken bone in women can begin as early as age 30. Additionally, long-term use of medications such as corticosteroids can weaken bone.
Q: What are the risk factors for osteoporosis ?
A: The International Osteoporosis Foundation has identified the following as risk factors for osteoporosis:
- Family history of osteoporosis or fractures (in a close relative)
- Broken bone after age 50
- Height loss of more than 3 cm (just over 1 inch) in adulthood
- Low calcium in diet
- Smoking, excessive alcohol consumption or taking certain medications (e.g. glucocorticoids)
- Normal or early menopause (before age 45)
- Low testosterone in men
Q: How common is osteoporosis?
A: One in three women and one in five men over age 50 will have an osteoporosis-related fracture in her/his remaining lifetime. The International Osteoporosis Foundation cites osteoporosis as a major public threat affecting 19 million Europeans (45% of the population aged 50 and older).
Back Pain and Spinal Fractures
Q: How does “normal” back pain compare with the pain of a spinal fracture?
A: There are many potential sources of non-fracture related back pain. Sudden, severe back pain, unrelated to specific injury, may indicate that a spinal fracture has occurred. Regardless of the intensity of back pain, it’s never wise to self-diagnose. Patients experiencing back pain should go to their doctor for a physical exam.
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Q: What can happen if a spinal fracture isn’t diagnosed and treated?
A: Left untreated, one fracture can lead to another, resulting in kyphosis (curvature of the spine) and an overall decline in health. Kyphotic deformity and progressive bone weakness increase your risk for additional fractures and can adversely affect your ability to breathe, walk, eat or sleep. Consult with your physician to determine your condition and the appropriate treatment.
Q: How have spinal fractures been treated in the past?
A: Traditional treatment for spinal fractures includes extended bedrest, pain medication and back braces. These treatments can reduce pain, but do not stabilize the fracture or correct the related spinal deformity.
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Q: How long does balloon kyphoplasty/vertebroplasty take? What type of anesthesia is used?
A: On average, the procedure takes about one hour per fracture treated and may be done on an inpatient or outpatient basis, depending on medical necessity. The procedure can be done under local or general anesthesia; the physician will recommend the most appropriate sedation based on the patient’s general condition. After the procedure, the doctor will most likely schedule a follow-up visit and explain limitations, if any, on physical activity.
Q: What are the potential benefits of balloon kyphoplasty/vertebroplasty?
A: Balloon kyphoplasty//vertebroplasty has been shown to achieve restoration of vertebral body height and correction of spinal deformity.
Additional benefits include:
- Significant and sustained reduction in back pain
- Significant and sustained improvement in quality of life and ability to perform activities of daily living [17,19]
- Significant and sustained improvement in mobility
- Significant reduction in number of days per month that a patient remains in bed due to back pain
- Significant and sustained reduction in number of days per month when pain interferes with such daily activities as walking, hobbies and work
- Sustained vertebral body height restoration
- Favorable patient outcomes have been shown to last through two-year follow-up. Studies that document benefits beyond two-year follow-up have not yet been reported.
Q: Are there risks associated with balloon kyphoplasty/vertebroplasty?
A: As with any surgery, there are potential risks. Although balloon kyphoplasty//vertebroplasty is designed to minimize these risks as much as possible, there is a chance that complications could occur. Serious adverse events can occur, including but are extremely rare:
- myocardial infarction (heart attack)
- cerebrovascular accident (stroke)
- pulmonary embolism (cement leakage that migrates to the lungs)
- cardiac arrest (heart stops beating)
- paralysis or muscle weakness
Patients should consult with their doctor for a full discussion of risks.
Q: What can a patient reasonably expect after undergoing kyphoplasty/vertebroplasty?
A: Published studies report a marked reduction in pain, sometimes within hours of the procedure. Balloon kyphoplasty has been shown to improve mobility and enable patients to return to everyday activities such as walking, bending, and lifting, with significantly less pain than they had prior to the procedure. Patients report improved mental health, vitality, social function and emotional well-being.
Q: Can a spinal fracture that occurred a long time ago be treated with kyphoplasty/vertebroplasty?
A: Age of a spinal fracture and treatment success varies from patient to patient; however, physicians generally agree that the earlier a fracture is treated, the better the chances for deformity correction.