Lumbar vertebral fractures are caused by strong force, disease-related weakness, or a combination of both.
Osteoporosis is a common cause of fractures of the lumbar vertebrae, especially in menopausal women.
Spinal fractures caused by osteoporosis can occur without apparent trauma.
An accurate diagnosis is important to rule out a tumor of the spine.
The five lumbar vertebrae are the largest and strongest vertebrae of the entire spine. These bones form the lower part of the back.
The lumbar spine begins below the last rib and extends to the sacrum.
The strongest stabilizing muscles of the spine start in this section.
- A vertebral fracture without injury to the spinal cord does not cause neurological damage.
- A vertebral fracture with injury to the spinal cord causes neurological damage with neurological deficit.
Contents
Frequency of lumbar and cervical vertebrae fractures
Most fractures of the lumbar spine that require surgical treatment are at the level of Th12 (thoracic vertebrae), L1 or L2 (lumbar vertebrae).
These injuries have mainly traumatic causes; On the other hand, lumbar vertebra fractures that are not based on trauma are usually osteoporosis-related.
The National Osteoporosis Foundation (NOF) estimates that 10 million Americans currently suffer from osteoporosis and 34 million from osteopenia (precursor of osteoporosis, there is a slightly reduced bone density).
In 2005, osteoporosis was the cause of more than 2 million bone fractures, of which about 547,000 were vertebral fractures.
Mortality
Mortality associated with lumbar vertebra fracture is rare. Nevertheless, it can be a serious injury.
Sex
Osteoporosis mainly affects menopausal women.
Wrist fractures and vertebral fractures usually occur in women with type I osteoporosis between the ages of 51 and 65. Estrogen deficiency is one of the most important risk factors for low bone density.
Type II osteoporosis (senile osteoporosis) occurs after the age of 75, with women being affected twice as often as men.
Age
Most fractures of the lumbar vertebrae that affect young and middle-aged people are of traumatic origin.
Falls with a violent impact can cause a fracture of the bone, while the seat belts in the car can lead to wedge fractures in case of whiplash.
Causes of fractures of the lumbar spine
According to the findings of the American Academy of Orthopedic Surgeons, the majority of lumbar vertebral fractures occur as a result of trauma. According to Dr. Keith Wilkinson of Michigan State University, about 40% of lumbar vertebra fractures occur in a car accident, 20% from falls, and the remaining 40% from firearms, other accidents, or illnesses.
Especially younger people under 30 are affected. The occurrence of compression fractures is favored by a lack of bone density and mainly affects older women.
Classification
- Stable vertebral fracture – does not cause deformity of the spine or neurological problems. With a stable vertebral fracture, the spine is still able to support the body weight and distribute it sufficiently.
The vertebral body may be deformed, but the posterior vertebral part is intact. - Unstable vertebral fracture – the spine has trouble supporting and distributing body weight. Untreated unstable fractures can worsen their condition and cause further damage. The vertebral body is injured together with the posterior spinal structures (vertebral arch and facet joints).
The posterior spine can deform during compression, rotation or lateral flexion. As a rule, post-traumatic kyphosis (round back) forms and progressive neurological symptoms occur.
Fracture forms depending on the type of injury
Extension fractures
A lumbar vertebral fracture can occur in a traffic accident that occurred in extension, such as sudden braking, in which the vertebrae are removed from each other by the force of the seat belt.
Flexion fractures Here,
a further division into compression and burst fractures takes place.
Compression fracture. The anterior vertebral part (body) collapses and loses height, the posterior part remains intact; as a rule, this form of vertebral fracture is stable and rarely causes neurological problems.
Compression fractures are usually caused by a force coming from above, which causes compression of the lumbar vertebrae.
As a rule, these fractures are caused by a sudden acceleration or deceleration: the pressure is transmitted through the spine and compresses the vertebrae on all sides.
Burst fracture. The vertebra loses height both at the front and at the back. It usually occurs when falling on the feet from a great height.
The fractures can sometimes push the vertebra backwards into the spinal canal.
Rotational fractures Fractures
of the transverse process are rare and the result of extreme lateral flexion.
Usually they do not affect the stability of the spine.
Dislocation A fracture with dislocation
is a fracture in which the bone and associated soft tissue are removed from the adjacent vertebra.
This form of fracture belongs to the unstable fractures and can lead to strong compression of the spinal cord.
Symptoms of lumbar vertebra fracture
The fracture site is located where the pain occurs, which can be seen well on the X-rays.
Elderly people with severe osteoporosis may not experience pain because the fracture occurred spontaneously.
In adults and young people, severe back pain may occur after the trauma (fall or traffic accident).
Weakness or numbness of the lower extremities are important signs that may indicate an additional injury to the nerves and spinal cord.
Vertebral fractures can also cause transmission pain. A scientific study examines 350 patients with vertebral fracture, 288 of whom have at least one compression fracture without damage to the cauda equina or spinal cord.
The examination shows that in 240 out of 350 cases, the pain occurs on the central axis. The pain was generally felt on the ribs, hips, groin and buttocks.
Treatment of vertebral fracture by vertebroplasty provided relief to patients in 83% of cases.
Many compression fractures do not cause pain. Osteoporosis is a silently progressive disease.
Osteoporotic fractures due to compression are often diagnosed when the patient visits a doctor for progressive scoliosis or mechanical low back pain and the doctor performs an X-ray of the lumbar region.
Diagnostic imaging
The X-ray examination is one of the standard procedures for the assessment of fractures of the spine and is carried out in two levels, in the view from the front (a.p. image) and from the side.
In the event of a fracture of the vertebral body, a possible collapse of the vertebral body becomes visible in the side view.
In the front view, unstable fractures can be detected because an enlargement of the intervertebral space is indicated.
The vertebra deforms because it is squeezed by body weight; a typical wedge vertebra (collapsed vertebral front edge) or biconcave vertebrae (with a short middle part) may develop.
A CT scan may indicate a narrowing of the spinal canal. This examination method is helpful to rule out a burst fracture, because vertebral arch and the posterior vertebral structures can be made visible.
A magnetic resonance imaging (MRI) scan is performed if a fracture with nerve root compression is suspected and the patient complains of sciatica. This imaging technique provides more accurate information regarding bleeding, tumors and infections and also shows better images of the spine.
Bone density measurement is currently the most frequently used method to investigate the density or calcium salt content of human bone.
These images are used to determine whether women over 50 in menopause and men over the age of 65 suffer from osteoporosis and how large the extent is.
With reduced lime salt content, there is an increased risk of vertebral fractures.
Special examinations The orthopaedic examinations
for the assessment of fractures of the fourth and fifth lumbar vertebrae (L4 e L5) include:
- Physical examination of the lumbar spine with palpation of the vertebrae;
- neurological examination of the lower limbs;
- Stretch test of the sciatic nerve (Lasègue sign), whereby the stretched leg is raised in the supine position.
The physiotherapist examines the lumbar region for overheating and redness and tries to detect deformations by palpating the lumbar vertebrae.
If there is a fracture, the patient feels severe pain at the fracture site of the bone during movement and palpation.
The patient may adopt a humpbacked body posture and feel tingling and numbness in the lower limbs.
Surgical treatment of a vertebral fracture L1 or L2
If neurological damage is present, surgical care is usually necessary to repair the injury.
There are several procedures that are selected depending on the degree of damage, vertebral position and state of health of the patient.
If it is a young patient, the surgeon can insert plates, screws and other mechanical structures to join the broken vertebrae together.
Vertebroplasty
This is an effective method of treatment for vertebral compression fractures. In vertebroplasty, the back is incised during surgery and bone cement is inserted into the fractured vertebral body.
Kyphoplasty
In this minimally invasive surgical method, the procedure is performed through a small opening instead of a scalpel incision.
The operation relieves the pain of the vertebral fracture by introducing bone cement into the vertebra.
The cement hardens and stabilizes the injured section.
In the course of the procedure, the surgeon inserts a cannula into the vertebral body and then a kyphoplasty balloon ensures the erection of the collapsed vertebra.
Scientific studies show that kyphoplasty produces about the same results as vertebroplasty, but recovers more lost vertebral height.
Conservative treatment
In the treatment of patients who do not require surgery, pain relief, reinforcement and physiotherapeutic measures are in the foreground.
In particular, compression fractures and fractures affecting the anterior and middle vertebral parts are treated conservatively.
The support corset used in this type of injury covers the area of the thoracic and lumbar spine.
During physiotherapy sessions, patients are designed to increase their own mobility without causing pain.
With the support corset, they can move and perform the rehabilitative stress exercises to prevent osteoporosis.
In the case of a lumbar vertebra fracture the conservative form of treatment is preferred because reinforcement and therapies are usually more effective than surgery.
The doctor may prescribe medications such as ben-u-ron or opioids to relieve the pain that the fracture of the lumbar spine provokes.
When compressing the spinal nerve, the injection of an anesthetic in the L2 area is effective against acute lumbalgia caused by fracture.
Complications of a vertebral fracture
Fracture of lumbar and thoracic vertebrae can entail various complications. A life-threatening complication is deep vein thrombosis in the legs, which can occur as a result of immobilization.
The thrombi can detach, be carried away by the bloodstream and transported to the lungs, where they can cause a fatal pulmonary embolism.
Other common complications of lumbar vertebral fractures include pneumonia and bedsores.
There are also surgery-related complications, including:
- Bleedings
- Infections
- Leakage of spinal fluid
- Pseudoarthrosis
- Intestinal obstruction (paralytic ileus)
The effects can be reduced by preventive and rapid action, which can be done by mechanical methods (e.g. compression stockings), medications such as blood thinners (anticoagulants) or an appropriate surgical technique and subsequent rehabilitation.
Physiotherapy and rehabilitation
Regardless of whether the patient has undergone surgery or not, rehabilitation must be done after the wound is scarred.
The objectives of rehabilitation are:
- pain reduction;
- regaining mobility;
- Strengthening and improved sense of balance.
The following factors can complicate these treatment goals:
- lack of reposition of fracture;
- neurological injuries (signs of paralysis);
- Deformation of the spine.
Recovery times after a vertebral fracture and prognosis
The healing times depend on the type of damage: a neurological injury cannot heal, while the bone is usually restored within 3 months.
Even if a deformation of the vertebra is still visible on the X-ray, the patient can resume his normal everyday activities if the spine is stable and he can move without pain.
Magnetotherapy can reduce bone healing times by up to 50%.
