What is a vertebral fracture?

A vertebral fracture is a ruptured vertebra. The vertebrae consist of the following parts: the body in its anterior part, the pedicles in the median part, and the laminae, the joints, and the spines in the posterior part. Rupture of any of the parts that make up a vertebra is considered a vertebral fracture. It can affect the vertebrae of the cervical, thoracic, lumbar, sacrum or coccyx spine.

Causes

Vertebral fractures can have a variety of causes:

1. Injury

Fractures resulting from accident (traffic accident, work accident…) are the most common. 

2. Osteoporosis

Another very frequent cause of vertebral fractures is this disease, which, as we know, is a problem related to bone metabolism causing the bones to lose density and therefore become more fragile. 

3. Other pathologies

A vertebral fracture can also be the result of another pathology, such as tumors. There are primary tumors (that originate from the bone) that directly affect the bone, weaken it until it breaks, and also, there are secondary ones (metastases, when the tumor originates elsewhere and then travels to the bone). 

4. Treatments

Other causes of vertebral fractures are chronic treatment with corticosteroids, chemotherapy and radiotherapy, an infection (osteomyelitis, tubercolosis) that extends to the bone, hyperthyroidism not treated correctly, etc.

Symptoms

The symptoms of vertebral fractures will depend on their location, the type of fracture and the cause.

Pain caused by broken bone

Without a doubt, the most common symptom is pain caused by broken bone. The pain may be located only in the fracture area or it can be irradiated, that is, it can be located remotely, due to the fact that some nerve area (medulla and/or nerves) is compressed by some broken fragment that has moved from its usual position as a consequence of the fracture.

Neurological deficit

In the most severe cases, in addition to pain with or without irradiation, the patient may also suffer some neurological deficit that can affect the sensory part (with loss of sensation in some area, trunk and or extremities) and/or motor function (with loss of movement of some anatomical area), which is usually due to the damage caused by the fragment displaced on the noble structures (medulla and nerves).

Diagnosis of vertebral fractures

To make a diagnosis of a fracture, in addition to the information gathered from the symptoms previously described, complementary imaging tests are used. Radiography (X-ray) has been the most commonly used method to identify a fracture and it is still very useful today, since it allows us to see the broken vertebra.

However, once a vertebral fracture has been identified, it is important to complete the study with a series of tests that will allow us to correctly classify the fracture and thus identify the most appropriate treatment for it. These tests, which we will see below, in some cases, also allow us to identify the fracture when the x-rays are inconclusive:

Computed tomography (CT)

Allows us to see in detail the bone structures affected by the fracture.

Magnetic resonance (MRI)

Allows us to identify and confirm the fracture. With an MRI we can see if there is inflammation, current state or healing of the fracture (acute/chronic) and the soft parts affected by the fracture (medulla, nerves, ligaments, tendons). In this way, we can classify it and choose the best therapeutic option.  

Full body x-ray (EOS)

Helps us study the fracture in the general context of the rest of the vertebral segments and the balance of the different curvatures (kyphosis, lordosis). This allows us to analyze different angles (such as that of the angular kyphosis of the fractured vertebra and of the adjacent-superior and inferior vertebrae), helping us to predict which fractures, even if they appear mild, can present complications and require more aggressive treatments from the beginning.

Treatment of vertebral fractures

The treatment of vertebral fractures varies widely. It must be based on the type, cause, location and characteristics of the fracture, and on whether or not there are any neurological symptoms associated with compression of the spinal cord or nerves.

Treatment can either be conservative or surgical, or a combination of both.

CONSERVATIVE TREATMENT

Conservative treatment is used for those fractures that are not considered dangerous. That is, in which there is no risk of secondary complications and the patient has no neurological symptoms from the beginning. 

This treatment is based on the use of pain-relieving medication. Sometimes it may be necessary to use a corset or orthopedic brace, which can be custom made depending on the type of fracture and its location. If there are metabolic or endocrinological problems, attempts will be made to correct the related causal problems, with or without the help of drugs. 

Surgical treatment varies, and will depend on the type of fracture, its cause and location. In some cases it may be necessary to inject cement into the vertebra (vertebroplasty, kyphoplasty), especially in the case of osteoporotic fractures, which are refractory to medical treatment. 

It may be necessary to perform a posterior stabilization of the fracture with the placement of posterior screws, which can be done by percutaneous (minimally-invasive) surgery and/or open surgery. These screws, depending on the type of fracture, can be removed at the time the fracture is considered healed, generally between 8 months and one year.

MORE SEVERE CASES

In more severe cases, a vertebral fusion may be necessary to permanently stabilize the segment affected by the fracture. This surgery can be performed by stages, in addition to the surgical stage for the placement of the screws, mentioned above, it may be necessary to place implants in the anterior part of the spine, which serve to completely or partially replace the vertebra fractured (corporectomy). 

In the case of a secondary tumor-related fracture, it may be necessary to remove the entire vertebra (vertebrectomy) for analysis, in which case the vertebra is replaced with an artificial one. In selected cases, just a biopsy will be taken instead of removing the whole vertebra, since there are some types of bone tumors that are treated with drugs (chemotherapy and/or radiotherapy).

Rarely, in cases of injury and/or other causes, urgent surgery is performed to avoid major complications, especially when there is direct compression on the neurological structures (medulla and/or nerves). In these cases, direct decompression of the affected structures may be necessary, performing a posterior laminectomy resection of the posterior elements of the vertebra). Decompression surgery with laminectomy is usually completed by stabilizing the segments with posterior screws with or without anterior support with an artificial vertebra.

Who are the doctors at Instituto Clavel who treat vertebral fractures?

Sources

  • Alpantaki et al., Thoracolumbar burst fractures: A systematic review of management.  Orthopedics. doi: 10.3928/01477447-20100429-24 
  • Sonali et al., Nonoperative versus operative treatment for thoracolumbar burst fractures without neurological deficit. A meta-analysis. Clinical Orthopedics and Related Research. DOI 10.1007/s11999-011-2157-7 
  • Siebenga et al., Treatment of Traumatic Thoracolumbar Spine Fractures: A Multicenter Prospective Randomized Study of Operative Versus Nonsurgical Treatment. SPINE Volume 31, Number 25, pp 2881–2890 
  • Blondel et al., Percutaneous management of thoracolumbar burst fractures: Evolution of techniques and strategy. Orthopaedics & Traumatology: Surgery & Research (2011) 97, 527—532 
  • Charles et al., Temporary Percutaneous Instrumentation and Selective Anterior Fusion for Thoracolumbar Fractures. SPINE Volume 42, Number 9, pp E523–E531 
  • Chu et al., Percutaneous Instrumentation Without Arthrodesis for Thoracolumbar Flexion-Distraction Injuries: A Review of the Literature. Neurosurgery 80:171–179, 2017 DOI:10.1093/neuros/nyw056 
  • Sebaaly et al., Percutaneous fixation of thoracolumbar vertebral fractures DOI: 10.1302/2058-5241.3.170026 
  • Barbagallo et al., Restoration of Thoracolumbar Spine Stability and Alignment
  • in Elderly Patients Using Minimally Invasive Spine Surgery (MISS). A Safe and Feasible Option in Degenerative and Traumatic Spine Diseases. DOI 10.1007/978-3-319-39546-3_11

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