Let's briefly review the anatomy of the spine to understand the spinal fracture issue a little better. The spine consists of 33 bones called vertebrae, which are connected to each other by soft tissue, joints and intervertebral pads (disc). This chain of vertebrae forms a support structure that allows our body to stand upright and to move in all directions (bending forward, backward, turning to the sides). In addition, at the back of each vertebra there is a ring of bone structure through which the spinal cord passes, and these protect the spinal cord.

The spinal cord consists of nerve tissue that provides the connection between the brain and the arms, trunk and legs and carries orders from the brain to these regions. By acting just like an electrical cable; It enables our hands and arms, feet and legs, and our sensory function to work. It also helps us breathe, controls urination and defecation functions.

Spinal injuries can range from mild soft tissue trauma to spinal fracture and spinal cord injury. Spinal fractures and dislocations can cause spinal cord injury and thus paralysis. The treatment of spinal injuries also varies according to the severity of the case.

 

Causes of spinal fractures:

Spinal fractures usually develop due to high-energy trauma. Traffic accidents are shown as one of the most common causes. Apart from this, falls (especially falls from height), gunshot injuries and sports accidents are among the main causes of spinal fractures. In the elderly with osteoporosis and in patients with spinal tumors, severe fractures may occur even after low-energy traumas such as minor falls, as the spinal bones affected by these diseases weaken.

 

Who is most affected by spinal fractures?

80% of patients with spinal fractures are between the ages of 18-50. Men are 4 times more likely to suffer a spinal fracture than women.

 

Back (thoracic) and Lumbar (lumbar) Spine Injuries:

The most common location for vertebral fractures is the junction of the back and waist. 60% of fractures occur between the 12th lumbar spine (T12) and  2. Lumbar spine region (L2) and approximately 90% are between T11-L4. Vertebral fractures can be found at more than one level between 5 and 20%. It usually occurs with high-energy trauma.

 

Classification

It is initially divided into two as minor and major injuries. minor injuries are isolated fractures, these are; transverse process fractures, spinous process fractures, pars interarticularis fractures. Denis divided major fractures into four groups:

• Compression fractures:

Approximately 48% of thoracolumbar vertebral fractures are this type. It occurs as a result of straining forward bending in the spine. Often there is a fracture involving the anterior part of the vertebral body. It causes a decrease in the anterior height of the vertebral body. If the object collapses more than half its anterior height, varying degrees of tearing may occur in the posterior ligaments.

• Burst fractures:

About 14% of vertebral fractures are of this type. Here, the axial load on the vertebral body is the cause of the fracture. As a result, a multi-part fracture occurs that concerns the entire body. Fractures that separate in the posterior part of the body often displace posteriorly, enter the vertebral canal, and can cause neurological lesions by compressing the neural structures.

• Seat-Belt type fractures:

These types of fractures are also called forward bending and tension fractures. 5% of vertebral fractures are of this type. It occurs as a result of bending forward in the anterior part of the spine and stretching in the posterior elements. As a result, lesions of different shapes appear, involving both anterior and posterior elements. The most classical lesion is a horizontal fracture that starts from the posterior elements and continues with the body by passing through the pedicle, which is called a “Chance fracture”.

• Fractured dislocations (Fracture-dislocation):

It is approximately 16% of vertebral fractures. It occurs by three mechanisms:

• Flexion (forward bending)-rotation (rotation)

• Shearing

• Flexion-distraction (stretching): It is the most common type of neurological lesion (75%). Another classification concerns whether the vertebral forties are stable, There are two types of instability:

  • Neurological instability: There is a neurological lesion with the fracture.

  • Mechanical instability: There is no neurological lesion, but the integrity of the vertebrae is severely impaired and its mechanical support is lost, and there is a risk of a neurological lesion. Deciding whether mechanical instability is present in a vertebral fracture is not easy.

 

Neck (Cervical) Spine Injuries

Fractures and dislocations of this region are quite common. Paralysis is common as a result of the compression of the incision and fracture fragments in the spinal cord. The most serious complication is respiratory paralysis. 

 

Hyperflexion injuriesIt occurs when the head is forced forward with force. It mostly causes crushing fractures of the vertebral body in the lower neck region, tears in the ligaments, facet joint fractures and forties dislocations.

 

Hyperextension injuriesis  occurs when the head is forced into extreme extension. It mostly causes lesions such as odontoid process fracture, Hangman (Cellad) fracture in the upper cervical region.

 

Vertical compression injurieson the other hand, it occurs as a result of the forces that come to the head. C1 (Atlas) fracture (Jefferson fracture) and burst (Burst) fracture may occur due to reasons such as falling from a height, being under a dent, diving.

 

Rotation Injuries: rotation injury alone is unlikely, often accompanied by flexion, vertical compression. Generally, dislocation of facet joints, complex fractures of pars interarticularis and posterior elements such as pedicle are seen.

 

Combined Flexion/Extension Injury (Whiplash Injury):It is a form of injury mostly seen in traffic accidents. If the speeding vehicle collides with a stationary object, the head moves forward rapidly, resulting in a hyperflexion of the neck. This causes lesions in the hyperflexion injury. In this case, if the vehicle from behind collides with the stationary vehicle, this time the head goes backwards, causing hyperextension in the neck. In this case, lesions in hyperextension injury occur. Such a combined injury may cause only soft tissue injury or even sudden death. Treatment is based on the existing lesion. Protection can be provided on the backs of car seats by visors that support the head.

 

Clinic

Early symptoms of spinal fractures vary according to the severity and location of the injury. Neck, back and low back pain and muscle spasm are the main findings. If there is a spinal cord injury, there may be various complaints such as numbness, numbness in the arms and legs, loss of strength, incontinence or inability to pass urine.

 

In fractures caused by indirect trauma, pathological findings are not always observed at first glance, but sometimes a local kyphosis deformity matching the fracture site may be noted. In direct trauma, skin lesions of varying degrees can be found at the site of the impact and the fracture site. There is pain in the fracture area. The movements of the spine are painful and therefore restricted. A careful neurological examination should be performed in a patient who has had a spinal trauma.

 

Diagnosis

• Anteroposterior and lateral radiography

It is the first step of the radiological evaluation. The anatomical shape of the spine, the height of the vertebral bodies, the disc space, the interpedicular distance, the localization of the spinous processes and pedicle shadows, the integrity of the lamina and pars interarticularis, the integrity of the facet joints and the transverse processes should be examined. If necessary, oblique radiographs are taken. Facet joints and pars interarticularis are best seen on oblique films. 

• Computed axial tomography (CT)

It gives objective information about whether the fracture is stable or not. The distribution of the fracture to three columns, the condition of the spinal canal, and the rate of invasion of the canal by the fracture fragments are determined by CT.

• Magnetic resonance imaging (MRI)

The spine is an osteoligamentous complex. The intervertebral disc and ligaments are as important as the bone structures in the stability of the spine. While MRI provides information about soft tissues, it is also a necessary imaging method in the diagnosis of neurological lesions. 

• myelography

Although it seems like an imaging method that loses its value with MRI, it can be used to determine the level of posttraumatic compression, to determine the neural elements, in cases where MRI is not available and because it is economical.

• Electroneuromyography (ENMG)

It gives information about the level and character of peripheral type neurological lesions.

 

Treatment

In order to decide whether the treatment is surgical or conservative, it is necessary to decide whether the fracture is stable or not. Vertebral fractures listed below are considered unstable: 

 

Instability criteria:

·      Vertebral fractures with neurological lesion.

·      Fractured dislocations.

·      Fracture of at least two columns, provided that there is a fracture in the middle column.

·      Compression fractures with more than 50% collapse.

·      Thoracolumbar (T12 - L1) and cervicothoracic (multiple fractures) fractures in the cervicothoracic junction (C7-T1).

 

Conservative treatment:

Stable fractures are treated conservatively. Here, after a period of bed rest, 12-16 weeks are completed with a rigid corset/neck collar. The brace can be lumbosacral or thoracolumbosacral depending on the level of the fracture..

 

Surgical treatment:

Unstable fractures are treated surgically. The type of surgical intervention differs according to the presence or absence of neurological lesions. Operations can be performed on the neck  only from the anterior part of the neck, by opening the thorax in the back and the abdominal cavity in the waist, from the front, only from the back, and sometimes from both sides. Recently, surgeries that have been required from the front can also be performed with a single attempt by opening them only from the back. Purpose If there is compression on the nerve tissues, it is to be removed, the spine is supported and fixed from the front, back or both anteriorly and posteriorly, and bone union is ensured.