Trauma (fractures, dislocations, instability)

WHAT IS SPINAL TRAUMA?

Trauma to the spinal column may be caused by a number of events. The most common causes are motor vehicle accidents and falls.

Soft-tissue injuries such as ‘whiplash’ are also common.

Fractures and dislocations may occur throughout the spine, but are particularly common in the neck (cervical) and thoracolumbar (mid-lower back) regions. In severe cases, the spinal cord may be damaged, leading to paralysis.

From a neurosurgical perspective, spinal trauma is classified as ‘stable’ or ‘unstable’. Unstable fractures need to be treated more aggressively in order to avoid the development of spinal cord injury and paralysis. This treatment often requires surgery, but sometimes involves the use of traction and/or an external brace.

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What is whiplash?

Whiplash is a neck injury caused by a strain, sprain, or tear in the soft tissues (muscles and ligaments). It is caused by a sudden and severe neck movement.

The most common form of injury is a rear-end motor vehicle accident, where the head and neck rapidly bend a long way forward before stopping suddenly or even being thrown backwards.

Approximately 20% of people involved in rear-end motor vehicle accidents experience neck symptoms later. It is common to find that these symptoms are worse a day after the injury. Although most recover quickly, some develop chronic severe pain that may result in significant disability.

The term "whiplash" is best used to describe the way the injury occurred, although some use it as a diagnosis. The actual cause of symptoms can be either a stretch or tear of the ligaments or muscles, or even compression of the spinal nerves.

Symptoms

The symptoms of whiplash may include neck stiffness or reduced range of movement, neck pain, headaches, and even arm pain.

Pain at the back of the neck is often worse with movement, and frequently peaks one or two days after the injury before improving. Muscle spasms and pain between the shoulder blades or over the trapezius muscles (between the shoulders and the neck) may also occur.

Headaches, especially at the back of the head (‘cervicogenic headaches’) are common.

Arm or hand pain, fatigue, numbness, tingling or weakness may be a result of nerve or spinal cord injury or compression. These symptoms usually warrant a more extensive investigation.

Treatment

Like sprains in other parts of the body, neck sprains usually heal gradually, with time and appropriate treatment.

Collars

A soft cervical collar may be worn for comfort. In cases where there is severe disc and/or ligamentous disruption, a hard collar (such as an Aspen Collar) may be prescribed.
 

Medication

Analgesics and anti-inflammatory medications are often used to reduce pain and swelling. Muscle relaxants can be used to help ease muscle spasms. An ice pack may be applied for 15-30 minutes, several times a day for the first two or three days after the injury. Heat can help relax cramped muscles, but should not be applied for the first few days. Other treatment options include massaging the tender area, ultrasound, and physiotherapy.

Modifying activities

Early return to work is encouraged, usually with modifications in your workplace activities, which can be eased with time and recovery. Aerobic activities, such as walking or swimming, should be started early.

Whilst most symptoms resolve in one or two months, severe injuries may take several months to heal completely. Symptoms of arm weakness, numbness, or shooting pains should be investigated further.

Surgery

Neck sprains or strains rarely require surgery. Indications for surgery include spinal cord compression, prolonged arm pain and/or weakness, and severe persistent headaches. Surgery may be recommended if other conditions such as verterbral fracture or disc herniation are present.

 

What are compression fractures?

A vertebral compression fracture is where a bone in the spine collapses. These fractures occur most commonly in the thoracic spine (the middle portion of the spine) and upper lumbar (the lower portion of the spine) regions. The lower vertebra of the thoracic spine (T11 and T12) and the first vertebra of the lumbar spine (L1) are most prone to these types of fractures, which are therefore termed ‘thoracolumbar fractures’.

Causes

There are several causes of compression fractures. Whilst the bones (vertebrae) that make up your spine are usually very strong, they can fracture (break) in under certain conditions.

Vertebral fractures are often due to conditions such as osteoporosis (which weakens the bones, seen particularly in elderly women), significant falls, or excessive pressure from other trauma.

The most common cause is osteoporosis, a metabolic disease which thins the bones. The weakened bones can collapse during normal activity, such as bending forward, leading to a spinal compression fracture. Spinal compression fractures are the most common type of osteoporotic fractures, affecting nearly half of all women by the time they are 80 years old. These fractures can permanently alter the shape and strength of the spine. Osteoporotic fractures usually heal on their own and the pain disappears. Sometimes, however, the pain persists if the crushed bone fails to heal adequately. In severe osteoporotic fractures, a kyphosis or a "dowager's hump" may result. This exaggeration of the normal curvature of the spine causes the shoulders to slump forward and the top of the back to look enlarged and humped.

Trauma to the spinal vertebrae can also lead to minor or severe fractures. Falls, forceful jumping, and motor vehicle accidents are frequent culprits.

Another cause of vertebral body fractures is metastatic disease involving the spine. ‘Metastasis’ refers to the spread of cancer cells into other regions of the body. The bones of the spine are a common place for many types of cancers to spread, with breast and prostate cancers being particularly common. A compression fracture of the spine that appears for no obvious reason may be the first indication of cancer spread to the spine. The cancer infiltrates and destroys of part of the vertebra, weakening the bone until it collapses.

Symptoms

Pain is the most common symptom of a compression fracture, however significant pain is not always present.

If the fracture is caused by a major traumatic event, you will probably feel severe pain in your back, and sometimes also in your legs and arms. You might also feel weakness or numbness in these areas if the fracture injures the nerves of the spine or the spinal cord itself.

Treatment

Thoracic compression fractures are usually treated with a combination of pain medications, activity restriction and modification, and bracing. Vertebral body fractures usually take around three months to fully heal. X-rays are usually taken monthly to check on the healing progress and to ensure that progressive collapse of the vertebral body is not occurring.

Pain medications should reduce back pain, but will not help the fracture to heal. In osteoporotic patients, medications to improve bone density and slow bone loss may be prescribed to prevent further fractures.

Restrict normal daily activities

You probably need to restrict your normal daily activities. You should avoid any strenuous activity or exercise. You must avoid heavy lifting and anything else that might place too much strain on your fractured spine. Otherwise the fractured bone may collapse further.

Braces

External bracing is another common form of treatment for some types of vertebral compression fractures. The brace (orthosis) supports the back and restricts movement. It is designed specifically to prevent you from bending forward and placing added stress on the fractured bone.

In some cases, invasive treatment may also be necessary. These treatment options include:

  1. Vertebroplasty: replacing the fractured bone with solid material to give it more strength
  2. Kyphoplasty: using a small balloon to restore some of the lost height of the vertebral body and altered curvature of the spine
  3. Spinal surgery

Surgery

Surgery is not usually required for compression fractures. With vertebral fractures, surgery (‘internal fixation’) is only considered if there is evidence of serious instability of the spine.

Your neurosurgeon or spinal surgeon will usually recommend using some type of internal fixation to hold the spinal bones in correct position whilst the fractured bone heals. If there is pressure on the spinal cord, the bone fragments pushing into the spinal cord may also need to be removed, or a laminectomy performed to alleviate the pressure. Surgery may be performed via an anterior approach (from the front) or posterior approach (from the back).

In most cases, surgery to stabilize the fractured vertebra is performed through an incision in the back, also known as a posterior approach. Metal screws and rods are used to hold the vertebrae in the correct alignment while the fractured vertebra heals. The spinal cord and nerves are decompressed (if necessary) by this approach.

During an anterior approach an incision is made in the chest or abdomen. Bone fragments may be then be removed to relieve pressure on the spinal cord. A spine fusion is then performed by replacing the crushed vertebra with bone graft or a cage. Eventually, the vertebrae above and below are joined by a bridge of solid bone. During the surgery, a combination of metal screws, plates, rods and cages are inserted to hold the spine in the correct position to permit a solid fusion to occur over the next few months. These metal implants remain within the body and are not removed unless they cause problems.

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