Understanding Accidental Spinal Compression Fractures

friendsofpolarbear
1 day ago
7 min read

Real-life scenarios

1. Consider a mountain biker who experiences a thrilling downhill ride. Suddenly, the individual loses balance and falls onto their buttocks. Initially, there is a sharp pain in the lower back; however, after a significant amount of time to recuperate, they manage to stand. A consultation with a physician and subsequent X-ray examination revealed an L1 spinal fracture.

2. In another scenario, a 60+ year-old woman missteps and lands forcefully on her buttocks. This fall presents as more serious; she is unable to rise and experiences significant pain, necessitating transportation to the emergency department via ambulance. An X-ray confirms a diagnosis of an L1 compression fracture.

These incidents are surprisingly prevalent in everyday life, often resulting in significant injuries. An understanding of how these injuries occur, their classifications, characteristics, diagnostic methods, and management options is essential for promoting spinal health.

Mechanisms of lumbar compression fractures

Compression fractures typically occur when an individual falls, landing either on their buttocks or feet. In such instances, a substantial vertical force travels upward through the spine. This axial load can compress vertebral bodies, leading to potential fractures or collapses. The thoracolumbar junction, extending from T11 to L2, is particularly vulnerable as it serves as a transitional zone between the rigid thoracic spine and the flexible lumbar spine, absorbing much of the impact during falls.

Types of fractures and associated forces

1. Bending forward (Flexion): During a fall, the spine may experience vertical compression accompanied by forward bending, resulting in a wedge-shaped vertebral compression fracture. This is the most prevalent type of compression injury, comprising 50% to 89% of cases. Fortunately, these fractures are typically stable and do not lead to long-term neurological complications.

2. Side bending (lateral flexion): This type accounts for approximately 11% of fractures and may result in potential curvature issues within the spine.

3. High-energy axial compression trauma: In younger individuals or during severe falls (such as falls from significant heights), the combination of high-energy axial compression and flexion may result in burst fractures. In such cases, the vertebral body suffers severe collapse, potentially leading to bone fragments intruding into the spinal canal, which poses serious risks for neurological injury.

4. Low-energy trauma in osteoporotic bone: For older adults with osteoporosis, even minor falls may lead to compression fractures, occasionally occurring with minimal or no visible trauma, such as during routine movements like coughing or bending.

5. Complex forces: Although less common, other forces, including rotation or lateral bending, may contribute to more complex fracture patterns. Nevertheless, vertical compression with flexion is primarily responsible for the majority of compression fractures.

Characteristics of accidental spinal compression fractures

Midline back pain is a hallmark indicator of compression fractures.
Acute Pain: Sudden fractures can cause severe back pain. There may be spasms in the surrounding muscles (paraspinal muscles) and pain when directly touching the area of the fracture. Or supine lying may cause discomfort.
Pain Characteristics: Patients may notice that their pain can be exacerbated when standing, walking, bending forward, or sitting for extended periods. The pain may present as central (localized), non-radiating, or stabbing, often proving to be debilitating. Fortunately, neurological deficits are relatively uncommon.
Long-term impact: These injuries may lead to ongoing pain (1-4 years), height reduction, and changes in daily activities that can persist for up to five years.
Postural changes: Severe fractures can result in kyphosis, defined as a forward curvature of the spine.
Demographic considerations: Older adults, particularly women, are more susceptible to these fractures due to generally lower bone mineral density.
Considerations for the elderly: In older individuals with severe osteoporosis, fractures may occur spontaneously and without pain. However, if left untreated, such injuries may lead to deformities or chronic pain.

**Important Note**: It is essential to investigate any fracture that occurs with minimal or no trauma in patients without a history of osteoporosis to rule out severe conditions such as metastatic or primary malignancies.

Diagnostic Approach

Radiography is critical in diagnosing spinal compression fractures, aiding in the assessment of injury severity, and informing treatment decisions. Key diagnostic indicators include:

X-ray shown L1 compression fracture with depressed superior end-plate

Loss of vertebral body height: A primary indicator is a reduction in vertebral body height, particularly in the anterior portion, resulting in a wedge-shaped deformity that is identifiable on lateral X-rays. Typically, a height reduction of at least *20% or a decrease of 4 mm compared to adjacent vertebrae serves as a diagnostic criterion. This height loss may be present in the anterior, middle, or posterior vertebral body.

*Genant Classification:

Mild: Up to 20-25% loss
Moderate: 25-40% loss
Severe: Greater than 40% loss

Additional imaging techniques, such as MRI or CT scans, can help differentiate other pathological conditions, assess the stage of a fracture, evaluate nerve root involvement, and examine the condition of cortical bone.

Mangement: conservative treatments

When a fracture is stable and there are no neurological deficits, doctors consider conservative treatments. Here are some key strategies:

Pain management: Use analgesics like NSAIDs or stronger medications to reduce discomfort.
Bracing: Wear a brace or orthosis for 6-12 weeks to limit flexion, maintain a neutral posture, and support healing. Depending on the severity of your fracture and your condition prior to the injury, you may not need a brace. e.g. (Doctors might prescribe a Jewett thoracolumbar brace to restrict forward bending and twisting.)
Activity modifications: Avoid heavy lifting, bending, or twisting. Gradually return to activities under supervision to minimize complications and stay active during recovery.
Physical therapy: Once your pain subsides, start supervised exercises to strengthen your back extensors and improve posture for better spinal stability.
Osteoporosis treatment: Optimize medications like bisphosphonates or hormone therapy to enhance bone density and reduce the risk of future fractures.

Non-conservative treatment:

For persistent pain or progressive collapse:

Consider vertebral augmentation procedures like vertebroplasty or kyphoplasty:

Minimally invasive procedures injecting bone cement into the fractured vertebra to stabilize it, reduce pain, and prevent further collapse.
Kyphoplasty can restore some vertebral height and correct deformity better than vertebroplasty.
These are considered if the pain is severe and unresponsive to medication or if there's a progressive loss of vertebral height without neurological deficits.

Surgical intervention may be necessary for unstable fractures or neurological symptoms involving open surgery with instrumentation and fusion, but this is rare for isolated compression fractures.

Acting early can significantly reduce pain, prevent deformity, and improve function.

For mild spinal compression fractures, stability usually develops within a few months. Here's a general timeline for healing:

Healing time: Most simple spinal compression fractures heal within 2 to 3 months, but fractures in individuals with osteoporosis may take up to a year for complete recovery.
Bone healing: The natural healing process for a vertebral compression fracture typically takes about 4 to 6 weeks. Poor nutrition, smoking, and health issues like diabetes can slow down healing.
Pain reduction: You may notice a decrease in pain after 4 weeks, with full healing expected around 12 weeks.

Physical therapy:

While rest is essential, avoid prolonged bed rest as it can weaken bones. Doctors usually recommend a gradual return to normal activities as you start to feel better. Engage in physical therapy to strengthen back muscles and enhance balance.

Tips before you start the exercises:

Regular follow-up appointments with your doctor are crucial to monitor your healing progress. Expect monthly X-rays to assess recovery.
Move slowly and stay within your pain limits.
Hold each position for about 5 seconds while breathing steadily.
Perform exercises once daily or as advised.
Use cushions or supports for comfort.
Stop if you feel sharp pain or any neurological symptoms.

These exercises help maintain muscle strength, improve circulation, reduce stiffness, and support spinal alignment during the recovery process. Start as soon as you feel ready after obtaining your doctor's approval, which is usually within days to weeks after the injury—progress gradually as pain decreases.

In the early stages after a spinal compression fracture, perform gentle, guided exercises to reduce pain, improve muscle tone, and support spinal stability without straining the healing vertebrae.

Examples of early-stage exercises for spinal compression fracture:

1. Circulation and muscle activation (Bed or Rest Phase):

Ankle pumps: Move your ankles up and down to promote circulation and prevent blood clots.
Toe curls and quadriceps sets: While lying down, tighten thigh muscles and pull your toes toward you, holding for 5 seconds to maintain strength without stressing the spine.
Deep breathing exercises: Take deep breaths and hold briefly to keep your lungs clear.

2. Core muscle activation:

Abdominal drawing in: Lie on your back with knees bent. Gently pull your stomach muscles toward your spine, breathing normally. Hold for 5 seconds and release to engage your deep core muscles.

3. Pelvic tilts:

While lying on your back, tilt your pelvis by flattening your lower back against the floor, then arch it back slowly. Repeat at a comfortable pace to improve spinal mobility and engage core muscles.

4. Gentle muscle activation for back extensors:

While seated, press your elbows into a surface or place your hands behind your head with elbows pointing out. Activate the muscles between your shoulder blades without straining your spine. Hold for 5 seconds, then relax and repeat.

scapular muscles exercises for compressed L1
fracture

Here are the key things to avoid during early rehabilitation:

After a spinal compression fracture, it's crucial to avoid movements that could strain the healing vertebrae.

1. Forward bending: Deep or repeated bending compresses the front of the vertebrae. Avoid exercises like abdominal curls and toe touches.

2. Loaded forward bends: Bending forward while lifting weights adds stress to the spine. Avoid lifting from the floor or bending forward with weights.

3. Spinal rotation: Twisting the spine too much can lead to injuries. Avoid full-range twisting exercises, especially with forward bending.

4. High-impact activities: Jumping and running put too much force on the spine.

5. Direct spinal loading: Heavyweights directly on the spine, like barbell squats, increase pressure.

6. Extreme spinal extension: Gentle backward bending is generally safe, but avoid extreme bending back, as it can stress the spine.

Following these guidelines helps protect your spine during the recovery process.

Exercises progression:

After the Acute Phase (3-4 weeks onwards), when pain subsides and mobility improves, you can progress under the guidance of your healthcare adviser. Recommended exercises include:

Four points kneeling: Lift one arm off the ground, progressing to lifting one leg.
Bridging in supine: With hips and knees bent, lift the pelvis by pushing with your feet.
Hip extension: In a prone position, lift one leg.
$hip extensor muscles exercises for spine fracture injury$
Thoracic extension stretches: Using a Swiss ball or kneeling position, extend the upper back to improve posture.