Spinal fractures encompass both cervical fractures as well as thoracolumbar fractures. Let’s discuss each of these separately as they differ.
However, before we look at the fractures, let’s review the anatomy of our spinal column:
We have 33 vertebrae which are separated by intervertebral discs. It can be divided into 5 segments:
- Cervical (C1-C7)
- Thoracic (T1-T12)
- Lumbar (L1-L5)
- Sacrum (S1-S5) [fused]
- Coccyx (Co1-Co4) [fused]
A typical vertebra has a vertebral body anteriorly, with a vertebral arch posteriorly (includes the spinous process). There are also superior and inferior articular processes which allow for movement.
The spine consists of 3 columns according to the Denis 3 column theory :
- Anterior column - anterior longitudinal ligament and anterior half of vertebral body and disc.
- Middle column - posterior half of vertebral body and disc and posterior longitudinal ligament.
- Posterior column - posterior ligamentous complex, vertebral arches and spinous processes.
Our cervical spine is there to support the head and provide mobility. However, due its small vertebral bodies it is susceptible injury. C2 fractures make up about 30% of cervical spine fractures, while C7 makes up about 20%.
🦴 Anatomy
The cervical vertebra have bean-shaped vertebral bodies and a large triangular vertebral canal. They have bifid spinous processes until C6 (C7 has a larger spinous process that is more similar to the thoracic spinous processes). C1-C6 have transverse foramina for the vertebral arteries to pass through to enter into the cranium (via foramen magnum).
C1 & C2 are unique:
- C1 - known as the atlas.
- C2 - known as the axis.
They articulate via the odontoid peg/dens. It is also supported by the transverse ligament of the atlas and other spinous ligaments.
Cervical vertebrae allow for specific movements such as:
- Flexion and extension - due to the atlanto-occipital joint (C0-C1)
- Rotation - due to the atlantoaxial joint (C1-C2).
- Lateral flexion - because of C3-C7.
😷 Presentation
Younger patients mostly present due to high-energy trauma. Older patients generally develop cervical fractures due to low-impact trauma (especially with present osteoporosis).
- Pain - especially in the neck region. However, it is not always present, especially if distracting injuries are present.
- Neurological involvement - dependant on the level of spinal cord involved. Look at the CCC of spinal cord injury for more information.
- Some special concerns with the cervical spine are of course the diaphragm, sympathetic tone and upper limb motor innervation. Damage of these can lead to:
- Breathing cessation
- Neurogenic shock
- Quadriplegia - upper limb paralysis of course accompanied with lower limb paralysis (although this is not specific to cervical spine trauma).
- Reduced range of movement
- Stroke - especially in high cervical fractures. This is due to damage to the vertebral artery which as we know gives rise to our vertebrobasilar system and subsequently our posterior cerebral artery → posterior circulation stroke. This presents in a variety of ways such as:
- Ipsilateral CN palsy with contralateral motor/sensory deficits
- Bilateral motor/sensory deficits
- Isolated homonymous hemianopia
- Cerebellar dysfunction
- Conjugate gaze palsy
A positive Hoffmann’s involves flicking the nail bed of the middle finger results in twitching of the other fingers ipsilaterally. It indicates an UMN lesion relating to the cervical spinal cord that occurs with spinal cord compression.
🔢 Classification
We use the AO classification most commonly. It can be used for atlantoaxial fractures (C1-C2) and also subaxial fractures (C3-C7).
Atlantoaxial (upper cervical) fractures
This classification system divides it into 2 components:
- Region involved
- Type 1 - occipital condole and craniocervical junction.
- Type 2 - C1 ring and atlantoaxial joint.
- Type 3 - C2 and C2/3 joint.
- Injury type
- Type A - bony injury only.
- Type B - tension band injuries.
- Type C - translation injuries.
Subaxial fractures
Is only divided into injury type:
- Injury type
- Type A - compression injuries.
- Type B - distraction injuries.
- Type C - translation injuries.
- Type F - facet joint injury.
They can be subdivided into 4 types (e.g. A1-A4).
Let’s look at 3 eponymous fractures of the cervical spine:
This is a burst fracture of the atlas (breaks in multiple directions).
It occurs due to axial loading of the cervical spine → occipital condyles drive into the lateral masses of the C1 vertebrae. It is associated with other head injuries and usually causes an unstable fracture. It makes up about 1/3rd of C1 fractures.
It is named as such as historically these were fractures delivered when hanging individuals with a noose.
It is a fracture through the pars interarticularis of C2 bilaterally accompanied with subluxation (partial dislocation) of C2 on C3.
It occurs when there is cervical hyperxtension with distraction.
They are unstable fractures as well.
More common in the elderly. They occur due to low-energy falls in the elderly or high-energy trauma in younger patients.
We can diagnose it with an open-mouth odontoid radiograph.
They often present with neck pain that worsens with rotation.
The neurology is often unaffected as the spinal canal at C1 is quite large.
🔍 Investigations
On arrival at the scene, we will use a modified A-E assessment known as the C-ABCDE assessment:
- C: Catastrophic haemorrhage
- A: Airway with in-line spinal stabilisation
- B: Breathing
- C: Circulation
- D: Disability - look for neurological signs and symptoms.
- E: Everything else - exposure and environment.
The C-spine should be secured at all stages and the remainder of the spinal column should also avoid movement. The C-spine is of greatest concern as damage to it may cause cessation of breathing which will ultimately lead to a much faster death.
As with any C-spine injury, we need to follow the Canadian C-spine rules to aid the assessment.
The Canadian C-spine rule is to be used if the patient has a GCS of 15 and is stable, but C-spine injury is a concern. It stratifies patients into high and low risk, where high risk patients mandate a high-resolution CT scan for adults and MRI scan for children. Plain film X-rays can only be used in children who do not meet MRI criteria but there still remains a high level of clinical suspicion.
High risk
- Age >65 years
- Dangerous mechanism of injury
- Paraesthesia
Low risk
- Minor rear-end motor vehicle collision
- Comfortable in a seated position
- Ambulatory (walking) at any time since the injury.
However, if they are unable to rotate their neck 45º left and right then they require a high resolution CT as well.
MRI is useful to assess for concurrent soft-tissue injury such as IVDs, spinal cord, nerve roots and posterior ligaments.
🧰 Management
Follow ATLS guidelines and stabilise the C-spine with a 3-point C-spine immobilisation until potential injuries are ruled out. This prevents neurological deficits and damage to the spinal cord that may occur with unstable fractures.
Referral and discussion with spinal specialists is required for all cervical fractures.
Stable fractures can be treated non-operatively.
- Rigid collars can be used for immobilisation.
- Halo vests are favoured for non-operative management. They offer more rigid support. It is mounted from the outer skull to a halo device which connects to a thoracic brace.
- Traction devices - provide definitive treatment when operative management is high risk.
These require operative management through spinal fusion of injured segments to uninjured segments above and below the injured region. This is done using pedicel screws and rods that stabilise the C-spine with a posterior approach.
Thoracolumbar fractures occurring at T11-L2 are the most commonly fractured region with more than 50% of all spinal fractures occur at these levels.
The fractures occur at zones of mechanical transition.
→ The movements within the thoracic vertebrae are: axial rotation and lateral flexion.
→ The lumbar vertebrae allow for: flexion and extension, lateral flexion, axial rotation.
🔢 Classification
Once again, we can use the AO classification:
- Type A - compression injuries (when bone collapses essentially).
- Type B - distraction injuries.
- Type C - translation injuries (displacement of the vertebral body relative to another).
Vertebral fractures due to excessive flexion of the spine, involving all 3 spinal columns. They are unstable and often occur in head on RTAs when wearing only a lap belt. They often have concurrent abdominal injuries as such too.
This is when there is a large compressive force on the anterior and middle column causing the bone to be propelled backwards into the spinal canal which can lead to spinal cord injury.
If they involve one endplate (portion of the vertebral body that meets the IVD) then it is an incomplete burst. If it involves both endplates then it is a complete burst.
😷 Presentation
It often occurs in elder patients with underlying osteoporosis, therefore low-impact injuries are often the mechanism. Younger patients are usually due to high-energy trauma.
- Back pain worsened with movement. It may be less noticed if distracting injuries are present. The level of pain often correlates with the level of spinal column injury.
- Bruising
- Neurological involvement - dependent on the level of spinal cord involvement. Some things we may see are:
- Paraesthesia and numbness
- Weakness
- Hypertonicity or hypotonicity
- Hyperreflexia or hyporeflexia - a positive Babinski’s sign also indicates an UMN lesion.
🔍 Investigations
On arrival at the scene, we will use a modified A-E assessment known as the C-ABCDE assessment:
- C: Catastrophic haemorrhage
- A: Airway with in-line spinal stabilisation
- B: Breathing
- C: Circulation
- D: Disability - look for neurological signs and symptoms.
- E: Everything else - exposure and environment.
The C-spine should be secured at all stages and the remainder of the spinal column should also avoid movement. The C-spine is of greatest concern as damage to it may cause cessation of breathing which will ultimately lead to a much faster death.
NICE currently states:
- 🥇 X-ray - first-line for suspected spinal column injury without abnormal neurological signs/symptoms.
- 🏆 CT scan - if radiograph is abnormal or there are clinical signs of spinal column injury.
- MRI - useful to identify soft tissue structures damage such as IVD, spinal cord, nerve roots and posterior ligaments.
If we identify a spinal column fracture, we need to image the rest of the spinal column.
In younger patients, we should suspect pathological fractures such as seen in hypocalcaemia or with myeloma. These should also be investigated if suspected.
🧰 Management
Follow ATLS guidance and immobilise the spine.
Non-operative management is indicated. This includes:
- Extension bracing
- Lumbar corsets
These resist kyphosis and stabilise the spine to allow it to recover naturally.
- Analgesia and physiotherapy should also be included.
Often require surgery.
The need for surgery can be quantified using the Thoracolumbar Injury Classification System (TLICS).
A score of >5 are considered unstable and are treated surgically (but this isn’t a fixed measure).
A score of <3 is considered stable and can follow conservative management usually.
Surgery will involve 2 aspects:
- Decompression
- Spinal fusion
Thoracolumbar Injury Classification System
Morphology | Points |
Wedge compression fracture | 1 |
Burst fracture | 2 |
Translation/rotation fracture | 3 |
Distraction fracture | 4 |
Integrity of posterior ligamentous complex | Points |
Intact | 0 |
Suspected or indeterminate | 2 |
Injured | 3 |
Neurological status | Points |
Intact | 0 |
Nerve root | 2 |
Cord or conus medullaris (incomplete) | 3 |
Cord or conus medullaris (complete) | 2 |
Cauda equina | 3 |