http://www.emedicinehealth.com/vertebral_compression_fracture/page3_em.

htm#Vertebral Compression Fracture Symptoms

Pain: It tends to be in the lower back but may occur in the upper back or neck. Some people may also have hip,abdominal, or thigh pain. Numbness, tingling, and weakness: Such symptoms could mean compression of the nerves at the fracture site. Losing control of urine or stool or inability to urinate: If these symptoms are present, the fracture may be pushing on the spinal corditself.

Sciatica
From Wikipedia, the free encyclopedia

Sciatica

Classification and external resources

Left gluteal region, showing surface markings for arteries and sciatic nerve

ICD-10

M54.3-M54.4

ICD-9

724.3

eMedicine

emerg/303

MeSH

D012585

Sciatica (

/satk/; sciatic neuritis)[1] is a set of symptoms including pain that may be caused by general

compression and/or irritation of one of five spinal nerve roots that give rise to each sciatic nerve, or by compression or irritation of the left or right or both sciatic nerves. The pain is felt in the lower back, buttock, and/or various parts of the leg and foot. In addition to pain, which is sometimes severe, there may be numbness, muscular weakness, pins and needles or tingling and difficulty in moving or controlling the leg. Typically, the symptoms are only felt on one side of the body. Pain can be severe in prolonged exposure to cold weather. Although sciatica is a relatively common form of low back pain and leg pain, the true meaning of the term is often misunderstood. Sciatica is a set of symptoms rather than a diagnosis for what is irritating the root of the nerve, causing the pain. This point is important, because treatment for sciatica or sciatic symptoms will often be different, depending upon the underlying cause of the symptoms and pain levels. The first known use of the word sciatica dates to 1451.[2]
Contents
[hide]

1 Cause

o o o

1.1 Spinal disc herniation 1.2 Spinal stenosis 1.3 Piriformis syndrome

2 Diagnosis 3 Treatment 4 See also 5 References

[edit]Cause
Sciatica is generally caused by the compression of lumbar nerves L4 or L5 or sacral nerves S1, S2, or S3, or by compression of the sciatic nerve itself. When sciatica is caused by compression of a dorsal nerve root (radix) it is considered a lumbar radiculopathy (or radiculitis when accompanied with an inflammatory response). This can occur as a result of a spinal disk bulge orspinal disc herniation (a herniated intervertebral disc), or from roughening, enlarging, and/or misalignment (spondylolisthesis) of the vertebrae, or as a result

of degenerated discs that can reduce the diameter of the lateral foramen through which nerve roots exit the spine. The intervertebral discs consist of an annulus fibrosus which forms a ring surrounding the inner nucleus pulposus. When there is a tear in the annulus fibrosus, the nucleus pulposus (pulp) may extrude through the tear and press against spinal nerves within the spinal cord, cauda equina, or exiting nerve roots, causing inflammation, numbness or excruciating pain. Sciatica due to compression of a nerve root is one of the most common forms of radiculopathy. Pseudosciatica or non-discogenic sciatica, which causes symptoms similar to spinal nerve root compression, is most often referred pain from damage to facet joints in the lower back and is felt as pain in the lower back and posterior upper legs. Pseudosciatic pain can also be caused by compression of peripheral sections of the nerve, usually from soft tissue tension in the piriformis or related muscles (see piriformis syndrome and see below).

[edit]Spinal

disc herniation

Main article: Spinal disc herniation One of the possible causes of sciatica is a spinal disc herniation pressing on one of the sciatic nerve roots. The spinal discs are composed of a tough spongiform ring of cartilage (annulus fibrosus) with a more malleable center (nucleus pulposis). The discs separate the vertebrae, thereby allowing room for the nerve roots to properly exit through the spaces between the L4, L5, and sacral vertebrae. The discs cushion the spine from compressive forces, but are weak to pressure applied during rotational movements. That is why a person who bends to one side, at a bad angle to pick something up, may more likely herniate a spinal disc than a person jumping from a ladder and landing on his or her feet. Herniation of a disc occurs when the liquid center of the disc bulges outwards, tearing the external ring of fibers, extrudes into the spinal canal, and compresses a nerve root against the lamina or pedicle of a vertebra, thus causing sciatica. This extruded liquid from the nucleus pulposus may cause inflammation and swelling of surrounding tissue which may cause further compression of the nerve root in the confined space in the spinal canal. Sciatica caused by pressure from a disc herniation and swelling of surrounding tissue can spontaneously subside if the tear in the disc heals and pulposis extrusion and inflammation cease. Sciatica can be caused by tumours impinging on the spinal cord or the nerve roots. Severe back pain extending to the hips and feet, loss of bladder or bowel control, or muscle weakness, may result from spinal tumours. Trauma to the spine, such as from a car accident, may also lead to sciatica.

[edit]Spinal

stenosis

Main article: Lumbar spinal stenosis

Other compressive spinal causes include lumbar spinal stenosis, a condition in which the spinal canal (the spaces through which the spinal cord runs) narrows and compresses the spinal cord, cauda equina, and/or sciatic nerve roots. This narrowing can be caused by bone spurs, spondylolisthesis, inflammation, or herniated disc which decreases available space for the spinal cord, thus pinching and irritating nerves from the spinal cord that travel to the sciatic nerves.

[edit]Piriformis

syndrome

Main article: Piriformis syndrome In 15% of the population, the sciatic nerve runs through the piriformis muscle rather than beneath it. When the muscle shortens or spasms due to trauma or overuse, it can compress or strangle the sciatic nerve beneath the muscle. Conditions of this type are generally referred to as entrapment neuropathies; in the particular case of sciatica and the piriformis muscle, this condition is known as piriformis syndrome. It has colloquially been referred to as "wallet sciatica" since a wallet carried in a rear hip pocket will compress the muscles of the buttocks and sciatic nerve when the bearer sits down. Piriformis syndrome may be a cause of sciatica when the nerve root is normal.[3][4]

[edit]Diagnosis
Sciatica is diagnosed by physical examination, neurological testing and patient history, though Vroomen et al. report that "the diagnostic value of patient history and physical examination has not been well studied" [5] and Koes et at. conclude that "if a patient reports the typical radiating pain in one leg combined with a positive result on one or more neurological tests indicating nerve root tension or neurological deficit the diagnosis of sciatica seems justified."[6] The most applied diagnostic test is the straight leg rising test, or Lasgue's sign, which is considered positive "if pain in the sciatic distribution is reproduced between 30 and 70 degrees passive flexion of the straight leg"[7] If no improvement in symptoms has occurred in six weeks or red flags are present, imaging is appropriate. Imaging may include either CT or MRI.[8] MR neurography has been shown to diagnose 95% of severe sciatica patients, while as few as 15% of sciatica sufferers in the general population are diagnosed with disc-related problems.[9] MR neurography may help diagnose piriformis syndrome which is another cause of sciatica that does not involve disc herniation.[citation needed]

[edit]Treatment
When the cause of sciatica is due to a prolapsed or lumbar disc herniation 90% of disc prolapses will be resolved with no intervention. Treatment of the underlying cause of the compression is needed in cases ofepidural abscess, epidural tumors, and cauda equina syndrome.

Although medications are commonly prescribed for the treatment of sciatica, the UK's National Health Service reports that "There is no good evidence from clinical trials to guide the use of analgesics to relieve pain and disability", and suggests that recommendations for analgesic use are extrapolated from guidelines on low back pain.[10] Research has shown no significant difference between placebos, NSAIDs, analgesics, and muscle relaxants. Evidence is lacking in use of opioids and compound drugs.[11][12] Research has failed to show a significant difference in outcomes between advice to stay active and recommendations of bed rest.[13] Similarly, physical therapy (exercises) has not been found to be better than bed rest.[14] Elective surgery is the main option for unilateral sciatica and focuses on removal of the underlying cause by removing disk herniation and eventually part of the disc. In a controlled study, surgical intervention was found to have better results after one year but after four and ten year follow ups no significant differences were found.[15] A comprehensive systematic review found moderate quality evidence that spinal manipulation is effective for the treatment of acute sciatica, however, only low level evidence was found to support spinal manipulation for the treatment of chronic sciatica.[16] Spinal manipulation has been found to be safe for the treatment of discrelated pain
What is a compression fracture of the spine? A compression fracture occurs when the normal vertebral body of the spine is squished, or compressed, to a smaller height. This injury tends to happen in two groups of people. First, are patients who are involved in traumatic accidents. When a load placed on the vertebrae exceeds its stability, it may collapse. This is commonly seen after a fall. The second, and much more common, group of patients are those with osteoporosis. Osteoporosis is a condition that causes a thinning of the bone. As the bone thins out, it is less able to support a load. Therefore patients with osteoporosis may develop compression fractures without severe injuries, even in their daily activities. What are the symptoms of a compression fracture of the spine? Back pain is by far the most common problem in patients with a compression fracture. Patients with osteoporosis who sustain multiple compression fractures may begin to notice a curving of the spine, like a hunchback, called akyphotic deformity. The reason for this is the vertebrae are compressed in front, and usually normal in back. This wedge shaped appearance causes the spine to curve forward. When enough compression occurs, this may become a noticeable curvature. Patients with compression fractures also often notice a loss of their overall height because of the decreased size of the spinal column. Nerve complaints are unusual in compression fractures because the spine and its nerves are behind the vertebra, and, as mentioned above, the front of the vertebra is compressed and the back remains normal. In some serious traumatic fractures, called "burst fractures," the compression occurs around the spinal cord and nerves. This is more serious and may require immediate treatment to prevent or relieve pressure on the spinal cord or nerves. What is the treatment of compression fractures? The best treatment is prevention. Usually, treatment is aimed at alleviating the pain, and preventing injuries in the future. This is best accomplished by treating osteoporosis with exercise, calcium, and medications. If the pain is severe, and collapse is becoming problematic, a procedure called a vertebroplasty may be considered. In this procedure an interventional radiologist restores the height of the bone and injects cement into the vertebra to stabilize the fracture and prevent further collapse.

Compression fractures tend to heal completely in about 8 to 12 weeks. Patients who have one compression fracture are much more likely to have more, and therefore prevention of future compression fractures must be addressed. Understanding osteoporosis can help you avoid this common problem.

Nerve compression syndrome or compression neuropathy, also known as entrapment neuropathy, is a medical condition caused by direct pressure on a singlenerve. It is known colloquially as a trapped nerve, though this may also refer to nerve root compression (by a herniated disc, for example). Its symptoms include pain,tingling, numbness, and muscle weakness. The symptoms affect just one particular part of the body, depending which nerve is affected. Nerve conduction studies help to confirm the diagnosis. In some cases, surgery may help to relieve the pressure on the nerve, but this does not always relieve all the symptoms. Nerve injury by a single episode of physical trauma is in one sense a compression neuropathy, but is not usually included under this heading.
Contents
[hide]

1 Pathophysiology 2 Causes 3 Diagnosis 4 Treatment 5 List of syndromes

o o

5.1 Upper limb 5.2 Lower limb, abdomen and pelvis

6 See also

[edit]Pathophysiology External pressure reduces flow in the vessels supplying the nerve with blood (the vasa nervorum). This causes local ischaemia, which has an immediate effect on the ability of the nerve axons to transmit action potentials. As the compression becomes more severe over time, focal demyelination occurs, followed by axonal damage, and finally scarring. [edit]Causes A nerve may be compressed by prolonged or repeated external force, such as sitting with one's arm over the back of a chair (radial nerve), frequently resting one's elbows on a table (ulnar nerve), or an ill-fitting cast or brace on the leg (peroneal nerve).

Part of the patient's own body can cause the compression, and the term entrapment neuropathy is used particularly in this situation. The offending structure may be a well-defined lesion such as a tumour (for example a lipoma, neurofibroma or metastasis), a ganglion cyst or a haematoma. Alternatively, there may be expansion of the tissues around a nerve in a space where there is little room for this to occur, as is often the case in carpal tunnel syndrome. This may be due to weight gain or peripheral oedema (especially in pregnancy), or to a specific condition such as acromegaly, hypothyroidism or scleroderma. Some conditions cause nerves to be particularly susceptible to compression. These include diabetes, in which the blood supply to the nerves is already compromised, rendering the nerve more sensitive to minor degrees of compression. The genetic condition HNPP is a much rarer cause. The causes of each particular syndrome are discussed on the relevant pages, listed below. [edit]Diagnosis The symptoms and signs depend on which nerve is affected, where along its length the nerve is affected, and how severely the nerve is affected. Positive sensory symptoms are usually the earliest to occur, particularly tingling and neuropathic pain, followed or accompanied by reduced sensation or complete numbness. Muscle weakness is usually noticed later, and is often associated with muscle atrophy. A compression neuropathy can usually be diagnosed confidently on the basis of the symptoms and signs alone. However, nerve conduction studies are helpful in confirming the diagnosis, quantifying the severity, and ruling out involvement of other nerves (suggesting a mononeuritis multiplex or polyneuropathy). A scan is not usually necessary, but may be helpful if a tumour or other local compressive lesion is suspected. Nerve injury, as a mononeuropathy, may cause similar symptoms to compression neuropathy. This may occasionally cause diagnostic confusion, particularly if the patient does not remember the injury and there are no obvious physical signs to suggest it. The symptoms and signs of each particular syndrome are discussed on the relevant pages, listed below. [edit]Treatment When an underlying medical condition is causing the neuropathy, treatment should first be directed at this condition. For example, if weight gain is the underlying cause, then a weight loss programme is the most appropriate treatment. Compression neuropathy occurring in pregnancy often resolves after delivery, so no specific treatment is usually required. Some compression neuropathies are amenable to surgery: carpal tunnel syndrome and cubital tunnel syndrome are two common examples. Whether or not it is appropriate to offer surgery in any particular

case depends on the severity of the symptoms, the risks of the proposed operation, and the prognosis if untreated. After surgery, the symptoms may resolve completely, but if the compression was sufficiently severe or prolonged then the nerve may not recover fully and some symptoms may persist. Drug treatment may be useful for an underlying condition (including peripheral oedema), or for ameliorating neuropathic pain. [edit]List

of syndromes
limb
place usually referred to as

[edit]Upper

nerve

median

carpal tunnel

carpal tunnel syndrome

median (anterior interosseous) proximal forearm

anterior interosseous syndrome

median

pronator teres

pronator teres syndrome

median

ligament of Struthers ligament of Struthers syndrome

ulnar

cubital tunnel

cubital tunnel syndrome

ulnar

Guyon's canal

Guyon's canal syndrome

radial

axilla

radial nerve compression

radial

spiral groove

radial nerve compression

radial (posterior interosseous) proximal forearm

posterior interosseous nerve entrapment

radial (superficial radial)

distal forearm

Wartenberg's syndrome

suprascapular

suprascapular notch suprascapular nerve entrapment

[edit]Lower

limb, abdomen and pelvis

place usually referred to as

nerve

common peroneal

fibular neck

peroneal nerve compression

tibial

tarsal tunnel

tarsal tunnel syndrome

lateral cutaneous nerve of thigh inguinal ligament meralgia paraesthetica

sciatic

piriformis

piriformis syndrome [not always due to entrapment]

iliohypogastric

lower abdomen

iliohypogastric nerve entrapment

obturator

obturator canal

obturator nerve entrapment

pudendal

pelvis

pudendal nerve entrapment

abdominal cutaneous nerves

abdominal wall

abdominal cutaneous nerve entrapment syndrome

C. LOUIS, S. NAZARIAN, R. LOUIS Hpital de la Conception, Marseille

INTRODUCTION About 10,000 thoracic and lumbar spine fractures are treated every year in France. In our experience, a few very minor cases can be treated with bed rest and physiotherapy; 60 % of lesions can be managed with closed treatment; and only 30 % will require surgery. Our experience includes more than 500 cases treated in our Department over a 25-year period.

It should be emphasised that no treatment program can be implemented safely and effectively unless a sufficiently skilled surgical team, sufficiently competent paramedical personnel and adequate equipment are available. I. ASSESSMENT I. A. Clinical assessment This must be as detailed as possible as it will determine how urgently treatment is required and which medical facility is most appropriate for the patients particular needs. A few specific points about the assessment should be borne in mind : 1 Fractures of the thoracic and lumbar spine are often the result of high-energy trauma (a fall from a height or a road accident); the mechanism which caused the lesion should be investigated as this will provide useful clues to the injury pattern that may be encountered. 2 If a patient has been involved in an accident and is complaining of back pain, the examination should include palpation of the contour of the spinous processes with the patient in the dorsal or lateral decubitus position. Any tenderness elicited will then pinpoint the location of the lesion and can be used to target further investigations more precisely. Excessive protrusion of a spinous process with an enlarged space between the spines, a subcutaneous haematoma, or even transverse stretch marks, are suggestive of a lesion caused by distraction of the posterior ligamentous structures. 3 A full and systematic neurological examination should be carried out, not forgetting the perineal region, which is often overlooked in emergency situations. The result of this examination should be clearly recorded in writing, as it will be referred to during the subsequent management of the patient. If the patient has to be transferred to a specialist unit, the clinical examination should be repeated in case there are any changes in the neurological signs and symptoms. 4 It should be borne in mind that a common finding in fractures of the thoracolumbar junction and the lumbar spine is reflex ileus related to a retroperitoneal haematoma around the fracture; this may be mimicking or masking an intra-abdominal or a retroperitoneal lesion. 5 Finally, we would emphasise that the rest of the spine (C-spine, sacrum and coccyx), the pelvis and ribcage should be examined for lesions, which may require their own forms of treatment, and may rule out certain treatment methods.

I. B. Further investigations The examination of the vertebrae should include : 1 Good quality standard films showing the whole of the damaged vertebra (lateral views from the anterior prevertebral space right out to the spinous process, and anteroposterior views from one transverse process to the other) including as many adjacent vertebrae above and below as possible, with right and left oblique views if appropriate. There should also be a lateral view of the lumbosacral region. As we will see later, it is important to know the degree of lumbosacral lordosis in the patients spine, so that kyphotic sequelae in the thoracolumbar spine can be assessed. 2 A CT scan centred on the damaged vertebra and including adjacent vertebrae above and below the trauma site, with sagittal reconstructions. 3 Coronal and sagittal tomograms, which provide high quality information if CT is not available. 4 We do not perform magnetic resonance imaging (MRI), except in the rare cases of paraplegia without any radiographically demonstrable bony or ligamentous lesions, to screen for haematomyelia. 5 Myelography/radiculography are not usually done when the examinations described above are available. I. C. Injury patterns Vertebral lesions can be classified on the basis of their clinical and radiological characteristics. For this purpose we use the Magerl(12) scheme (Fig. 1) modelled on the AO classification of limb fractures, which provides an alphanumerical 3-3-3 grid: There are three types, A, B and C (Fig. A1), each of which is further classified into 3 groups (1, 2 and 3), which themselves each contain 3 sub-groups (1, 2 and 3), and further specification. Each type represents a principal injury mechanism, while the groups and sub-groups are based upon morphological characteristics, with ranking (1, 2 or 3) of the lesions according to progressive severity. Without going into too much detail, the system can by explained in simple terms by saying that type A represents a compression mechanism (lesions located mainly in the vertebral body), with group A1 representing wedge impaction fractures; group A2, split fractures, and group A3, comminuted or burst fractures (Fig. 1B). The mechanism in type B is distraction of the posterior or anterior structures

(distinguishing in each case whether there is a lesion of the vertebral body and/or of the disc), with group B1 representing predominantly ligamentous posterior flexiondistraction injuries; group B2, predominantly osseous posterior flexion-distraction injuries; and group B3, hyperextension-shear injuries with disruption through the disc (Fig. 1C). Type C represents lesions caused by a rotational mechanism in addition to the mechanism of one of the types described above (Fig. 1D). Within this grid, the injuries are hierarchically ranked according to the progressive severity of the pathomorphological findings and the instability caused. This in turn makes it possible to suggest a prognosis for recovery, and to choose the most suitable method of treatment. We have used this very specific classification to create a database which enables us to decide on treatment in relation to type of fracture, and to compare the efficacy of the various techniques available. If it were more generally used, it should produce better comparisons of the therapeutic results obtained by different teams specialising in spinal disorders. Of course, in an emergency situation the most pressing need is not to identify the precise type of fracture, which is the domain of scientific research, but rather to recognise the principal causative mechanism of a given lesion and to decide whether the function of the spine in terms of stability and neural protection has been compromised.
FIGURE 1

1A : Main characteristics of the three injury types : A Type A, injury caused by compression of the anterior column; B Type B, injury of the anterior column and the two posterior columns with distraction of the anterior or posterior elements; C Type C, rotational injury of all three columns.

1B : Type A, vertebral body compression injury : A1 Group A1, vertebral body wedge impaction fracture; A2 Group A2, split fracture; A3 Group A3, comminuted fracture or burst fracture.

1C : Type B, anterior and posterior element injuries with distraction : B1 Group B1, predominantly ligamentous posterior flexion-distraction injury; B2 Group B2, predominantly osseous posterior flexion-distraction injury; B3 Group B3, injury involving hyperextension and shearing through the disc.

1D : Type C, anterior and posterior element injuries with rotation : C1 Group C1, type A injury with rotation; C2 Group C2, type B injury with rotation; C3 Group C3, oblique fracture with rotational shear.

I. D. Spine functions and therapeutic indications In an attempt to refine the therapeutic indications, we routinely determine the effects of the fracture on the 4 main functions of the spine : stability, posture, neural protection, and neurological function (14, 16). - 1. Stability and instability.

It has to be decided whether the trauma sustained has destabilised the spine to the point where the spine can no longer maintain intervertebral displacement within normal limits. The basis for this decision is R. Louis three-column theory (Fig. 2A). The function of stability will remain uncompromised only if the trauma has left all three columns intact, i.e. the major anterior column formed by the discs and vertebral bodies, and the two posterior columns formed by the partes interarticulares and the facet joints linked by bridges formed by the pedicles and the laminae. Each column consists of alternating sections of bony and of fibrous (discoligamentous) structures. The more columns that have been damaged, the more unstable the spine will be. Each column may be damaged by loss of continuity in a section of bone or of fibrous tissue, or by a defect (loss of substance). A stable traumatic lesion is one which damages only the bony portion of one column or a horizontal bridge. In contrast, lesions of two or three columns will be unstable. Damage to the bony part of two or three columns causes transient osseous instability. The fracture may be adequately and rapidly stabilised by consolidation if treated with reduction and immobilisation (Fig. 2B). In contrast, lesions of the articular constituents of the columns, i.e. of the discs and ligaments (B2, B3 and some C types) have only a small chance (30 % to 50 %) of achieving solid and stable consolidation with conservative treatment. These lesions are said to exhibit chronic ligamentous instability, and are therefore clear indications for surgery (Fig. 2C). Similarly, surgery will be required if there is a defect involving loss of substance in one or more of the columns. Such a defect may take the form of a severe wedge impaction fracture (A1 injuries) with anterior compression by 50 % or more of the height of the vertebral body; a burst fracture (A3.3) leaving a defect in the vertebral body after reduction (Fig. 2D); a coronal fracture of a vertebral body (A2), leaving a defect underneath the suprajacent vertebral body; or a pincer fracture (Fig. 2E). Defects will require bone grafting.

FIGURE 2 2A : Diagram of the R. Louis three-column theory. 1. Large anterior column consisting of the discs and vertebral bodies; 2 and 3, posterior columns consisting of the partes interarticulares and the facet joints. 2B : Osseous instability (Chance fracture). 2C : Ligamentous instability (dislocation). 2D : Anterior defect in a reduced wedge impaction fracture. 2E : Anterior defect caused by coronal fracture (split fracture and pincer fracture).

- 2. Posture and deformity The postural function of the spine depends on a physiological pattern of spinal curvatures. Any serious deformity compromises posture, exposing the patient to the risk of pain and imbalance at the fracture site and in the compensatory curves. This may involve kyphosis or scoliosis, which becomes abnormal at between 15 and 20 at the fracture site (local kyphosis), depending on the original curvature of the patients spine. This type of vertebral deformity should therefore be reduced by conservative treatment; or surgically, if conservative treatment is not effective or if it is likely that local kyphosis will be more than 15 or 20, irrespective of regional kyphosis. This is especially true if the subject has hyperlordosis or narrow spaces between the spinous processes or between the facets and the laminae (see Indications for Conservative Treatment). Of course, the extent of normal kyphosis or lordosis at the site of the lesion should be taken into account in any assessment of postural disorders. - 3. Protection of the nervous system, stenosis of the spinal canal

The morphology of the vertebral canal and the foramina must be preserved in order to protect the spinal cord and the nerve roots. If there is a severe deformity resulting in spinal stenosis and causing varying degrees of compression, the walls of the canal would have to be reconstructed as far as possible in order to relieve the compression or to prevent subsequent compression. Closed reduction will be effective in many cases, but if this fails and residual compression persists, the canal will have to be decompressed by surgery. However, it should be remembered that only 50 % of the volume of the canal is occupied by neural structures. Spinal stenosis should therefore not be treated surgically in cases where the reduction in canal diameter is less than 30 % (or less than 50 % of the cross-sectional area of the canal, which can be calculated from a CT scan). However, we do operate as a matter of course in all cases where there is a neurological deficit, irrespective of the extent of canal obstruction. - 4 Nerve lesions Some neurological lesions are clearly irreversible, such as when nerve structures have been overstretched, crushed, or severed. However, many other lesions caused by partial compression may recover when the compression is removed. Although closed reduction may be effective in treating compression, neurological deficits are a contraindication to continued conservative treatment, and must be treated surgically. The chances of recovery are best if a compressed neural structure can be be released quickly, within 8 hours if possible. When lesions involve mainly the spinal cord, drug therapy may be necessary during the first 24 hours to reduce necrosis and oedema at the level of the injury. We have abandoned high-dose corticosteroid regimens, and now administer only more standard doses (120 mg of Solumedrol [methylprednisolone sodium succinate] for the first two days, tapering off the dosage thereafter). Depending on the extent to which the four functions are affected, there may be a clear indication for closed treatment, or there may be one or more arguments in favour of surgery. When surgery is required because of compromised function, an approach must be chosen which will allow each of the functions to be recovered as effectively and as easily as possible. II. CONSERVATIVE TREATMENT (Images - Case No. 1) II. A. General remarks We find that most cases of recent vertebral deformity can be reduced without any major problems or complications using our method of treatment, which is derived

from the method proposed by Bhler, using closed reduction followed by a plaster cast. The method consists in reduction with the patient placed on a Cotrel scoliosis frame(8,13,15,19,22), using well-defined manoeuvres under image intensifier control.

IMAGES - CASE No. 1 1 : 41-year-old man, road accident. Burst fracture of L1 without neurological deficit. 25 % canal narrowing. 2 : Result after closed reduction. 3 : Excellent functional result at 2 years.

II. B. Technique While Bhler used a method of reduction involving lumbar hyperlordosis, we prefer a three-stage reduction on a Cotrel frame (Fig. 3). Neither local nor general anaesthesia is required. 1 The first stage of reduction consists in applying axial traction with a head halter and two pelvic straps. A dynamometer is used to check the force applied, which is in the order of 10 to 15 kilograms. The fracture site is therefore maintained in its position of deformity, i.e. in kyphosis at the level of the affected vertebra. Traction is monitored on the image intensifier, to check that the volume of the vertebral body has been restored, measuring the distance between the adjacent discs above and below the fracture (Fig. 3A-3B). 2 The second stage consists in re-establishing a certain amount of lordosis by passing a sling under the fracture site to pull the spine vertically upwards. The sling is

tensioned until physiological lordosis is obtained. This procedure is beneficial in cases where a fragment of the posterior wall has been displaced into the vertebral canal : The vertebral body can be opened at the site originally occupied by the fragment, and the fragment itself can be pushed home by pressure from the posterior longitudinal ligament. In contrast, if lordosis is induced before the axial tension has been applied in kyphosis, the site of origin would be closed and it would be impossible to reduce the posterior fragment; there would then be a risk of the fragment being driven back into the canal and causing or aggravating neurological compromise. If the patient is conscious he or she will be able, at this stage, to report pain and neurological phenomena. Reduction manoeuvres should be stopped as soon as neurological manifestations occur or if they become aggravated (Fig. 3C). 3 The third stage consists in applying a classical Bhler body cast with three points of contact on the sternum, back and pubis, leaving a window over the upper abdomen (Fig. 3D). The patient is allowed out of bed the same day, and may be discharged on the second or third day if there is no posttraumatic ileus. When there is neurological loss, we use this method before surgery to reduce the fracture, which simplifies our operative technique (see Surgical Treatment). However, if the neurological deficit regresses completely (single-root compression), conservative treatment is given on a trial basis. Outpatients are asked to return three weeks after the first plaster cast is fitted to check that there has been no loss of reduction and aggravation of the initial deformity, which would mandate surgical stabilisation. It should be remembered that some loss of reduction while the patient is in a plaster cast is normal; however, with appropriate patient selection, this should not be so severe as to require surgery.

FIGURE 3 Controlled closed reduction done under anaesthesia and under fluoroscopic control. A Cotrel frame is particularly suitable for this

type of reduction, which is performed in three stages : The patient is positioned in such a way that the initial kyphotic deformity at the fracture site is maintained (A), axial traction is applied (B), followed by induction of lordosis while traction is maintained (C). A plaster body jacket is applied after the closed reduction (D). Key to diagram : CYPHOSE + TRACTION = KYPHOSIS + TRACTION LORDOSE = LORDOSIS

II. C. Subsequent treatment After a patient has spent three to four months in a plaster cast, there is a danger of muscle atrophy. Isometric proprioceptive exercises should therefore be started as soon as the pain has subsided, in order to prevent wasting of the abdominal and spinal muscles. A fracture will usually take between three and four months to consolidate. As a precaution, a reinforced canvas brace with shoulder bands is often used to immobilise the spine for a further period of one to three months. Active and dynamic exercises are begun during the fifth month, with emphasis on the patient learning the "lumbar locking" technique. Stress films are then taken in order to check that there is no instability. The patient can go back to work at six months. This time may be substantially shorter for subjects in sedentary occupations or in professional activities that do not require major physical exertion; however, labourers should not lift heavy loads (more than 25 kg) for a further 6 months. II. D. Complications Localised pain underneath the plaster brace suggests that there is a pressure sore, which should be treated with standard local care followed by a change of cast. We have never observed any neurological complications during the reduction procedure; however, if such a situation were to arise, immediate surgical release would be required. II. E. Indications We have been able to analyse and evaluate the results of closed reduction performed in 240 cases treated over a 10-year period; this analysis has enabled us to define the indications (single or multiple factors). The following types of fracture should be managed conservatively :

- fractures of the thoracolumbar junction down as far as L3, and of the lower thoracic spine. For fractures at other sites, reduction is much less effective and a simple support without reduction is indicated; - fractures in which local kyphosis is between 10 and 15 and the coronal deformity is less than 10. When local kyphosis is between 15 and 20, only patients with an adequate hyperlordotic reserve should be treated this way. When local kyphosis is less than 10 a simple support without reduction will be sufficient; - stable lesions and unstable injuries involving predominantly bone (types A and B2), apart from cases where there is a defect or a rotational lesion; - fractures without any signs of cord or multiple-root compromise. Patients with signs suggesting compromise of a single root may be treated conservatively, providing that the signs are completely abolished by reduction. - fractures where canal encroachment is less than 50 % of the cross-sectional area of the canal, without any neurological compromise; as well as - fractures which are not associated with major chest injuries, or, more generally, multiple trauma. Subjects should be able to get up and take part in early and sustained rehabilitation while in plaster, and should not be obese. In contrast, conservative treatment is not effective in the following cases, which are likely to require surgical treatment : - any fracture causing more than 20 of local kyphosis and more than 10 of coronal deformity; - any cases where the instability is mainly ligamentous (types B1 and B3), cases of bony instability with a defect (some types A1 and A2, and A3.3) and rotational lesions (type C); - all fractures which have been complicated in the initial or later stages by neurological signs. For technical reasons (impossibility of performing the reduction manoeuvres required, or nursing problems), spinal fractures associated with fractures of more than one rib, unstable fractures of the sternum, unstable fractures of the pelvic ring, and fractures occurring as part of a multiple-trauma pattern should be managed either by bed rest and physiotherapy or surgically, depending on the extent to which the major functions of the spine are affected.

However, we use preoperative conservative reduction whenever possible, so that we can operate on a spine which has already been reduced. III. POSTERIOR SURGERY (Images - Cases No. 2-3) III. A. General remarks We will describe the method used in our department, which is based on R. RoyCamille's principle of fixation by means of plates and pedicle screws (1,2,5,6,7,15,16,17,20,21). We use Louis plates.

IMAGES - CASE No. 2 1 : 21-year-old man, motorcycle accident. Multi-level fracture with oblique fracture line, T8, T9 and T10, no neurological deficits. 2-3 : Posterior internal fixation with fusion of T6-T12 without decompression. Excellent functional result at 3 years.

III. B. Indications This is the approach used in neurological emergencies. The posterior approach is the preferred route when there is trauma to the thoracic and lumbar spine with neurological lesions, and in other cases of trauma, when there is no imperative requirement to repair a defect of the vertebral bodies or to relieve severe anterior compression. However, in that last-mentioned case, we use a posterior approach first to remove any retropulsed fragments from the canal, in order to avoid an anterior approach.

Similarly, the posterior route would be used in preference to the anterior route in an obese subject or in one likely to be at high risk during surgery.

IMAGES - CASE No. 3 1-2 : 32-year-old man, motorcycle accident. Burst fracture with rotation of L2. Bilateral weakness of thigh muscles. 3 : Posterior decompression and fusion of L1-L3 with a short construct. No neurological sequelae, no pain at 2 years.

III. C. Advantages and disadvantages Internal fixation by plating will produce a semi-rigid form of construct. A reinforced fabric brace will need to be worn for three months after surgery. The advantages of our method are : - The hardware generally does not have be removed, as our plates have a low profile and produce little bulk. In addition, we often use short constructs combined with fusion of the facet joints. - As the approach does not require the transverse processes to be exposed, the neurovascular bundles of the paraspinal muscles passing just outside the pars interarticularis are preserved (Fig. 4).

FIGURE 4 4A : Exposure technique which preserves the neurovascular structures of the spine. Our plate-andscrew system and fusion mass add little bulk, so no pressure is applied to the structures during closure of the incision. 4B : Diagram illustrating the hazards to the neurovascular structures of the paraspinal muscles from vertebral exposure beyond the facet joints and the insertion of prominent hardware and bulky iliac grafts between the transverse processes.

- The need for iliac bone grafting can usually be obviated if corticocancellous bone chips taken from the spinous processes are used for facet joint fusion. - Our procedure using lordosing spinal traction provides easy reduction during surgery, which generally means that over-aggressive manipulation during surgery can be avoided. The disadvantages are :

- Our plate and pedicle screw system does not reduce fracturs in same way as a system using rods. For this reason the fracture is often reduced preoperatively by closed reduction, which is maintained by lordosing traction applied throughout the surgical procedure (see Position of the Patient). - The use of a semi-rigid system involves a very small amount of postoperative loss of reduction. III. D. Operative technique. - 1. Position of the patient The posterior approach means that the patient has to be turned on the operating table after general anaesthesia has been induced, while wearing a bivalved body jacket (after preliminary closed reduction has been performed). Lordosing spinal traction is then applied using a head halter, a pulley and a dynamometer fixed to a hook hanging from the operating table at the head end, and two boots fixed to the operating table. The operating table is gradually bent into a lordosing angle, while 10 to 15 kg of vertebral traction is maintained, to correct or maintain correction of the fracture site under image intensifier control. Surgery will then be performed on reduced lesions (Fig. 5).

FIGURE 5 Patient positioning with lordosing spinal traction for a posterior incision.

- 2 Incision and placement of the screw tracts The incision is in the posterior midline. The fascia is detached from the spinous processes using cutting diathermy, and the muscles are stripped first from the spinous processes and then from the laminae using a very wide elevator which is too big to pass between two transverse processes. If possible, the muscles should be detached at both ends of the incision, away from the actual fracture site. The site can then be approached, holding the elevator or scissors very carefully so that they do not penetrate the dural sac through the fracture site. Laterally, exposure is confined to the

outer margin of the facet joints, preserving the neurovascular structures lying between the transverse processes (Figs. 4 and 6).

FIGURE 6 Posterior incision, nerve decompression, and repair of the dural sac.

Retractors are inserted and haemostasis is obtained with bipolar diathermy. The vertebral canal can then be either decompressed or stabilised by fusion, depending on the specific requirements of the situation. We recommend that if canal decompression is envisaged, the screw tracts should be prepared immediately, without inserting the screws. Decompression of the canal can cause bleeding which makes it difficult to identify the pedicles, and rapid closure may be necessary if bleeding is heavy and uncontrollable. Once the screw tracts are in place, the fracture can be stabilised rapidly. The entry points for the screws will depend on the section of spine involved (Fig. 7) :

FIGURE 7 Anatomical landmarks for thoracolumbar screw tracts, and image intensifier control of the placement of the marker K-wires.

- Between T1 and T3, the insertion point is 3 mm below the facet joint and 3 mm medial to its lateral margin. In these vertebrae only, the screw tract is routed slightly obliquely and medially. - Between T4 and T10, the insertion point is 5 mm medial to the lateral margin of the facet joint and 3 mm from its lower margin on a crest which medially continues the upper border of the transverse process. - Between T11 and L5, the insertion point is located at the intersection of a vertical line that runs tangent to the inside of the notch formed by the outside limit of the pars, and a horizontal line drawn 4 mm above the upper margin of that notch, i.e. inside the lower part of the facet joint space.

Whichever insertion point is chosen, small K-wires may be introduced at the intended point; a.p. and lateral views on the image intensifier are used to verify that the position is correct and that the wire is in the centre of the pedicle. (If this marking is done before nerve roots are freed, the holes should be temporarily filled with bone wax). - 3. Nerve decompression A preoperative CT scan is used to decide on where decompression is required, and to show whether bits of bone have been displaced at the fracture site. It will also be used to guide the lifting and extraction of any fragments displaced towards the vertebral canal. Dislocation of the facet joints can be reduced by resecting a third of the end of the upper facet. A tyre-lever manoeuvre can be used to replace the dislocated facet in a posterior position while applying posterior distraction by means of two bone-holding forceps placed on the spinous processes above and below the site of injury. If there are neurological symptoms and the radiographs suggest that there is stenosis, laminectomy should be done, preserving the facet joints and the partes interarticulares. If there is a complete or a greenstick vertical translaminar fracture (which is common in burst fractures), rootlets of spinal nerve roots are likely to have been entrapped, and the laminectomy should be started some way away from the fracture of the lamina. The margins of the laminectomy may be covered with bone wax to obtain haemostasis. The lateral recesses are explored with a dissector to find a focus of compression, and the posterior surface of the vertebral bodies and discs is likewise probed. The main source of compression is one or more posterosuperior (or, more rarely, posteroinferior) fragments of a vertebral body that have been driven back into the canal. The fragment or fragments should be removed or pushed well forward. To do this, we use a special L-shaped bone impactor. To ensure that the procedure is effective, the offending fragment has to be reimpacted deeply into the posterior third of the vertebral body. This stage is likely to cause bleeding, and small neuro sponges should be packed liberally into the bleeding sites in each of the recesses, taking care to avoid compressing the dural sac. Strips of Surgicel may also be used, instead of these sponges, at the end of surgery.

The bone fragments removed from the spinous processes and the laminae are given to the scrub nurse, who will clean off any fibrous tissue or cartilage to make them into corticocancellous strips which can subsequently be used as bone grafts (Fig. 6). - 4 Repair of the dural sac Any breaches of the dural sac must be exposed and then repaired using nonabsorbable 5/0 vascular sutures on small curved atraumatic needles. A single figureof-eight stitch will be sufficient to repair an isolated puncture wound, but wider tears will have to be oversewn. If the breach is very lateral or anterolateral and is therefore difficult to suture, or if there is major defect, it is best to put Surgicel around the tear or defect, or to take down a piece of muscle from the margin and reinforce this patch with tissue glue. When a tear in the dural sac is being repaired, a patty should be put over the end of the suction tip to prevent damage to nerve roots. When there is a complete neurological lesion, it may be necessary to open the dural sac to verify the lesions, which can then be reported to the patient and his or her family. Postoperative MRI may be interfered with by the hardware inserted at surgery. It is also recommended that the sac should be opened if the cord is very swollen because of a central haematoma. The haematoma should be aspirated through the posterior commissure of the spinal cord with a very fine needle. When there is incomplete neurological loss and all epidural compression has been relieved, the dura mater should not be opened, as this would add iatrogenic microtrauma. If there has been significant loss of CSF (floppy dural sac), the contents of the dural sac can be reconstituted by introducing physiological saline using a fine needle and a syringe, until the sac is once more smooth and cylindrical. This procedure also reduces epidural bleeding. After the dural sac has been repaired, either a double layer of Surgicel or a layer of tissue glue should be applied (Fig. 6). - 5 Stabilisation and fusion For internal fixation we use paired symmetrical R. Louis stainless steel plates with closely-spaced holes, and pedicle screws. All the plates can be bent and cut as required.

For the pedicles of the upper thoracic spine we usually use 4.5 mm diameter screws (drill size 2.8 mm); for the others, we use 5.5 mm screws (drill size 3.2 mm). The screws are inserted in the sagittal plane perpendicular to the plane of the neighbouring lamina. The screws should be inserted in such a way as to ensure that the tip does not penetrate further than the middle of the vertebral body (on the lateral views). For an average adult, screw length will range from 30 mm at T1 to 45 mm at L5. We have two plates with oblique screw paths which go towards the upper surface of the lateral bone mass of the sacrum for L3 or L4 fusion to the sacrum (which is done very occasionally in traumatology). The holes in the plate are arranged in such a way as to ensure that the sacral screws are routed with angulation in two planes. Before putting the plates into position, the facet joints of the vertebrae between those receiving the end screws are freshened by shortening the inferior facet by a third at the thoracic level and excising visible cartilage, and by excising the sagittal portion of the lumbar facet joints with a narrow rongeur. Similarly, at the lumbar level, the part distal to the joint space is freshened between the tip of the inferior articular process and the subjacent lamina (Fig. 8). The plate is applied by inserting the top screw first. It is then aligned on the facet joints and the bottom screw is inserted. The intermediate screws are then inserted guided by the contralateral landmarks. If used, chips of corticocancellous bone are placed on the freshened facet joints and the plate is tightened onto the graft mass (Fig. 8).

FIGURE 8 Internal fixation procedure with posterior fusion.

In cases of dislocation or lesion of a motion segment, the construct should extend to one pedicle above and one below the lesion.

For fractures, the construct should run from the pedicle above to the pedicle below the fractured vertebra; in the case of complete neurological lesions, a longer construct is preferred, from two vertebrae above to two vertebrae below the level of the lesion. For fractures of the thoracolumbar junction, an extended short construct may be used, covering 2 pedicles on either side of the fractured vertebra, with fusion of the motion segments above and below the fracture. In the latter case, we expect to remove the hardware after six months to avoid the screws at the ends of the construct breaking. It is sometimes difficult to reduce fractures of the upper thoracic spine preoperatively. In this case, we would ease the spine onto prebent plates, gradually inserting the screws into the pedicles above the fracture. We always include the 2 vertebrae above the fracture, and the plates are contoured according to the curvature to be obtained in that region of the spine. - 6 Closure In most cases we close the muscles, fascia, subcutaneous tissue and skin with interrupted sutures, without inserting drains. However, if there was excessive bleeding during surgery, a suction drain should be used to prevent compression of the dural sac. - 7 Postoperative care To prevent cardiovascular shock and to avoid the risks involved in any heterologous transfusion, a Cell-Saver unit should be used to salvage the patient's red cells for reinfusion. When the dura mater is damaged, we routinely prescribe postoperative antibiotic therapy (Bactrim). During the first few days after surgery, the patient is at risk from ileus. Nasogastric decompression should be performed for the first 24 hours, and the passage of flatus should be checked. Anticoagulants should not be given for the first 12 hours, to prevent epidural haematoma formation. We routinely perform postoperative CT scans to check that nerve decompression has been successful, and to verify that the pedicle screws have been placed correctly.

Patients with severe paralysis should be nursed in bed, with turning every 3 hours to prevent bedsores(9). After 2 to 3 weeks they may sit up, protected by a reinforced fabric brace. These patients will require rehabilitation at a specialist centre. Patients who are not paralysed may be got up from the day after the operation, protected by a reinforced fabric brace (for long constructs) or by a plaster or heatmoulded resin cast (for short constructs), which will be worn for three to four months. The patient will be followed-up every month for 6 months, then every year. Dynamic exercises are started at the end of the third postoperative month. Patients in sedentary occupations may go back to work after four months; labourers may resume work after six months. In order to preserve healthy motion segments, we ask our patients to practise the technique of "locking" the lumbar spine in neutral position for the rest of their lives. - 8 - Complications The first complication to prevent is major blood loss during surgery, because recent trauma to the spine tends to cause substantial bleeding. Hot moist swabs should therefore be used to cover those parts of the operative field which are remote from the site that is being addressed. On entering the spinal canal, hot moist neuro sponges and Surgicel should also be packed into the lateral recesses, taking care not to compress the dural sac. A screw may be inserted into the pedicle of the fractured vertebra to increase the stability of the construct. In the case of burst fractures, the interior of the canal should be checked after the screw has been tightened, as it is possible that cortical bone on the inside of the split and fractured pedicle may break off while the screw is being inserted, causing compression of a nerve by the screw and/or by bone fragments avulsed from the pedicle. The interior of the canal should also be checked in the case of a fracture of a pars or of an articular process. When the screw is tightened, the plate presses against the facet joints, which may displace one or more of the fractured joints into the canal. Occasionally, one or more screws may have been slightly misrouted in the pedicle (this will show up on a postoperative CT scan). Only screws which are causing symptoms of nerve root compromise should be repositioned. The screw tract is often excessively medially routed and too low down on the pedicle. A suction drain should never be left in contact with a breach of the dural sac as it is likely to cause tonsillar herniation.

Postoperative infection means that asepsis was inadequate. The operative site should be irrigated frequently with an antibiotic solution. Further surgery by the anterior route will be required if a postoperative CT scan shows persistent residual anterior compression of more than 50 % of the anteroposterior diameter of the vertebral canal, particularly if the patient was paralysed before surgery. IV. ANTERIOR SURGERY (Images - Case No. 4)

IMAGES - CASE No. 4 1 : 21-year-old soldier, parachuting accident. Burst fracture of L2; no neurological deficits. Anterior defect and < 20 % canal encroachment. 2-3 : Anterior reconstruction with arthrodesis of L1-L3 via a left-sided thoracoabdominal incision without decompression. Return to work at 6 months. No pain 2 years later.

IV. A. General remarks Most vertebral lesions occur at the front of the spine, and one would therefore logically expect to repair them directly using an anterior approach. However, the spine runs through anatomical regions which involve various specialties, so a surgeon working on the spine must be able to access the spine by the thoracic, thoracolumbar, lumbar or abdominal routes. This technical requirement is obviously an obstacle to the general use of the anterior approach to the thoracolumbar spine, unless the orthopaedic surgeon can call upon the services of a chest or general surgeon to establish the access. Without special training or help from an appropriate specialist, anterior surgery is difficult and dangerous. In addition, the internal fixation methods

which are possible using this approach do not provide such good stability as those used in posterior surgery. For these reasons, the anterior approach should be performed only in stringently selected patients (3,4,10,11,16,20). IV. B. Indications There are two types of lesions which require an anterior approach : anterior column defects, and spinal canal encroachment by a vertebral body. Loss of bone substance appears in the form of substantial defects which are visible on a CT scan of the vertebral body in severe wedge impaction fractures reduced by conservative treatment, or of compression of the vertebral body by more than 50 % of its normal height. Anterior exposure and fixation will also be required in the case of a coronal fracture of a vertical body creating a space below the anterior inferior margin of the suprajacent vertebral body. Residual spinal canal encroachment by the vertebral body causing > 50 % canal lumen reduction will require decompression by the anterior approach, especially if there is incomplete neurological loss. Thus, if there are no neurological complications and if there is an anterior column defect with no sign of posterior lesions, the repair may be done using an anterior approach alone. In the other cases, posterior surgery will be done before anterior surgery. Major obesity may be an obstacle to anterior surgery. Associated thoracic or lumbar disorders may be a contra-indication to this form of surgery. IV. C. Operative technique - 1 Position of the patient and incisions We perform anterior surgery with the subject supine, so as to be able to work very close to the midline sagittal plane, and so have direct access to the vertebral canal. Similarly, internal fixation is easier when the spine remains straight, which is not always the case when the patient is lying on one side. We routinely put our patients in spinal traction, using the same equipment and the same forces that we use for posterior surgery. The table is broken in such a way as to place the hinge immediately beneath the fracture site, to induce lordosis (Fig. 9).

FIGURE 9 Patient positioning with lordosing traction for an anterior incision.

We use an image intensifier to ensure good reduction, so that the fracture can be reduced even before an incision is made. We always harvest a piece of fibular shaft to act as an anterior strut graft. We remove it by making an incision below the middle of the leg with the lower end at least 10 cm from the lateral malleolus. A segment of fibula 3 to 4 cm long should be harvested for use in the upper thoracic spine, two fibular segments for the thoracolumbar spine, and three fibular segments for the lumbar spine. To access the thoracic spine from T3 to T10, we use a submammary right anterolateral thoracotomy, resecting 3 to 4 costal cartilages, which will be reattached at the end of surgery. For access to the thoracolumbar junction, from T10 to L2, we recommend a thoracoabdominal approach (thoracophrenolumbotomy) that is transpleural but retroperitoneal. All transthoracic approaches will require two chest drains. For the middle lumbar vertebrae, from L2 to L4, it is best to use a left-sided retroperitoneal flank approach with an oblique incision parallel to the neurovascular structures of the abdomen. To repair lesions situated in the lumbosacral region, from L3 to S1, we prefer a midline transperitoneal approach. New possibilities for treatment have been opened up with the introduction of endoscopic or video-assisted surgery, making it possible to reconstruct a vertebral body or release a nerve root using internal fixation. These minimal-access procedures can be performed between T4 and T12 using a thoracoscopic approach; between T12 and L4 using a laparoscopic retroperitoneal approach; and between L4 and S1 using transperitoneal laparoscopic surgery. To reach the thoracolumbar junction, thoracoscopic surgery can be combined with a minimal-access technique using the retroperitoneal approach. A long learning period is needed for these endoscopic

techniques, together with an excellent knowledge of the classical approaches in case conversion to an open procedure becomes necessary. The advantage of endoscopic techniques is that they reduce postoperative complications and leave smaller scars than do the classical anterior approaches (18). We can only mention these methods in passing, as we are only just beginning to use them. - 2 Anterior decompression If an anterior incision is used to repair a defect without narrowing of the spinal canal, resection of the bony part of the vertebral bodies and of the discs can be limited to the free or mobile anterior portion of these structures, allowing the posterior wall to be preserved. In contrast, if there is any canal encroachment with neurological symptoms, a true rachiotomy must be done, exposing the anterior surface of the dural sac for the entire length of the lesions shown on the radiographs (including CT scans). Each of the vascular structures is taken on a suture passer, ligated or clipped, and divided midway between the aorta and the neural foramina. The surfaces of the vertebral bodies are then gently stripped using a medium-wide curved elevator, from the side of approach towards the anterior surface of the vertebral bodies, passing in front of the anterior longitudinal ligament towards the start of the opposite surface. When exposure is complete, a malleable blade retractor bent into an S-shape may be inserted against the opposite surface of the vertebral body, protecting the large prevertebral vessels in the upper excavation of the S(Fig. 10).

FIGURE 10 Anterior approach via a left-sided thoracoabdominal approach. Ligature and division of the segmental vessels, and exposure of the spine.

The trauma site may then be resected, starting from one centimetre in front of the neural foramina and continuing to the anterior surface of the vertebral bodies, leaving a small contralateral wall. Straight and angled rongeurs and curettes are used to resect progressively the vertebral body and one disc or the two adjacent discs. The resection often causes bleeding, so bone wax should be applied to the raw cancellous surface at frequent intervals. The resection gradually gets closer and closer to the posterior wall of the vertebral body. When extracting a large fragment impacted in the vertebral canal, no manoeuvres should be performed from front to back; instead, the disc immediately above the displaced fragment should be detached so that the dura mater is visible in the intervertebral space. An angled curette can then be inserted underneath the trapped fragment and the fragment can be drawn out. A strip of Surgicel covered with hot moist swabs should be left on for a few minutes to obtain haemostasis. The anterior surface of the dural sac will then be completely free, with only a wall of bone by the foramina (Fig. 11).

FIGURE 11 Anterior decompression; the vertebral body is opened and fibular grafts are inserted.

- 3 Stabilisation and fusion We prefer not to use inert replacement materials or internal fixation devices that may cause major damage if the implant fails. It should always be borne in mind that a major vessel may be damaged by an unstable construct, and that revision may be difficult if there are subsequent complications. Our method is based on the three factors which are necessary and sufficient for a good repair of the anterior column : The first factor is sagittal bone grafting using shaft of fibula; the second is the preservation of healthy endplates with sound cortical bone to act as supports for the flat ends of the fibular pegs; and the third factor is an anterolateral plate with screws inserted into the healthy vertebral bodies above and below the decompression site (Fig. 12).

FIGURE 12 Insertion of an anterolateral plate through a right-sided thoracotomy.

Although the fibula has traditionally been regarded as poor graft material, we can confirm that we have never observed non-union in any of the cases when fibular grafts have been inserted under the conditions described. The fibular graft must be supported by cortical bone, since a cancellous bed would not be strong enough. An anterolateral plate will not interfere with the large vessels, since the screw heads and plate will be tucked away in a neutral zone along the thoracic and the lumbar spine. When the fibular graft or grafts have been cut to the exact dimensions of the defect between two healthy endplates, they are wedged in with some force, and spinal traction is released, which compresses the grafts. The plates we use are the same as those for posterior fixation. The plate is chosen according to the length of the vertebral bodies to be fixed; any holes not required are cut off. The plate is positioned with a temporary pin at each end so that it is snugged down onto the anterolateral aspect of the vertebral bodies. The screws (diameter 5.5 mm) are also the same as those used in posterior surgery. A pilot hole 1 cm deep is drilled into the vertebral body, using a 3.2 mm drill bit. The screw is inserted in the direction of the opposite surface of the vertebral body, angling the tract slightly backwards, as if aiming at the opposite pedicle. It is not essential to try to engage the posterior cortex, as the construct will be sufficiently solid. In adults, the screw length used is about 25 mm for thoracic vertebrae, and between 35 mm and 45 mm for lumbar vertebrae. Two screws may be inserted into each thoracic vertebral body, and three into each lumbar vertebral body. If L3-L5 are being fused, anterior internal fixation is not necessary if posterior fixation has been performed. An anterolateral plate is likely to interfere with the left iliac vessels. Suction drainage should be by means of two tubes in the thoracic region and one drain in the lumbar region; it is not required if the midline transperitoneal route is used. - 4 Postoperative care After a thoracic approach, the patient remains supine, with an air and a fluid drain, which are generally kept in for 4 days. A Y-shaped connector with a one-way valve is inserted into the ends of the two tubes. When closing the chest wall, the surgeon and the anaesthetist should take care to evacuate the pneumothorax, clamping the drain after each expiration, to bring the lung back to the chest wall. Re-expansion of the lungs should be checked every day by auscultation and by bedside chest radiographs. After surgery confined to the lumbar region, a suction drain should be left in for 48 hours.

When the transperitoneal or the left thoracoabdominal routes have been used, the patient should receive antibiotic cover, with nil by mouth and parenteral nutrition until flatus is passed. Anticoagulation is not essential, but should be used after 12 hours in at-risk patients or if prolonged recumbency is expected. If anticoagulation is given too early it may cause dural sac compression by a haematoma. It is generally sufficient to put the patient into a reinforced fabric brace as soon as the drains have been removed. The support may be loosened after meals and at night; it must be worn for about 4 months. If anterior surgery alone was used, it would be preferable to use a slightly more rigid external support. No specific rehabilitation is required, apart from a good deal of brisk walking. Postoperative follow-up is the same as after posterior surgery. - 5 Complications There are many possible types of complication, which may be vascular, neural, respiratory or mechanical. Postoperative haematomas may be caused by failure to obtain adequate haemostasis. Neurological complications may be caused inadvertently during decompression : There tends to be a great deal of bleeding at this stage, making it impossible for the surgeon to see what is happening before it is too late. It would be best to use curettes working outwards from the danger area (the deeper layers) towards the surface, and protecting the large vessels by malleable blade retractors. Thoracic complications may include pneumothorax, haemothorax or atelectasis. Haemothorax may be caused by vascular leaks; if it is severe, revision may be required. Pneumothorax may be caused by inadequate re-expansion of the lung during closure, or by postoperative air leaks. The chest tubes should therefore be checked to ensure that they are patent and properly sealed. They may be connected to a suction apparatus (50 cm H2O). Atelectasis is caused by bronchial obstruction, which may need to be cleared endoscopically. On the abdominal side, it is possible for gastrointestinal function to be inhibited for 4 days, without this being an indication that something is wrong.

It is not a good idea to pack screws into the vertebral body at all costs, as this might disrupt the vertebra. Two screws in each vertebral body are sufficient to ensure adequate stability of the construct. If the vertebral bodies are very osteoporotic, the fibular strut grafts are likely to protrude through the endplates. In this case, we use another, more rigid type of internal fixation device (anterior thoracolumbar plates from Synthes). V. COMBINED APPROACH (Images - Case No. 5)

IMAGES - CASE No. 5 1-2 : 25-year-old man, road accident. Burst fracture with rotation of L3 and incomplete cauda equina syndrome. 3-4 : Canal completely blocked, with major anterior defect. 5 : First, posterior decompression and fusion of L2-L4 with a short construct. On D8, anterior reconstruction via a left flank approach with fibular strut grafts without internal fixation after decompression. Sequelae of erectile and sphincter dysfunction. Occasional pain.

V. A. Indications Both anterior and posterior surgery will be required when the objectives of surgery cannot be achieved with a single approach. This may apply in the case of very comminuted fractures (complete burst fractures) with neurological lesions where there is also an anterior defect and/or gross residual anterior compression after the first stage of surgery.

The development of minimal access techniques should extend the range of indications for a combined approach. V. B. Sequence of approaches Logically, the first stage should be the one which will give the most rapid results, especially in terms of nerve decompression. The posterior approach satisfies this requirement. In practically all other cases, the anterior approach is used as the first stage. V. C. Timing Obviously, the anterior and posterior stages can be done at one operation, but surgery is likely to take excessively long, particularly as there may be substantial blood loss which cannot be adequately compensated by the use of a Cell-Saver alone. For this reason, our usual practice is to leave a week between the two stages. CONCLUSION Our technique produces excellent results. Purely conservative treatment can be used to correct all types of deformity, albeit with subsequent loss of reduction; this loss does not, however, exceed the original deformity, i.e. this form of treatment prevents the kyphosis that occurs in the wake of unreduced fractures. In contrast, patients treated surgically experience only a very minor loss of reduction, particularly with anterior surgery. With posterior surgery, the loss is in the order of 7, as compared with 2 following anterior surgery. In our patient material, union was obtained in 97 % of cases. In cases where there are neurological lesions, anterior decompression has been clearly shown to be effective; 87 % of patients who had neurological deficits prior to surgery improved. Our mean neurological recovery rate is 68 %, comparing the patients' neurostatus grading before treatment and at one year after surgery. The potential benefit of endoscopic and video-assisted techniques is not yet clear; however, these modalities appear to hold promise for the future. They do make it possible to use very short constructs by allowing less invasive anterior reconstructive and/or neurological surgery.

Pathophysiology The lumbar spine provides both stability and support, allowing humans to walk upright. Proper function of the lumbar spine requires that it have a normal posture (ie, a normal lumbar curve). Any injury that changes the shape of a lumbar vertebra will alter the lumbar posture, increasing or decreasing the lumbar curve. As the body attempts to compensate for the alteration in the lumbar spine in order to maintain an upright posture, this will tend to distort the curves of the thoracic and cervical spine. Lumbar compression fractures can be a devastating injury, therefore, for 2 reasons. First, the fracture itself can cause significant pain, and this pain sometimes does not resolve. Second, the fracture can alter the mechanics of the posture. Most often, the result is an increase in thoracic kyphosis, sometimes to the point that the patient cannot stand upright. In trying to maintain their ability to walk, patients with kyphosis report secondary pain in their hips, sacroiliac joints, and spinal joints. These patients are also at risk for falls and accidents, increasing the risk of secondary fractures in the spine and elsewhere. Fractures in the lumbar spine occur for a number of reasons. In younger patients, fractures are usually due to violent trauma. Car accidents frequently cause flexion and flexion distraction injuries. Jumps or falls from heights cause burst fractures. These fractures can also result in serious neurological injury. In older patients, lumbar compression fractures usually occur in the absence of trauma, or in the context of minor trauma, such as a fall. The most common underlying reason for these fractures in geriatric patients, especially women, is osteoporosis. Other disorders that can contribute to the occurrence of compression fractures include malignancy, infections, and renal disease.

Traumatic fractures
Different types of fractures can occur in the lumbar (or thoracic) spine. Classification of these fractures is based on the 3-column anatomic theory of Denis, which describes anterior, middle, and posterior spinal columns consisting of aspects of the spine and their corresponding ligaments and other soft-tissue elements. The Denis system, however, was created to classify traumatic fractures. A similar classification system does not exist for compression fractures. The main reason to use such a classification is to help determine whether a fracture is stable. Instability in the Denis system implies that damage has occurred to at least 2 of the columns of the lumbar spine. Wedge fractures are the most common type of lumbar fracture and are the typical compression fracture of malignancy or osteoporosis. They occur as a result of an axially directed central compressive force combined with an eccentric compressive force. In pure flexion-compression injuries, the middle column remains intact and acts as a hinge. Although wedge fractures are usually symmetric, 8-14% are asymmetric and are termed lateral wedge fractures. Fractures involving flexion and distraction forces are often due to lap belts in motor vehicle accidents. Commonly, the posterior columns are compromised in these injuries because the ligaments of the posterior elements are disrupted. This type of injury is quite common in young children. Most patients with flexion-distraction injuries remain neurologically intact. Burst fractures result from high-energy axial loads to the spine. Multiple classification systems exist for these fractures. The severity of the deformity, the severity of canal compromise, the extent of loss of vertebral body height, and the degree of neurologic deficit affect the determination of whether these injuries are unstable. When any of the above injuries occurs with a severe rotational force, the degree of injury and of instability increases. The lumbar vertebrae are the 5 largest and strongest of all vertebrae in the spine. These vertebrae comprise the lower back. They begin at the start of the lumbar curve (ie, the thoracolumbar junction) and extend to the sacrum. The strongest stabilizing muscles of the spine attach to the lumbar vertebrae. Fractures of lumbar vertebrae, therefore, occur in the setting of either severe trauma or pathologic weakening of the bone. Osteoporosis is the underlying cause of many lumbar fractures, especially in postmenopausal women. Osteoporotic spinal fractures are unique in that they may occur without apparent trauma. However, a thorough diagnostic workup is always required to rule out spinal malignancy. The image below reveals a wedge compression fracture. (See Pathophysiology.)

Anteroposterior and lateral radiographs of an L1 osteoporotic wedge compression fracture.

In the past, treatment options for lumbar fractures were quite limited, with bracing and rest prescribed most often. While many patients improved with this regimen, some did not and were left with chronic, disabling pain. Suh and Lyles found that vertebral compression fractures were associated with significant performance impairments in physical, functional, and psychosocial domains in older women.[1] However, medical and surgical options are now available that can relieve the severe pain and disability from these fractures.

Recent studies
In a study of 55 patients with vertebral compression fracture, Rapan et al investigated changes in pain intensity following vertebroplasty (injection of a cement polymer into the fractured vertebral body; see Other Treatment). Treatment was administered to a total of 28 thoracic and 57 lumbar vertebrae; patients in the study had sustained vertebral fractures from spinal metastases or osteoporosis. Prior to surgery, the patients' average pain score on the Visual Analog Scale (VAS) was 8.36, while 24 hours postsurgery it had fallen to an average of 2.23. At 3-month follow-up, the reduction in the VAS score remained nearly the same. Among the study's patients, 1 serious complication, paraparesis resulting from cement leakage into the spinal canal, occurred. The authors concluded that in patients with vertebral compression fracture who undergo vertebroplasty, the degree of pain reduction that occurs by 24 hours postsurgery predicts the intensity of pain patients will be experiencing 3 months later. [2]

http://emedicine.medscape.com/article/309615-clinical#a0218 http://www.google.com.ph/#q=comminuted+fracture+vertebrae&hl=tl&prmd=imvns&ei=cQ93TvnrBsa4 iAfe6NCxDQ&start=10&sa=N&bav=on.2,or.r_gc.r_pw.&fp=956d21c367d66279&biw=1440&bih=809 SCC

Vertebral Compression Fractures in the Elderly

JERRY L. OLD, M.D., University of Kansas School of Medicine, Kansas City, Kansas MICHELLE CALVERT, M.D., University of Kansas School of Medicine, Wichita, Kansas
Am Fam Physician. 2004 Jan 1;69(1):111-116. This article exemplifies the AAFP 2004 Annual Clinical Focus on aging.

Compression fracture of the vertebral body is common, especially in older adults. Vertebral compression fractures usually are caused by osteoporosis, and range from mild to severe. More severe fractures can cause significant pain, leading to inability to perform activities of daily living, and life-threatening decline in the elderly patient who already has decreased reserves. While the diagnosis can be suspected from history and physical examination, plain roentgenography, as well as occasional computed tomography or magnetic resonance imaging, are often helpful in accurate diagnosis and prognosis. Traditional conservative treatment includes bed rest, pain

control, and physical therapy. Interventional procedures such as vertebroplasty can be considered in those patients who do not respond to initial treatment. Family physicians can help patients prevent compression fractures by diagnosing and treating predisposing factors, identifying high-risk patients, and educating patients and the public about measures to prevent falls.

Vertebral compression fractures affect approximately 25 percent of all postmenopausal women in the United States.1 The prevalence of this condition steadily increases with advancing age, reaching 40 percent in women 80 years of age.2 Women diagnosed with a compression fracture of the vertebra have a 15 percent higher mortality rate than those who do not experience fractures.3 Although less common in older men, compression fractures also are a major health concern in this group.46 Because the age group of those older than 65 years is now the fastest growing segment of the U.S. population, the incidence of this age-specific fracture is likely to increase. According to data collected in 1995, the annual direct medical cost of vertebral compression fractures in the United States is estimated to be $746 million.1 Vertebral compression fractures are less expensive compared with hip fractures; however, vertebral compression fractures have a substantial negative impact on the patient's function and quality of life.7 Acute and chronic pain in the elderly commonly is attributed to severe pain from vertebral compression fractures, and often leads to further disability.8 In addition to physical limitations, vertebral compression fractures may produce a psychosocial and emotional burden on the aging person who already faces losses of independent function. This may cause the person to worry about what the future may bring. These worries are not unfounded, because there is a substantial risk of subsequent fractures of all types and further morbidity in persons who have had a vertebral compression fracture.9

Pathophysiology and Risk Factors

Vertebral compression fractures are recognized as the hallmark of osteoporosis,10 and many of the risk factors are the same.11 Risk factors are categorized as those not modifiable and those that are potentially modifiable. Nonmodifiable risk factors include advanced age, female gender, Caucasian race, presence of dementia, susceptibility to falling, history of fractures in adulthood, and history of fractures in a first-degree relative. Potentially modifiable risk factors include being in an abusive situation, alcohol and/or tobacco use, presence of osteoporosis and/or estrogen deficiency, early menopause or bilateral ovariectomy, premenopausal amenorrhea for more than one year, frailty, impaired eyesight, insufficient physical activity, low body weight, and dietary calcium and/or vitamin D deficiency. Fracture rates are lower in most nonwhite populations, but vertebral compression fractures are as common in Asian women as in white women. Ironically, obesity is protective to fractures as it is to bone loss in general. Acute fractures occur when the weight of the upper body exceeds the ability of the bone within the vertebral body to support the load. Generally, some trauma occurs with each compression fracture. In cases of severe osteoporosis, however, the cause of trauma may be simple, such as stepping out of a bathtub, vigorous sneezing, or lifting a trivial object, or the trauma may result from the load caused by muscle contraction.12(p 880 1) Up to 30 percent of compression fractures occur while the patient is in bed.13In cases of moderate

osteoporosis, more force or trauma is required to create a fracture, such as falling off a chair, tripping, or attempting to lift a heavy object. Of course, a healthy spine can sustain a compression fracture from severe trauma such as an automobile crash or a hard fall.

FIGURE 1. Wedge fracture.

FIGURE 2. Burst fracture.

The applied force usually causes the anterior part of the vertebral body to crush, forming an anterior wedge fracture (Figure 1). The middle column remains intact and may act as a hinge. This results in loss of anterior height of the vertebra while the posterior height remains unchanged. As the collapsed anterior vertebrae fuse together, the spine bends forward, causing a kyphotic deformity. Because the majority of damage is limited to the anterior vertebral column, the fracture is usually stable and rarely associated with neurologic compromise.14 A fracture is considered a burst fracture if the entire vertebral body breaks(Figure 2). Spinal compression fractures can be insidious and may produce only modest back pain early in the course of progressive disease. Over time, multiple fractures may result in significant loss of height. Progressive loss of stature results in shortening of paraspinal musculature requiring prolonged active contraction for maintenance of posture, resulting in pain from muscle fatigue. This pain may continue long after the acute fracture has healed.15 Patients develop thoracic kyphosis and lumbar lordosis as vertebral height is lost. The rib cage presses down on the pelvis, reducing thoracic and abdominal space. In severe cases, this results in impaired pulmonary function, a protuberant abdomen, andbecause of compressed abdominal organsearly satiety and weight loss.16 Complications from compression fractures are summarized in Table 1.

Diagnosis
About one third of vertebral fractures are actually diagnosed,17,18 because many patients and families regard back pain symptoms as arthritis or a normal part of aging. Therefore, compression fracture should be suspected in any patient older than 50 years with acute onset of sudden low back pain. Most patients will remember a specific injury as the cause10; however, fractures may occur without any history of increased force on the spine. Lying in the supine position generally relieves some of the discomfort. Standing or walking exacerbates the pain. Physical examination will reveal tenderness directly over the area of acute fracture, and an increased kyphosis may be noted.19 In cases of uncomplicated compression fractures, straight leg raise will be negative and neurologic examination will be normal. An ileus, or decreased bowel sounds, may be present. The diagnosis can be confirmed if plain radiographs show the classic wedge deformity correlating with the area of tenderness found on physical examination.

Radiographic Findings
Plain frontal and lateral radiographs are the initial imaging study obtained for a suspected compression fracture. Compression of the anterior aspect of the vertebrae results in the classic wedge-shaped vertebral body with narrowing of the anterior portion (Figure 3).20.

FIGURE 3. (Top) Anterior portion and (bottom) lateral views of the lumbar spine show a mild compression deformity of the L1 vertebral body (there are six nonribbed lumbar-type vertebrae). Also noted are narrowed disk spaces at L45 and L56.

Radiographically, a decrease in vertebral height of 20 percent or more, or a decrease of at least 4 mm compared with baseline height is considered positive for compression fracture.10 Compression fractures can occur anywhere from the occiput to the sacrum, although they usually occur at the lumbodorsal junction, namely T8-T12, L1, and L4.13 It is important to image the entire spine because 20 to 30 percent of vertebral compression fractures are multiple. When multiple, the fractures occur at different levels or in one to five consecutive vertebral bodies.12(p 2501) Serial plain films may be necessary to visualize the vertebral injury because the deformity can take days to weeks to develop.
TABLE 1

Complications from Compression Fractures of the Spine

ConstipationBowel obstructionProlonged inactivityDeep venous thrombosisIncreased osteoporosisProgressive muscle weaknessLoss of independenceKyphosis and loss of height Crowding of internal organsRespiratory decreaseatelectasis, pneumoniaProlonged painLow selfesteemEmotional and social problemsIncreased nursing home admissionsMortality

Computed tomography (CT) and magnetic resonance imaging (MRI) are used for evaluating the posterior vertebral wall integrity and for ruling out other causes of back pain (Figure 4).21 CT can be helpful for identifying a fracture that is not well visualized on plain films, for distinguishing a compression fracture from a burst fracture, and for further evaluation of a complex fracture. CT also can reveal spinal canal narrowing. MRI is recommended when patients have suspected spinal cord compression or other neurologic symptoms. Malignancy, not osteoporosis, should be considered as the cause in patients younger than 55 years with a compression fracture without trauma or only minimal trauma.19 In these patients, or in patients with known or suspected malignancy, MRI should be obtained as part of the work-up. The fluid-sign (presence of a fatfluid level, or lipohemarthrosis) on MRI can be useful to distinguish osteoporosis from malignancy as the cause for pathologic fracture.22 MRI also allows for the differentiation of edema caused by a benign fracture from that of tumor infiltration. The bone marrow signal on MRI can help identify an acute fracture and distinguish ages of compression fractures.23 Follow-up films or further evaluation with CT or MRI is indicated for patients with continued pain

despite conservative therapy or when symptoms are progressive. Bone density studies are beneficial for evaluating the severity of osteoporosis and in advising patients of the likelihood of subsequent fractures.24 A nuclear medicine bone scan (Figure 5) is useful when surveying the entire skeleton for osteoporotic fractures, especially when symptoms are atypical. It is particularly helpful in diagnosing sacral insufficiency fractures, which are common in osteoporosis but difficult to visualize on radiographs. On bone scan, they appear as increased radiotracer activity in an H or butterfly pattern across the sacrum. Bone scans also can differentiate between an acute versus healed compression fracture because new fractures will appear hot.

FIGURE 4. Magnetic resonance imaging of the thoracic cord shows a wedge-shaped deformity with increased signal intensity of T7 indicating an acute severe compression fracture. There are older compression deformities of T8 and T12.

Treatment
The physician must first determine if the fracture is stable or unstable. A stable fracture will not be displaced by physiologic forces or movement. Fortunately, compression fractures are normally stable secondary to their impacted nature. Traditional treatment is nonoperative and conservative. Patients are treated with a short period (no more than a few days) of bedrest. Prolonged inactivity should be avoided, especially in elderly patients. Oral or parenteral analgesics may be administered for pain control, with careful observation of bowel motility. If bowel sounds and flatus are not present, the patient may require evaluation and treatment for ileus. Calcitonin-salmon (Miacalcin) nasal spray can be used for treatment of pain.25 Muscle relaxants, external back-braces, and physical therapy modalities also may help.26[Evidence level B] Nonsteroidal antiinflammatory drugs have been shown to significantly increase gastrointestinal bleeding in the elderly and must be used with caution.27 [Evidence level A, randomized control trial (RCT)]

FIGURE 5. Bone scan revealing an area of increased uptake at the level of L3, consistent with acute compression fracture.

Patients who do not respond to conservative treatment or who continue to have severe pain may be candidates for percutaneous vertebroplasty. Percutaneous vertebroplasty involves injecting acrylic cement into the collapsed vertebra to stabilize and strengthen the fracture and vertebral body.21 This procedure does not, however, restore the shape or height of the compressed vertebra. Kyphoplasty, where cement is injected into a cavity created by a high-pressure balloon, is being evaluated for use and may be successful in restoring height to the collapsed vertebra. Most patients can make a full recovery or at least significant improvements from their compression fracture after six to 12 weeks, and can return to a normal exercise program after the fracture has fully healed. A wellbalanced diet, regular exercise program, calcium and vitamin D supplements,28 smoking cessation, and medications to treat osteoporosis (such as bisphosphonates) may help prevent additional compression fractures. Age should never preclude treatment.

There is now good evidence that diagnosing and treating osteoporosis does indeed reduce the incidence of compression fractures of the spine.24,29,30 [Reference 29Evidence level A, RCT; Reference 30Evidence level A, RCT] Regular activity and muscle strengthening exercises have been shown to decrease vertebral fractures and back pain.31 Measures to prevent falls must be initiated by patients and their caregivers. Table 232 lists items that should be assessed when determining what preventive measures should be followed. Additionally, family physicians can take a leadership role in their communities by assessing and addressing those factors that can increase the incidence of vertebral compression fractures in elderly persons, such as inappropriate or over-medication, use of restraints, unsafe home situations, and physical abuse.
TABLE 2

Assessment of Risk for Falls in Older Persons

Avoidance of restraintsBalance assessmentCardiac function, cardiac rhythm heart rate, orthostatic pulse, and blood pressureGait Muscle strengthNeurologic function; cortical, extrapyramidal, and cerebellar functions; lower extremity peripheral nerves; proprioception; reflexesVision

Information from Guideline for the prevention of falls in older persons. American Geriatrics Society, British Geriatrics Society, and American Academy of Orthopaedic Surgeons Panel on Falls Prevention. J Am Geriatr Soc 2001;49:66472.

The Authors
JERRY L. OLD, M.D., is clinical assistant professor in the Department of Family Medicine at the University of Kansas School of Medicine, Kansas City. He received his medical degree from the University of Kansas School of Medicine, Kansas City, and completed a residency in family medicine at the University of Kansas Medical Center, Kansas City. MICHELLE CALVERT, M.D., is a third-year radiology resident at the University of Kansas School of Medicine, Wesley Hospital, Wichita. She received her medical degree from the University of Kansas School of Medicine, Wichita. Address correspondence to Jerry L. Old, M.D., Department of Family Medicine, University of Kansas School of Medicine, 3901 Rainbow Blvd., Kansas City, KS 66160 (e-mail: jold@kumc.edu). Reprints are not available from the authors. The authors indicate that they do not have any conflicts of interest. Sources of funding: none reported. The authors thank Mark Meyer, M.D., and Allen Greiner, M.D., University of Kansas School of Medicine, Kansas City, Kan., for their review and assistance in the preparation of the manuscript. Figures 3 5 provided by Jerry L. Old, M.D.

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Comminuted Fracture | Comminated Bone Fracture Treatment and Types

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Comminuted fracture is a broken bone that has three or even more fragments. This is essentially the best and most profound way to define comminuted fracture. This type of bone fracture is deemed a serious bone fracture due to the fragmentation of the bone. It is also called as multi-fragmentary fracture. Like some other fractures, this can be under the classification of open or closed fracture. An open comminuted fracture would have the fragments tearing the skin of the injured area resulting to an open wound. On the other hand, a closed comminuted bone fracture does not have any outward wounds at all. When it comes to the question of the difficulty of how to heal this type of fracture, an open fracture is at risk of infection which is why it is more difficult and more urgent to treat it. Open comminuted fractures are considered more dangerous than closed ones because they are prone to infection which makes their comminuted recovery time take even longer. It would be quite hard to know how comminuted fracture treatment should be done quickly. Due to the multi-fragmented condition of the fractured bone, it only becomes a complicated case to handle. A good surgeon can provide you great assurance that your comminuted fracture treatment will go well despite the complication of the fracture. Bones are made up of calcium phosphate, the minerals that can make them grow denser. As the person ages, this particular mineral is deposited to the bones. The peak of the density of the bones will happen when the person is already 30 years of age. This is the time when the bones are really at their densest and strongest. This is why comminuted skull fracture in children or any other multifragmented fracture in other parts of the body would easily happen. Children still have softer bones at their age but they are still lucky because their fracture healing time is relatively fast compared to adults, especially the older people. This is because the kids bones are still growing making them recover faster after a greenstick fracture, for instance. It is a different case in adults though because the recovery time might be longer. Comminuted fracture treatment has to be done with more care for patients who have multi-fragmented fractures due to diseases. The comminuted fracture definition is having three or more fragmented bones but it does not cite any specific reason for the fragmentation. For instance, lumbar compression fracture might be caused by osteoporosis or cancer of the bone. There are several causes that might result to comminuted fracture injury. Fragmented bones are the result of a strong force that happens during impact of any bony part of the body with a hard surface. There are also several other types of bone fractures that might be broken into pieces as well. A boxer fracture might have fragmented metacarpal bones. Dens fracture or hip fracture can also become fragmented when hit with an extremely strong impact. This also goes the same for dancers fracture which can be caused by even a single misstep. Overly used foot might result to foot stress fracture. Comminuted Fracture Causes There are many causes of this kind of fracture. When a bone is crushed hard with a very strong force, this would likely break the bone into pieces. When the hips are hit by a powerful external impact, comminuted intertrochanteric fracture would likely occur. Even if the bones are dense, they are still prone to breaking, much more so those bones that lack the deposit of calcium phosphate. This is also likely the same story about how a comminuted spiral fracture happens. Older

people are also prone to crushed bones. This could result to nondisplaced comminuted fracture. Bones become weaker as people age and as diseases eat them up, such as the case with osteoporosis. Comminuted fracture humerus is also caused by some diseases like osteogenesis imperfect, cancer, and other diseases that weaken the bones in the body. Weak bones would not require too much force to get broken and to get comminuted injury or other fractures. A fall or some other accidents would likely result to fracture of hips, wrist, spine, and other bones. Accidents are cited as among the common causes of the different types of comminuted fracture. These accidents would include severe fall, vehicular trauma, bullet injury, and many other types of accidents. Vehicular accidents are the usual reasons why younger people have comminuted intraarticular fracture, or any other type of fractures. Diseases that affect the bones are the usual causes of the comminuted fractures among the older people. These are also pointed as the causes of severely comminuted fracture in some cases. Due to age and diseases, bones have the tendency to turn brittle which is why they become easy to break, and when they do, they often result to comminuted compound fracture. Fracture Symptoms There are also certain signs and symptoms that would show if the patient has broken a comminuted bone fracture. Pain is also felt by people who have comminuted tuft fracture and the other types of similar fracture. Swelling and bruises in the injured part are other symptoms that can be used to tell if there broken comminuted bones. The fractured area also feels warmer relative to the other parts of the body, another common symptom for fractured comminuted bone. When you have comminuted femur fracture, your thigh area would likely feel hotter than the other parts of your body that are still in perfect condition. Tenderness can be felt as well. If the fractured bone is used to exert effort on something, the pain might be too extreme to bear. There are even patients with comminution fracture who can no longer bear the pain and pass out. Having a comminuted calcaneal fracture is a serious matter because of the pain involved in the injury. This is a fracture on the heel that would make it difficult for the patient to walk or to even stand. Fracture Diagnosis X-ray is common equipment that is used by doctors who are examining patients who might have fractures, based on their initial findings. Repeated x-rays need to be done for those who just met an accident or just came from a severe fall and earned a comminuted tibial fracture in the process. This kind of examination is necessary because there are certain fractures that are quite hidden. To treat comminuted fracture completely and to let it undergo rehabilitation without any problem at all, all the fragments must be pieced back together in the right places. This is necessary to reduce the probability of the patient experiencing fracture complications, such as arthritis. A complete rehab would help you restore the fragmented bones back to their normal condition. Even if you would need to be more careful in using or moving an already fractured part of your body, at least you can already move without much inhibition. The right treatment for the fracture would be known after the results of the x-ray would come out. It is through this kind of examination that the fracture will be seen clearly. The doctor would know how the fragments are positioned, how the damage of the

comminuted displaced fracture is, and the like. This is how the doctor can tell if you need braces or not. You might even need fracture surgery if the damage is too big to be repaired by fracture cast alone. Treatment for Fracture Comminuted Compound comminuted fracture or some other fractures might need surgery in the soonest time possible, especially when the fracture also has an open wound. This is usually the case in any compound fracture. The surgery can certainly help put the fragments of the comminuted pilon fracture back together. This way, the fragments would connect back to each others tips and heal faster. There are also cases of comminuted clavicle fracture wherein due to the severity of the damage, the entire area might be opened during surgery to see the bones more closely. This also goes the same for comminuted fracture tibia and the other types of comminuted bone breakage. The exposed bones that are broken and separated from each other can be reassembled using pins. Some medicines are necessary because comminuted patellar fracture would put the patient in so much pain. Emedicine for preventative treatment would be necessary in some cases. There are also certain prescriptions that need to be taken in order to stay away from the risk of infection.

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