Laboratory Studies

Laboratory studies are not useful in the diagnostic workup of patients with vertebral fractures, although they are important ancillary studies for evaluating possible comorbid conditions.

Patients with vertebral or pelvic fractures resulting from a major trauma require serial hemoglobin determinations as an indicator of hemodynamic stability.

Other laboratory studies aid the evaluation of associated organ damage. A urinalysis or urine dip for blood can help rule out associated kidney injury. An elevated amylase or lipase level may suggest pancreatic injury. Elevated cardiac markers in the setting of chest trauma may indicate a cardiac contusion. Elevated urine myoglobin or serum creatine kinase level in the context of a crush injury may indicate evolving rhabdomyolysis. A pregnancy test should be obtained in females of childbearing age.

In patients with metastatic disease to the bone and resultant pathologic fractures, a serum calcium determination is necessary. These patients may have hypercalcemia that requires medical attention.

Routine laboratory analysis is part of the preoperative workup. The evaluation should include a complete blood cell count, serum chemistries, coagulation profile, and urinalysis. Results of these studies have a bearing on total patient care rather than specific issues related to the fracture.

Imaging Studies

Upon initial presentation to the emergency department, plain radiographs should be obtained if a vertebral fracture is suggested based on the results of the clinical examination. Plain radiographs are helpful in screening for fractures, but hairline fractures or nondisplaced fractures may be difficult to detect.

CT scan imaging can readily detect bony fractures and help with the assessment of the extent of fractures. CT scans are very sensitive and can identify even subtle fractures.^[1]A CT myelogram can be used to determine the degree of impingement of the bony fragments on the thecal scan when MRI imaging is not available or is contraindicated.

MRI is usually the study of choice to detect the extent of damage to the spinal cord. MRI is the most sensitive tool for detecting lesions of both neural tissue and bone.^[13] The American College of Radiology recommends MRI for patients with suspected spinal cord injury, cord compression due to disc protrusion or hematoma, or suspected ligamentous instability.^[1]

In a study to determine thoracolumbar spine injury in 13 US trauma centers, the majority underwent computed tomography (93.3%), 6.3% only plain films, and 0.2% magnetic resonance imaging exclusively. Thoracolumbar spine injury was identified in 499 patients (16.3%). Positive clinical examination (pain, midline tenderness, deformity, neurologic deficit) resulted in a sensitivity of 78.4% and a specificity of 72.9%. The addition of age of 60 years or older and high-risk mechanism (fall, crush, motor vehicle crash with ejection/rollover, unenclosed vehicle crash, auto vs. pedestrian) increased sensitivity to 98.9% with specificity of 29.0% for clinically significant injuries and 100% sensitivity and 27.3% specificity for injuries requiring surgery.^[14]

Bone densitometry can be performed in an attempt to predict the risk of fracture from osteoporosis. Results from an imaging study such as plain radiography or spiral CT scan can be compared to a known standard. Patients with significant loss of bone density can be given treatment to enhance bone deposition.

Treatment & Management

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Media Gallery

Anteroposterior and lateral radiographs of an L1 osteoporotic wedge compression fracture.
Fluoroscopic view of a kyphoplasty procedure.

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Author

George M Ghobrial, MD Resident Physician, Department of Neurological Surgery, Thomas Jefferson University Hospital

Disclosure: Nothing to disclose.

Coauthor(s)

Zachary J Senders, MD Resident Physician, Department of General Surgery, Case Western/UH Case Medical Center, Case Western Reserve University School of Medicine

Disclosure: Nothing to disclose.

James S Harrop, MD Associate Professor, Departments of Neurological and Orthopedic Surgery, Jefferson Medical College of Thomas Jefferson University

James S Harrop, MD is a member of the following medical societies: American Association of Neurological Surgeons, American College of Surgeons, American Spinal Injury Association, Cervical Spine Research Society, Congress of Neurological Surgeons, North American Spine Society

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Depuy spine consulant, Asterias, Bioventus, Tejin serve on advisory boards<br/>Received research grant from: DOD, PICORI<br/>Received income in an amount equal to or greater than $250 from: Stryker honorarium.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Brian H Kopell, MD Associate Professor, Department of Neurosurgery, Icahn School of Medicine at Mount Sinai

Brian H Kopell, MD is a member of the following medical societies: Alpha Omega Alpha, American Association of Neurological Surgeons, American Society for Stereotactic and Functional Neurosurgery, Congress of Neurological Surgeons, International Parkinson and Movement Disorder Society, North American Neuromodulation Society

Disclosure: Received consulting fee from Medtronic for consulting; Received consulting fee from Abbott Neuromodulation for consulting; Received Consulting Fee from ClearPoint Neuro.

Additional Contributors

Michael G Nosko, MD, PhD Associate Professor of Surgery, Chief, Division of Neurosurgery, Medical Director, Neuroscience Unit, Medical Director, Neurosurgical Intensive Care Unit, Director, Neurovascular Surgery, Rutgers Robert Wood Johnson Medical School

Michael G Nosko, MD, PhD is a member of the following medical societies: Academy of Medicine of New Jersey, Congress of Neurological Surgeons, Canadian Neurological Sciences Federation, Alpha Omega Alpha, American Association of Neurological Surgeons, American College of Surgeons, American Heart Association, American Medical Association, New York Academy of Sciences, Society of Critical Care Medicine

Disclosure: Nothing to disclose.

Acknowledgements

Joseph T Alexander, MD, FACS Director of Spine Research, Assistant Professor, Department of Neurosurgery, Division of Surgical Science, Wake Forest University School of Medicine

Disclosure: Nothing to disclose.

Gary Godorov, MD Staff Physician, Department of Emergency Medicine, Bellflower Medical Center

Disclosure: Nothing to disclose.

George Timothy Reiter, MD Associate Professor, Department of Neurosurgery, Pennsylvania State University College of Medicine; Director of Spinal Neurosurgery, Associate Director, Penn State Spine Center, Milton S Hershey Medical Center; Active Staff, Hershey Outpatient Surgery Center; Active Staff, Wilkes-Barre General Hospital; Hospital Appointment, Penn State Rehabilitation Hospital

George Timothy Reiter, MD is a member of the following medical societies: American Association of Neurological Surgeons and Congress of Neurological Surgeons

Disclosure: Synthes Spine Consulting fee Consulting; Integra Grant/research funds None; Integra Consulting fee Consulting

Amiram Shneiderman , MD Assistant Program Director, Co-Director of Quality Assurance, Department of Emergency Medicine, Martin Luther King-Charles Drew Medical Center

Disclosure: Nothing to disclose.

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