Vertebral Fracture Workup

Updated: Feb 22, 2016
  • Author: George M Ghobrial, MD; Chief Editor: Brian H Kopell, MD  more...
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Workup

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.

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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. 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. [8]

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. [9]

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Other Tests

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.

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Histologic Findings

A tissue sample from a presumed pathologic fracture may be used to evaluate the tissue type of the primary cancer.

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Staging

For patients with metastatic disease, staging of the primary cancer is important and is used to guide treatment.

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