Vertebrae Fracture Treatment

[Nu Alessio]

Allcomponents of treatment have improved greatly in the last decade, says Michael Schaufele, MD, a physiatrist and professor of orthopaedics at Emory University School of Medicine in Atlanta. "We have better interventional options to treat fractures and better treatments to prevent future fractures," he tells WebMD.

The majority of fractures heal with pain medication, reduction in activity, medications to stabilize bone density, and a good back brace to minimize motion during the healing process. Most people return to their everyday activities. Some may need further treatment, such as surgery.

Pain medications. A carefully prescribed "cocktail" of pain medications can relieve bone-on-bone, muscle, and nerve pain, explains F. Todd Wetzel, MD, professor of orthopaedics and neurosurgery at Temple University School of Medicine in Philadelphia. "If it's prescribed correctly, you can reduce doses of the individual drugs in the cocktail."

Over-the-counter pain medications are often sufficient in relieving pain. Two types of non-prescription medications -- acetaminophen and non-steroidal anti-inflammatory drugs (NSAIDs) -- are recommended. Narcotic pain medications and muscle relaxants are often prescribed for short periods of time, since there is risk of addiction. Antidepressants can also help relieve nerve-related pain.

Activity modification. Bed rest may help with acute pain, but it can also lead to further bone loss and worsening osteoporosis, which raises your risk for future compression fractures. Doctors may recommend a short period of bed rest for no more than a few days. However, prolonged inactivity should be avoided.

Back bracing. A back brace provides external support to limit the motion of fractured vertebrae -- much like applying a cast on a broken wrist. The rigid style of a back brace limits spine-related motion significantly, which may help reduce pain. Newer elastic braces and corsets are more comfortable to wear but don't work, says Wetzel. "There's an old saying, 'The inconvenience of the brace is directly proportional to its effectiveness,'" he tells WebMD. However, braces should be used cautiously and only under a doctor's supervision. Weakening and loss of muscle can occur with excessive use of braces for lumbar conditions.

Osteoporosis treatment. Bone-strengthening drugs such as bisphosphonates (such as Actonel, Boniva, and Fosamax) help stabilize or restore bone loss. This is a critical part of treatment to help prevent further compression fractures.

When chronic pain from a spinal compression fracture persists despite rest, activity modification, back bracing, and pain medication, surgery is the next step. Surgical procedures used to treat spinal fractures are:

These procedures for spinal compression fractures involve small, minimally invasive incisions, so they require very little healing time. They also use acrylic bone cement that hardens quickly, stabilizing the spinal bone fragments and therefore stabilizing the spine immediately. Most patients go home the same day or after one night's hospital stay.

"These procedures are amazing, when you look at how well patients do," says Rex Marco, MD, chief of spine surgery and musculoskeletal oncology at the University of Texas Health Science Center at Houston. "They're often in terrible, terrible pain, and it's not going away. But with two small incisions we can take care of something that needed a huge operation in the past but without really good results."

"We do everything we can to make the operation go as smoothly as possible," says Marco. "Antibiotics decrease the chance of infection. And a special x-ray machine helps us get the needle into the bone and assure that cement goes into the bone and stays in the bone."

Spinal fusion surgery is sometimes used for spinal compression fractures to eliminate motion between two vertebrae and relieve pain. The procedure connects two or more vertebrae together, holds them in the correct position, and keeps them from moving until they have a chance to grow together, or fuse.

Metal screws are placed through a small tube of bone and into the vertebrae. The screws are attached to metal plates or metal rods that are bolted together in the back of the spine. The hardware holds the vertebrae in place. This stops movement, allowing the vertebrae to fuse. Bone is grafted into the spaces between vertebrae.

"Spinal fusion is often the last resort," Wetzel tells WebMD. "If the bone is more than 50% compressed in height, if patients are in a great deal of pain, and if they have had complications from another spinal surgery, we suggest spinal fusion surgery."

The patient's own bone or bone from a bone bank can be used to create a graft. The patient's own bone marrow or blood platelets -- or a bio-engineered molecule -- can be used to stimulate growth of bone for the procedure.

Recovery from spinal fusion surgery takes longer than with other types of spinal surgery. Patients often have a three- or four-day hospital stay, with a possible stay on a rehabilitation unit. Patients typically wear a brace immediately after surgery. Rehabilitation is often necessary to rebuild strength and functioning. Activity level is gradually increased. Depending on the patient's age and health status, getting back to normal functioning can happen within two months or up to six months later.

There are drawbacks to spinal fusion surgery. It eliminates the natural movement of the two vertebrae, which limits the person's movement. Also, it puts more stress on vertebrae next to the fusion - increasing the chance of fracture in those vertebrae. Even after healing is complete, patients may need to avoid certain lifting and twisting activities to prevent putting excess stress on the spine.

Once in the hospital, remove the patient from the board as soon as practical. Prolonged use may be uncomfortable and even counterproductive, because uncomfortable patients may start moving on the board. Some patients develop skin breakdown and decubitus ulcers, even after 1 hour of use. Controlled transfer, use of a sliding board or scoop system, and the logroll technique can prevent further injury. Adequate personnel are needed to facilitate these transfers.

Focus the initial assessment and stabilization of patients with spine injuries on the ABCs and patient immobilization. As part of the initial assessment and stabilization, the airway may need to be secured using rapid-sequence intubation and spinal stabilization. Once the ABCs algorithm is satisfied, focus attention on the secondary survey. Quite often, these patients are victims of multiple traumas. Associated injuries, such as brain, thoracic, or abdominal injuries, take precedence. The neurologic examination helps determine the presence of deficits. In the presence of neurologic deficits, hypotension and bradycardia may indicate neurogenic shock.

The treatment goal for patients in neurogenic shock is to maintain hemodynamic stability. Maintain the systolic blood pressure at a value of at least 90 mm Hg with a heart rate of 60-100 beats per minute. Initial treatment of hypotension is fluid resuscitation; typical adults may require up to 2 liters of crystalloids. Bradycardia may be titrated by the use of atropine. Attempt to maintain urine output at a minimum of 30 mL/hr. If all of the above parameters are difficult to maintain, consider support with inotropic agents. These patients are also at risk for hypothermia and should be warmed to maintain a core temperature of at least 96F. Place a Foley catheter to help with voiding. A nasogastric tube can help with ileus, which is common in the setting of spinal injury. Priapism is not usually treated.

Paramedics and rescue personnel often transport patients on a spinal board with complete spinal immobilization. The objective is to minimize the possibility of injury during transport. Traditionally, patients have been kept on the spinal board until all radiographic studies were completed and no fractures were identified. A more practical approach is to logroll patients off the board, even prior to obtaining radiographs. A cervical collar can be kept in place until the cervical spine is cleared. The objective is to provide maximal patient comfort while minimizing iatrogenic injury. Early clearance from the spinal board can prevent formation of pressure sores and necrosis. Ensure that patients are turned every 1-2 hours to prevent decubitus ulcer formation. Administer pain medication to maintain patient comfort.

For patients with blunt trauma injuries and neurologic deficits, consider the administration of high-dose intravenous steroids to help minimize deficits. Begin steroid therapy within 8 hours of the injury. The initial dose of methylprednisolone is 30 mg/kg administered over 15 minutes. Start an infusion for the maintenance dose of 5.4 mg/kg/hr at the beginning of the first hour and continue it through the 23rd hour. Studies have shown that steroid use may result in complications and inconsistent results. [15, 16, 17, 18]

Fractures may be managed operatively or nonoperatively depending on the extent of spinal cord injury and the overall health of the patient. Minor fractures or those with column stability are managed nonoperatively. Major fractures or those with significant instability can be managed operatively. Operative management is used for stabilization of the spinal column and prevention of spinal deformity, although major factors in nonsurgical candidates can be treated conservatively with nonoperative treatment.

Nonoperative management of unstable spinal fractures involves the use of a spinal orthotic vest or brace. The objective of the brace is to prevent rotational movement and bending. Give consideration to the stabilization of patients with spinal cord injuries and paraplegia. These patients need to be stabilized sufficiently so that their upper body and axial skeleton are appropriately supported, which allows for effective rehabilitation. Stabilization allows patients to use their upper body strength to help with mobility and rehabilitation.

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