Spinal fractures

In one minute

A spinal fracture is a break in one of the vertebrae. This page covers fractures caused by force: a fall, a road accident, a heavy object. Fractures of weak, osteoporotic bone are covered on the vertebral compression fracture page. Most traumatic fractures happen where the stiff chest spine meets the mobile low back. They cause pain at the site and, in a minority, weakness or numbness in the legs. A CT scan (computed tomography, an X-ray based scan that shows bone precisely) shows the fracture pattern and an MRI (magnetic resonance imaging) shows the ligaments and nerves. Compression and most burst fractures with intact ligaments and normal nerves heal with early walking, with or without a brace; fractures that have torn the ligaments, shifted the vertebrae or injured the nerves are stabilised with screws, through small stab incisions or open surgery.

What it is

Each vertebra has a body at the front that carries the load, a bony arch behind that protects the spinal cord and nerves, and ligaments along the back that act as a tension band, the way a cable holds a bent mast. The thoracolumbar junction (T11 to L2) is where the rib-supported chest spine meets the mobile lumbar spine, so force concentrates there; a trauma centre review reports that thoracolumbar injuries account for 30 to 60% of all spine fractures.

Surgeons describe traumatic fractures with the AO Spine classification, published in 2013. Type A injuries are compression injuries: A0 a minor fracture of a bony process, A1 a wedge of one endplate with the back wall intact, A2 a split through both endplates with the back wall intact, A3 an incomplete burst involving the back wall and one endplate, and A4 a complete burst involving the back wall and both endplates. Type B injuries have torn the tension band, through bone (B1, the Chance fracture), through bone or ligament with a type A fracture (B2), or by hyperextension (B3). Type C is a displacement or dislocation. A neurological grade from N0 (intact) to N4 (complete cord injury) is added, plus two modifiers: M1 for an uncertain ligament injury and M2 for a condition such as ankylosing spondylitis that changes the decision. The older words are still used: compression fracture, burst fracture, flexion-distraction or seat-belt injury, fracture-dislocation.

Causes and risk factors

In the trauma centre series, road accidents caused just over half of thoracolumbar fractures and falls came second, and the people who needed surgery had fallen from a greater height on average. Younger adults are more often in the surgical group and older adults in the non-surgical one, partly because low-energy fractures in older bone are usually stable compression injuries.

Some conditions change how a spine breaks. Osteoporosis lowers the force needed. A stiff, fused spine, as in ankylosing spondylitis or after a long fusion, breaks like a long bone and is unstable even when the X-ray looks innocent, which is why the AO system flags it with the M2 modifier. Smoking slows bone healing and long steroid treatment weakens bone.

How it develops

The direction of force decides the pattern. A vertical load crushes the body: a small load makes a wedge, a larger one bursts the body and can push fragments backward into the canal (retropulsion). A sudden forward bend over a lap belt pulls the back of the spine apart and tears the tension band. Rotation or shear slides one vertebra on another.

Whether a fracture is dangerous depends on three things: whether the bone can still carry load, whether the ligaments at the back still hold, and whether the nerves are injured. A burst fracture with bone in the canal looks alarming, but if the ligaments are intact and the nerves are normal it usually heals, with the canal remodelling over the following months. A tension band injury can look modest and still be unstable, because bone heals and torn ligament does not. Bone knits over the following months: the bracing trial restricted bending for eight weeks and weaned braces by eight to ten weeks, and the kyphosis (forward angle) may increase slightly while it heals.

Symptoms

The story is an accident followed by pain at one level of the spine, worse with any movement, with muscle spasm and sometimes bruising or a step in the line of the spine. In a minority there is weakness, numbness or tingling in the legs, difficulty passing urine or loss of bowel control, which means the cord or the cauda equina (the bundle of nerve roots below the cord) has been injured. Pain elsewhere, head injury or alcohol can mask a spinal fracture, so anyone with a high-energy injury is examined and scanned before the spine is cleared.

Diagnosis

Emergency doctors immobilise the spine, examine the strength, sensation and reflexes of the legs and the function of the bladder, and look for other injuries. Plain X-rays miss detail, so a CT scan is the standard test for the fracture pattern. An MRI is added when there is a neurological deficit, when the ligaments may be torn, or when the CT cannot decide: it shows the tension band, the disc, the cord and any bleeding in the canal.

Words in the report: burst, retropulsion, canal compromise as a percentage, kyphosis angle in degrees, interspinous widening (a sign that the tension band has torn), posterior ligamentous complex or PLC disruption, and translation. For an opinion after the emergency phase, send the CT and MRI images, the written reports, and a description of the accident and of any leg or bladder symptoms.

Treatment without surgery

Fractures with intact ligaments and normal nerves (AO types A0 to A3 and many A4 injuries with N0) are treated by getting up and walking within days, with pain control and a restriction on bending for about eight weeks. A brace is optional. In a multicentre randomised trial of 96 patients with A3 burst fractures between T11 and L3, no neurological deficit and kyphosis under 35 degrees, early walking without a brace was equivalent to a brace at three months, with disability scores of 7.7 versus 6.8 on a 24-point scale. Six of the 96 needed surgery, five of them before they first left hospital, which is why a fracture treated without surgery is still followed with repeat X-rays.

For burst fractures without nerve injury, surgery adds little. A meta-analysis of the two randomised trials, 79 patients followed for two to ten years, found no difference in pain, disability or return to work between operated and non-operated patients; surgery improved the final kyphosis by about two degrees and carried more complications and cost. Months of rigid bracing and prolonged bed rest are not supported.

When surgery is considered

Three findings push toward surgery: a neurological deficit, a torn tension band, and displacement. The AO Spine surgical algorithm, built from a survey of surgeons worldwide, scores the injury type, the neurological grade and the modifiers: a total of three or less is treated with a trial of non-operative care, more than five with surgery, and four or five either way depending on the surgeon and patient. The older TLICS system (Thoracolumbar Injury Classification and Severity score) from 2005 works the same way, scoring fracture shape, the state of the posterior ligaments and nerve function, with three or less non-operative, five or more operative and four a judgement call.

Timing follows the nerves. A progressive or incomplete deficit is decompressed and stabilised urgently. A stable fracture with normal nerves gains nothing from early surgery, so there is time to decide. In the trauma centre series, 94% of surgically treated patients had a neurological deficit and none of the braced patients did.

Surgical options

Percutaneous pedicle screw fixation places screws through the pedicles of the vertebrae above and below the fracture through stab incisions under X-ray guidance, joined by rods, as an internal splint. A meta-analysis of nine studies and 433 patients found that, compared with open screw fixation, the percutaneous method lost less blood, took less operating time, caused less early pain and led to a shorter stay and a smaller scar, with the same radiological result and the same complication rate. Often no fusion is done, and the screws may be removed once the bone has healed.

Open posterior fixation with decompression and fusion is used when the canal must be cleared of bone, when torn ligaments need to be replaced by a fusion, or when a deformity must be corrected. When the front of the vertebra has collapsed, the surgeon may replace it through an anterior or lateral approach with a cage, sometimes combined with posterior screws. Fusion is described on the spinal fusion page; painful osteoporotic compression fractures may instead be treated with vertebroplasty or kyphoplasty. Endoscopic surgery is not a treatment for fractures.

How we treat it at spine.uz

Fractures are an emergency first and a planning problem second. If the injury has just happened, go to the nearest emergency hospital.

We are Tashkent's first endoscopic spine team, five surgeons operating as one, and the team treats the full range of surgical spine pathology, which for fractures means percutaneous or open fixation, decompression and fusion when they are indicated. For a fracture that has already been scanned and is not an emergency, send the CT and MRI images through Telegram or WhatsApp and a doctor from the team replies by voice within 48 hours. The in-person consultation and the operation are paid, and after the consultation you receive a written conclusion from the team. Across the team's 27,600+ endoscopic and spine operations, our complication rate is well below 1%.

Recovery and outcomes

For a stable fracture treated without surgery, walking starts within days, bending is restricted for about eight weeks, and any brace is weaned by eight to ten weeks. In the bracing trial, disability at three months was mild on average. In the trauma centre series, pain fell from about 8 out of 10 at admission to 2 to 3 out of 10 by three months in both the operated and the non-operated groups, and hospital stay averaged 3.7 days without surgery and 6.9 days with it. In the long-term meta-analysis, pain, function and return to work at about four years were the same whether or not a stable burst fracture had been operated on.

Neurological recovery depends on the injury, not on the surgery alone: an incomplete deficit often improves, a complete cord injury rarely does, and no surgeon can promise more than that. Some residual kyphosis is common after any fracture and is only weakly related to pain.

Living with it and prevention

Wear a seat belt, use a harness at height, and never dive into water of unknown depth. Stop smoking while the bone heals. Return to lifting gradually and keep the trunk muscles strong. After 50, treat the bone itself: a low-energy fracture is a reason to test for osteoporosis and to lower the risk of the next one.