Second Vertebrae Fracture

[Francisco Raya]

Yourspine is made up of bones called vertebrae. The vertebrae in your neck are called cervical vertebrae, and there are 7 of them. They protect your spinal cord. A hangman's fracture is a break in the second vertebra of your neck, called the C2, or axis. This bone forms a ring around your spinal cord. A hangman's fracture occurs on both sides of this bone.

In elderly people, a hangman's fracture can be caused by low-impact trauma as well. This is more common in people who have conditions like osteoporosis, cancer that has spread to the bones, or vitamin D deficiency.

A hangman's fracture occurs when your head is forcefully snapped back and up. This is a hyperextension injury, meaning that your neck is extended beyond its normal range. While the biggest worry in many cases of neck fracture is damage to the spinal cord, a hangman's fracture doesn't usually damage the spinal cord at the time of the injury.

However, it can be an unstable fracture, which means the bones might move if it's not treated. If that happens, it can damage the spinal cord, which can cause pain, paralysis, or even death. Because of this, it's important for you to be checked out by a health care provider after any type of injury in which your head is snapped up and back.

Your doctor will do a physical exam first to check for pain or bruising. They will also check to see if you have any symptoms of spinal cord damage like numbness, weakness, or trouble breathing. You will also need imaging studies like an X-ray or a computed tomography (CT) scan. A CT scan is the best option because it can also show if the C2 bone is out of alignment with the bone below it.

You may also need magnetic resonance imaging (MRI) to diagnose a hangman's fracture. An MRI uses strong magnets, radio waves, and a computer to create detailed images. This can give your doctor a more detailed picture of the inside of your neck.

A hangman's fracture is usually classified as a particular type, depending on factors such as whether the broken bone is angled in a different direction from the bone below it, has shifted out of position, or is out of alignment with the bone below it. Knowing the type of fracture you have will help your doctor determine how it should be treated.

The treatment for a hangman's fracture will depend on how bad the fracture is, including how stable it is, whether there is damage to the discs in-between the vertebrae, and whether the spinal cord is involved. There are several treatment options, including:

External fixation. This type of treatment involves using a hard neck collar, called a cervical brace, or a halo vest. A halo vest is a type of brace that is used to keep you from moving your neck so that your fracture can heal. It includes a ring around your head held in place by pins attached to your skull. This ring is connected to a torso brace with rods. Approximately 90% of hangman's fractures heal with this treatment, which is also called immobilization.

Internal fixation. This type of treatment is done with surgery. It's usually only done in severe cases. Surgery can realign your bones and hold them in place with screws, rods, or plates. Surgery may also be needed if your fracture doesn't heal with immobilization.

If your hangman's fracture is treated appropriately, the chances are good for an excellent recovery. A review of 32 papers showed that the least severe type of hangman's fracture had a healing rate of 100% with immobilization alone. Another study of 30 people with hangman's fracture found that 85% had a full recovery within a year.

Vertebral fractures can result from trauma and metastatic disease but, in most cases, are the result of osteoporosis. This activity describes the evaluation and treatment of vertebral fractures and highlights the appropriate use of surgical intervention and the role of the healthcare team in managing patients with this condition.

Objectives:Identify the various etiologies of vertebral fractures.Review the steps for the evaluation of vertebral fractures.Explain the management options available for vertebral fractures.Summarize interprofessional team strategies for improving care coordination and communication to advance vertebral fracture treatment and improve outcomes.Access free multiple choice questions on this topic.

Vertebral fractures result from improper axial loading with or without a rotational component and/or distraction/dislocation in the setting of trauma, osteoporosis, infection, metastatic, or other bone diseases.[1][2]

Fracture classification systems were designed to guide treatment decisions. Systems evaluate spinal stability, neurological deficit, location, the extent of damage to the bony elements, and associated ligamentous complexes. One of the first models to classify traumatic thoracolumbar fractures and pathomorphology was the three-column system of Denis. The anterior column is made up of the anterior longitudinal ligament, annulus fibrosus, and the anterior part of the vertebral body. The middle column includes the posterior part of the vertebral body, annulus, and posterior longitudinal ligament (PLL). The posterior column includes all the structures posterior to the PLL. Three system types currently prevail in classifying traumatic fractures: the Spine Trauma Study Group developed the Subaxial Injury Classification and Severity scale (SLICS) and Thoracolumbar Injury Classification and Severity score (TLICS). While in 1994, the AO spine classification was proposed (a two-column model) but has had poor intraobserver and interobserver reliability.

Osteoporosis is the most common precipitating factor for vertebral fracture. However, trauma, cancer, chemotherapy, infection, long-term steroid use, hyperthyroidism, and radiation therapy are also known to weaken bones that can lead to compression fractures. The etiology of lower bone density can be related to smoking, alcohol abuse, lower estrogen levels, anorexia, kidney disease, medications, proton pump inhibitors, and other medications. Risk factors include female gender, osteoporosis, osteopenia, age greater than 50, history of vertebral fractures, smoking, vitamin D deficiency, and prolonged use of corticosteroids.[3]

Trauma is the second most common cause of spine fracture, and motor vehicle accidents are the number one cause of spinal cord injury. A spinal cord injury occurs from C1 to L2, the approximate level of the cauda equina. Injuries below the conus are cauda equina injuries. According to the National Spinal Cord Injury Statistical Center, other high-ranking causes of spinal cord injury include falls and gunshot wounds. Osteomyelitis infection accounts for admission incidence of 4.8 of 100000 patients.[4]

Estimates are that over 200 million people have osteoporosis.[5] Osteoporosis affects up to 30% of women.[3] Vertebral compression fractures affect more than 1.5 million Americans annually, 10.7 per 1000 women and 5.7 per 1000 men.[4][6] If the clinician diagnoses a vertebral compression fracture, there is a fivefold increase in the new incidence of fracture, and two fractures increase the risk by twelvefold.[6][7][8] These fractures result in chronic and acute pain, reduced quality of life, loss of self-esteem, social isolation, increased risk of falls and fractures, and an approximate mortality rate twice that of matched controls.[9] The most common levels for compression fractures caused by osteoporosis are at the thoracolumbar junction T11-L2. Traumatic spine fractures estimates are 160000 per year, with 50% affecting the thoracolumbar junction. They are more frequent in men with an average age of 30.[10]

Peak bone density occurs approximately between the ages of 18 and 25. Bone remodeling is a part of the normal physiological activity where osteoclasts, assisted by transcription factors, degrade bone matrix, and osteoblasts are signaled to rebuild the bone. Osteoporosis is a degenerative pathway resulting from excessive bone resorption or inadequate formation of new bone and results in a decrease in cancellous bone density, thereby weakening its architecture and structure. Subsequently, a rapid increase in bone remodeling increases fragility to the point that low impact movement leads to compression fractures.[11]

Infection and other spine diseases cause erosion of the vertebral body. The spine begins to collapse, causing deformity and potentially resulting in a compression/burst type fracture affecting the anterior and middle columns.

When should osteoporotic compression fractures be high on the differential diagnosis? Both men and women are subject to vertebral compression fractures. However, one in four women with vertebral fractures goes undiagnosed.[13] Patients with compression fractures will typically present with acute or chronic back pain. Symptoms include a sudden onset of pain that may be related to impact movements. This pain is focal at the level of disease. There is increased pain during standing or walking, a decrease in pain when lying down, and increased pain over the palpated affected area. This condition can lead to increases in kyphotic and lumbar deformity, loss of activity in daily life, constipation, decreased respiratory drive, deep vein thrombosis due to prolonged inactivity, and social problems. The physical exam can reveal loss of height, loss of muscle tone, and change in sagittal balance. Vertebral column fractures are typically not related to myelopathic signs, and radicular pain unless severe or involve some form of spinal canal stenosis/compression.

The acute trauma patient will undergo CT of the spine after securing the airway, ensuring breathing and hemodynamic stability. A full neurological evaluation, including rectal tone, is undertaken to assess spinal cord injury and classified under the ASIA scale. Intubated patients who are unable to participate in the exam will be evaluated based on reflexes and responses to painful stimuli. The basis for evaluation for vertebral fractures is in the clinical guidelines.

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