What are Spinal Injuries?
Spinal cord injuries range in severity, from a simple soft tissue trauma to spine fracture and spinal cord injury. Spine fracture and dislocations may cause spinal cord injury, and as a result, in paralysis. Treatment depends on the severity of injury.
Which Parts of the Spine are Fractured?
About 5-10% of fractures involve the neck, 70% the thoracic and lumbar spine, and the remainder occur in lower areas. The most frequently injured area is the junction of the thoracic and lumbar areas (12th thoracic vertebra and 1st lumbar vertebra), which is also the most mobile portion of the spine.
Three types of vertebral fractures exist:. When a load exerted on bone is greater that it can withstand, that bone will be fractured. The most common type of fracture is the "compression fracture" in which the anterior (front) part of the vertebra collapses. If the load impacted on the spine is even greater, than the middle and back portions of the vertebra may also be fractured, and fracture fragments may be displaced toward the spinal canal, injuring the spinal cord. This type of fracture is called "burst fractures". Although spinal injury and paralysis are common in burst fractures, not all burst fractures result in paralysis or spinal cord injury. Although most fractures involve a single vertebra, in 20-30% of the cases the fracture involves more than one vertebra, which may be either consecutive or separate.
When the loads impacted on the spine increase, then injury to soft tissues, discs, ligaments and joints connecting the vertebrae may occur in addition to fractures. In that case, the connection between two vertebra ruptures and dislocation occurs. Vertebral dislocation alone, which results from soft tissue injury, is a rare injury. They are mainly seen as fracture-dislocations, which is in combination with a fracture. Spinal cord injury frequently accompanies both of these injuries, and they are the most dangerous injury type. Healing after dislocations and fracture dislocations is also more difficult compared to fractures alone. As a result, dislocations or fracture dislocations frequently require surgical treatment.
What are Symptoms?
The symptoms in the early phase differ according to the severity and location of the fracture. Neck, back or lower back pain, muscle spasm are the major symptoms. If there is a spinal cord injury, various symptoms such as numbness in the arms and/or legs, loss of strength, inability to hold, or conversely, to expel urine or stool may be observed.
In patients without nerve injury who are not appropriately treated on time, gibbosity (kyphosis) and the resulting severe pain is the most common complaint. Patients with nerve injury suffer from paralysis and its consequences.
What are Common Causes?
Vertebral fractures most commonly result from high energy trauma. Traffic accidents are the most common causes. Others include falling from height, gunshot injuries, or sports injuries. In elderly patients with osteoporosis or tumors in the spine, the vertebral bones are weakened by disease, hence fractures can result from relatively lower energy trauma, such as a simple fall.
Who is Affected?
About 80% of patients are between ages 18 to 50. Men have four times’ greater risk of sustaining spine fracture compared to women.
How is it Diagnosed?
Immediately upon spine injury, your transfer to a hospital and how you are transferred is very important. Prior to transport, a proper ambulance with specialized paramedics should be waited. Transport of the patient in an inappropriate position is one of the most important factors that affect the fate of injury. When you are in the emergency unit, doctors will make your first evaluation, and may order the following tests for diagnosis:
- Direct X-rays: This is the first examination that will be made in patients with suspected injury. In most patients it can successfully rule out the presence of an injury.
- Computerized tomography: This method shows fractures better than direct X-rays. It is routinely applied in some hospitals. In others, it may be requested to evaluate the severity and type of fracture.
- Magnetic resonance imaging (MRI): This is the best method to evaluate the spinal cord and soft tissues. It is not necessary in all patients, however it may be requested in patients with an established fracture to assess the severity of the fracture and condition of soft tissues. Also, it may be requested in spinal cord injuries with unknown cause, where the levels of the fracture and spinal cord injury do not match.
What are the Principles of Treatment?
In patients without spinal cord injury, the aim of treatment is to control pain, provide and restore the integrity of the spine. Spinal injury may progress in time, and cause a gibbosity, or gibbosity results in a spinal cord injury that was not initially present. The prevention of these consequences are among the main goals of treatment. In patients with spinal cord injury, factors causing the injury such as bone impingement (pressure) and spinal cord compression are attempted to be corrected. The application of this treatment in the early phase is especially important in patients with partial paralysis because those patients have a greater possibility of recovery. Chances of recovery are fewer in patients with complete paralysis. However, early reconstruction of the broken spine and restoration of its integrity are still necessary for rapidly initiating the rehabilitation of these patients.
What are the treatment options?
- Brace (corset) or cast treatment: Immobilization (preventing movement between the bone edges) is necessary for fracture healing. Especially in compression fractures, if there are no spinal cord or soft tissue-connective tissue injuries, brace or cast treatment is preferred. The aim of this treatment is to achieve fracture union with external fixation, and to prevent further collapse of the spine which can cause spinal cord compression and gibbosity. The cast or brace is generally worn for 3 months.
- Instrumentation and fusion: This is fixation of the broken spine using metal instruments while simultaneously fusing it. This procedure is performed from the back or front of the spine, occasionally from both. Achieving fusion may take months. In patients with concomitant spinal cord injury, bone pieces which compress the spinal cord may be removed during surgery. This treatment is preferred in burst fractures with injury to the posterior connective tissues without an associated neurologic injury, in all other types of burst fractures or fracture dislocations with neurologic injury (Figure 2).
- Vertebroplasty & kyphoplasty: This is a minimally invasive treatment method that can be applied in selected compression fractures, in fractures due to osteoporosis or tumors, and some burst fractures. The procedure can be performed under local anesthesia. Large caliber needles are inserted through small cuts made in the skin and correct the fracture. Cement is injected into the vertebral bone for correction and strengthening.