Vertebral injuries

Vertebral injuries consist of fractures, subluxations, dislocations, and ligamentous injuries with or without consequent nerve root and/or spinal cord injury. They are usually caused by high-energy blunt trauma, but pathological fractures may occur. During the initial evaluation, it is imperative to determine if the injury is stable and whether neurological injury has occurred. Spinal motion restrictions are maintained until these questions are resolved. Clinical decision rules are used to determine whether imaging studies are needed; CT spine is the most common initial diagnostic test. Stable vertebral injuries are often managed conservatively with external spinal immobilization, analgesics, and physical therapy. Most unstable vertebral injuries require surgical immobilization. Expert consultation (e.g., with orthopedics, spine surgery, neurosurgery) is usually necessary to determine definitive management.

The primary focus of this article is the thoracolumbar spine. See “Cervical spine injuries” for details on the cervical spine.

For injuries involving the spinal cord, see “Spinal cord injuries.”

• Common in older women (osteoporotic fractures) and young men (traumatic injuries) [1]
• Location: ∼ 50% in the cervical spine and ∼ 50% in the thoracic, lumbar, and sacral spine [2]

Epidemiological data refers to the US, unless otherwise specified.

Trauma

• Blunt trauma: e.g., motor vehicle crashes (MVCs), falls
• Penetrating trauma: e.g., gunshot wounds

Atlanto-occipital dislocation can be caused by various injury mechanisms, including flexion, flexion rotation, and extension. [2][3]

Pathological fractures

• Osteoporosis (most common)
• Malignancy (e.g., bone metastases)
• Infection (e.g., Pott disease)

The following initial steps apply to all levels of vertebral injury. For further details on cervical spine injuries, see “Initial management of C-spine injury.”

Primary survey [4][5]

• If indicated, manage the airway with manual in-line C-spine stabilization.
• Maintain spinal motion restrictions until unstable vertebral injury is excluded.
• Begin management of urgent concurrent injuries, if present (e.g., TBI management, management of trauma).
• Treat neurogenic shock, if present.

Secondary survey [4][5]

• Palpate the entire spine using log roll.
• Perform a focused neurological examination, e.g., segmental motor testing, deep tendon reflexes, identifying sensory level.
• Assess rectal tone on digital rectal examination.
• Begin acute management for spinal cord injury, if suspected.
• Continue management of concurrent injuries.

Initial diagnostics [4][5]

• If applicable, use clinical decision rules to guide decisions on obtaining imaging studies (see “Diagnostics of vertebral injuries” for details).
• When indicated, obtain diagnostics for spinal injuries, e.g., CT spine for adults with blunt trauma.

Urgent consults

• Consult a spine surgeon for known or suspected vertebral or spinal cord injury.
• Consult neurosurgery for concomitant TBI.
• Consult trauma surgery for polytrauma and other multisystem injuries.

For unstable spinal injuries, urgent surgical intervention is typically indicated to minimize the risk of irreversible neurological injury.

Vertebral injury stability [3][6][7]

Determining stability typically requires clinical and radiographic assessment of spinal bones, ligaments, and nervous system by a spine specialist. [8]

• Mechanical instability
  • Determined by assessing the integrity of spinal bones and ligaments (especially those of the posterior spinal column)
  • If more than one of the following structures are involved, mechanical instability is likely: [6]
    • Anterior spinal column
    • Middle spinal column
    • Posterior spinal column
  • Imaging signs of mechanical instability include: [8]
    • Significant vertebral body height loss (i.e., > 50%) [8]
    • Significant kyphosis (e.g., > 15–35°) [8][9]
• Neurological instability: determined by the ASIA scale
• Mixed instability: a combination of mechanical and neurological instability

Stable vertebral injuries

• Characteristics
  • No risk of displacement, deformity, or progressive neurological injury
  • No independently mobile vertebrae or fracture fragments
• Typical examples
  • Vertebral fractures limited to the anterior spinal column, e.g., anterior wedge fractures
  • Isolated transverse process fractures
  • Isolated spinous process fractures (e.g., Clay-shoveler fracture)
  • Isolated laminar or articular processes fractures (e.g., spondylolysis)
  • Unilateral cervical facet dislocation [10]

Unstable vertebral injuries

• Characteristics
  • At risk of displacement, deformity, and progressive neurological injury
  • Independently mobile vertebrae or fracture fragments
• Typical examples
  • Vertebral fractures involving the posterior spinal column, e.g.:
    • Most burst fractures (including Jefferson fracture)
    • Other severe compression fractures
  • Flexion-distraction injuries
  • Vertebral fracture-dislocations
  • Flexion teardrop fracture
  • Atlanto-occipital dislocation [11]
  • Bilateral cervical facet dislocation [10]
  • Type II odontoid fractures [12][13]

AO Spine classification [14][15][16]

AO Spine Upper Cervical Injury Classification System [14][17]

• Class
  • Class I: occipital condyle and craniocervical junction injuries
  • Class II: C₁ ring and C_1–2 joint injuries
  • Class III: C₂ and C_2–3 joint injuries
• Type
  • Type A: bone injury only
  • Type B: ligament injury with or without bone injury but with anatomical integrity intact
  • Type C: significant translation of spine, loss of anatomical integrity

AO Spine Subaxial and Thoracolumbar Injury Classification Systems [15][16]

This is a simplified version; additional subclassification is based on fracture characteristics, neurological complications, and patient modifiers. [18][19]

• Class A: compression injuries of the vertebral body without ligament damage
• Class B: distraction injuries of the anterior tension band or the posterior tension band
• Class C: displacement or translational injury

• Vertebral injury
  • Localized pain
  • Tenderness with pressure, percussion, and/or compression
  • Palpable unevenness or disruption of vertebral process alignment
  • Paravertebral hematoma
  • Kyphosis (secondary to ventral vertebral compression)
• Neurological injury: clinical features of spinal cord injury and/or nerve root injuries
  • Paralysis, weakness, numbness, paresthesias, and/or abnormal proprioception
  • Hyperreflexia and/or hyporeflexia
  • Urinary retention or urinary incontinence
  • Spinal shock
• Concomitant traumatic injuries: e.g., traumatic pneumothorax, traumatic hemothorax, blunt abdominopelvic trauma, blunt cerebrovascular injury (BCVI)

Approach [4][20][21]

See “Diagnostics for cervical spine injuries” for details on C-spine injuries.

• Indications for imaging
  • C-spine: See ”NEXUS criteria” and “Canadian C-Spine Rule.”
  • T- and L-spine: See ”Indications for T- and L-spine imaging.”
• First-line study (if indicated)
  • Children: x-rays of the spine
  • Adults with blunt trauma: CT spine
  • Adults with penetrating trauma: CTA or MRA of neck, thorax, and/or abdomen

Do not delay urgent interventions (e.g., intubation, fluid resuscitation) to obtain spine imaging in patients with hemodynamic or respiratory instability.

Following blunt trauma, use clinical decision rules to determine the need for C-spine imaging and avoid unnecessary radiation exposure. [22]

X-rays of the spine [4][20]

• Not routinely recommended in adults, often the initial study in children [4][20][23]
• Views
  • Thoracolumbar and sacral spine: anteroposterior (AP) and lateral
  • C-spine: AP, lateral, swimmer's view, and odontoid view [24]
• See also “C-spine X-rays” and “C-spine x-rays in children.”

CT imaging [4][21]

• CT spine without IV contrast
  • Initial imaging study of choice after blunt trauma in adults
  • Obtain CT imaging of the whole spine if an injury at any level of the spine is identified. [21]
• CTA head and neck: in patients meeting the expanded Denver screening criteria for BCVI

MRI spine [4][21]

• General principles
  • Typically used as an adjunct to CT spine
  • Highest sensitivity for soft tissue injuries of the spine
    • Neurological: spinal cord injuries or nerve root injuries
    • MSK: disc or ligamentous injuries
• Indications
  • Soft tissue injury suggested by clinical or CT findings
  • Discordant clinical and CT findings [4]
  • Concern for unstable vertebral injuries [4][21]
• Patients with altered mental status, negative CT, and grossly intact motor function: not routinely indicated [4][21][25][26]
  • Follow local protocols.
  • See “C-spine clearance” for further details.

• See “Back pain.”
• See “Weakness and paralysis.”

The differential diagnoses listed here are not exhaustive.

See also “Initial management of vertebral injuries.”

General principles

• Definitive treatment should be guided by a spine surgeon and depends on: [4]
  • Injury characteristics
  • Degree of neurological involvement
  • Patient factors
• For cervical spine injuries, see “Definitive management of C-spine injuries.”

Conservative management [4][27][28]

• Indications: : typically used for stable vertebral injuries
• Measures:
  • Acute pain management
  • External immobilization (orthotic bracing): e.g., halo vest, rigid cervical collar, thoracolumbar brace [4][29]
  • Physiotherapy [29]

Surgical management

• Surgical immobilization (spondylodesis) [27][28][30]
  • Indications: unstable vertebral injury; or neurological injury
  • Technique [30]
    • Decompression of neural elements
    • Realignment of the spine
    • Fusion of two or more vertebral bodies via internal fixation to stabilize the spine
• Minimally invasive procedures: See “Vertebral augmentation” for compression fractures.

Disposition [3]

• Patients with identified fractures and/or unstable ligamentous injuries are usually admitted.
• Patients with only soft tissue injuries may be discharged with analgesics and return precautions.
• Perform fall risk assessment for all falls in older adults.
• Consider discharge and follow-up in consultation with a spine specialist for patients with all of the following:
  • Minor uncomplicated fractures
  • Adequate symptom control
  • Minimal functional impairment
  • Low risk of complications

See “Cervical spine injuries” for information on the following:

Upper cervical spine injuries

• Occipital condyle fractures
• Atlanto-occipital dislocation
• Atlantoaxial dislocation
• Atlas (C₁) fractures (including Jefferson fracture)
• Axis (C₂) fractures (including odontoid process fracture, hangman's fracture, and extension teardrop fracture)

Lower cervical spine injuries

• Flexion teardrop fracture
• Clay-shoveler fracture
• Cervical facet dislocation

Diagnostics

• Indications for imaging the thoracic and/or lumbar spine [31][32][33]
  • Thoracolumbar pain or tenderness
  • Neurological deficits
  • Multiple concurrent or distracting injuries
  • Glasgow coma scale score < 15 or intoxication
  • Cervical spine fracture [21]
  • Other: head injury, age > 60 years, high-risk injury mechanism [34]
• Imaging: typically CT spine, see “Diagnostics of vertebral injuries” for details

Management [28][35][36]

• Initial management
  • See “Initial management of vertebral injuries.”
  • Identify and treat concomitant life- or limb-threatening injuries.
    • Injuries at or below L₁: conus medullaris syndrome or cauda equina syndrome
    • T-spine injuries: blunt chest trauma, e.g., rib fractures, pneumothorax, cardiac contusion
    • L-spine injuries: blunt abdominopelvic trauma, e.g., intraabdominal hemorrhage, splenic injury, diaphragmatic injury
    • Any penetrating thoracic trauma or penetrating abdominal trauma
• Definitive management: depends on injury stability and score based on the AO Spine classification
  • Stable vertebral injuries without neurological deficits: conservative treatment with external orthosis (optional), early mobilization, and close follow-up [28]
  • Unstable vertebral injuries and/or spinal cord injury: Surgical immobilization is usually required.

Background

• Definition: collapse of the vertebral body with ≥ 20% reduction in its height [37][38]
• Epidemiology [39]
  • Most common in adults > 65 years old, especially those with osteoporosis
  • ♀ > ♂
• Mechanism: usually caused by axial loading with flexion
• Morphology
  • Wedge fracture: Collapse is most prominent in the anterior vertebral body. [38]
  • Vertebra plana: severe compression fracture with uniform loss of height across the vertebral body [40]
  • Codfish vertebra: biconcave vertebral body [41]

Etiology

• Pathological fractures: e.g., due to osteoporosis (most common cause) or bone metastasis
• Trauma

Risk factors [37]

• Osteopenia or osteoporosis
• Older age
• Female sex
• History of inactivity, falls, or prior vertebral compression fractures
• Chronic systemic corticosteroid use
• Low body weight
• Alcohol consumption and/or smoking
• Vitamin D deficiency

Red flags for malignancy-related compression fractures [42]

• Fracture without trauma in individuals aged < 50 years
• History of malignancy
• Weight loss
• Persistent pain

Clinical features [37][42][43]

• Often asymptomatic [37]
• Pain
  • Midline and localized to a spinal segment (bandlike)
  • Sudden onset after minor trigger, e.g., sneezing, coughing, turning in bed
  • Exacerbated by rotation, movement, standing
• Localized midline tenderness
• Thoracic kyphosis and lumbar lordosis
• Loss of height [38]
• See also “Clinical features of vertebral fractures.”

Diagnostics [42][44]

• X-ray spine (AP and lateral views)
  • Usual initial study
  • Typically shows wedge-shaped vertebral body with loss of height
• CT spine or MRI spine
  • Indicated for new and/or symptomatic compression fractures
  • MRI spine is often chosen to discriminate between osteoporosis and a neoplastic etiology.
• Dual-energy x-ray absorptiometry: indicated for bone mineral density assessment in patients with suspected fragility fractures

Management [44][45][46]

Approach [29][37][42]

• All patients: Begin initial management of vertebral injuries.
• Unstable vertebral injuries and/or neurological impairment: typically require spondylodesis
• Stable vertebral injuries: usually conservative management, vertebral augmentation in select cases
• Burst fractures: usually unstable (see “Vertebral burst fractures”)
• Osteoporotic fractures
  • 3-month trial of conservative management for most patients
  • Vertebral augmentation for severe symptoms or significant deformity
• Underlying radiosensitive malignancy: radiotherapy

Compression fractures involving only the anterior spinal column (most common) are usually stable. [29]

Conservative management [29]

• Acute pain management
  • NSAIDs or acetaminophen: first-line [47]
  • Opioids: limited second-line use at minimal effective doses to avoid opioid adverse effects.
  • Other: antidepressants, calcitonin, bisphosphonates, teriparatide [29]
• Orthotic bracing [29]
• Physical therapy [29][48]
• Treatment of osteoporosis: e.g., bisphosphonates for osteoporosis

Consult a spine specialist if symptoms do not resolve within 4–8 weeks. [39][44]

Vertebral augmentation [29][46][49]

• Indications
  • Progressive pain or kyphosis despite conservative treatment
  • Acute compression fracture with severe pain and/or functional limitation
  • Acute compression fracture with significant kyphosis and/or loss of vertebral body height
• Procedures
  • Vertebroplasty: percutaneous injection of bone cement into the fractured vertebra
  • Kyphoplasty: reexpansion of vertebral body with an inflatable balloon followed by injection of bone cement

Compression fractures are the most common type of vertebral fracture. Most are stable vertebral injuries and can be managed conservatively. [42]

Complications [37][42][43]

• Loss of mobility
• Reduced lung function
• Decreased appetite and early satiety
• Chronic pain
• Reduced quality of life

For cervical burst fractures, see “Jefferson fracture.”

• Description [50][51][52]
  • A type of vertebral compression fracture with displacement of a posterior segment of the vertebral body (middle spinal column) into the spinal canal
  • Commonly caused by severe axial loading injuries that disrupt the anterior spinal column and middle spinal column, e.g., MVCs, high-energy falls, sports injuries, and combat injuries
• Clinical features
  • See “Clinical features of vertebral fractures.”
  • Clinical features of spinal cord injury are common.
• Diagnosis: See “Diagnostics of vertebral injuries.” [50][51][52]
  • Most occur between T₁₀ and L₂, primarily at the thoracolumbar junction.
  • Findings include:
    • Anterior wedging of the vertebral body
    • Increased distance between the vertebral pedicles
    • Retropulsion of the posterior vertebral body with narrowing of the spinal canal
• Management [8][50][53][54]
  • Initial management: See “Initial management of vertebral injuries.”
  • Definitive management
    • Neurologically intact and stable vertebral injury (e.g., kyphosis ≤ 35°): conservative management
    • Neurological deficit or unstable vertebral injury (e.g., kyphosis > 35°): surgical management (e.g., spondylodesis)

Burst fractures often involve the posterior spinal column as well as the middle spinal column, making them more likely to be unstable vertebral injuries. [50][53]

• Description [3][55]
  • An unstable vertebral injury involving the middle spinal column and posterior spinal column
  • Caused by forceful spinal flexion against a stabilized vertebral segment, e.g., seatbelt restraint in an MVC [55]
• Chance fracture: a type of flexion-distraction injury characterized by fracture of the posterior vertebral body, spinous process, and/or pedicles with or without posterior ligamentous complex injury
• Clinical features: See “Clinical features of vertebral fractures.” [55]
  • Kyphosis
  • Seatbelt abrasions on the abdomen
  • Clinical features of common concurrent injuries, e.g., blunt abdominal trauma, spinal cord injury
• Diagnosis: See “Diagnostics of vertebral injuries.” [3][55]Management [55]
  • Begin initial management of vertebral injuries.
  • Manage concurrent blunt abdominal trauma.
  • Consult spine surgery for surgical stabilization.
  • Most occur at the thoracolumbar junction between T₁₁ and L₁.
  • The following bony structures can be distracted, burst, or compressed on imaging (e.g., CT spine):
    • Spinous process
    • Vertebral laminae
    • Transverse processes
    • Vertebral pedicles
    • Vertebral body
  • Ligamentous injury (e.g., to the posterior ligament complex) may be seen on MRI.

Obtain abdominal imaging and consider trauma surgery consultation in patients with flexion-distraction injuries. [55]

• Definition: fracture of the transverse process in the absence of fractures in other parts of the involved vertebra [56]
• Mechanism: avulsion fracture caused by high-energy blunt trauma [56][57]
• Clinical features [56][57]
  • Localized pain
  • Clinical features of vertebral fractures from concomitant vertebral injuries
  • Signs of associated injuries (common)
    • Cervical: head injury, brachial plexopathy, and/or BCVI
    • Thoracolumbar: blunt chest injuries and/or blunt abdominopelvic trauma
• Diagnosis: See “Diagnostics of vertebral injuries.” [56][57]
  • Can affect any spinal level, frequently occurs at multiple levels concomitantly
  • X-ray spine: often identified on lateral view
  • CT spine: more sensitive than x-ray for detection of transverse process fractures
  • CTA neck: for fractures extending into the transverse foramina or signs of vertebral artery dissection
• Management: conservative management [56][57]
  • Early mobilization and physical therapy
  • Analgesics
  • Bracing and orthotics are not routinely recommended.

Isolated transverse process fractures are typically stable vertebral injuries.

Vertebral fracture-dislocation

• Ligament disruption and displacement of a vertebra and/or vertebral fragments
• Typically an unstable vertebral injury that requires surgical fixation

Vertebral facet dislocation

• Typically occur in the C-spine (see “Cervical facet dislocation”)
• Facet joint dislocations of the thoracolumbar spine are rare. [58][59]
  • Consult spine surgery as they may be unstable vertebral injuries.
  • Can be associated with flexion-distraction injuries

• Spinal cord injury
  • Severe injury of the spinal cord → respiratory depression
  • Spinal contusion/concussion to spinal shock → neurological deficits
  • Injuries of the cervical spine may result in a retropharyngeal hematoma → dysphagia.
• Vessel injury: dissection or thrombotic blockage of the vertebral artery
• Posttraumatic deformation of the spine: loss of height, scoliosis, or kyphosis
• Gibbus
  • A hump or kyphotic deformity in the spine (usually thoracolumbar spine)
  • Common causes include vertebral fracture and spondylodiscitis (especially Pott's disease).

We list the most important complications. The selection is not exhaustive.

Deviations in the initial management of vertebral injuries may be necessary for different age groups.

Vertebral injuries in children [60][61]

• Cervical spine injuries (most common): See “C-spine injuries in children.”
• Thoracolumbar spine injuries [23][60]
  • Most common in children > 9 years of age, uncommon in young children
  • Often involve vertebral compression fractures and/or burst fractures
  • Diagnostics for vertebral injuries
    • X-ray spine (anterior and lateral views): preferred initial study; lower radiation exposure than CT
    • CT and/or MRI spine: Consider in consultation with specialists for patients with neurological deficits or abnormal x-ray findings.
• Related injuries: See ”Spinal cord injury without radiographic abnormality (SCIWORA).”

Vertebral injuries in older adults [4][62]

• Common injuries
  • Upper cervical spine injuries
  • Vertebral compression fractures
  • Concurrent incomplete spinal cord injuries, especially acute cervical central cord syndrome
• High injury risk
  • Significant injuries can be caused by minimal or low-energy trauma.
  • High prevalence of risk factors for vertebral injuries, e.g.:
    • Falls in older adults
    • Osteopenia and osteoporosis
    • Stiff spine
    • Underlying malignancy
• Higher risk of missed vertebral fractures
  • Lower rates of reported pain and detectable tenderness [63]
  • Lower accuracy of clinical decision rules to guide imaging [64]

Maintain a low threshold for imaging in older adults with suspected vertebral injury, even with minimal trauma. [4][62]