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Fracture of vertebral column — Clinical Guidelines

Overview

Fractures of the vertebral column can result from high-energy trauma or minor incidents like speed bumps, leading to significant morbidity including pain, deformity, and disc degeneration. Proper evaluation and management are crucial for optimal recovery and functional outcomes. 6 1

Diagnosis

Imaging: X-rays and CT scans are initial diagnostic tools for identifying vertebral fractures. MRI is essential for assessing disc and endplate degeneration 1 2.

Classification: AO classification system categorizes fractures into types A, B, and C based on fracture morphology 1.

Disc and Endplate Assessment: Use Pfirrmann and Oner classifications for disc degeneration; endplate scoring system (1-6) for evaluating endplate defects 1 2.

Kyphosis Measurement: Assess kyphosis angle to evaluate spinal deformity 1.

Management

Surgical Fixation: Posterior reduction and pedicle screw fixation for stabilizing fractures and promoting endplate healing 2.

Internal Fixators: Titanium internal fixators for stabilization in thoracolumbar fractures 3.

Percutaneous Vertebroplasty: Consider for intravertebral clefts, with potential benefits in pain relief and kyphosis correction 4.

Assisted Sedation: Utilize for pain-free procedures like vertebroplasty, using fentanyl, propofol, and local anesthesia 5.

Special Populations

Elderly: Higher risk of osteoporotic fractures; careful assessment of bone density and fixation stability is crucial 1 4.

Pediatrics: Not directly addressed in provided abstracts; specialized pediatric orthopedic care is recommended for fractures in children 8.

Key Recommendations

MRI Evaluation Post-Injury: Regular MRI assessments are recommended to monitor disc and endplate degeneration post-fracture 1 2 (Evidence: Moderate).

Successful Endplate Reduction: Achieving successful endplate reduction correlates with better healing morphology and reduced disc degeneration 2 (Evidence: Moderate).

Use of Internal Fixators: Posterior stabilization with internal fixators can effectively manage traumatic intervertebral disk lesions in thoracolumbar fractures 3 (Evidence: Moderate).

Consider Vertebroplasty for Symptomatic Cases: Percutaneous vertebroplasty may be beneficial for patients with intravertebral clefts and persistent pain 4 (Evidence: Weak).

References

1 Subramanian P, Ramachandran K, Arumugam T, Shetty AP, Kanna RM, Shanmuganathan R. Evaluation of Disc and Endplate Degeneration in AO Type A Fractures Using Magnetic Resonance Imaging Analysis. World neurosurgery 2023. link 2 Su Y, Ren D, Chen Y, Geng L, Yao S, Wu H et al.. Effect of endplate reduction on endplate healing morphology and intervertebral disc degeneration in patients with thoracolumbar vertebral fracture. European spine journal : official publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society 2023. link 3 Sander AL, Lehnert T, El Saman A, Eichler K, Marzi I, Laurer H. Outcome of traumatic intervertebral disk lesions after stabilization by internal fixator. AJR. American journal of roentgenology 2014. link 4 Kim YJ, Lee JW, Kim KJ, Chung SK, Kim HJ, Park JM et al.. Percutaneous vertebroplasty for intravertebral cleft: analysis of therapeutic effects and outcome predictors. Skeletal radiology 2010. link 5 Della Puppa A, Andreula C, Frass M. Assisted sedation: a safe and easy method for pain-free percutaneous vertebroplasty. Minerva anestesiologica 2008. link 6 Aslan S, Karcioglu O, Katirci Y, Kandiş H, Ezirmik N, Bilir O. Speed bump-induced spinal column injury. The American journal of emergency medicine 2005. link 7 Tägil M, Johnsson R, Strömqvist B, Aspenberg P. Incomplete incorporation of morselized and impacted autologous bone graft: a histological study in 4 intracorporally grafted lumbar fractures. Acta orthopaedica Scandinavica 1999. link 8 Shores A, Nichols C, Rochat M, Fox SM, Burt GJ, Fox WR. Combined Kirschner-Ehmer device and dorsal spinal plate fixation technique for caudal lumbar vertebral fractures in dogs. Journal of the American Veterinary Medical Association 1989. link

Fracture of vertebral column