Spinal trauma assessment, classification and treatment

From "Worldwide Spine Surgery:  Products, Technologies, Markets and Opportunities, 2010-2020", Report #M520.

Trauma to the spine can involve one of more of the bony elements, soft tissues, and neurological structures. Surgeons are most concerned about instability of the vertebral column and sustained, or potential, neurological damage. Many cases of spinal trauma involve both dislocations and fractures, and they can occur in any region of the spine.

Causes of Trauma to Spinal Regions

Spinal Region Common Causes
Cervical Motor vehicle accidents, falls, and sports injuries
Thoracic Motor vehicle accidents and falls
Lumbar Falls, motor vehicle accidents, penetrating trauma (e.g. gunshot wounds)

Source: MedMarket Diligence, LLC

Spinal fracture classification is a critical first step in determining treatment. In order to describe and diagnose spinal fractures, spine surgeons use a system that involves segmenting the spine into three sections. These sections are comprised of:  the anterior column, which includes the anterior longitudinal ligament and the anterior one-half of the vertebral body, disc, and annulus; the middle column, which covers the posterior half of the vertebral body, disc, and annulus, and the posterior longitudinal ligament; and the posterior column, comprised of the facet joints, ligamentum flavum, the posterior elements and the interconnecting ligaments. 

Most spinal fractures may be classified into one of four major types, listed here from least to most severe:  flexion-compression mechanism (wedge fractures), axial-compression mechanism (burst fractures), flexion-distraction mechanism (seat belt fractures); and rotational fracture-dislocation mechanism (dislocation injuries). A wedge fracture is a compression break in which the front part of the vertebral body is crushed, forming a wedge shape easily viewed on X-ray. A burst fracture is said to have occurred when the vertebral body is crushed in all directions, which can drive bone fragments into the spinal cord. Dislocation-type injuries occur when any part of the spinal column undergoes severe compression, rotation or tension and breaks away from another part of the spine. Rotational fracture-dislocation fractures are often the result of a car crash in which the individual (usually a passenger as opposed to the driver) is wearing a lap-only seat belt and experiences a forceful forward flexion of the spine. The mechanism of this fracture is a combination of lateral flexion and rotation with or without a component of posterior-anteriorly directed force.
A burst fracture pattern involves failure of both the anterior and middle columns. Both columns are compressed, and the result is loss of height of the vertebral body. Five subtypes of this type of fracture are described, and each is dependent on rotation, extension, and flexion. The 5 subtypes are:  fracture of both endplates; fracture of the superior endplate (which is the most common subtype); fracture of the inferior endplate;  burst rotation fracture; and burst lateral flexion fracture.
Minor fractures include fractures of the transverse processes of the vertebrae, spinous processes, and pars interarticularis. Minor fractures do not usually result in associated neurologic compromise and are considered mechanically stable.
Osteoporosis causes fractures of the vertebrae, as well as fractures of other bones. Women are at greatest risk. The prevalence rate for these fractures increases steadily with age, ranging from 20% for 50-year-old women to 65% for older women. Most vertebral fractures are not associated with severe trauma. Many patients remain undiagnosed and may present with symptoms such as back pain and increased kyphosis.
Pathologic fractures are the result of metastatic disease of primary cancers affecting the lung, prostate, and breast. For example, Kaposi sarcoma can result in vertebral body fractures. Pathologic fractures tend to affect the vertebral body at both the thoracic and lumbar levels. They can cause kyphotic deformity and may result in compression of the spinal cord.
As discussed in Report #M520, tuberculosis may result in fractures of the spine. Pott disease (tuberculosis spondylitis) results from the hematogenous spread of bacteria to the spine. Other bacteria can potentially be spread to the spine and cause osteomyelitis. As bacteria proliferate, vertebral damage can occur; when it does, the damage primarily affects the vertebral bodies. As in the case of pathologic fractures, associated fractures and an increase in kyphotic deformity may be present.
Treatment of Traumatic Spine Injury
Treatment of spine injuries starts with restraining the spine and controlling inflammation with NSAIDs to prevent further damage. The actual treatment can vary widely depending on the location and extent of the injury. In many cases, traumatic spine and spinal cord injuries require substantial physical therapy and rehabilitation, especially if the patient's injury interferes with activities of daily life.
The Joint Section on Disorders of the Spine and Peripheral Nerves of the AANS/CNS developed the Guidelines for Management of Acute Cervical Spine and Spinal Cord Injuries. The group’s members reflected expertise in spinal neurosurgery, neurotrauma, and clinical epidemiology. Treatment of traumatic spinal injuries varies widely depending on the location and severity of the injury, and may involve distraction of the affected vertebrae using bedrest and traction, and medications to reduce swelling and relieve pain. Eventually one or several of an array of procedures may be utilized, including treatment or replacement of a herniated disc, kyphoplasty, and/or spine fusion.
[MedMarket Diligence Report#M520 discusses the devices and other products in spine surgery, including devices used by the orthopedic surgeon to effect such treatments on patients who have suffered a traumatic spinal injury.]


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