Trauma to the spinal column may result from a variety of mechanisms,
the most common of which are motor vehicle-related accidents and
falls.
Soft-tissue (‘musculoligamentous’) injuries are fairly
common, and include ‘whiplash’
Fractures and dislocations may occur throughout the spine, but
are particularly common in the neck (cervical) and thoracolumbar
(mid-lower back) regions. In severe cases, the spinal cord may
be damaged, leading to paralysis.
From a neurosurgical perspective, spinal trauma is classified
as ‘stable’ or ‘unstable’. Unstable fractures
need to be treated more aggressively in order to avoid the development
of spinal cord injury and paralysis. This treatment often requires
surgery, but sometimes comprises the application of traction and/or
an external brace.
Whiplash
What is whiplash and how does
it occur?
Whiplash is a neck injury caused by a strain, sprain, or tear in
the soft tissues (muscles and ligaments). It results from a sudden
and severe neck movement.
The most common mode of injury is a rear-end motor vehicle accident,
where the head and neck rapidly bend a long way forward before
stopping suddenly or even being thrown backwards. Approximately
20% of people involved in rear-end motor vehicle collisions experience
neck symptoms later. It is common to find that these symptoms are
worse a day after the injury. Although most recover quickly, some
develop chronic severe pain that may result in significant disability.
The term "whiplash" is best used to describe the mechanism
of injury, although some use it as a diagnosis. The actual cause
of symptoms can be either a stretch or tear of the ligaments or
muscles, or even compression of the spinal nerves.
What are the symptoms of whiplash?
The symptoms of whiplash may include neck stiffness or reduced
range of movement, neck pain, headaches, and even arm pain.
Pain at the back of the neck is often worse with movement, and
frequently peaks one or two days after the injury before improving.
Muscle spasms and pain between the shoulder blades or over the
trapezius muscles (between the shoulders and the neck) may also
occur.
Headaches, particularly at the back of the head are well-described
(‘cervicogenic headaches’).
Arm or hand pain, fatigue, numbness, tingling or weakness may
be a consequence of nerve or spinal cord injury or compression,
and mandates more extensive investigation.
How is whiplash treated?
Like sprains in other parts of the body, neck sprains usually heal
gradually, with time and appropriate treatment. A soft cervical
collar may be worn for comfort, and in certain cases (where there
is more severe disc and/or ligamentous disruption) a hard collar
(such as an Aspen Collar) may be prescribed. Analgesics and anti-inflammatory
medications reduce pain and swelling, and muscle relaxants can
help ease muscle spasms. An ice pack may be applied for 15-30
minutes, several times a day for the first two or three days
after the injury. Heat can help relax cramped muscles, but should
not be applied for the first few days. Other treatment options
include massaging the tender area, ultrasound, and physiotherapy.
Early return to work is encouraged, usually with modifications
in your workplace activities, which can be eased with time and
recovery. Aerobic activities, such as walking or swimming, should
be commenced early.
Whilst most symptoms resolve in one or two months, severe injuries
may take several months to heal completely. Symptoms of arm weakness,
numbness, or shooting pains should be investigated further.
Neck sprains or strains rarely require surgery. Indications for
surgery include spinal cord compression, prolonged arm pain and/or
weakness, and severe persistent headaches. Surgery may be recommended
if other conditions such as verterbral fracture or disc herniation
are present.
Compression Fractures of the Thoracolumbar Spine
What are compression fractures and
how do they occur?
A vertebral compression fracture is where a bone in the spine collapses.
These fractures occur most commonly in the thoracic spine (the
middle portion of the spine) and upper lumbar (the lower portion
of the spine) regions. The lower vertebra of the thoracic spine
(T11 and T12) and the first vertebra of the lumbar spine (L1) are
most prone to these types of fractures, which are therefore termed ‘thoracolumbar
fractures’.
There are several causes of compression fractures. Whilst the
bones (vertebrae) that constitute your spine are usually very strong,
they can fracture (break) in certain circumstances. Vertebral fractures
are often due to conditions such as osteoporosis (which weakens
the bones, seen particularly in elderly women), significant falls,
or excessive pressure from other trauma.
The most common cause is osteoporosis, a metabolic disease which
thins the bones. The weakened bones can collapse during normal
activity, such as bending forward, leading to a spinal compression
fracture. Spinal compression fractures are the most common type
of osteoporotic fractures, affecting nearly half of all women by
the time they are 80 years old. These fractures can permanently
alter the shape and strength of the spine. Osteoporotic fractures
usually heal on their own and the pain disappears. Sometimes, however,
the pain persists if the crushed bone fails to heal adequately.
In severe osteoporotic fractures, a kyphosis or a "dowager's
hump" may result. This exaggeration of the normal curvature
of the spine causes the shoulders to slump forward and the top
of the back to look enlarged and humped.
Trauma to the spinal vertebrae can also lead to minor or severe
fractures. Falls, forceful jumping, and motor vehicle accidents
are frequent culprits.
Another cause of vertebral body fractures is metastatic disease
involving the spine. ‘Metastasis’ refers to the spread
of cancer cells into other regions of the body. The bones of the
spine are a common place for many types of cancers to spread, with
breast and prostate cancers being particularly common. A compression
fracture of the spine that appears for no obvious reason may be
the first indication of cancer spread to the spine. The cancer
infiltrates and destroys of part of the vertebra, weakening the
bone until it collapses.
What are the symptoms of compression
fractures?
Pain is the most common symptom, but significant pain is not always
present. If the fracture is caused by a significant traumatic event,
you will probably feel severe pain in your back, and sometimes
also in your legs and arms. You might also feel weakness or numbness
in these areas if the fracture injures the nerves of the spine
or the spinal cord itself.
How are compression fractures
treated?
Thoracic compression fractures are usually treated with a combination
of pain medications, activity restriction and modification, and
bracing. Vertebral body fractures usually take around three months
to fully heal. X-rays are usually taken monthly to check on the
healing progress and to ensure that progressive collapse of the
vertebral body is not occurring.
Pain medications should reduce back pain , but will not help the
fracture to heal. In osteoporotic patients, medications to improve
bone density and slow bone loss may be prescribed to prevent further
fractures.
You probably need to restrict your normal daily activities. You
should avoid any strenuous activity or exercise. You must avoid
heavy lifting and anything else that might place too much strain
on your fractured spine. Otherwise the fractured bone may collapse
further.
External bracing is another common form of treatment for some
types of vertebral compression fractures. The brace (orthosis)
supports the back and restricts movement. It is designed specifically
to prevent you from bending forward and placing added stress on
the fractured bone.
In some cases, invasive treatment may also be necessary. These
treatment options include:
- Vertebroplasty: replacing the fractured bone with solid material
to give it more strength
- Kyphoplasty: using a small balloon to restore some of the
lost height of the vertebral body and altered curvature of the
spine
- Spinal surgery
Surgery is required in the minority of compression fractures.
With vertebral fractures, surgery (‘internal fixation’)
is only considered if there is evidence of serious instability
of the spine.
Your neurosurgeon will usually recommend using some type of internal
fixation to hold the spinal bones in correct position whilst the
fractured bone heals. If there is pressure on the spinal cord,
the bone fragments pushing into the spinal cord may also need to
be removed, or a laminectomy performed to alleviate the pressure.
Surgery may be performed via an anterior approach (from the front)
or posterior approach (from the back).
In most cases, surgery to stabilize the fractured vertebra is
performed through an incision in the back, also known as a posterior
approach. Metal screws and rods are used to hold the vertebrae
in the correct alignment while the fractured vertebra heals. The
spinal cord and nerves are decompressed (if necessary) by this
approach.
During an anterior approach an incision is made in the chest or
abdomen. Bone fragments may be then be removed to relieve pressure
on the spinal cord. A spine fusion is then performed by replacing
the crushed vertebra with bone graft or a cage. Eventually, the
vertebrae above and below are joined by a bridge of solid bone.
During the surgery, a combination of metal screws, plates, rods
and cages are inserted to hold the spine in the correct position
to permit a solid fusion to occur over the next few months. These
metal implants remain within the body and are not be removed unless
they cause problems. |
