Fracture of the lumbar spine can occur whenever forces applied to the lower spinal column exceed the strength and stability of the spinal column unit (see the images below). Common injuries resulting in fractures of the lumbar spine include fall from a height; motor vehicle and motor vehicle and pedestrian accidents; and penetrating trauma, including gunshot wounds and stabbings. Unstable injuries to the pelvis often are associated with injury to the sacral plexus and the lower lumbar spine.

Lumbar spine trauma. Three-dimensional reconstruction of a CT scan of the thoracic and lumbar spine in a patient with complex injury. The L1 vertebral body is compressed with a severe rotation of the L1 vertebral body under the T12. This injury was associated with a severe neurologic injury to the conus and cauda equina.

Here we are considering L3 not L1 and with a hairline fracture only not such a serious injury.

Type A represents a compression mechanism (lesions located mainly in the vertebral body), with group A1 representing wedge impaction fractures; group A2, split fractures, and group A3, comminuted or burst fractures (Fig. 1B). The mechanism in type B is distraction of the posterior or anterior structures (distinguishing in each case whether there is a lesion of the vertebral body and/or of the disc), with group B1 representing predominantly ligamentous posterior flexion-distraction injuries; group B2, predominantly osseous posterior flexion-distraction injuries; and group B3, hyperextension-shear injuries with disruption through the disc (Fig. 1C). Type C represents lesions caused by a rotational mechanism in addition to the mechanism of one of the types described above (Fig. 1D).

Within this grid, the injuries are hierarchically ranked according to the progressive severity of the pathomorphological findings and the instability caused. This in turn makes it possible to suggest a prognosis for recovery, and to choose the most suitable method of treatment.

1A : Main characteristics of the three injury types : A Type A, injury caused by compression of the anterior column; B Type B, injury of the anterior column and the two posterior columns with distraction of the anterior or posterior elements; C Type C, rotational injury of all three columns.

B : Type A, vertebral body compression injury : A1 Group A1, vertebral body wedge impaction fracture; A2 Group A2, split fracture; A3 Group A3, comminuted fracture or burst fracture.

1C : Type B, anterior and posterior element injuries with distraction : B1 Group B1, predominantly ligamentous posterior flexion-distraction injury; B2 Group B2, predominantly osseous posterior flexion-distraction injury; B3 Group B3, injury involving hyperextension and shearing through the disc.

1D : Type C, anterior and posterior element injuries with rotation : C1 Group C1, type A injury with rotation; C2 Group C2, type B injury with rotation; C3 Group C3, oblique fracture with rotational shear.

Why should I be concerned about spinal fractures?

Just one spinal fracture can increase your risk for another spinal fracture to 3-5 times more than it was before the initial fracture occurred^7,16. This risk increase occurs because the broken bone (vertebra) affects the distribution of weight along the spinal column. Misalignment brought on by a fractured vertebra places more stress on adjacent vertebrae. In short, the spine is forced to withstand more stress or weight with fewer functioning parts, resulting in a structure that’s weakened and more vulnerable to additional vertebral compression fractures.

What are the symptoms of a spinal fracture?

Most spinal fractures have a gradual onset, unrelated to specific injury. Spinal fractures can occur as a result of normal activity, like bending over or reaching for something. In some cases, patients experience sudden and severe back pain without engaging in activity at all.

Because spinal fracture can be easily confused with other back problems, many spinal fracture patients don’t receive proper diagnosis and treatment. To complicate proper diagnosis even more, a spinal fracture may not show up on an X-ray for several weeks, even when the patient is experiencing pain. If your doctor does not find a fracture on the initial X-ray, but you have persistent back pain with no clear cause, consider asking for a second imaging study. In some cases, your doctor may order magnetic resonance imaging (MRI) to confirm a diagnosis of spinal fracture.

Can spinal fractures affect my overall health?

Multiple vertebral compression fractures can cause a forward curvature of the spine known as “kyphosis.” This increases your risk for future fracture and can reduce your quality of life. With each additional fracture, the spinal curvature can become more pronounced, painful and debilitating. Severe kyphosis can reduce the space in your thoracic cavity and compress your organs, making it difficult to breathe, walk, eat, or sleep. Lung capacity can become reduced, which can affect your stamina and restrict your mobility. Early satiety (a feeling of fullness after having eaten only a small amount) can cause you to lose weight and become malnourished. In addition, sleep disorders are common with pronounced kyphosis.^{3,5,6,8,9,10,11,12,13,14,15}

What are the psychological effects of spinal fractures?

In addition to medical complications, patients with spinal fractures can experience depression, anxiety, and lowered self-esteem. The alterations in lifestyle that accompany severe kyphosis can profoundly affect well-being and cause feelings of isolation and sadness. ^5,9,12,18

What is osteoporosis?

Osteoporosis is a disease that causes the bones to become fragile and weak, making them break more easily than normal. Often referred to as ”the silent thief,” osteoporosis usually progresses and “steals” bone without obvious signs or symptoms until the first fracture occurs.

Who is at risk for an osteoporosis-related fracture?

The International Osteoporosis Foundation estimates that 40% of women and 15% of men over the age of 50 will have one or more osteoporosis-related fractures in their remaining lifetime. Long-term use of medications such as corticosteroids can weaken bone, making it more susceptible to fracture. Medical treatments like chemotherapy and radiation therapy have been shown to cause bone loss. Finally, lifestyle choices and genetic factors can adversely affect bone density.

Is osteoporosis preventable?

Osteoporosis prevention should begin in childhood with a calcium-rich diet, regular weight-bearing exercise and either safe exposure to sunshine or vitamin D supplementation. In adulthood, continuing to eat foods rich in calcium, getting sunshine or taking vitamin D, regular exercise and avoidance of smoking and excessive alcohol use can help your body maintain healthy bone.

What are the risk factors

In 2010, the National Osteoporosis Foundation identified the following risk factors for osteoporosis:¹

• Prolonged use of medications like steroids and certain cancer medications
• Low levels of the sex hormone testosterone (in men)
• Low levels of the sex hormone estrogen (in women)
• Smoking and excessive alcohol intake
• History of broken bones
• Inadequate physical exercise or
• Dietary factors, such as low intake of calcium or vitamin D, and high intake of salt and caffeine
• Age—as you get older, bone loss increases
• Family history
• Gender—osteoporosis is more common in women

How common are fractures caused by osteoporosis?

The International Osteoporosis Foundation estimates that 40% of women and 15% of men over the age of 50 will have one or more osteoporosis-related fractures in their remaining lifetime.¹⁹

How does normal back pain compare with the pain from a spinal fracture?

There are many potential sources of back pain unrelated to fracture, but sudden, severe back pain unrelated to specific injury, may indicate that a spinal fracture has occurred. Regardless of the intensity of back pain, it’s never wise to self-diagnose. Patients with back pain should see their doctor for a physical exam.

What can happen if a spinal fracture isn’t diagnosed and treated?

One spinal fracture can lead to another, possibly resulting in kyphosis (curvature of the spine) and an overall decline in health. Kyphotic deformity and progressive bone loss increase your risk for additional fractures and can adversely affect your ability to breathe, walk, eat, or sleep. Consult with your doctor to determine your condition and the appropriate treatment.^{3,4,5,6,8,9,10-16}

What is balloon kyphoplasty?

Balloon kyphoplasty is a minimally invasive procedure designed to repair vertebral compression fractures (VCFs) by reducing and stabilizing the fractures. It has been clinically shown to be more effective than nonsurgical care for reducing the fracture, relieving back pain, and improving mobility and quality of life.²⁰

Unlike other treatments, balloon kyphoplasty utilizes orthopedic balloons to restore vertebral body height and correct angular deformity. Balloons are guided through working cannulae into the vertebra and carefully inflated to reduce the spinal fracture.

After reduction, the balloons are deflated and removed. The resulting cavity (void) allows for a controlled deposition of KYPHON® bone cement, forming an internal cast and stabilizing the fracture.

Are there risks associated with balloon kyphoplasty?

The complication rate for KYPHON^® Balloon Kyphoplasty has been demonstrated to be low. There are risks associated with the procedure, including serious complications, and though rare, some of which may be fatal. These include, but are not limited to heart attack, cardiac arrest (heart stops beating), stroke, and embolism (blood, fat or cement that migrates to the lungs, heart, or brain). Other complications include infection and leakage of bone cement into the muscle and tissue. Cement leakage into the blood vessels may result in damage to the blood vessels, lungs, heart, and/or brain. Cement leakage into the area surrounding the spinal cord may result in nerve injury that can, in rare instances, cause paralysis. A prescription is required. Please consult your physician for a complete list of indications, contraindications, benefits, and risks. Only you and your physician can determine whether this procedure is right for you.

What were the results of the clinical study comparing balloon kyphoplasty and nonsurgical treatment?

In the largest randomized controlled trial, FREE study, Balloon kyphoplasty was shown to be more effective than nonsurgical care for the treatment of acute vertebral compression fractures. Patients treated with balloon kyphoplasty had faster and greater improvement in back pain relief, back function, and quality of life at one month after surgery. The benefits of balloon kyphoplasty were sustained on average through 12 months. The overall frequency of patients with adverse events did not differ between the balloon kyphoplasty and the nonsurgical groups.

Spine Basics

Understanding your spine and how it works can help you better understand some of the problems that occur from aging or injury.

Many demands are placed on your spine. It holds up your head, shoulders, and upper body. It gives you support to stand up straight, and gives you flexibility to bend and twist. It also protects your spinal cord.

Spinal Curves

Your spine is made up of three segments. When viewed from the side, these segments form three natural curves. The “c-shaped” curves of the neck (cervical spine) and lower back (lumbar spine) are called lordosis. The “reverse c-shaped” curve of the chest (thoracic spine) is called kyphosis.

These curves are important to balance and they help us to stand upright. If any one of the curves becomes too large or small, it becomes difficult to stand up straight and our posture appears abnormal.

Abnormal curvatures of the spine are also referred to as spinal deformity. These types of conditions include kyphosis of the thoracic spine (“hunchback”) and lordosis of the lumbar spine (“swayback”).

Scoliosis is another type of spinal deformity. When viewing the spine from the front or back, scoliosis is a sideways curvature that makes the spine look more like an “S” or a “C” than a straight “I.”

Parts of the Spine

Vertebrae

Your spine is made up of small bones, called vertebrae, which are stacked on top of one another and create the natural curves of your back.

These bones connect to create a canal that protects the spinal cord.

Parts of the lumbar spine.

The cervical spine is made up of seven small vertebrae that begin at the base of the skull and end at the upper chest. The thoracic spine is made up of 12 vertebrae that start from the upper chest to the middle back and connect to the rib cage. The lumbar vertebra consists of five larger vertebrae. These vertebrae are larger because they carry more of your body’s weight.

Spinal Cord and Nerves

The spinal cord extends from the skull to your lower back and travels through the middle part of each stacked vertebra, called the central canal. Nerves branch out from the spinal cord through openings in the vertebrae and carry messages between the brain and muscles.

The cauda equina.

The spinal cord ends around the first and second lumbar vertebrae in the lower back and continues as nerve roots. This bundle of nerve roots is called the cauda equina. They exit the spinal canal through openings in the vertebrae (foramen), just like other nerve roots.

Muscles and Ligaments

These provide support and stability for your spine and upper body. Strong ligaments connect your vertebrae and help keep the spinal column in position.

Healthy intervertebral disk (cross-section view).

Intervertebral Disks

Intervertebral disks sit in between the vertebrae. They are flat and round, and about a half inch thick.

Intervertebral disks are made up of two components.

Nucleus pulposus. The nucleus pulposus is jelly-like and makes up the center of the disk. The jelly is partly made of water and gives the disk flexibility and strength.

Annulus fibrosus. This is the flexible outer ring of the disk. It is made up of several layers, similar to elastic bands.

When you are standing or moving, weight is put onto the nucleus. In response, the nucleus expands. The annulus holds the nucleus in place. This allows movement to take place, yet maintains the strength of the spine. In effect, disks act as shock absorbers for the spine.

The intervertebral disk is a very important structure. Many nerve endings supply the annulus and, as a result, an injured annulus can cause pain.

Facet Joints

Between the back of the vertebrae are small joints that also help your spine move. These facet joints have a cartilage surface, very much like a hip or a knee joint does. The facet joints are important for allowing rotation of the spine but may develop arthritis and become a source for low back or neck pain.

Types of Spinal Fractures

A compression fracture of the lumbar (lower) spine.

There are different types of spinal fractures. Doctors classify fractures of the thoracic and lumbar spine based upon pattern of injury and whether there is a spinal cord injury. Classifying the fracture patterns can help to determine the proper treatment. The three major types of spine fracture patterns are flexion, extension, and rotation.

Flexion Fracture Pattern

Compression fracture. While the front (anterior) of the vertebra breaks and loses height, the back (posterior) part of it does not. This type of fracture is usually stable and rarely associated with neurologic problems.

Axial burst fracture. The vertebra loses height on both the front and back sides. It is often caused by a fall from a height and landing on the feet.

Extension Fracture Pattern

Flexion/distraction (Chance) fracture. The vertebra is literally pulled apart (distraction). This can happen in accidents such as a head-on car crash, in which the upper body is thrown forward while the pelvis is stabilized by a lap seat belt.

Rotation Fracture Pattern

Transverse process fracture. This fracture is uncommon and results from rotation or extreme sideways (lateral) bending, and usually does not affect stability.

Fracture-dislocation. This is an unstable injury involving bone and/or soft tissue in which a vertebra may move off an adjacent vertebra (displaced). These injuries frequently cause serious spinal cord compression.

Symptoms

The primary symptom is moderate to severe back pain that is made worse by movement.

When the spinal cord is also involved, numbness, tingling, weakness, or bowel/bladder dysfunction may occur.

In the case of a high-energy trauma, the patient may have a brain injury and may have lost consciousness, or “blacked-out.” There may also be other injuries — called distracting injuries — which cause pain that overwhelms the back pain. In these cases, it has to be assumed that the patient has a fracture of the spine, especially after a high-energy injury (motor vehicle crash).

Examination

Emergency Stabilization

At first evaluation, it may be difficult to assess the extent of injuries to patients with fractures of the thoracic and lumbar spine.

At the accident scene, EMS rescue workers will first check vital signs, including the patient’s consciousness, ability to breathe, and heart rate. After these are stabilized, workers will assess obvious bleeding and limb-deforming injuries.

Before moving the patient, the EMS team must immobilize the patient in a cervical (neck) collar and backboard. The trauma team will perform a complete and thorough evaluation in the hospital emergency room.

Physical Examination

An emergency room physician will conduct a thorough evaluation, beginning with a head-to-toe examination of the patient. He or she will inspect the head, chest, abdomen, pelvis, limbs, and spine.

Investigation, Tests

Neurological tests. The doctor will also evaluate the patient’s neurological status. This includes testing the ability to move, feel, and sense the position of all limbs. In addition, the doctor will test the patient’s reflexes to help determine injury to the spinal cord or individual nerves.

Imaging tests. After the physical examination, a radiologic evaluation is required. Depending on the extent of injuries, this may include x-rays, computed tomography (CT ) scans, and magnetic resonance imaging (MRI) scans of multiple areas, including the thoracic and lumbar spine.

Treatment

The treatment plan for a fracture of the thoracic or lumbar spine will depend on:

• Other injuries and their treatment
• The particular fracture pattern

Once the trauma team has stabilized all other life-threatening injuries, the doctor will evaluate the spinal fracture pattern and decide whether spine surgery is needed.

Flexion Fracture Pattern

Nonsurgical treatment. Most flexion injuries (compression fractures, burst fractures) can be treated in a brace for 6 to 12 weeks. By gradually increasing physical activity and doing rehabilitation exercises, most patients avoid post injury problems.

Surgical treatment. Surgery is typically required for unstable burst fractures that have:

• Significant comminution (fracture fragments)
• Severe loss of vertebral body height
• Excessive forward bending or angulation at the injury site
• Significant nerve injury due to parts of the vertebral body or disk pinching the spinal cord

These fractures should be treated surgically with decompression of the spinal canal and stabilization of the fracture. Decompression involves removing the bone or other structures that are pressing on the spinal cord. This procedure is also called a laminectomy.

To perform the decompression, your surgeon may decide to access your spine with an incision either on your side or on your back. Each approach allows for safe removal of the structures compressing the spinal cord, while preventing further injury.

Extension Fracture Pattern

The treatment plan for extension injuries will depend on:

• Where the spine fails
• Whether the bones can be fit together again (reduction) using a brace or cast

Nonsurgical treatment. Extension fractures that occur only through the vertebral body can typically be treated nonsurgically. These should be observed closely in a brace or cast for 12 weeks.

Surgical treatment. Surgery is usually necessary if there is an injury to the posterior (back) ligaments of the spine. In addition, if the fracture falls through the disks of the spine, surgery should be performed to stabilize the fracture.

Rotation Fracture Pattern

Nonsurgical treatment. Transverse process fractures are predominantly treated with gradual increase in motion, with or without bracing, based on comfort level.

Surgical treatment. Fracture-dislocations of the thoracic and lumbar spine are caused by very high-energy trauma. They can be extremely unstable injuries that often result in serious spinal cord or nerve damage. These injuries require stabilization through surgery. The ideal timing of these surgeries can often be complicated. Surgery is sometimes delayed because of other serious, life-threatening injuries.

Surgical Procedure

The ultimate goal for surgery is to achieve adequate reduction (fitting the bones together), relieve pressure on the spinal cord and nerves, and allow for early movement.

Depending on the fracture pattern, your surgeon may decide to do the procedure through an anterior (front), lateral (side), or posterior (back) approach, or a combination of all three.

Many types of instruments are used in surgery, including metal screws, rods, and cages to stabilize the spine.

An x-ray taken from the front shows metal screws and rods used to stabilize the spine after a burst fracture.

Complications

There are several complications associated with fractures of the thoracic and lumbar spine. One potentially fatal complication is blood clots in the legs, which may develop from immobility. These clots can travel to the lungs and cause death (pulmonary embolism). Pneumonia and pressure sores are also common complications of spinal fractures.

There are also specific surgical complications, including:

• Bleeding
• Infection
• Spinal fluid leaks
• Instrument failure
• Nonunion

Complications can be reduced by early treatment, mechanical methods (lower leg compression stockings), and medication to protect against clots, as well as proper surgical technique and postoperative programs.

Long-Term Outcomes

Regardless of whether the patient is treated with surgery, rehabilitation will be necessary after the injury has healed.

The goals of rehabilitation are to reduce pain, regain mobility, and return the patient to as close to preinjury state as possible. Both inpatient and outpatient physical therapy may be recommended to meet these goals.

Issues that may complicate these goals include inadequate reduction of the fracture, neurologic injury (paralysis), and progressive deformity.

Signs and symptoms of a rib stress fracture

Patients with this condition typically experience a localized pain in the chest or upper back that increases with exercise and activities which place strain on the ribs (e.g. rowing, throwing or bumping the ribs). Often the patient may have to stop activity due to the pain. Pain usually decreases with rest.

Occasionally, pain may radiate into the back, side of the ribs, shoulder or neck. In severe cases, deep breathing, laughing, coughing or sneezing may also provoke symptoms. Symptoms typically increase on firmly touching the affected region of the bone and occasionally night ache may also be present.

Diagnosis of a rib stress fracture

A thorough subjective and objective examination from a physiotherapist may be sufficient to diagnose a rib stress fracture. Further investigations such as an X-ray, MRI, CT scan or bone scan are usually required to confirm diagnosis and determine the severity of injury.

Prognosis of a rib stress fracture

With appropriate physiotherapy management, most patients with a rib stress fracture can make a full recovery (i.e. return to sport or normal activities) in a period of 6 – 24 weeks. In more severe cases, recovery may take longer. In rare cases, some patients may experience ongoing symptoms or complications which may require further management.

Initial Exercises

Shoulder Blade Squeezes

Begin sitting or standing tall with your back and neck straight (figure 2). Squeeze your shoulder blades together as far as you can go without pain and provided you feel no more than a mild to moderate stretch. Hold for 1-2 seconds and repeat 10 times provided there is no increase in symptoms.

Deep Breathing

Begin sitting or standing tall with your back straight (figure 3). Breathe in as deeply as possible without increasing symptoms and then relax. Focus on breathing with your lower lungs (instead of elevating your shoulders) and allow your stomach to gently expand. Repeat 5 times

Begin sitting tall, with your arms across your chest. Keeping your legs still, gently rotate to one side as far as you can go without pain and provided you feel no more than a mild to moderate stretch (figure 4). Hold for 1 – 2 seconds and repeat 10 times to each side provided the exercise is pain free.