Spine fracture

Question 1

A 75 year old women develops acute back pain. An X ray has shown a vertebral fracture. Blood tests show raised calcium and ESR. What diagnosis do you suspect and which investigation would help with diagnosis?

Answer 1

• Myeloma
• Protein electrophoresis and Bence Jones protein or free light chains to look for clonal Ig

Question 2

What is one of the most common sites of osteoporotic fractures?

Answer 2

Spine/vertebrae

Question 3

What are the main causes of spinal injuries?

Answer 3

• Motor vehicle injuries (half of all spinal injuries)
• Violent trauma
• Falls in the elderly
• Sports

Question 4

How many bones in the spine?

Answer 4

33 vertebrae - 7C, 12T, 5L, 5S, 4C

Question 5

Which part of the spine is most injured?

Answer 5

Cervical is most injured - exposed location and flexible

Thoracic is very rigid and so a lot of force would be needed to injure it

Question 6

What are the mechanisms of injury of the spinal column?

Answer 6

• flexion
• flexion-rotation
• extension
• vertical compression

Question 7

Cervical fractures

What is hangman’s fracture?

Answer 7

C2 (axis) pedicle fracture

Question 8

Cervical fractures

How do anterior wedge fractures occur?

Answer 8

Forceful flexion of the cervical spine can compress the anterior portion of a vertebral body → fracture

Question 9

Cervical fractures

What type of spinal fracture is shown and how does it occur?

Answer 9

Spinous process fracture - clay shoveler’s fracture; stable fracture

MOA - direct trauma to the spinous process and car crashes due to sudden deceleration.

Question 10

Cervical fractures

Where is the lamina of the spine?

Answer 10

Question 11

Cervical fractures

What type of fracture is shown?

Answer 11

Burst fracture - compression fracture; stable since all ligaments intact but can press on spinal cord

MOA- axial load exerted on the spine from above or below

Question 12

What are the most common types of fractures of the thoracolumbar spine?

Answer 12

Compression fractures - either wedge, anterior or compression account for ~70%

Question 13

What is a Chance fracture and what is the mechanism of injury?

Answer 13

Flexion distraction injury caused by wearing a lap belt and no chest support belt e.g. in back middle seat

Causes fractures of the lamina, pedicles and interspinous ligament

Question 14

What are the risk factors for osteoporotic fractures (of the spine)?

Answer 14

• Age >65F or >75M
• Hx of fragility fracture
• Glucocorticoids
• Hx of falls
• FH of hip fracture
• Cushing’s, hyperthyroid, CKD
• Low BMI <18.5
• Tobacco smoking
• High alcohol use

Question 15

What are the clinical features of osteoporotic vertebral fractures?

Answer 15

• Asymptomatic
• Acute back pain
• Breathing difficulties due to compression of organs
• GI problems due to compression
• May have history of falls
• Loss of height
• Kyphosis
• Localised tenderness on palpation of the spinous processes

Question 16

What investigations would you do for vertebral fractures?

Answer 16

XR spine - will show old and new fractures

Other:

CT spine - more detailed

MRI spine - may look for tumours or assess ligaments

Question 17

What calculators can be used to assess 10yr risk score in osteoporosis of fracture?

Answer 17

First order DEXA scan for bone mineral density then use result in:

• FRAX tool
• QFracture tool

… to estimate 10yr risk of fracture

Question 18

What is the management of spinal fractures?

Answer 18

Non-operative: e.g. for burst and compression fractures

• Observation
• Bracing/orthosis for 6-12 weeks - depending on degree of instability
• +/- calcitonin - decreases pain if osteoporotic
• +/- bisphosphonates

Operative: e.g. for neurological deficits, myelomalacia, instability

• Surgical decompression and stabilisation

Question 19

What are the complications of spinal fractures?

Answer 19

• Entrapped nerve roots and dural tear
• Cauda equina syndrome
• Non-union after spinal fusion
• Pain
• Deformity e.g. progressive kyphosis, flat back
• Pseudoarthrosis
• Surgical site infection
• Iatrogenic neurologic injury
• DVT

Question 20

What is the prognosis with spinal fractures?

Answer 20

Most heal within 3-4 months

If pain persists then surgical intervention may be required