Acute Spinal Fracture Management
By Jennifer Small
AbstractSpinal orthotics can be an area of concern for orthotists who are not familiar with the proper treatment of acute spinal fractures. A patient who is in acute care means the injury was recent, usually within 24 hours. This is a critical time for the patient. Proper treatment is crucial during this time period so further damage to the spinal column does not arise. This research project is a culmination of recent literature found on the most common types of spinal fractures and their proper orthotic treatment. At the end of this paper, a chart has been provided to be used by orthotists as a quick reference guide to assist them with acute spinal fracture patient care. The purpose of this project is to inform orthotists about the most common acute spinal fractures so they can better understand the condition of their patient.
The Spinal ColumnProper fit of an orthosis is essential to patient care. Correct and appropriate use of an orthosis facilitates healing and decreases the severity of the deformity. The three main functions of the spine are support, mobility, and spinal cord protection. Orthoses are needed to assist the spine in all three main functions. Orthoses use applied forces to change the existing deformity and kinematics of the spine. Spinal orthoses typically must substitute for or assist the musculature around the spine. In acute settings, immediate spinal column protection is essential. This is an example of how an orthosis offers support for the spine. If a particular movement or position is painful, orthoses can be used to decrease motion. Some spinal orthoses, in particular cervical collars, remind the patient to not move and, therefore, aid in limiting motion (Benzel, 1999). Orthotists should be familiar with spinal orthoses in order to be successful in the use of orthoses in acute environments. Inappropriate orthotic treatments can lead to a costly waste of resources and possible patient injury.
BiomechanicsSpinal orthoses, ranging from the cervical vertebrae to the sacral vertebrae, apply forces to the spine and biomechanically affect the spine. The magnitude and resultant effect of these forces depends on the type of orthosis used and the patient. According to Benzel 1999, the spine is viewed as a chain of semi-rigid vertebra, separated by viscoelastic discs and ligaments, and encased in materials with multiple moduli of elasticity and viscosities. The biomechanical goal of any spinal orthosis is the transmission of appropriate forces to the vertebra through viscoelastic elements. Force is not generally applied directly on the spine, but on the surrounding structures (like the ribs). Whether the goal of the orthosis is to support, immobilize, or protect the spinal column, the orthotic device is dependent on the transmission of forces to the spine. The stiffness of the surrounding structures around the spine varies and, therefore, effects the usefulness of the orthosis. The ribs are the most rigid transmitter of force. Fat, which has less rigidity, is the least rigid transmitter of force. Also, the amount of soft tissue surrounding the spine decreases the effectiveness of the orthosis. The thicker the tissue, the less effective the orthosis (Benzel, 1999).
Vertebral LevelsThe spine consists of four levels of vertebra: cervical, thoracic, lumbar, sacral. Each has unique characteristics that make it different from the level above or below them. There is a total of 33 vertebrae. The cervical region consists of 7 vertebra. The primary motion is rotation, but lateral flexion, flexion, and extension occur too. The thoracic region contains 12 vertebra. The proximal thoracic vertebra mainly rotate, the middle thoracic vertebra primarily laterally flex, and the distal thoracic vertebra flex and extend the spine. The lumbar region contains 5 vertebra that primarily flex and extend. The sacrum contains 5 vertebra and the coccyxgeal level contains 4 vertebra. The sacrum and coccyxgeal are fused vertebra and offer minimal motion. Each level of the spine has different motions that are predominant. Therefore, an appropriate orthosis must be prescribed to support the correct vertebrae, limit motion in a particular direction, or offer protection to the injury and surrounding structures.
Determination of Spinal StabilizationThe most popular determination of the stability of the spine is the Denis three-column model. The Denis method is simple for physicians to use and constitutes perhaps the most widely used clinical method at present (Baldwin, 1999). According to Denis, the spine is divided into 3 columns. The anterior column consists of the anterior longitudinal ligament, anterior ½ of vertebral body, and anterior ½ of vertebral disc. The middle column consists of the posterior longitudinal ligament, posterior ½ of the vertebral body, and posterior ½ of the vertebral disc. The posterior column consists of the facets, pedicles, spinous processes, lamina, posterior ligaments, and interspinous ligaments. If two of the three columns are damaged in an injury, the patient is considered to be in an unstable condition. A more aggressive form of treatment is needed. If, however, a patient only has damage to one of the three columns they are considered to be in stable condition and do not need aggressive forms of treatment. Once the physician determines the condition of the patient, whether stable or non-stable, orthotists can better understand the seriousness of the spinal injury.
Fractures of the First Cervical Vertebra (C1) and Corresponding OrthosesFractures at C1 account for 10% of all cervical spine injuries. Most C1 fractures arise from vehicle accidents, although several occur due to falls or diving accidents. Typically, the body of C1 is large, which helps protect the spinal cord from injury. Therefore, neurological damage is rare (Kurz, 1998). Two common C1 fractures are the ring of atlas and Jefferson's fracture.
Ring of AtlasThis fracture occurs at C1 from a hyperextension force and axial force applied across the atlantoccipital joint. The posterior arch is most commonly fractured. This separates the posterior elements from the anterior ones. The patient is typically in stable condition. Treatment consists of traction, followed by a SOMI, and then a Philly or similar semi-rigid collar (Levine, 1998).
Jefferson FractureThis type of injury occurs at C1 from an axial load. The fracture occurs at the anterior arches, posterior arches, and/or transverse ligament. Recent literature states that half of all patients with a Jefferson fracture are considered to be in stable condition. If the patient is determined to be in stable condition, the most common treatment is a halo, followed by a Philly or similar semi-rigid collar. If the patient is not neurologically intact, treatment typically involves traction, followed by a halo, and then a Philly or similar semi-rigid collar (Levine, 1998).
Fractures of the Second Cervical Vertebra (C2) and Corresponding Orthoses
Odontoid ProcessThe classification system for fractures of the odontoid process that is widely used today was reported by Anderson and D'Alonzo in 1974. The scheme consists of three types of fractures based on the anatomic location of the fracture line. Type 1 involves the tip of the odontoid breaking off. It most likely involves an avulsion fracture at the insertion of the alar ligaments. Type 1 is the least common fracture at the odontoid. The patient is normally inherently stable. The treatment usually involves some type of conservative treatment, like a cervical collar. Type 2 involves a fracture at the junction of the base of the odontoid. Type 2 fractures are the most common. They result from a horizontal shear force and an axial force. They typically result in the patient not being stable. The apical and alar ligaments insert into the rostral fragment of C2 and probably contribute to the patient's instability. The most common treatment is fusion of C1-C2, then a halo, followed by a Philly or similar semi-rigid collar. Type 2 fractures have the highest rate of nonunion when treated nonoperatively. Type 3 involves a fracture into the cancellous bone of the body of the axis. The patients are typically more stable because of a large cancellous surface with an excellent vascular supply, all of which contribute to the high rate of union in fractures managed nonoperatively. The patient is typically placed in a halo (Ballard & Clark, 1998).
Hangman'sThere are three classifications for a hangman's fracture, also known as a traumatic spondylolisthesis of the axis. The categories are based on the degree of angulation and translation between C2 and C3. Angulation is determined by the angle between the inferior end plate of C2 and the inferior end plate of C3. Translation is determined by the distance between the posterior aspect of C2 and the posterior end plate of C3 at the location of C2-C3 disk. The three classifications of a hangman's fracture are described by Effendi, Roy, and Cornish in 1981. A type I fracture occurs through the neural arches just posterior to the body. They are typically the result of hyperextension and an axial load force. They can be caused by motions moving in the transverse plane, such as a blow to the back of the head or whiplash. There is typically no neurological, disc, or ligament damage. Also, there is rarely significant angulation nor translation. Due to the stability of the patient in a type I injury, a cervical collar is used to immobilize the patient. This should be a semi-rigid collar, like a Philly or Miami J. The most common hangman's fracture is a type II. A type II fracture occurs at the pars interarticularis of C2, just posterior to the body. It usually presents with significant angulation and more than 3 mm of translation. It is created in the same manner as a type I hangman's fracture, however, there is typically disruption of the intervertebral disc. This results when the patient's neck first hyperextends and then with deceleration flexes. There is typically no neurological damage. The goal of treatment is to reduce angular deformity and increase alignment of spine. This is commonly done by placing the patient in a halo followed by a Philly or similar semi-rigid collar. A type III hangman's fracture results from a "type I" fracture through the neural arches, just posterior to the body, and a bilateral or unilateral fracture through the facets. The posterior arches of C2 becoming free-floating fragments. There is typically posterior ligamentous damage as well. A type III hangman's fracture commonly has neurological disruption. A halo should not be used immediately because a malunion might form, due to the large space between the fragments. Also, if a halo is used immediately, alignment may be unacceptable and lead to long-term pain. Therefore, proper treatment involves traction until the displacement is reduced. A patient can then be placed in a halo. If reduction can not be maintained through traction or a halo, surgery is an option. Post-operatively, the patient can be mobilized in a semi-rigid collar (Levine, 1998).
Fractures of the Lower Cervical Vertebra 3-7 and Corresponding OrthosesThis is the most common site in the cervical spine for injury. According to Allen, Ferguson, Lehman, and O'Brien (1982), the three most commonly occurring lower cervical vertebra (3-7) fractures are compressive flexion, distractive flexion, and compressive extension. A compressive fracture is referring to the axial force that initially led to the damage in the spine and distractive refers to the concept of tension or horizontal shear producing the initial structural damage. The use of flexion or extension states the position the spine was in at the moment of injury.
Compressive FlexionA compressive flexion fracture occurs in about 20% of lower cervical vertebra (3-7) injuries. It results in a fracture through the anterior body of the vertebra and/or posterior ligament damage. The posterior ligaments that can be damaged are the posterior longitudinal ligament and posterior interspinous ligament. Recent literature states that 50% of patients with compressive flexion fractures at C3-C7 are stable. For compressive flexion fractures that are not severe, where posterior ligaments remain intact, a SOMI should be applied followed by a Philly or similar semi-rigid collar. A more serious type of compressive flexion injury results in a fracture of the anterior part of the vertebral body with posterior longitudinal ligament and posterior interspinous ligament disruption. This type is unstable initially, but can become stable after conservative treatment in a halo followed by a Philly or similar semi-rigid collar.
Distractive FlexionA distractive flexion injury in the lower cervical vertebra (3-7) region is also known as a flexion dislocation injury. Fracture of the vertebrae is rare, but there is injury to the posterior ligaments with or without displacement of the body. Most patients are in unstable condition. They are treated with traction, then a halo, followed by a Philly or similar semi-rigid collar. Neurologic improvement typically occurs following traction.
Compressive ExtensionThe final type of lower cervical vertebra (3-7) injury is a compressive extension fracture. It usually results in a fracture through the vertebral arch unilaterally. In the majority of cases, the fracture is nondisplaced and there is no neurological damage. The forms of treatment for compressive extension fractures include a SOMI followed by a Philly or similar semi-rigid collar (Rah & Errico, 1998).
Thoracic Vertebra FracturesIn this research project, there was not much literature found on acute spinal fractures of the thoracic vertebra. This is apparently not a common site for acute spinal fractures. The thoracic spine, on account of the rib cage, is very rigid. Therefore, considerable force is necessary to produce a fracture. In addition, if a fracture did occur in the thoracic region, not only would the ribs be fractured, but there might be internal bleeding or organ damage. For a thoracic vertebra fracture, the most important thing would be to treat any organ damage, internal bleeding, or fractured ribs. This could be the reason why most physicians do not address thoracic vertebra fractures. In my experience with fitting orthoses prescribed for patients with a thoracic vertebra fracture, it is generally prescribed for comfort. Most commonly the patients' thoracic vertebra has deteriorated, possibly from the fracture itself, and they need a TLSO corset to help decrease any discomfort or pain they are experiencing. Most patients in this condition have been diagnosed with cancer.
Fractures of the Thoracolumbar Spine (T11-L2) and Corresponding Orthoses
Anterior CompressionAnterior compression fractures account for the majority of osseous injuries of the thoracolumbar spine (T11-L2), due to the fulcrum point of the motion between the relatively stiff thoracic spine and the mobile lumbar spine. In anterior compression fractures at the thoracolumbar junction, the injury mechanism involves a combination of flexion and axial loading, producing a wedge-shaped vertebral deformity. Violent trauma is the most common cause of anterior compression fractures in young and middle-aged people. Motor vehicle accidents and vertical plunges represent the largest sources, followed by sports and recreational activities. In the elderly, osteoporosis is the most common cause of anterior compression fractures. With osteoporotic bone, the vertebral bodies are especially vulnerable, and minor trauma, such as acutely flexing forward or lifting, may result in a compression fracture. An anterior compression fracture at T11-L2 most commonly results in fracture of the superior vertebral end plate and compression of the superior anterior vertebral body. Anterior compression fractures are typically stable injuries. The classic management of stable anterior compression fractures of T11-L2 consists of postural reduction by hyperextension in a Jewett or CASH orthosis (Cohen, Blair, & Garfin, 1998).
Distractive Flexion (Chance)Chance fractures, or distractive flexion fractures, in the thoracolumbar (T11-L2) region involve a flexion force and an axial force. This type of fracture is commonly known as a "seat belt injury" because it is commonly caused by a motor vehicle accident where the victim was wearing a seat belt. Patients with chance fractures typically present initially with a fracture running through the spinous process, lamina, pedicle, and body. There is typically anterior and posterior ligamentous damage. There is also an ecchmosis or contusion of the abdomen. Some patients have also presented late (at 4 to 6 weeks after their accident) with intestinal obstruction due to narrowed ischemic bowel or obstructing hernias through the mesentery or even hernias through the posterior abdominal fascia. Neurologically, the majority of patients with chance fractures are unstable. Therefore, most physicians will prescribe a thermoplastic TLSO (Eismont, 1998).
BurstBurst fractures result from high-energy axial loads to the spine. These loads can come from a cephalad direction or a caudad direction, such as during a fall from a height. When the victim of a fall hits the ground feet first, deceleration is almost instantaneous, and the axial force on the spine produced by the head, torso, and upper extremities decelerating may be sufficient to cause a burst fracture. There is an association between burst fractures and fractures of the calcaneus produced from falls. The degree of comminution of burst fractures attests to the high-energy nature of this injury. Holdsworth (1970) stated that actual bursting of the vertebral body results from the nucleus pulposus being rapidly forced through the vertebral end plate into the body, causing an explosion of the body. If the magnitude of the force is great enough, the entire vertebral body fails and a wedge compression fracture results. As the nucleus pulposus enters the vertebral body, the bony fragments are forced out away from the center of the body in a radial pattern, and the vertebral body collapses to various degrees. Neurologically, the majority of burst fracture patients are unstable. Therefore, physicians normally prescribe a thermoplastic TLSO (Scheffer & Currier, 1998).
Fractures of the Low Lumbar Vertebra (L3-L5) and Corresponding OrthosesTreatment of injuries to the low lumbar vertebra (L3-L5) requires consideration of a number of additional factors beyond those relevant to injuries of the cervical, thoracic, and thoracolumbar (T11-L2) spine. Normally, very high loads are borne in the lower lumbar region of the spine, and well-developed paraspinal musculature aids in mechanical support of this region. Biomechanical evidence suggests that the lower lumbar vertebrae are mechanically stronger than the upper lumbar vertebrae. Additionally, this area maintains a lordotic posture, which may somewhat shield the vertebral bodies from high direct compressive forces. Injuries to the low lumbar spine disrupt the normal lordotic alignment of the spine, and restoration of that lordotic alignment is critical to overall vertebral mechanics and spinal alignment in the sagittal plane. Failure to maintain or restore the normal sagittal alignment in the lower lumbar spine has led to degenerative changes and symptoms in long-term follow-up. Some of the most common fractures in this region include: spinous process and/or transverse process, anterior compression, distractive flexion (chance), burst (Levine, 1998).
Spinous Process and/or Transverse ProcessA spinous process and a transverse process fracture can occur simultaneously or separately. Both are caused by a hyperextension force and an axial force. The fracture site is located at the spinous process or transverse process, depending on the injury. Most patients with this type of low lumbar vertebra (L3-L5) fracture are considered to be in stable condition. They are normally fit with a lumbosacral corset (Levine, 1998).
Anterior CompressionThis type of fracture results from a predominantly flexion force. The superior subchondral plate of the body is fractured. Recent literature states that half of the patients that have an anterior compression fracture in the low lumbar vertebra (L3-L5) region are stable. Whether or not they are in stable or unstable condition, the most common orthosis prescribed is a thermoplastic LSO with hip spica. Due to the level of the injury, a thigh extension is added (Levine, 1998).
Distractive Flexion (Chance)A chance fracture in the low lumbar vertebra (L3-L5) region is caused by a flexion force and a horizontal shear force. The fracture usually occurs through the spinous process, lamina, pedicle, and body. There is also typically anterior and posterior ligamentous damage. This is most commonly an unstable injury and most physicians will perform surgery on the patient first, followed by a thermoplastic LSO with hip spica. Due to the level of the injury, a thigh extension is added (Levine, 1998).
BurstA burst fracture in the low lumbar vertebra (L3-L5) region is caused by an axial force. The fracture usually occurs through the vertebral body. Disc implosion with retropulsion of bone into canal with common. This is most commonly an unstable injury and most physicians will perform surgery on the patient first, followed by a thermoplastic LSO with hip spica. Due to the level of the injury, a thigh extension is added (Levine, 1998).
Fractures of the Sacrum S1-S5Approximately 40% to 45% of sacral fractures occur in combination with pelvis fractures. The most common method of treatment is surgery. Only if the patient is intact neurologically, has minimal displacement, and has a minimal angulated fracture can an orthosis be used. The most common orthosis used is a sacroiliac belt. The main goal is for the patient to begin ambulating as soon as possible after bed rest (Levine & Curcin, 1998).
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