Vertebral Fracture Treatment & Management

Prehospital care

Paramedics and first responders ascribe to the basic tenet of "do no harm." Their routine protocol is to use spinal immobilization for patients with major traumatic injuries, patients whose mechanism of injury is not clear, and patients who may have experienced some trauma. Of course, the initial focus is on cervical spine injuries, and they routinely apply a cervical spine immobilization device, typically a rigid plastic cervical collar. They use a logroll technique when transferring the patient onto a long spine board or rescue board, which avoids unnecessary movement. Once on a spine board, the patient is secured and prepared for transport. Even patients with no spinal tenderness or neurologic deficits are transported in this fashion. The goal of routine spinal immobilization protocols is to avoid injuries during transport and during the prehospital phase.

Once in the hospital, remove the patient from the board as soon as practical. Prolonged use may be uncomfortable and even counterproductive, because uncomfortable patients may start moving on the board. Some patients develop skin breakdown and decubitus ulcers, even after 1 hour of use. Controlled transfer, use of a sliding board or scoop system, and the logroll technique can prevent further injury. Adequate personnel are needed to facilitate these transfers.

Emergency department management

Focus the initial assessment and stabilization of patients with spine injuries on the ABCs and patient immobilization. As part of the initial assessment and stabilization, the airway may need to be secured using rapid-sequence intubation and spinal stabilization. Once the ABCs algorithm is satisfied, focus attention on the secondary survey. Quite often, these patients are victims of multiple traumas. Associated injuries, such as brain, thoracic, or abdominal injuries, take precedence. The neurologic examination helps determine the presence of deficits. In the presence of neurologic deficits, hypotension and bradycardia may indicate neurogenic shock.

The treatment goal for patients in neurogenic shock is to maintain hemodynamic stability. Maintain the systolic blood pressure at a value of at least 90 mm Hg with a heart rate of 60-100 beats per minute. Initial treatment of hypotension is fluid resuscitation; typical adults may require up to 2 liters of crystalloids. Bradycardia may be titrated by the use of atropine. Attempt to maintain urine output at a minimum of 30 mL/hr. If all of the above parameters are difficult to maintain, consider support with inotropic agents. These patients are also at risk for hypothermia and should be warmed to maintain a core temperature of at least 96°F. Place a Foley catheter to help with voiding. A nasogastric tube can help with ileus, which is common in the setting of spinal injury. Priapism is not usually treated.

Paramedics and rescue personnel often transport patients on a spinal board with complete spinal immobilization. The objective is to minimize the possibility of injury during transport. Traditionally, patients have been kept on the spinal board until all radiographic studies were completed and no fractures were identified. A more practical approach is to logroll patients off the board, even prior to obtaining radiographs. A cervical collar can be kept in place until the cervical spine is cleared. The objective is to provide maximal patient comfort while minimizing iatrogenic injury. Early clearance from the spinal board can prevent formation of pressure sores and necrosis. Ensure that patients are turned every 1-2 hours to prevent decubitus ulcer formation. Administer pain medication to maintain patient comfort.

For patients with blunt trauma injuries and neurologic deficits, consider the administration of high-dose intravenous steroids to help minimize deficits. Begin steroid therapy within 8 hours of the injury. The initial dose of methylprednisolone is 30 mg/kg administered over 15 minutes. Start an infusion for the maintenance dose of 5.4 mg/kg/hr at the beginning of the first hour and continue it through the 23rd hour. Studies have shown that steroid use may result in complications and inconsistent results. ^{[15, 16, 17, 18]}

Nonsurgical management of fractures

Fractures may be managed operatively or nonoperatively depending on the extent of spinal cord injury and the overall health of the patient. Minor fractures or those with column stability are managed nonoperatively. Major fractures or those with significant instability can be managed operatively. Operative management is used for stabilization of the spinal column and prevention of spinal deformity, although major factors in nonsurgical candidates can be treated conservatively with nonoperative treatment.

Nonoperative management of unstable spinal fractures involves the use of a spinal orthotic vest or brace. The objective of the brace is to prevent rotational movement and bending. Give consideration to the stabilization of patients with spinal cord injuries and paraplegia. These patients need to be stabilized sufficiently so that their upper body and axial skeleton are appropriately supported, which allows for effective rehabilitation. Stabilization allows patients to use their upper body strength to help with mobility and rehabilitation.

Spinal orthoses are somewhat uncomfortable and only partially effective in providing full stabilization of the thoracic and lumbar spine. The thoracolumbar junction is especially difficult to immobilize externally. As with cervical collar immobilization of the neck, the patient can exhibit an almost complete range of motion with minimal effort. External braces and orthoses primarily serve as a reminder to the patient to minimize movement. A more effective means of immobilization is the body cast, although the body cast is very uncomfortable and may not be well tolerated.

High-dose steroids

Results from the National Acute Spinal Cord Injury Study (NASCIS) demonstrated the benefit of high-dose steroid administration after blunt spinal cord trauma. ^{[16, 19]} Methylprednisolone administration resulted in improved motor and sensory function in subjects with moderate or severe spinal cord injuries. The conclusion of the study was that high-dose methylprednisolone administered within 8 hours of injury resulted in improved motor and sensory function. In the first hour of the protocol, a bolus of 30 mg/kg was administered. For the following 23 hours, patients were given a steroid infusion of 5.4 mg/kg/hr. Because researchers noted that patients improved significantly, the clinical trial was halted with the assumption that high-dose steroids were a viable treatment for acute spinal cord injury. The treatment was not targeted at patients with penetrating trauma injuries.

Later studies showed inconsistent results. Some studies did not demonstrate an improvement of the neurologic deficit. Other studies showed long-term detrimental effects, such as increased rates of infection, including pneumonia.

Positioning of the patient and anesthesia considerations

Depending on the surgical approach, the patient must be properly positioned. For a posterior approach, place the patient in the prone position with either horizontal or flexed positioning at the hips. For a lateral approach, the surgeon can use either the prone position or a modified lateral decubitus position. For the ventral approach, position the patient supine. Ensure that the anesthesiologist has proper intravenous access and access to the extremities and chest for intraoperative monitoring. Exercise the usual precautions of positioning and avoidance of pressure on peripheral nerves, eyes, and other organs. Surgery is usually performed with the patient under general anesthesia with endotracheal intubation. Prophylactic antibiotics are routine. To obtain maximum pain control, the incision is infiltrated with a local anesthetic. During surgery, implement prophylaxis for deep venous thrombosis with use of pneumatic sequential compression devices or thromboembolic disease (TED) stockings.

Operative approaches

The goals of operative treatment are to decompress the spinal cord canal and to stabilize the disrupted vertebral column. Three basic approaches are used for surgical management of the thoracolumbar spine: (1) the posterior approach, (2) the posterolateral approach, and (3) the anterior approach. Selection of the best approach is guided by the anatomy of the fracture and the location of spinal canal encroachment. Also consider the need for stabilization procedures.

The posterior approach with a midline incision and a laminectomy allows for access to the posterior elements, although it does not permit access to the vertebral bodies and, as a result, is not commonly used. Spinal cord compression as a result of isolated fractures of the posterior elements is not very common. Spinal canal compromise is more frequent when the vertebral bodies and anterior elements are involved. The posterior approach is useful for stabilization procedures that involve fixation of the posterior bony elements. The posterior approach is used when early mobilization is considered and decompression of the spinal canal is not a major consideration.

The posterolateral technique improves access to the vertebral bodies, although access is still limited. Decompression of ventral impingement of the canal is technically difficult using this approach. It is useful when only a limited exposure of the ventral elements is required. It may be combined with a posterior stabilization procedure when limited ventral exposure is needed. The approach to the high thoracic segments is technically difficult. This technique is often used for high thoracic fractures such as T1 through T4.

The anterior approach allows access to the vertebral bodies at multiple levels. Transthoracic exposure is required in order to access the vertebral bodies down to L2. Lower fractures require a transabdominal-retroperitoneal exposure. It is most useful for decompression of injuries and spinal canal compromise caused by vertebral body fractures. Examples of significant vertebral body fractures include a burst fracture, sagittal slice fracture, and severe compression fractures. Sometimes, a modified combined approach is used to maximize exposure and access. When an anterior approach is used, the vertebral bodies are often resected and replaced with autologous bone or bone from the bone bank. This technique, unlike the posterior stabilization procedures, does not result in early stability.

Surgical exposure

Proper exposure of the affected area is necessary. Often, going several segments above and below the affected area is necessary in order to ensure optimal exposure and proper placement of stabilizing hardware. The skin and soft tissue incision may be 10 cm or more in depth, and the incision requires retractors for optimal exposure. Meticulous attention to hemostasis is required because even minimal bleeding may cause the operative area to eventually fill with blood. If at all possible, keep the thecal sac intact. Evacuate epidural or subdural hematomas.

Categories of procedures for spine stabilization

Posterior lumbar interspinous fusion is the least-invasive method and involves the use of screws to obtain stability and promote fusion. Most patients have good results with this technique. It can be used effectively for isolated or relatively stable fractures. ^[20]

Posterior rods require extensive exposure and are effective in stabilizing multiple fractures or unstable fractures. The use of rods prevents further deformity and deterioration. The rods are attached with pedicle screws, stainless steel wires, clips, and clamps to achieve a stable construct. Also, in the case of spinal tuberculosis, use of posterior stabilization using long rods prevents further deterioration and deformity. ^{[21, 22, 23]}

Compression fractures with an intact posterior cortical wall can be treated by means of a kyphoplasty, which involves transpedicular placement of a balloon through a bone biopsy needle and cannula into the compressed vertebral body under fluoroscopic guidance. The balloon is inflated under controlled pressure, resulting in expansion of the vertebral body and creation of a cavity. The cavity is then filled with bone cement. This results in elevation of the endplate and stabilization of the fracture fragments, with a consequent reduction of pain. ^{[24, 25, 26]}

The Z-plate anterior thoracolumbar plating system has been used for the treatment of burst fractures. Surgery is performed for neurologic deficits, deformity, progressive kyphosis, and late pain. Ghanayem and Zdeblick reported good success with this form of anterior arthrodesis.

Postoperative care of the surgical incision

The incision is usually closed in a layered fashion, and the skin is either stapled or sutured. A dressing is applied and taped in place. Some surgeons keep the dressing in place postoperatively for 24-48 hours. Other surgeons elect to inspect the incision the next day and subsequently place a fresh dressing. Postoperative antibiotics may be given for up to a total of 3 doses. If a significant amount of stabilizing hardware was implanted, continuation of antibiotics is appropriate.

Prevention of complications

Patients are susceptible to postoperative cardiac complications such as myocardial infarction. Place patients with risk factors in an intensive care unit or monitored setting. Pulmonary complications, which cause pain and decreased tidal volume, can occur as a result of stabilizing procedures. Use incentive spirometry to help patients with deep breathing and early ambulation. The patient's hematocrit value should be monitored, especially for those patients with significant blood loss during surgery. Similarly, monitor renal function and electrolyte values, especially for susceptible patients. Patients are at risk for deep venous thrombosis after any surgery or prolonged immobilization. Precautions include the use of pneumatic compression devices, TED stockings, or subcutaneous heparin injections.

Remove the Foley catheter after 24-48 hours or once the patient is ambulatory. This decreases the risk of urinary tract infections and possible hematogenous spread to the spine and implanted hardware.

The operating surgeon reevaluates the patient within 1-2 weeks of surgery. Of course, if patients experience postoperative complications or complicated surgeries, they are seen within 2-3 days after discharge.

Rehabilitation and physical therapy

Early ambulation is recommended for patients who are neurologically intact or those who have limited neurologic impairment. Pain control is important to facilitate early ambulation. Patients with significant neurologic impairment or those who are paraplegic should also have active recovery and early mobilization. Full stabilization may take up to 2 years. The rate of improvement depends on the ongoing maturation of the fused vertebrae and the conditioning of the muscles. Recommend that patients refrain from smoking because this impairs the healing process.

Rehabilitation facilities

Patients with significant neurologic impairment or those who are paraplegic may need to spend time at a rehabilitation facility until they have been trained to adapt and to cope with their disability. The focus of rehabilitation is on bowel and bladder management and on transfer techniques. Psychological counseling is essential to help patients cope with their injury. Some patients may require antidepressant or antianxiety medications. Proper pain management is also important for successful rehabilitation.

Complications of vertebral fractures may include mechanical complications from the fracture itself, neurologic deficits, and resultant comorbid conditions. Surgical stabilization procedures also have associated complications.

A study by Dimar et al identified factors predictive of complications after surgery to stabilize thoracolumbar spinal injuries. ^[27] The study determined that severity of neurologic injury, quantity of associated morbidities, and high-dose steroid use independently increase the risk for major complications after stabilization.

Mechanical complications

Vertebral fractures of the thoracic and lumbar spine that are somewhat mechanically unstable and have not been stabilized with instrumentation may develop progressive deformity despite the use of an orthotic brace. Such a deformity may hamper rehabilitation. Unstable fractures may result in further deterioration of a partial neurologic lesion.

Neurologic deficits

In the acute phase, patients with partial spinal cord injuries may experience an increase of the neurologic deficit. The initial flaccid paralysis may turn into spasticity.

Resultant comorbid conditions

A major complication of thoracic or lumbar spinal cord injury and the resultant paraplegia is the development of pressure sores. Prevention starts in the emergency department; patients need to be removed from spinal cord immobilization as soon as possible. During hospitalization, decubitus precautions should be implemented; the patient should be turned frequently. Use of egg-crate foam mattresses or air mattresses is also protective. Educating the patient and any caregivers is another important component of prevention.

Pulmonary complications may occur in patients with high thoracic injuries. In the acute phase, associated rib fractures and pulmonary contusions may occur. This predisposes the patient to hypoxemia and other complications. Also, the diaphragm, the major muscle of respiration, is supplied by the phrenic nerve at cervical spine levels C3 through C5; the diaphragm is also supplemented by the intercostal muscles from thoracic segmental levels. This could result in a decrease in the tidal volume of respiration, thus predisposing the patient to atelectasis and pneumonia.

Patients with spinal cord injuries are predisposed to the development of ileus and constipation. They should be treated to prevent impaction and associated complications. In the acute phase, a nasogastric tube may be placed for the first 24-48 hours. Early enteral feeding via a feeding tube at a slow rate may be tolerated. The feeding rate should be advanced slowly until complete nutritional support is provided and is adequately tolerated.

The initial multicenter clinical trials that used methylprednisolone for the treatment of spinal cord injury, the NASCIS II trial, were promising and methylprednisolone quickly turned into the standard of care. Patients showed significant improvement of neurologic function at 6 months after injury, provided they were treated within 8 hours of injury. In some individuals who had spinal cord epidural hematomas with neurologic deficits, significant improvement was observed after high-dose methylprednisolone treatment.

At the molecular level, some benefit appears to be gained with the use of high-dose methylprednisolone. Animal studies show a decrease in the production of deleterious compounds and molecules by the cell, such as the expression of p75 neurotrophin receptor. Likewise, methylprednisolone reduces spinal cord injury in rats by decreasing lipid peroxidation; however, a decrease in production of protective tumor necrosis factor-alpha also occurs.

Bracken performed a meta-analysis of several studies on the topic. He concluded that high-dose methylprednisolone given within 8 hours is a safe and relatively effective therapy in some patients. A meta-analysis by Hurlbert (and other studies) failed to show that high-dose steroids improved patient outcomes. Controversy exists because methylprednisolone is not a completely benign drug and adverse effects can occur. High-dose steroids may have detrimental effects, such as immunosuppression and adrenal suppression. From an evidence-based approach, methylprednisolone should not be recommended for routine use. ^{[16, 17, 19]}

Osteoporosis screening to prevent fractures is recommended by the following organizations:

• American Association of Clinical Endocrinologists (AACE)--(guidelines for postmenopausal women) ^[28]  
• US Preventive Services Task Force (USPSTF) ^[29]
• American Academy of Family Physicians (AAFP) ^[30]

AACE guidelines recommend evaluation of all women age 50 years or older for osteoporosis risk. The initial evaluation should include a detailed history, physical exam, and clinical fracture risk assessment with the Fracture Risk Assessment (FRAX) tool or other fracture risk assessment tool. ^[28]

The USPSTF and AAFP both recommend screening for osteoporosis with bone measurement testing to prevent osteoporotic fractures in women 65 years and older and in postmenopausal women younger than 65 years who are at increased risk of osteoporosis, as determined by a formal clinical risk assessment tool. ^{[29, 30]}