Lumbosacral Spine Acute Bony Injuries 

Updated: Dec 11, 2018
Author: Federico C Vinas, MD; Chief Editor: Sherwin SW Ho, MD 

Overview

Background

Injuries to the lumbar spine have received only a small amount of attention compared with other athletic injuries.[1] This can be explained by a number of reasons. Spinal fractures are relatively uncommon in sports participation compared with other types of injuries; most injuries to the lumbar spine are relatively minor and fit into the category of soft-tissue injuries. These soft-tissue injuries are usually self-limited and resolve without coming to the attention of healthcare professionals.[2]

The mechanisms and severity of sports-related lumbar spinal injuries reflect a competitive and risk-taking culture.[3, 4, 5, 6, 7, 8] Lumbar spine bony injuries are often limited to specific sports, most frequently seen in sports such as automobile or motorcycle racing,[9, 10, 11] skydiving[12] (see the image below), power weight lifting,[13, 14] wrestling,[15] gymnastics,[16, 17, 18] football,[19, 20, 21, 22, 23, 24] hockey,[25] rowing,[26] horseback riding,[27, 28] and high-speed snow sports.[29, 30, 31, 32, 33] This article reviews the diagnosis and management of acute lumbar vertebral fractures.

Sagittal computed tomography scan reconstruction o Sagittal computed tomography scan reconstruction of a young female who had a skydiving accident. The parachute deployed, but the patient landed on concrete and sustained a lower-extremity fracture and a fracture of L1. She was neurologically intact but required an open reduction with a fusion and instrumental fixation of the fracture.

For excellent patient education resources, see eMedicineHealth's patient education articles Vertebral Compression Fracture and Low Back Pain.

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Epidemiology

Frequency

United States

The epidemiology of thoracic and lumbar spine injuries in athletes is very difficult to document. Most epidemiologic studies on lumbar spine injuries in athletes lack prospective data. The thoracolumbar junction and lumbar spine are common sites for fractures due to the high mobility of the lumbar spine compared with the more rigid thoracic spine. Injury to the cord or cauda equina occurs in approximately 10-38% of adult thoracolumbar fractures and in as many as 50-60% of fracture dislocations. The rate of bony injury without neurologic consequence is undoubtedly higher.

In the United States, Keene reported an overall rate of 7% for sport-related lumbar injuries in the athlete population.[32] Most of these injuries occurred during practice or preseason conditioning, and only 6% occurred during actual competition. Lumbar spine injuries were significantly more common in football[19, 20, 21, 22] and gymnastics.[16, 17, 18]

Statistics from the US Air Force Academy indicated that 9% of all athletic injuries affect the spinal column. In an analysis of injuries in a professional football team, Ryan et al reported a 6% rate of spinal injuries.[11] Snook reviewed all musculoskeletal injuries sustained by college wrestlers and female gymnasts and found a rate of thoracolumbar spine injuries of 2% for the wrestlers[15] and 13% for the female gymnasts.[34]

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International

Information on the incidence of sports-related spinal injuries in other countries is also limited and difficult to determine due to differences in data collection and reporting among countries. In England, Williams estimated that spinal injuries accounted for 15% of all injuries sustained in sports.[12] Furthermore, injuries to the thoracic and lumbar spine seemed to be more frequent in automobile racing, horseback riding, parachuting, mountain climbing, and weightlifting.

Functional Anatomy

The lumbar spine consists of a mobile segment of 5 vertebrae, located between the relatively immobile segments of the thoracic and sacral segments at either end. The thoracic spine is stabilized by the attached rib cage and intercostal musculature, whereas the sacral segments are fused, providing a stable articulation with the ilium. The lumbar vertebrae are particularly large and heavy compared with the cervical and thoracic vertebrae. The bodies are wider, the pedicles are shorter and heavier, and the transverse processes project somewhat more laterally and ventrally when compared with other spinal segments. The laminae are shorter vertically than the bodies and are bridged by strong ligaments. Finally, the spinal processes are broader and stronger than those in the thoracic and cervical spine.[35]

The lumbar spine must transmit compressive, bending, and twisting forces that are generated between the upper and lower body. Consequently, as one moves more caudally into the lumbar spine, the muscle groups and ligaments become larger and stronger.

The intervertebral discs consist of 2 components, the annulus fibrosus and the nucleus pulposus. The annulus is a dense fibrous ring located at the periphery of the disc, which has strong attachments to the vertebrae and serves to confine the nucleus pulposus. The lumbar spine is surrounded by powerful musculature and ligaments, which dynamically stabilize the spine.

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Sport-Specific Biomechanics

The lumbar spine is a complex, 3-dimensional (3-D) structure that is capable of flexion, extension, lateral bending, and rotation. In the spine, the total range of motion is the result of a summation of the limited movements that occur between the individual vertebrae. Strong muscles and ligaments are crucial for supporting the bony structures and for initiating and controlling movement.

The most common movement of the lumbar spine is flexion. During flexion, anterior compression of the intervertebral disc and widening of the spinal canal occurs along with some sliding movement of the articular process in the zygapophyseal joint. This movement is limited by the posterior ligamentous complex and the dorsal muscles. Extension of the lumbar spine is more limited, producing posterior compression on the disc, narrowing of the spinal canal, and a sliding motion of the zygapophyseal joint. The anterior longitudinal ligament, ventral muscles, lamina, and spinous processes limit the extension of the lumbar spine.

Lateral bending involves lateral compression of the intervertebral disc, along with sliding separation of the zygapophyseal joint on the convex side. An overriding of the zygapophyseal joint occurs on the concave side. The intertransverse ligaments limit the lateral bending of the spine. Rotation of the lumbar spine involves compression of the annulus fibrosus fibers. It is limited by the geometry of the facet joints and the iliolumbar ligaments. The motion of the lumbar spine cannot be considered without evaluating the synchronous movements of the cervical and thoracic spine. The entire spinal column moves as one unit in all planes of motion. Each region of the spine has its own characteristic curvature. These curves allow an upright posture while maintaining the center of gravity over the pelvis and lower limbs. Although most rotation is accomplished at the cervical spine, flexion and lateral bending are primarily cervical and lumbar functions.

Spinous process fractures may occur as a result of direct trauma to the posterior spine or as a result of forcible flexion and rotation. These injuries are usually not associated with neurologic deficits. Violent muscular contraction or direct trauma can cause fractures of the transverse processes. For example, a football helmet blow to the back can cause fractures of either the spinous or transverse processes. Burst fractures (see the images below) are usually associated with axial loading and compression of the spine. Acute traumatic spondylolisthesis is usually associated with major trauma and extreme hyperextension of the spine.

Sagittal T1-weighted magnetic resonance imaging st Sagittal T1-weighted magnetic resonance imaging study of a professional driver who was in a rollover motor vehicle accident while racing his car. This figure shows a T-10 unstable burst fracture producing severe kyphotic deformity of the spine. The abnormal signal on the vertebral body and the extradural defect represents a subacute hematoma producing spinal cord compression. The patient had severe paraparesis and underwent an emergency operation. The procedure involved an anterolateral retroperitoneal approach with a corpectomy and vertebral reconstruction.
Postoperative plain x-ray film of a professional d Postoperative plain x-ray film of a professional driver who experienced a burst fracture in a rollover motor vehicle accident while racing his car. This image shows a vertebral reconstruction with the use of a titanium cage filled with bone and the arthrodesis with a Z plate.
Sagittal computed tomography scan reconstruction o Sagittal computed tomography scan reconstruction of an athlete who had a burst fracture.

The intervertebral discs are thick and strong. The annulus fibrosus receives most of the forces that are transmitted from one vertebral body to another, and it is designed to resist tension and shearing forces. The nucleus pulposus is designed to resist compression forces; it receives primarily vertical forces from the vertebral bodies and redistributes them in a radial fashion to the horizontal plane. This structure allows the intervertebral discs to dissipate the axial loading.

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Presentation

History

In the assessment of an injured athlete, the history should include a description of the trauma and an exact description of the pain and any exacerbating factors. A past history of any spinal problem should always be obtained. Patients with lumbosacral fractures present with severe pain, deformity, and neurologic deficits related to compression of neural structures.

In healthy athletes, a significant traumatic event is required to produce a fracture of the lumbar spine, whereas in patients with caused by metabolic or endocrine imbalance, a relatively minor trauma can produce a pathologic fracture.

Any neurologic change at the time of the event, such as weakness, paresthesias, or radicular pain, should be documented. For example, lumbar fractures may cause solitary or multiple radiculopathies. Massive disc herniations, fracture-dislocations, and burst fractures can cause a cauda equina syndrome with variable paraparesis, asymmetrical saddle anesthesia, radiating pain, and sphincter disturbances. Complete damage of the sacral cord and nerve roots is manifested as no motor function or sensation below L1.

  • Classification

    • The most useful classification of lumbar spine fractures is Denis's 3-column spine stability classification.[36, 37] According to this model, the spine consists of 3 columns.

    • The anterior column is represented by the anterior half of the vertebral body, the anterior half of the annulus fibrosus, and the anterior longitudinal ligament.

    • The middle column consists of the posterior half of the vertebral body, the posterior half of the annulus fibrosus, and the posterior longitudinal ligament.

    • The posterior column is represented by the supraspinous and infraspinous ligaments, ligamentum flavum, articular processes, joint capsules, spinous processes, and the laminae.

    • Instability occurs when 2 or more columns are injured. Because contiguous columns are commonly affected by the same injury, instability is heavily dependent on middle column failure.

    • Magerl and colleagues proposed a classification scheme with 3 morphologic injury patterns, types A, B, and C, which result from 3 basic forces, compression, distraction, and rotation, respectively.[38] These categories have been applied to all levels of the spine, and subcategories and subdivisions have been described based on the mechanism and severity of the fractures.

  • Mechanism of injury and relative force sustained

    • A detailed history must be obtained, if possible, to ascertain the mechanism of injury and the relative force sustained.

    • Individuals who fall often receive hyperflexion or compression injuries, such as spinous process fractures, burst fractures, or traumatic spondylolisthesis. These injuries are commonly associated with pelvic and lower-extremity fractures.

    • Automobile racers who were using seat belts during motor vehicle accidents often receive compression or distraction injuries to the spine, which are frequently associated with cervical spine injuries. In these patients, burst fractures and fractures dislocations are relatively common.

    • Head injuries and extremity fractures commonly accompany vertebral fractures.

    • Abdominal or urologic trauma can occur frequently in patients with lumbar fractures.

    • The possible presence of concurrent direct injuries to adjacent intracavitary soft-tissue structures, such as renal, spleen, or liver lacerations, must be considered. In general, the more caudal the vertebral injury, the greater the biomechanical forces that are sustained and the greater the propensity for injuries to the pelvis and sacrum.

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Physical

The initial management of patients with a lumbar spine injury begins in the field. Any patient who may have a spinal injury is placed on a board in a neutral supine position and immobilized in a neck collar for expeditious transportation to a trauma center. In the emergency department, all patients should be treated as having a spinal injury until this condition is excluded. Fractures of the thoracolumbar junction can produce a mixture of cord and root syndromes caused by lesions of the conus medullaris and lumbar nerve roots, whereas lower lumbar fractures may cause solitary or multiple root deficits.

The Advanced Trauma Life Support (ACLS) guidelines of the American College of Surgeons should be followed. Stabilization of the patient's airway and hemodynamic status in order to secure adequate oxygenation and tissue perfusion should precede any treatment. A Foley catheter should be inserted. In patients with neurologic deficit, immediate peritoneal lavage is often advocated to rule out intra-abdominal injuries. Once the patient has been resuscitated, plain films of the cervical, thoracic, and lumbosacral spine should be taken.

  • Physical examination

    • The physical examination of the athlete with an acute spinal fracture is usually limited by the patient's severe pain.

    • During the spinal examination, the overlying skin should be inspected for abrasions or contusions.

    • Attention should be directed to general deviations from the normal spine curves (ie, thoracic kyphosis, lumbar lordosis).

    • Muscle spasm from pain frequently flattens the spine, whereas spinal fractures may cause a kyphotic or scoliotic deformity.

    • The spine should be palpated for areas of tenderness or fractured, displaced spinous processes.

  • Neurologic examination

    • Sometimes, the initial examination of these patients can be difficult because of multiple trauma, spinal shock, or sedation. Any neurologic deficit should be documented according to the American Spinal Injury Association (ASIA) Motor Index.

    • A motor examination should be performed on all conscious patients. Muscle strength and weakness are graded based on a strength scale from 0 to 5, with 5 considered normal and 0 considered paralysis. Muscle strength grading is as follows:

      • Grade 0 – No contraction

      • Grade 1 – Flicker of movement

      • Grace 2 – Can move when gravity is eliminated

      • Grade 3 – Can elevate against gravity

      • Grade 4 – Can move against resistance (-4 for slight resistance, 4 for moderate resistance, and +4 for strong resistance)

      • Grade 5 – Normal strength

    • A detailed neurologic evaluation should include detection of a sensory level, posterior column function, and normal and abnormal reflexes and an examination of rectal tone and perianal sensation. The cutaneous abdominal reflex, bulbocavernosus, anal wink, and the presence of a Babinski sign should also be noted and documented. The Beevor sign consists of a cephalic movement of the umbilicus when the patient is asked to elevate the head in the supine position. This is due to paralysis of the lower abdominal muscles.

    • A rectal examination to check for rectal tone and voluntary sphincter function should always be included.

    • Repeated neurologic examinations should be performed and documented at regular intervals to serve as references for improvement or deterioration in the patient's neurologic status over time.

    • In patients with a complete spinal injury (paraplegia or quadriplegia), spinal shock can last 24-48 hours, suppressing all reflex activity below the level of the lesion. The return of reflex activity (bulbocavernosus and anal reflexes) in the absence of any return of sensation or motor function is generally a poor prognostic indicator. Some return of motor or sensory function below the level of the lesion encourages the possibility of some return of useful neurologic function.

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Causes

The forces responsible for spinal fractures are compression, flexion, extension, rotation, shear, distraction, or a combination of these mechanisms. In athletes, the most common acute fractures are compression fractures (see the image below) or vertebral endplate fractures caused by sudden axial loading, transverse process avulsion by the origin of the psoas muscle, spinous process avulsions, and acute fracture of the pars interarticularis from hyperextension.[39]

Lateral plain radiograph. This image shows an L3 c Lateral plain radiograph. This image shows an L3 compression fracture.

See the list below:

  • Vertebral body compression is more common in athletes with decreased bone density from a cause such as exercise-induced amenorrhea. In adolescents, endplate fractures (Schmorl node) or apophyseal avulsion fractures are relatively common. All these injuries are generally stable and heal with immobilization and nonsurgical management.

  • Spinous process fractures may occur as a result of direct trauma to the posterior spine or as a result of forcible flexion and rotation. These injuries are not usually associated with neurologic deficits. Violent muscular contraction or direct trauma can cause fractures of the transverse processes. For example, a football helmet blow to the back can cause fractures of both spinal and transverse processes. Despite their relatively innocuous appearance, these fractures can cause significant bleeding into the retroperitoneal space, resulting in acute anemia, or ileus.

  • Sports that cause frequent hyperextension of the lumbar spine induce stress on the pars interarticularis. A defect in the pars interarticularis or spondylolysis is common in competitors in sports that require repetitive or prolonged hyperextension of the spine, such as tennis (the serve), volleyball (the spike), and track (the high jump). Athletes with back pain and spondylolysis fall into 2 main groups, (1) those with acute or subacute lesions related to a precipitating episode of hyperextension or trauma and (2) those with well-established, chronic spondylolysis. Although each of the following lesions in isolation can appear benign, the spinal column must be evaluated further to rule out additional injury.

    • Female gymnasts have an incidence of pars defects 4 times greater than the general population. This is presumably the result of gymnastics maneuvers that load the spine in hyperextension (eg, dismounts, back walkovers, aerials).

    • Other athletes at higher risk for pars spondylolysis include ballet dancers, divers, and football linemen.

    • Thoracolumbar fractures have been estimated to occur in 14% of snowmobile injuries, 5% of alpine skiing injuries, and 8% of freestyle skiing injuries.

    • Direct trauma from hockey- or football-related injuries can also cause a fracture of an articular process.

  • Acute traumatic spondylolisthesis is usually associated with major trauma and is usually caused by extreme hyperextension. Although patients with a new fracture of the pars interarticularis may have a slip present at the time of the injury, a slip can occur months to years later as the disc degenerates under shear loads that it cannot sustain.

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DDx

 

Workup

Laboratory Studies

See the list below:

  • The evaluation of a patient with an acute lumbar spine fracture should include routine laboratory tests such as a complete blood cell (CBC) count, electrolyte evaluation, coagulation profile, and blood type and crossmatch. Spinal fractures are often associated with open fractures of the limbs, with significant blood loss and acute anemia.

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Imaging Studies

See the list below:

  • The combination of plain radiographs, computed tomography (CT) scans, and magnetic resonance images (MRIs) allows definition of the bony and ligamentous injuries that have been inflicted. The information from these studies helps in the (1) classification of the injury, (2) identification of unstable injuries, and (3) selection of the proper instrumentation to adequately stabilize the unstable bony elements.

  • The initial radiographic examination in the emergency department is a complete spine radiograph series.

    • Analysis of plain radiographs should proceed in an organized sequence beginning with the alignment of both anteroposterior and lateral radiographs; identification of the margins of the vertebral bodies, spinolaminar line, articular facets joints, and interspinous distance; and the position of the transverse processes.

    • Abnormalities of alignment include disruption of the anterior or posterior vertebral body lines, disruption of the spinolaminar line, dislocation of the facets, and rotation of the spinous processes.

    • Kyphotic angulation is often associated with misalignment and bony fractures. Disruption of the posterior margin of the vertebral body line and widening of the interpediculate distance are important signs of vertebral disruption. Narrowing of a disc space usually accompanies a flexion injury and is seen at the level above the fractured vertebra. Widening of the facet joint or complete baring of the facets indicates a severe posterior ligamentous injury. These findings are usually associated with widening of the interspinous distance.

  • Following the analysis of routine spine x-ray films, a CT scan is performed on areas of suspected bony injury.

    • CT scan images best define complex fractures and involvement of the posterior elements of the spine, as shown below.

      Axial computed tomography scan of an athlete who h Axial computed tomography scan of an athlete who had a hyperextension injury that resulted in disruption of the posterior spinal elements. This patient had compromise of the anterior and middle spinal columns, resulting in an unstable fracture.
    • The scan should include 1 full vertebra above and 1 full vertebra below the level of the fracture, with 3- to 5-mm thickness. Both bone and soft-tissue windows should be imaged.

    • Fractures oriented in a horizontal plane, such as Chance fractures and fracture-compression, may not be well visualized with axial scans. Therefore, sagittal and coronal reconstructions should be performed routinely in the evaluation of spinal fractures. 3-D reconstructions can be used to better define the extent of canal compromise and posterior element fractures, although this is not always necessary. See the images below.

      A computed tomography scan with sagittal reconstru A computed tomography scan with sagittal reconstructions allows better visualization of the compression fracture.
      Computed tomography scan with coronal reconstructi Computed tomography scan with coronal reconstruction of an athlete who had multiple compression fractures.
      Computed tomography scanning with 3-dimensional re Computed tomography scanning with 3-dimensional reconstruction facilitates the assessment of some complex fractures. In this case, the patient experienced a severe compression fracture.
  • MRI allows better visualization of the spinal cord and ligamentous structures. See the image below.

    • On T2-weighted images, high-signal intensity indicates edema. This can be seen in the vertebral body, ligaments, and thoracic spinal cord.

    • Ligament disruptions can sometimes be demonstrated with MRI. The anterior longitudinal ligaments are best seen on T1-weighted images, and the posterior longitudinal ligaments are best seen on T2-weighted images. Frequently, identifying disrupted ligaments is easier than identifying intact ligaments.

    • One disadvantage of MRI in unstable patients is the need for special, nonmagnetic mechanical ventilators and other MR-compatible life-support monitors. Some hemodynamically unstable patients may not be candidates for MRI. In addition, patients with multiple traumas frequently have external fixators used to stabilize pelvic fractures, which makes the process of obtaining an MRI difficult.

      Magnetic resonance image of a young female with a Magnetic resonance image of a young female with a severe unstable fracture of L4. The patient had a partial neurologic deficit and required urgent surgical fixation.
  • When a neurologic deficit is present and a contraindication to MRI is evident, myelography with a postmyelogram CT scan may be used to rule out neural compression. Nonfilling of nerve roots, hematomas, and cauda equina nerve root avulsions may be demonstrated with myelography.

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Other Tests

See the list below:

  • Electromyography and nerve conduction studies

    • The examination of muscles with needle electrodes and nerve conduction studies are complementary techniques, usually performed together.[40]

    • Electromyography can show evidence of denervation in the lower-extremity muscles or abnormalities in the sphincter muscles.

    • Examination of the paraspinal muscles is also important to distinguish lesions on the spinal cord or cauda equina from lesions in the lumbar or sacral plexus.

    • Nerve conduction studies are an essential part of the evaluation of possible radiculopathy. For example, the demonstration of a superficial peroneal sensory response in the face of L5 symptoms and a sural sensory response in the face of S1 symptoms are useful in localizing the lesions to proximal levels. Results from motor nerve conduction studies are normal in most patients with lumbosacral radiculopathies, and peroneal motor conduction velocity may be mildly slowed.

  • Urodynamic studies

    • Patients with spinal fractures can develop urinary retention. Methods of objectively testing the behavior of the lower urinary tract during filling, storage, and micturition include uroflowmetry, cystometry, sphincteric electromyography, and combined studies. The appropriate use of urodynamic testing provides valuable information for the evaluation and subsequent treatment of neurourologic dysfunction.

  • Evoked potentials

    • Somatosensory evoked potentials and nerve action potentials may be used to illustrate preoperative dysfunction and to confirm postoperative improvement.

    • Motor evoked potentials may be sensitive and specific to changes in neural function and may help to call "attention to the need for intraoperative corrections including widening decompressions, improving perfusion, and limiting deformity correction so that more severe neural compromise may be prevented."[41]

 

Treatment

Acute Phase

Rehabilitation Program

Physical Therapy

Once the spine in a lumbar spine injury is stabilized, physical therapy is initiated with the goals of early mobilization, patient and family education (ie, therapeutic exercises, proper body mechanics, precautions), and neuromuscular reeducation.

A physical therapist evaluates range of motion, strength, sensation, bed mobility, balance in sitting and standing, transfers, and ambulation. The goal of physical therapy is to promote independent and safety in ambulation and functional mobility. If a patient reaches the above goals, discharge home with further therapy is recommended. Appropriate equipment is issued once the patient is safe and independent with the necessary equipment such as a cane, walker, or crutches.

Occupational Therapy

Occupational therapy is initiated once the spine is stabilized. The purpose of occupational therapy at this early stage is similar to that of physical therapy.

An occupational therapist evaluates range of motion, strength, sensation, coordination, dexterity, functional muscle use, balance, transfers, and level of independence in activities of daily living. The goal of occupational therapy is to promote maximum independence and safety with activities of daily living, including basic self-care and daily activities such as dressing, bathing, home management, and functional mobility. Further therapy or durable medical equipment such as a bedside commode, assistive devices, and shower chair are recommended if the patient is to be discharged home. Physical and occupational therapy are likely to work in conjunction to promote maximum functional independence.

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Patient Safety

Medical Issues/Complications

Many potential complications can occur in patients with lumbar spine fractures. Often, these patients have experienced multiple traumas, and undetected injuries to intracavitary viscera can precipitate a sudden clinical deterioration. Neurologic deterioration can occur from neural traction, compression, or interruption of the vascular supply to the neural elements.

The stress resulting from a traumatic injury, a complicated surgery, and mechanical ventilation can predispose a patient to gastric ulcers. However, the widespread use of prophylaxis measures, such as H2 blockers, sucralfate, and proton pump inhibitors, has reduced the incidence of severe bleeding from stress ulcers.

In patients with spinal cord injury, another frequent source of acute morbidity is sepsis that is related to urinary tract infections.

Adynamic ileus is common in patients with a complete spinal cord injury. Preventive measures for both conditions include minimizing bed rest, returning to ambulation as early as possible, and limiting the use of narcotics. Early recognition and treatment of these conditions are essential to reduce morbidity and mortality. Initial treatment includes cessation of oral intake, nasogastric suction, insertion of rectal tubes, and cessation of narcotics.

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Surgical Intervention

Surgical intervention is often necessary for patients with an unstable fracture or with neurological deficits related to compression of the neural structures by bony elements or hematomas, partial cord, or cauda equina injuries. The effect of the timing of decompressive surgery on the rate of neurologic recovery has remained unclear. Improved neurologic function has been reported with early and late decompression.

A variety of operative techniques are used in the treatment of spinal trauma.[42, 43, 44, 45, 46, 47, 48, 49, 50] The surgical approach used is determined by the level of the injury, characteristics of the fracture, and the location of the neural compression. Modern surgical techniques allow for effective decompression of the neural structures, usually by microsurgical approaches. In patients with unstable fractures, the use of segmental instrumental fixation is often necessary in conjunction with a fusion of the spine, either by an anterior or posterior surgical approach to the spine. This allows for the reduction and stabilization of the injured segments. See the image below.

Postoperative radiograph of a patient status post Postoperative radiograph of a patient status post reduction, fusion, and internal fixation of an unstable fracture. Note that the anatomic alignment has been restored.

In contrast with patients with spinal cord injuries at the cervical and thoracic spine, patients with nerve root compression at the lumbosacral region often achieve better outcomes following surgical decompression.

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Consultations

All patients with compromise of multiple systems or pulmonary or cardiac contusions must be evaluated by a trauma surgeon. The presence of neurologic deficits prompts an evaluation by a neurosurgeon or orthopedic spine surgeon. An orthopedic surgeon is consulted to treat limb fractures. Consultations with other specialists depend on the condition of the patient and the system affected (ie, ophthalmologist; ear, nose, and throat specialist; cardiologist). Treating patients with a multidisciplinary team, including early consultation with a physical therapist, occupational therapist, and rehabilitation specialist, is important.

Recovery Phase

Rehabilitation Program

Physical Therapy

If, upon discharge from the acute care setting, the patient is not safe and independent with activities of daily living, functional mobility, and/or ambulation, an inpatient rehabilitation stay may be necessary. Inpatient rehabilitation is a continuation of comprehensive therapies in a more intense manner. The physical therapist works on bed mobility, transfers, strengthening, and ambulation, if applicable. The goal is to assist the patient in becoming independent with the above skills in a safe manner so that the individual may return home. Family instruction is provided so family members can assist patients at home with mobility and ambulation upon discharge.

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Patient Safety

Occupational Therapy

The occupational therapist works on activities of daily living retraining (eg, home safety and management, functional mobility, and basic self-care tasks) and activity tolerance and energy conservation/work simplification techniques. The goal is to assist the patient and family members to achieve the maximum level of independence with activities of daily living and functional mobility. The occupational therapist conducts a home evaluation to assess potential modification needs secondary to environmental barriers, if necessary.

Medical Issues/Complications

Deep venous thrombosis (DVT) is a significant potential complication in patients with spinal fractures. Thromboembolism has been reported to occur in as many as 70% of patients with complete motor paralysis. Pulmonary embolism (PE) significantly affects the probability of survival following a spinal fracture.

Infections can occur following spine surgery, especially after a long surgical procedure for a complicated instrumentation placement. Superficial infections should be opened and debrided. The wound may be packed open or closed using retention sutures. Appropriate antibiotics should be employed, starting with coverage against gram-positive cocci and adjusting according to culture results.

Urinary complications continue to be significant sources of morbidity following spinal injuries. In patients with spinal cord injuries, distention of the bladder can lead to autonomic dysreflexia, impairment of bladder sensation, detrusor hyperreflexia, and sphincter dyssynergia, which can lead to renal damage from hydronephrosis or vesicourethral reflux.

Maintenance Phase

Rehabilitation Program

Physical Therapy

Outpatient physical therapy may be necessary for further muscle strengthening and reconditioning of the spinal musculature once the patient is medically cleared by the physician. A physician's prescription is required for outpatient physical therapy and must include any precautions or contraindications that may still apply. The focus of this phase is an aggressive exercise program for both stretching and strengthening. Pain management modalities may be used to promote decreased pain in order to increase function and participation with therapy. Body mechanics training is also an important focus to reduce the risk of reinjury.

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Occupational Therapy

If a spinal injury prevents a patient from returning to their job, a work-hardening program may be warranted. This program is designed to assist an injured person in returning to work. The work-hardening clinician, usually an occupational therapist, designs an individualized treatment plan for each patient. The goals are to build strength, increase endurance, reduce the risk of reinjury, and improve overall function. Work-hardening incorporates physical conditioning, work simulation, and education to achieve the above goals. A doctor's prescription is necessary to begin a work-hardening program.

Medical Issues/Complications

Pseudarthrosis is a cause of chronic pain as result of malunion of the fusion. It may lead to progressive deformity, neural compromise, and pain. Failure of the instrumentation, such as dislodgment or breakage, is usually related to a failed fusion.

 

Medication

Medication Summary

If the patient arrives at the treating facility within 8 hours of the initial injury and has evidence of a spinal cord injury, 30 mg/kg of methylprednisolone should be given as a slow bolus within the first hour, followed by an infusion of 5.4 mg/kg each hour for the next 23 hours. The use of large doses of steroids can induce stress ulcers and gastritis; therefore, prophylaxis with H2 blockers and/or other antacids should be implemented. Note: This regimen of methylprednisolone is contraindicated in pregnant patients.

Steroids

Class Summary

Steroids—in particular, methylprednisolone—have been proven in clinical trials to reduce the formation of free oxygen radicals and improve clinical outcomes following spinal cord injuries.

Related Medscape Reference topics:

Corticosteroid Injections of Joints and Soft Tissues

Corticosteroid-Induced Myopathy

Epidural Steroid Injections

Related Medscape resources:

Resource CenterSpinal Disorders

Specialty SiteOrthopaedics

Methylprednisolone (Medrol, Solu-Medrol, Depo-Medrol)

Several studies have demonstrated that if started within 8 h of injury, this high-dose steroid protocol can improve outcome in patients with a spinal cord injury.

Analgesics

Class Summary

Pain control is essential to quality patient care. Analgesics ensure patient comfort, promote pulmonary toilet, and have sedating properties, which are beneficial for patients who have sustained trauma.

Related Medscape Reference topic:

Opioid Toxicity

Related Medscape resources:

Resource CenterAdverse Drug Events Reporting

Resource CenterOpioids: A Guide to State Opioid Prescribing Policies

Resource CenterPain Management: Pharmacologic Approaches

Resource CenterSpinal Disorders

Morphine (Duramorph, Astramorph, MS Contin)

In the acute phase following acute lumbar bony injury, patients are severely incapacitated by severe pain. Any movement, coughing, or straining produces severe pain. Morphine sulfate is the most-used drug and can be given via IV, IM, or IV pump on demand (PCA pump). Some physicians prefer to use codeine because they consider it less sedative.

Stool Softeners

Class Summary

Patients with spinal fractures are at risk of developing constipation and fecal impaction. In these patients, straining causes severe pain. In addition, patients with acute spinal fractures require narcotic analgesics for pain control.

Related Medscape Reference topics:

Constipation

Intestinal Motility Disorders

Opioid Toxicity

Related Medscape resources:

Resource CenterFracture

Resource CenterOpioids: A Guide to State Opioid Prescribing Policies

Resource CenterPain Management: Pharmacologic Approaches

Resource CenterSpinal Disorders

Docusate (Colace, Dialose, Surfak)

For patients who should avoid straining during defecation. Allows incorporation of water and fat into the stool, causing stool to soften.

H2 Blockers, Antihistamine

Class Summary

Antihistamine H2 blockers are reversible competitive blockers of histamine at the H2 receptors, particularly those in the gastric parietal cells, where they inhibit acid secretion. The H2 antagonists are highly selective, do not affect the H1 receptors, and are not anticholinergic agents.

Related Medscape Reference topics:

Necrotizing Enterocolitis

Antihistamine Toxicity

Ranitidine (Zantac)

Inhibits histamine stimulation of the H2 receptor in gastric parietal cells, which, in turn, reduces gastric acid secretion, gastric volume, and hydrogen ion concentrations.

 

Follow-up

Return to Play

Most athletes who experience lumbosacral spine fractures are involved in violent sports or sports that require heavy physical activity or carry a significant risk for recurrence of the injury. Although the decision on when to return to play should be made on a case-by-case basis, many patients with minor spinal injuries, such as an isolated fracture of the transverse or spinous process, may be able to return to play after the injuries have healed (4-8 wk); however, patients who have vertebral body fractures may require a longer time for the fracture to heal. The time frame depends specifically on the characteristics of the fracture and the specific sport. In some cases, patients who require a major surgical intervention with a spinal fusion and instrumental fixation may not able to return to participate in that specific sport.

Related Medscape Reference topics:

Degenerative Lumbar Disc Disease in the Mature Athlete

Lumbar Disk Problems in the Athlete

Related Medscape resources:

Resource CenterExercise and Sports Medicine

Resource CenterSpinal Disorders

Specialty SiteOrthopaedics

Prognosis

The prognosis of a patient who sustained a sport-related acute fracture of the lumbar spine depends on numerous factors, including the characteristics of the fracture, severity of the associated neurologic deficits, associated injuries, and the patient's compliance after the discharge.[51, 52] For example, patients who routinely smoke cigarettes have delayed bone healing and a higher risk of developing a pseudoarthrosis. Other patients may injure themselves in their eagerness to return promptly to physical activity or contact sports.