Spinal Fracture (Adult)

1. Clinical Overview

Summary

Spinal fractures represent a spectrum of vertebral injuries ranging from stable compression fractures to complex unstable fracture-dislocations with neurological compromise. These injuries occur when mechanical forces exceed the structural capacity of vertebral bone and supporting ligamentous structures. The spine can be conceptualised as a weight-bearing column with three functional components: the anterior column (anterior longitudinal ligament, anterior two-thirds of vertebral body and disc), middle column (posterior one-third of vertebral body, posterior longitudinal ligament), and posterior column (pedicles, facets, laminae, spinous processes, and posterior ligamentous complex). [1]

Fracture patterns result from specific injury mechanisms including axial compression, flexion, extension, rotation, and distraction forces, often in combination. Understanding these biomechanical forces is essential for classification, stability assessment, and treatment planning. [2] The critical distinction lies between stable fractures that can heal with conservative management and unstable injuries requiring surgical stabilisation to prevent progressive deformity or neurological injury.

Spinal cord injury (SCI) complicates 10-25% of spinal fractures and represents the most devastating consequence. [3] The level of spinal injury dictates neurological impact: cervical injuries may cause quadriplegia affecting all four limbs and potentially requiring ventilatory support; thoracic injuries typically result in paraplegia; and thoracolumbar injuries may cause lower limb weakness and cauda equina syndrome. Immediate recognition, proper immobilisation, systematic assessment using validated tools, and timely intervention are paramount to optimising outcomes.

Key Facts

• Definition: Disruption of vertebral integrity due to trauma, pathology, or insufficiency
• Incidence: 64-160 per 100,000 population annually; bimodal distribution [4]
• Mortality: Overall less than 1% for isolated fractures; increases to 3-10% with SCI [3]
• Peak age: Bimodal (young adults 15-30 years from high-energy trauma; elderly >65 years from osteoporotic fractures)
• Most common level: Thoracolumbar junction (T11-L2) accounts for 60-70% of traumatic injuries [5]
• SCI incidence: 10-25% of all spinal fractures; higher with cervical and thoracolumbar junction injuries [3]
• Critical feature: Back pain, deformity, neurological deficit (in 10-25%)
• Key investigations: Lateral cervical spine X-ray (initial), CT (gold standard for bony detail), MRI (ligamentous injury and neural compression)
• First-line treatment: Immobilisation, ABCDE assessment, early decompression if SCI (less than 24 hours improves outcomes) [6]
• Stability criteria: Denis three-column model; TLICS score ≥5 indicates surgical candidacy [7]

Clinical Pearls

"Immobilise first, clear later" — Maintain spinal precautions in all trauma patients with concerning mechanism until injury is excluded using validated clinical decision rules (NEXUS or Canadian C-Spine Rule). Premature mobilisation risks secondary neurological injury.

"The thoracolumbar junction is a watershed" — T11-L2 represents the transition from rigid thoracic spine (stabilised by rib cage) to mobile lumbar spine, concentrating mechanical stress. This region accounts for 60-70% of spinal fractures.

"Time is spine" — Early decompression (less than 24 hours) in incomplete SCI is associated with improved neurological recovery. [6] Don't delay definitive imaging or surgical consultation.

"Complete the ASIA examination" — Standardised neurological assessment using ASIA Impairment Scale is essential for grading injury severity, guiding treatment, prognostication, and medicolegal documentation. [8]

"TLICS guides surgical decision-making" — Thoracolumbar Injury Classification and Severity Score combines morphology, posterior ligamentous complex integrity, and neurological status. Score ≥5 typically indicates surgical management. [7]

"Don't miss the unstable pattern" — Flexion-distraction (Chance) fractures and fracture-dislocations are inherently unstable and require surgical stabilisation regardless of neurological status.

Why This Matters Clinically

Spinal fractures represent a time-critical orthopaedic emergency requiring systematic evaluation and management. Failure to recognise unstable patterns or neurological injury can result in permanent disability. Conversely, inappropriate immobilisation and over-investigation of stable injuries leads to increased morbidity, particularly in elderly patients. Evidence-based clinical decision rules (NEXUS, Canadian C-Spine Rule), standardised classification systems (Denis, AO Spine, TLICS), and validated neurological assessment tools (ASIA scale) enable rational, safe management. This is high-yield for FRCS Orth/FRACS examinations, particularly viva scenarios involving trauma management algorithms and surgical decision-making.

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2. Epidemiology

Incidence & Prevalence

Spinal fractures demonstrate marked epidemiological heterogeneity based on age, mechanism, and anatomical level:

• Overall incidence: 64-160 per 100,000 population per year [4]
• Cervical fractures: 12-13 per 100,000 (higher mortality due to SCI)
• Thoracolumbar fractures: 30-40 per 100,000
• Osteoporotic compression fractures: 500-750 per 100,000 in those >50 years [9]
• Spinal cord injury: 40-50 new cases per million population annually [3]

Age Distribution:

• Young adults (15-30 years): High-energy trauma (MVA, falls from height, sports)
• Middle age (30-65 years): Mixed aetiology (moderate trauma, early osteoporosis)
• Elderly (>65 years): Low-energy insufficiency fractures, ground-level falls

Temporal Trends:

• Increasing incidence in elderly due to ageing population and osteoporosis
• Decreasing high-energy trauma in young adults (improved vehicle safety, workplace regulations)
• Stable SCI rates overall (~40-50 per million) [3]

Demographics

Risk Factors

Non-Modifiable:

• Age >65 years (osteoporosis, frailty)
• Male sex (high-energy trauma)
• Female sex (post-menopausal osteoporosis)
• Previous spinal fracture (2-5x increased risk) [9]
• Genetic bone disorders (osteogenesis imperfecta)

Modifiable:

Common Mechanisms

Anatomical Level Distribution:

• Cervical (C1-C7): 25-30% of all fractures
  • C2 most common (odontoid fractures, hangman's fracture)
  • C5-C7 most common in high-energy trauma
• Thoracic (T1-T10): 15-20%
  • Less common due to rib cage stabilisation
  • Higher SCI risk due to narrow spinal canal
• Thoracolumbar junction (T11-L2): 60-70% [5]
  • Biomechanical stress concentration
  • Transition from rigid to mobile spine
• Lumbar (L3-L5): 10-15%
  • Cauda equina injury rather than SCI

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3. Pathophysiology & Classification

Biomechanical Principles

Denis Three-Column Model (1983) remains the foundation for understanding spinal stability: [1]

Anterior Column:

• Anterior longitudinal ligament
• Anterior two-thirds of vertebral body and disc
• Primary load-bearing in flexion

Middle Column:

• Posterior third of vertebral body and disc
• Posterior longitudinal ligament
• Critical for stability; disruption indicates instability

Posterior Column:

• Pedicles, facet joints, laminae, spinous processes
• Supraspinous ligament, interspinous ligament, ligamentum flavum, facet joint capsules
• Resists tension forces in flexion

Stability Principle:

• Failure of one column: Usually stable
• Failure of two columns: Potentially unstable
• Failure of all three columns: Unstable; high risk neurological injury

Injury Mechanisms and Fracture Patterns

1. Compression Fractures

• Mechanism: Axial loading + flexion
• Columns involved: Anterior column only
• Stability: Stable if less than 50% vertebral body height loss, no posterior column injury, less than 20° kyphosis
• SCI risk: Very low (less than 1%)
• Clinical features: Back pain, kyphotic deformity if severe, intact neurology
• Management: Typically conservative (bracing, analgesia)

2. Burst Fractures

• Mechanism: Pure axial loading (fall from height, head-first impact)
• Columns involved: Anterior + middle columns (retropulsed bone into canal)
• Stability: Unstable if >50% canal compromise, posterior column disruption, neurological deficit
• SCI risk: 20-30% (retropulsed fragments compress cord/cauda equina)
• Clinical features: Severe back pain, neurological deficit variable
• Key imaging: CT shows "sagittal split" of vertebral body, retropulsion into canal, posterior element fractures
• Management: Surgery if unstable or neurological deficit; TLICS score guides decision [7]

3. Flexion-Distraction Injuries (Chance Fracture)

• Mechanism: Hyperflexion around anterior fulcrum (e.g., lap belt injury in MVA)
• Columns involved: Posterior and middle columns under tension; may extend through bone (bony Chance) or ligaments (ligamentous type)
• Stability: Unstable; risk progressive kyphosis
• Associated injuries: Abdominal visceral injury in 50% (seat belt sign) [10]
• SCI risk: 15-20%
• Clinical features: Horizontal fracture/diastasis, "seat belt sign" (abdominal bruising)
• Management: Surgical stabilisation required; assess for abdominal injury

4. Fracture-Dislocation

• Mechanism: Complex multidirectional forces (flexion + rotation + distraction)
• Columns involved: All three columns
• Stability: Highly unstable
• SCI risk: 70-90% (highest of all patterns) [3]
• Clinical features: Gross deformity, usually complete SCI
• Management: Urgent surgical reduction and stabilisation

Thoracolumbar Injury Classification and Severity (TLICS) Score

The TLICS score is the contemporary gold standard for thoracolumbar fracture classification and treatment decision-making: [7]

Three Components:

1. Morphology of Injury (Maximum 4 points)

• Compression: 1 point
• Burst: 2 points
• Translational/rotational: 3 points
• Distraction: 4 points

2. Integrity of Posterior Ligamentous Complex (PLC) (Maximum 3 points)

• Intact: 0 points
• Suspected/indeterminate: 2 points
• Injured: 3 points

MRI findings suggesting PLC injury: supraspinous ligament disruption, interspinous widening, facet diastasis, paraspinal oedema

3. Neurological Status (Maximum 3 points)

• Intact: 0 points
• Nerve root injury: 2 points
• Complete SCI: 2 points
• Incomplete SCI: 3 points
• Cauda equina syndrome: 3 points

Treatment Algorithm:

• TLICS ≤3: Non-operative management (bracing)
• TLICS = 4: Surgeon discretion (consider patient factors, fracture characteristics)
• TLICS ≥5: Operative management [7]

Advantages of TLICS:

• Validated interobserver reliability
• Incorporates neurological status
• Evidence-based treatment threshold
• Applicable across thoracolumbar spine (T1-L5)

AO Spine Classification

The AO Spine Classification system provides a comprehensive, hierarchical framework:

Type A: Compression Injuries

• A0: Minor fractures
• A1: Wedge compression
• A2: Pincer (coronal split)
• A3: Incomplete burst
• A4: Complete burst

Type B: Distraction Injuries

• B1: Posterior tension band injury (osseous)
• B2: Posterior tension band injury (ligamentous - highly unstable)
• B3: Hyperextension injury

Type C: Displacement Injuries

• Inherently unstable
• Includes all rotational and translational injuries

Modifiers:

• N0-N4: Neurological status (mirrors ASIA)
• M1: Case-specific modifiers (e.g., osteoporosis, ankylosing spondylitis)

Cervical Spine Specific Patterns

Odontoid (Dens) Fractures (Anderson and D'Alonzo Classification):

• Type I: Avulsion of tip (rare, stable)
• Type II: Fracture through base (most common, unstable, high non-union risk)
• Type III: Extends into C2 body (better healing potential, stable in halo)

Hangman's Fracture (C2 Traumatic Spondylolisthesis):

• Bilateral pedicle/pars fractures
• Mechanism: Hyperextension + axial loading
• Usually neurologically intact (canal decompressed by fracture)
• Management: Most heal in halo; surgery if C2/3 disc injury or severe displacement

Subaxial Cervical Fractures (C3-C7):

• Use Subaxial Injury Classification (SLIC) score (mirrors TLICS)
• Facet dislocations (unilateral vs bilateral) require reduction ± fusion

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4. Clinical Presentation

Symptoms: The Patient's Story

Acute Traumatic Presentation:

Cardinal Symptoms:

• Back pain: Immediate, severe, localised to fracture level; exacerbated by movement
• Inability to move: Patient refuses to move due to pain or neurological deficit
• Neurological symptoms: Numbness, tingling, weakness, paralysis (if SCI)
• Bladder/bowel dysfunction: Urinary retention, incontinence (suggests cauda equina or SCI)

History to Elicit:

1. Mechanism of injury:

   • High-energy: MVA (speed, restraints, ejection), fall from height (how many metres), diving (water depth)
   • Low-energy: Ground-level fall (suggests osteoporosis or pathological fracture)
   • Time since injury (critical for planning early decompression)

2. Pain characteristics:

   • Location: Cervical, thoracic, lumbar, sacral
   • Severity: Usually severe (8-10/10) in acute fracture
   • Radiation: May radiate to extremities if nerve root compression

3. Neurological symptoms:

   • Immediate vs delayed onset (delayed suggests evolving haematoma)
   • Complete loss of function vs partial weakness
   • Sensory level (aids localisation)
   • Bowel/bladder: Retention (cauda equina) vs incontinence (SCI)

4. Associated injuries:

   • Head injury (33% have concomitant spinal injury) [11]
   • Chest/abdominal trauma (lap belt injury → Chance fracture)
   • Limb fractures (20% have multiple injuries)

5. Past medical history:

   • Osteoporosis, malignancy (pathological fracture)
   • Anticoagulation (epidural haematoma risk)
   • Ankylosing spondylitis (highly unstable fractures)

Osteoporotic Compression Fracture Presentation:

• Acute back pain following minor trauma (cough, lifting, ground-level fall)
• Gradual onset over days (may be atraumatic)
• Height loss and progressive kyphosis over time
• Multiple levels common (20-30% have >1 fracture) [9]
• Usually no neurological deficit

Signs: What You Find on Examination

ABCDE Assessment (Primary Survey):

A - Airway (with C-spine protection)

• Assessment: Talking normally? Airway obstruction? Stridor?
• High cervical injury (C3-C5) may compromise phrenic nerve → respiratory failure
• Action: Maintain inline stabilisation; if compromised, secure airway with inline stabilisation

B - Breathing

• Look: Respiratory rate, paradoxical breathing (diaphragmatic only → high cervical injury), chest wall bruising
• Listen: Air entry, added sounds
• Measure: SpO₂, ABG if concerns
• High thoracic SCI → intercostal paralysis → impaired cough, secretion retention
• Action: High-flow O₂, consider ventilatory support if C3-C5 injury

C - Circulation

• Look: Skin colour, capillary refill, external haemorrhage
• Feel: Pulse (rate, rhythm, character), peripheries (temperature)
• Measure: BP, HR, ECG
• Spinal shock (neurogenic shock): Hypotension + bradycardia (loss of sympathetic tone below injury level)
  • Differentiates from hypovolaemic shock (hypotension + tachycardia)
  • "Management: Cautious fluid resuscitation, vasopressors if needed (noradrenaline)"
• Action: Identify and treat haemorrhagic shock first (spinal shock is diagnosis of exclusion)

D - Disability (Neurological Assessment)

• GCS (exclude head injury)
• Full ASIA examination (see below)
• Pupillary response
• Blood glucose

E - Exposure

• Full examination with log-roll (maintaining spinal alignment)
• Look for: Bruising (seat belt sign, spinous process tenderness), deformity (step-off, kyphosis), open wounds
• Rectal examination (anal tone, perianal sensation, bulbocavernosus reflex)

Focused Spinal Examination

Inspection:

• Patient position: Unable to move, self-immobilising
• Deformity: Kyphosis, scoliosis, step-off between spinous processes
• Bruising: Seat belt sign (horizontal abdominal/chest bruising → Chance fracture risk) [10]
• Swelling: Localised paraspinal swelling

Palpation (Perform During Log-Roll):

• Bony tenderness: Palpate each spinous process (tenderness indicates fracture until proven otherwise)
• Step-off: Palpable displacement between spinous processes (indicates dislocation)
• Paraspinal spasm: Severe involuntary muscle guarding

Neurological Examination (ASIA Impairment Scale - Detailed): [8]

The ASIA examination is the international standard for SCI assessment:

Motor Examination:

• Test 10 key muscles (5 upper limb, 5 lower limb), graded 0-5 (MRC scale)
• Upper limb: C5 (elbow flexors - biceps), C6 (wrist extensors), C7 (elbow extensors - triceps), C8 (finger flexors - FDP to middle finger), T1 (small finger abductors - abductor digiti minimi)
• Lower limb: L2 (hip flexors - iliopsoas), L3 (knee extensors - quadriceps), L4 (ankle dorsiflexors - tibialis anterior), L5 (long toe extensors - EHL), S1 (ankle plantarflexors - gastrocnemius/soleus)
• Total motor score: 0-100 (50 per side)

Sensory Examination:

• Test 28 dermatomes bilaterally for light touch and pinprick (0-2 scale each)
  • 0 = Absent
  • 1 = Impaired
  • 2 = Normal
• Total sensory score: Light touch 0-112, pinprick 0-112
• Sensory level: Most caudal dermatome with normal sensation

Key Dermatomes (High-Yield):

• C5: Lateral arm (over deltoid)
• C6: Thumb
• C7: Middle finger
• C8: Little finger
• T4: Nipple line
• T10: Umbilicus
• L4: Medial ankle
• L5: Dorsum of foot (first web space)
• S1: Lateral foot
• S4-S5: Perianal (critical for sacral sparing)

Sacral Sparing Assessment (Critical for ASIA Grading):

• Deep anal pressure: Voluntary contraction of external anal sphincter (tests S2-S4 motor)
• Perianal sensation: Light touch and pinprick S4-S5 dermatomes
• Presence of sacral sparing → Incomplete injury (ASIA B, C, or D)
• Absence of sacral sparing → Complete injury (ASIA A)

ASIA Impairment Scale (AIS) Grading:

Clinical Significance:

• ASIA A: Poorest prognosis; less than 5% chance significant recovery [8]
• ASIA B: 20-30% convert to ambulatory status with rehabilitation
• ASIA C: 50-70% achieve functional ambulation
• ASIA D: >90% achieve independent ambulation
• Sacral sparing predicts better outcomes even if motor complete

Special Neurological Syndromes

1. Central Cord Syndrome

• Mechanism: Hyperextension injury in elderly with cervical spondylosis/stenosis
• Pattern: Upper limb weakness >> lower limb weakness (inverted cape distribution)
• Pathophysiology: Central grey matter injury (medial corticospinal tracts to arms affected more than lateral tracts to legs)
• Prognosis: Best recovery of incomplete SCI syndromes (70-80% ambulate) [12]
• Management: Usually conservative initially; delayed decompression if no improvement

2. Anterior Cord Syndrome

• Mechanism: Flexion injury, anterior spinal artery occlusion, retropulsed disc/bone
• Pattern: Loss of motor, pain, and temperature; preserved proprioception and vibration (posterior columns spared)
• Prognosis: Poorest recovery of incomplete syndromes (10-20% functional recovery) [12]
• Management: Urgent decompression

3. Brown-Séquard Syndrome

• Mechanism: Penetrating injury, hemisection of cord
• Pattern: Ipsilateral motor and proprioception loss, contralateral pain and temperature loss
• Prognosis: Best prognosis (>90% ambulate) [12]

4. Posterior Cord Syndrome

• Mechanism: Hyperextension, rare
• Pattern: Loss of proprioception and vibration; preserved motor and pain sensation

5. Cauda Equina Syndrome

• Mechanism: Fracture-dislocation L1-L2 or lower, burst fracture with canal compromise
• Pattern: Lower motor neuron (LMN) pattern - flaccid paralysis, areflexia, saddle anaesthesia, bladder/bowel dysfunction
• Key difference from conus medullaris: Asymmetric, predominantly LMN signs
• Management: Urgent decompression (less than 48 hours for bladder recovery) [13]

Red Flags

[!CAUTION] Red Flags — Immediate Escalation Required:

• Any neurological deficit (numbness, weakness, paralysis) — Indicates SCI; requires urgent imaging (MRI) and neurosurgical/spinal surgical review
• Saddle anaesthesia + bladder/bowel dysfunction — Cauda equina syndrome; requires urgent MRI and decompression less than 48 hours [13]
• Spinal shock (hypotension + bradycardia with SCI) — Neurogenic shock; requires cautious resuscitation, vasopressors
• Neurological deterioration — Evolving haematoma, unstable fracture; requires urgent re-imaging and surgical review
• Seat belt sign (horizontal abdominal bruising) — 50% have Chance fracture + abdominal visceral injury [10]
• High-energy mechanism with normal radiographs but midline tenderness — Ligamentous injury; requires MRI to exclude unstable purely ligamentous injury
• Ankylosing spondylitis with ANY spinal trauma — Highly unstable fractures; often missed on radiographs; requires CT entire spine [14]

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5. Clinical Decision Rules for Cervical Spine Clearance

NEXUS Low-Risk Criteria [15]

Cervical spine imaging is not required if ALL five criteria are met:

1. No posterior midline cervical tenderness
2. No focal neurological deficit
3. Normal level of alertness (GCS 15)
4. No intoxication
5. No painful distracting injury

Performance:

• Sensitivity: 99.6% (95% CI 98.6-100%)
• Specificity: 12.9%
• NPV: 99.8%

Interpretation: Very sensitive; if all criteria met, can clinically clear C-spine without imaging. [15]

Canadian C-Spine Rule [16]

Three-Step Process:

Step 1: Are there any high-risk factors that mandate imaging?

• Age ≥65 years
• Dangerous mechanism (fall >1 metre/5 stairs, axial load to head, MVA high-speed/rollover/ejection, bicycle collision, motorised recreational vehicle)
• Paraesthesias in extremities

If YES to any → Image

Step 2: Are there any low-risk factors that allow safe assessment of range of motion?

• Simple rear-end MVA
• Sitting position in ED
• Ambulatory at any time
• Delayed onset neck pain (not immediate)
• Absence of midline C-spine tenderness

If NO to all → Image

Step 3: Can patient actively rotate neck 45° left and right?

• If YES → Can clear clinically
• If NO → Image

Performance:

• Sensitivity: 100% (95% CI 98-100%)
• Specificity: 42.5%
• More specific than NEXUS; superior for reducing unnecessary imaging [16]

Practical Application:

• Canadian C-Spine Rule preferred in alert, stable patients
• NEXUS simpler, often used in obtunded or intoxicated patients
• Either rule acceptable; local protocol dependent
• If any doubt, image (risk of imaging much less than risk of missed injury)

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6. Investigations

First-Line Investigations

1. Clinical Assessment (Mandatory)

• History: Mechanism, timing, neurological symptoms, past medical history
• Examination: ABCDE, full spinal palpation, complete ASIA examination
• Risk stratification: Apply NEXUS or Canadian C-Spine Rule

2. Imaging - Traumatic Fractures

Initial X-Rays:

• Cervical spine:
  • Lateral (must visualise C1-T1; 75% sensitivity for fractures)
  • AP
  • Peg view (odontoid)
  • Inadequate if C7-T1 not visualised → CT
• Thoracolumbar spine:
  • AP and lateral if suspected
  • Low sensitivity (~60%); CT preferred in high-risk patients

CT Spine (Gold Standard for Bony Injury):

• Indications:
  • All high-risk patients (NEXUS or Canadian C-Spine Rule positive)
  • Inadequate X-rays
  • Abnormal X-rays
  • High-energy mechanism
  • Neurological deficit
  • Multiple trauma (whole-body CT protocol)
• Sensitivity: >95% for fractures
• Advantages: Multiplanar reconstruction, detailed bony anatomy, canal compromise assessment
• Limitations: Poor visualisation of ligamentous injury, disc herniation, spinal cord contusion

MRI Spine (Gold Standard for Soft Tissue and Neurological Injury):

• Indications:
  • Any neurological deficit (to assess cord compression, cord oedema/haemorrhage, disc herniation)
  • Suspected ligamentous injury (PLC disruption)
  • Normal CT but persistent symptoms/signs
  • Planning surgery (identifies site of neural compression)
  • Prognostication in SCI (cord haemorrhage → worse prognosis)
• Key findings:
  • "Cord oedema (T2 hyperintensity): Contusion, potentially reversible"
  • "Cord haemorrhage (T2 hypointensity): Worse prognosis for recovery [17]"
  • "PLC injury: STIR hyperintensity in supraspinous/interspinous ligaments, facet diastasis"
  • "Disc herniation: Compressive lesion"
  • "Epidural haematoma: Compressive, may evolve over hours"
• Timing: Urgent if neurological deficit; within 24-48 hours if ligamentous injury suspected

Practical Imaging Algorithm:

1. High-energy trauma + multisystem injury: Whole-body CT (including spine)
2. Isolated spinal trauma, alert patient: Apply NEXUS/Canadian C-Spine Rule
   • If rule negative: Clinical clearance
   • If rule positive: CT spine
3. Any neurological deficit: CT (for bony injury) + MRI (for cord/soft tissue)
4. CT shows fracture: MRI if surgical planning needed, neurological deficit, or suspected PLC injury

Laboratory Tests

Specialised Investigations

Dynamic Flexion-Extension Radiographs:

• Indication: Suspected ligamentous injury with normal static imaging
• Contraindications: Neurological deficit, obtunded patient, bony fracture
• Technique: Active (patient-controlled) flexion-extension laterals
• Findings: >3.5mm translation or >11° angulation suggests instability
• Contemporary use: Largely replaced by MRI for ligamentous injury assessment

Bone Density (DEXA Scan):

• Indication: Osteoporotic fracture or low-energy mechanism age >50
• Purpose: Diagnose osteoporosis (T-score ≤-2.5), guide treatment (bisphosphonates)
• Timing: Can be performed acutely or during follow-up

Whole-Spine Imaging:

• Indication: 10-15% of spinal fractures have non-contiguous second fracture [18]
• Method: CT or MRI entire spine if high-energy mechanism
• Sites to image: Cervical, thoracic, lumbar, sacral

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7. Management

Management Algorithm

         SUSPECTED SPINAL FRACTURE
    (Trauma + back pain ± neurological deficit)
                    ↓
┌────────────────────────────────────────────────┐
│         IMMEDIATE ACTIONS (ABCDE)              │
│  • Immobilise spine (collar, blocks, scoop)    │
│  • Airway with C-spine protection              │
│  • Breathing: High-flow O₂, assess ventilation │
│  • Circulation: Identify spinal vs haemorrhagic│
│    shock; cautious fluids ± vasopressors       │
│  • Disability: GCS, ASIA examination           │
│  • Exposure: Log-roll, inspect spine           │
└────────────────────────────────────────────────┘
                    ↓
┌────────────────────────────────────────────────┐
│         IMAGING                                 │
│  • Apply NEXUS/Canadian C-Spine Rule            │
│  • CT spine (gold standard for bony injury)     │
│  • MRI if neurological deficit or ligamentous   │
│    injury suspected                             │
│  • Whole-spine imaging if high-energy           │
└────────────────────────────────────────────────┘
                    ↓
┌────────────────────────────────────────────────┐
│         CLASSIFICATION & STABILITY ASSESSMENT   │
│  • Denis three-column model                     │
│  • TLICS score (morphology + PLC + neuro)       │
│  • AO Spine classification                      │
└────────────────────────────────────────────────┘
                    ↓
┌────────────────────────────────────────────────┐
│         TREATMENT DECISION                      │
├────────────────────────────────────────────────┤
│  STABLE FRACTURE (TLICS ≤3, No SCI)            │
│  → Conservative management                      │
│  → Bracing (thoracolumbosacral orthosis)        │
│  → Early mobilisation as tolerated              │
│  → Analgesia, VTE prophylaxis                   │
│  → Outpatient follow-up                         │
│                                                 │
│  INDETERMINATE (TLICS 4)                        │
│  → Surgeon discretion                           │
│  → Consider: Age, bone quality, pain, ability   │
│    to comply with bracing, medical fitness      │
│                                                 │
│  UNSTABLE FRACTURE OR SCI (TLICS ≥5)           │
│  → Surgical management                          │
│  → Urgent if incomplete SCI (less than 24h improves      │
│    outcomes) [6]                                │
│  → Reduction, decompression, stabilisation      │
│  → Anterior vs posterior vs combined approach   │
│                                                 │
│  SPECIAL CASES                                  │
│  → Cauda equina: Urgent decompression less than 48h [13] │
│  → Complete SCI (ASIA A): Stabilisation for     │
│    rehabilitation; no role for steroids [19]    │
│  → Ankylosing spondylitis: Surgery for most     │
│    fractures (highly unstable) [14]             │
└────────────────────────────────────────────────┘
                    ↓
┌────────────────────────────────────────────────┐
│         REHABILITATION & FOLLOW-UP              │
│  • Early mobilisation (stable fractures)        │
│  • Spinal cord injury rehabilitation centre     │
│  • Physical therapy, occupational therapy       │
│  • Bowel/bladder management                     │
│  • Psychological support                        │
│  • Imaging follow-up: 6 weeks, 3 months, 1 year│
│  • Osteoporosis treatment if applicable         │
└────────────────────────────────────────────────┘

Acute/Emergency Management - The First Hour

1. Prehospital Care

• Spinal immobilisation:
  • Cervical collar (hard collar, sized appropriately)
  • Head blocks/sandbags
  • Scoop stretcher or long spine board (transfer only; prolonged use causes pressure sores)
• Extrication: Maintain inline stabilisation during patient movement
• Early notification: Pre-alert trauma centre if high-energy mechanism or SCI

2. Emergency Department - ATLS Protocol

Primary Survey (ABCDE):

Airway (with C-spine protection):

• Maintain inline stabilisation (manual or collar)
• If airway intervention needed: Rapid sequence intubation with manual inline stabilisation (NOT jaw thrust)
• Avoid hyperextension (risk secondary injury)

Breathing:

• High-flow oxygen (15L via non-rebreather mask)
• Assess respiratory function (high cervical/thoracic SCI → respiratory failure)
• Consider elective intubation if C1-C4 fracture or high thoracic SCI with declining respiratory effort

Circulation:

• Differentiate spinal (neurogenic) shock from haemorrhagic shock:

• Management of neurogenic shock:
  • Cautious IV fluids (500ml bolus; avoid fluid overload → pulmonary oedema)
  • "Vasopressors: Noradrenaline infusion (target MAP >85mmHg to perfuse spinal cord) [20]"
  • "Inotropes: Consider dobutamine if poor cardiac contractility"
• ALWAYS rule out haemorrhagic shock first (spinal shock is diagnosis of exclusion)

Disability:

• GCS (exclude head injury)
• Full ASIA examination (document baseline neurology)
• Blood glucose

Exposure:

• Complete examination with log-roll (3-person minimum: head, torso, legs)
• Inspect entire spine, look for bruising, deformity
• Rectal examination: Tone, perianal sensation, bulbocavernosus reflex

3. Spinal Clearance vs Further Imaging

• Apply NEXUS or Canadian C-Spine Rule
• If positive: CT spine
• If neurological deficit: CT + MRI

4. Resuscitation End-Points for SCI

• Target MAP 85-90 mmHg for 7 days post-SCI to optimise spinal cord perfusion [20]
• Avoid hypotension (MAP less than 85mmHg) and hypoxia (SpO₂ less than 95%)
• Insert urinary catheter (monitor output, prevent retention)

5. Urgent Surgical Consultation

• Indications for immediate contact:
  • Any neurological deficit
  • Unstable fracture pattern (burst, flexion-distraction, fracture-dislocation)
  • Cauda equina syndrome
  • Progressive neurological deterioration
• Timing critical: Early decompression (less than 24 hours) associated with improved neurological recovery in incomplete SCI [6]

Conservative (Non-Operative) Management

Indications:

• Stable fracture patterns (TLICS ≤3)
• Compression fractures less than 50% height loss, less than 20° kyphosis
• Neurologically intact
• Patient able to comply with bracing
• Minimal pain
• Elderly with significant comorbidities (relative indication)

Treatment Components:

1. Bracing

• Purpose: Limit motion, unload anterior column, maintain spinal alignment
• Types:
  • "TLSO (thoracolumbosacral orthosis): Most common for thoracolumbar fractures"
  • "Jewett hyperextension brace: Maintains lumbar lordosis"
  • "Halo vest: Cervical fractures (odontoid Type II, Hangman's)"
  • "Miami J collar: Stable cervical fractures, soft tissue injuries"
• Duration: 6-12 weeks (until fracture union on radiographs)
• Evidence: Bracing vs no bracing shows similar outcomes for stable fractures, but bracing aids early mobilisation and pain control [21]

2. Analgesia

• Paracetamol: 1g QDS (regular)
• NSAIDs: Ibuprofen 400mg TDS or diclofenac 50mg TDS (caution: may inhibit bone healing; limit to 2 weeks)
• Opioids: Morphine (short-term for severe pain), transition to tramadol/codeine
• Neuropathic pain (if nerve root involvement): Gabapentin 300mg TDS (titrate) or pregabalin

3. VTE Prophylaxis

• High risk: SCI, prolonged immobility
• Mechanical: TED stockings, intermittent pneumatic compression
• Pharmacological: Enoxaparin 40mg SC OD (once haemorrhage excluded)
• Duration: Until fully mobile; may require extended prophylaxis (3 months) in SCI [22]

4. Mobilisation

• Early mobilisation (day 1-2 post-injury if stable)
• Physical therapy: Gradual increase in activity
• Return to work: 6-12 weeks for sedentary work; 3-6 months for manual labour
• Return to sport: 3-6 months (contact sports may require longer)

5. Follow-Up Imaging

• X-rays: 6 weeks, 3 months (assess fracture healing, maintenance of alignment)
• CT: 3 months if union uncertain
• Criteria for fracture union: Bridging trabeculae, no progressive kyphosis, pain-free mobilisation

6. Complications of Conservative Management

• Progressive kyphosis: 10-20% develop >20° kyphosis; may require delayed surgery
• Non-union: Rare in compression fractures; more common in ligamentous injuries
• Chronic pain: 20-30% have persistent back pain [23]

Surgical Management

Surgical Indications (TLICS-Based):

Absolute Indications:

• TLICS ≥5
• Incomplete SCI with neural compression (urgent less than 24 hours) [6]
• Cauda equina syndrome (urgent less than 48 hours) [13]
• Progressive neurological deterioration
• Fracture-dislocation (gross instability)
• >50% canal compromise with neurological deficit

Relative Indications:

• TLICS 4 (surgeon discretion)
• Burst fracture with severe pain despite bracing
• Polytrauma patient (facilitates nursing, early mobilisation)
• Progressive kyphosis >20° on conservative management

Timing of Surgery:

• Incomplete SCI: less than 24 hours improves neurological outcomes (STASCIS trial) [6]
• Cauda equina: less than 48 hours for bladder recovery [13]
• Complete SCI (ASIA A): Urgent stabilisation not proven to improve neurology, but facilitates rehabilitation
• No SCI, unstable fracture: Semi-elective (within 1-2 weeks)

Surgical Approaches:

1. Posterior Approach (Most Common)

• Indications: Majority of thoracolumbar fractures, PLC injury, fracture-dislocation
• Technique:
  • Pedicle screw instrumentation (typically 2 levels above and 2 below fracture)
  • Decompression (laminectomy) if canal compromise and SCI
  • Reduction manoeuvres (distraction, lordosing)
  • Fusion (autograft, allograft, bone substitute)
• Advantages: Familiar approach, effective stabilisation, allows decompression
• Disadvantages: Doesn't address anterior column defect (risk kyphosis if severe comminution)

2. Anterior Approach

• Indications: Severe anterior column comminution, retropulsed bone fragments causing anterior cord compression, kyphotic deformity
• Technique:
  • Corpectomy (remove fractured vertebral body)
  • Reconstruction (cage, bone graft)
  • Anterior plate or screws
• Advantages: Direct decompression of anterior canal, restores anterior column support
• Disadvantages: More invasive, approach-related complications (vascular injury, ileus)

3. Combined Anterior-Posterior

• Indications: Severe instability (three-column injury), severe kyphosis, failed prior surgery
• Technique: Anterior reconstruction + posterior instrumented fusion
• Advantages: Most rigid construct, comprehensive treatment
• Disadvantages: Most invasive, longer operative time, higher morbidity

Specific Surgical Procedures:

Cervical Spine:

• Odontoid fracture Type II: Anterior odontoid screw fixation OR posterior C1-C2 fusion (Goel-Harms technique)
• Hangman's fracture: Halo immobilisation vs C2-C3 anterior cervical discectomy and fusion (ACDF)
• Subaxial fractures: ACDF (anterior) vs lateral mass/pedicle screw fixation (posterior)
• Facet dislocation: Reduction (closed vs open), then fusion

Thoracolumbar:

• Burst fracture (TLICS ≥5): Posterior short-segment instrumentation ± decompression
• Flexion-distraction: Posterior compression instrumentation (resist tension)
• Fracture-dislocation: Posterior long-segment instrumentation, often with anterior reconstruction

Post-Operative Care:

• ICU monitoring if SCI (haemodynamic stability, respiratory support)
• MAP target 85-90mmHg for 7 days [20]
• Early mobilisation (day 1-2 post-op)
• Bracing (surgeon-dependent; often not required with rigid instrumentation)
• VTE prophylaxis
• Rehabilitation

Surgical Complications:

Role of High-Dose Methylprednisolone (Controversial)

Historical Context:

• NASCIS II (1990) suggested modest benefit if started within 8 hours [24]
• NASCIS III (1997) suggested 48-hour protocol if started 3-8 hours post-injury

Current Consensus (2024):

• NOT recommended by AOSpine, AANS/CNS guidelines [19]
• Reasons:
  • Marginal benefit (NASCIS trials methodologically flawed)
  • "Significant harm: Increased infection, GI bleeding, respiratory complications, death"
  • No clear evidence of neurological improvement in modern meta-analyses
• Current practice: Do NOT give routine steroids for SCI
• Exception: Some centres offer as off-label treatment with informed consent if patient presents within 8 hours (recognising lack of evidence and risks)

Spinal Cord Injury-Specific Management

Acute Phase (0-7 Days):

• Haemodynamic support: MAP 85-90mmHg × 7 days (vasopressors) [20]
• Respiratory support: High cervical/thoracic SCI often requires ventilation
• Bladder management: Indwelling catheter acutely; transition to intermittent self-catheterisation
• Bowel management: Regular bowel regimen (stool softeners, suppositories, manual evacuation)
• DVT prophylaxis: LMWH + mechanical; high risk (15-30% without prophylaxis) [22]
• Pressure area care: Turn every 2 hours, pressure-relieving mattress
• Psychological support: Early involvement, anticipate depression/PTSD

Subacute/Rehabilitation Phase (1-12 Weeks):

• Transfer to spinal injury unit (specialist centres have better outcomes)
• Intensive physiotherapy: Strengthening, range of motion, functional training
• Occupational therapy: ADLs, wheelchair skills, home adaptations
• Bowel/bladder retraining
• Spasticity management: Baclofen, tizanidine, botulinum toxin, intrathecal baclofen pump
• Neuropathic pain: Gabapentin, pregabalin, amitriptyline, duloxetine
• Sexual function counselling
• Vocational rehabilitation

Long-Term Management:

• Regular follow-up (urology, rehabilitation, orthopaedics)
• Monitor for late complications (syringomyelia, autonomic dysreflexia)
• Osteoporosis screening and treatment (high fracture risk below injury level)

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8. Complications

Immediate (Hours-Days)

Early (Days-Weeks)

Late (Months-Years)

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9. Prognosis & Outcomes

Natural History (Without Treatment)

Untreated Stable Fracture:

• May heal in malposition (kyphotic deformity)
• Risk chronic pain (20-40%)
• Risk progressive kyphosis (15-25%)
• Rarely causes delayed neurological injury

Untreated Unstable Fracture:

• High risk progressive deformity
• Risk delayed neurological injury (cord compression from progressive kyphosis)
• Poor functional outcome

Untreated SCI:

• No spontaneous recovery of complete injuries (ASIA A) [8]
• Incomplete injuries may partially recover, but suboptimal without rehabilitation

Outcomes with Treatment

Fracture Healing (Conservative Management):

• Union rate: 85-95% by 3 months [21]
• Return to work: 70-85% (sedentary), 50-70% (manual labour)
• Chronic pain: 20-30% [23]
• Progressive kyphosis: 10-20% may require delayed surgery

Fracture Healing (Surgical Management):

• Union rate: 90-98% [7]
• Return to work: 75-90%
• Chronic pain: 15-25%
• Complication rate: 10-20% (infection, implant failure, non-union)

Neurological Recovery After SCI:

Factors Predicting Neurological Recovery:

• Sacral sparing: Single best predictor (incomplete injury has potential for recovery)
• Timing of decompression: less than 24 hours associated with improved recovery [6]
• Initial ASIA grade: Higher grade at presentation → better outcome
• Age: Younger patients recover better
• Fracture level: Cervical and thoracic worse than thoracolumbar
• Cord MRI findings: Cord haemorrhage → worse prognosis; oedema only → better prognosis [17]

Long-Term Outcomes in SCI:

• Life expectancy: Reduced (10-20 years less than general population)
• Primary causes of death: Pneumonia, sepsis (urinary/pressure sores), cardiovascular disease
• Quality of life: Variable; highly dependent on injury level, completeness, rehabilitation
• Employment: 30-50% return to work (complete SCI); 60-80% (incomplete SCI)

Prognostic Factors

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10. Evidence & Guidelines

Key Guidelines

1. AOSpine Thoracolumbar Injury Classification and Injury Severity Score (TLICS) - Vaccaro et al. (2013) [7]

Key Recommendations:

• Use TLICS score to guide operative vs non-operative management
• Score ≤3: Conservative management
• Score ≥5: Surgical management
• Score 4: Surgeon discretion
• Evidence Level: 1B (Strong recommendation, moderate-quality evidence)

2. AANS/CNS Guidelines on Management of Acute Spinal Cord Injury (2013, Updated 2024) [19]

Key Recommendations:

• DO NOT use high-dose methylprednisolone (no benefit, increased harm)
• Maintain MAP 85-90 mmHg for 7 days post-SCI to optimise cord perfusion [20]
• Early decompression (less than 24 hours) recommended for incomplete SCI with neural compression [6]
• Comprehensive rehabilitation at specialist SCI centre improves outcomes
• Evidence Level: Varies by recommendation (1A to 2C)

3. NICE Clinical Guideline - Spinal Injury: Assessment and Initial Management (NG41, 2016)

Key Recommendations:

• Use NEXUS or Canadian C-Spine Rule to guide imaging decisions
• CT is first-line imaging in high-risk patients
• MRI for all patients with neurological deficit
• Transfer to specialist spinal injury centre if SCI confirmed

4. British Orthopaedic Association Standards for Trauma (BOAST) - Spinal Trauma (2023)

Key Recommendations:

• All major trauma patients should have spinal immobilisation until cleared
• Whole-spine imaging in high-energy trauma
• Multidisciplinary team approach (orthopaedics, neurosurgery, radiology)
• Early involvement of spinal injury rehabilitation services

Landmark Trials & Evidence

1. STASCIS Trial (Surgical Timing in Acute Spinal Cord Injury Study, 2012) [6]

• Design: Prospective cohort study, 313 patients with cervical SCI
• Intervention: Early (less than 24 hours) vs late (≥24 hours) decompression
• Results: Early decompression associated with:
  • 2-grade improvement in ASIA Impairment Scale: 19.8% (early) vs 8.8% (late), p=0.034
  • Reduced length of stay
  • No increased complication rate
• Conclusion: Early decompression (less than 24 hours) recommended for incomplete cervical SCI
• Evidence Level: II (Prospective cohort)

2. NASCIS II & III Trials (High-Dose Methylprednisolone in SCI, 1990, 1997) [24]

• Design: Multicentre RCTs
• Intervention: High-dose methylprednisolone vs placebo
• Results: Marginal neurological improvement in subgroup analysis
• Criticism: Methodological flaws, post-hoc analysis, significant harm (infection, GI bleeding, death)
• Current Status: No longer recommended [19]

3. Canadian C-Spine Rule Validation Study (Stiell et al., 2001) [16]

• Design: Prospective multicentre cohort, 8,924 patients
• Results:
  • Sensitivity 100% (95% CI 98-100%)
  • Specificity 42.5%
  • Superior to NEXUS for reducing unnecessary imaging
• Conclusion: Canadian C-Spine Rule is highly sensitive and more specific than NEXUS
• Evidence Level: I

4. Denis Classification and Three-Column Concept (Denis, 1983) [1]

• Type: Landmark descriptive study
• Impact: Established foundation for understanding spinal stability
• Widely adopted: Remains cornerstone of fracture classification and treatment planning

5. TLICS Development and Validation (Vaccaro et al., 2005-2013) [7]

• Design: Expert consensus, interobserver reliability studies, prospective validation
• Results:
  • Kappa 0.71 (substantial agreement) for treatment recommendation
  • Score ≥5 predicts surgical treatment with 94% sensitivity
• Conclusion: TLICS is reliable, valid tool for guiding treatment decisions
• Evidence Level: II

Evidence Strength Summary

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11. Patient/Layperson Explanation

What is a Spinal Fracture?

A spinal fracture is a break in one of the bones (vertebrae) that make up your spine (backbone). Think of your spine as a stack of 33 building blocks (vertebrae) that protect your spinal cord—a bundle of nerves running from your brain down your back that controls movement and sensation in your body.

When a vertebra breaks, it can:

• Cause pain: The broken bone hurts, especially when you move
• Damage nerves: If the broken bone presses on the spinal cord or nerves, you may lose feeling or the ability to move parts of your body
• Change the shape of your spine: The break may cause your spine to bend forward (kyphosis, or "hunched back")

Types of Fractures:

1. Compression fracture: The vertebra squashes down (like stepping on a soft drink can). Common in older people with weak bones (osteoporosis). Usually not dangerous if diagnosed and treated properly.

2. Burst fracture: The vertebra explodes (like smashing the can from the top). This can push bone fragments back into the spinal cord, causing nerve damage. Requires urgent treatment.

3. Fracture-dislocation: The vertebra breaks and slides out of position. This is the most serious type and often causes paralysis.

Why does it matter?

If treated properly, most people recover well. However, if a spinal fracture damages the spinal cord, it can cause:

• Paralysis: Loss of movement in arms and/or legs
• Loss of sensation: Inability to feel touch, pain, or temperature
• Bladder and bowel problems: Loss of control
• Breathing difficulties: If the neck is injured

The good news: Modern treatment—proper immobilisation, surgery when needed, and rehabilitation—helps most people return to normal activities. Even people with spinal cord injuries can live full, independent lives with the right support.

How is it treated?

1. Immediate Care (Emergency Department)

If you've had an accident and might have a spinal fracture:

• Don't move: Paramedics will put you in a neck collar and on a special stretcher to keep your spine still
• Hospital checks: Doctors will check your breathing, circulation, and neurological function (can you feel and move everything?)
• Scans: You'll have X-rays, CT, or MRI scans to see the fracture clearly

2. Treatment Depends on the Type of Fracture

Stable Fracture (No Nerve Damage, Bone in Good Position):

• Brace: You'll wear a supportive brace (like a tight vest) for 6-12 weeks
• Pain medicine: Paracetamol, ibuprofen, or stronger painkillers
• Gradual mobilisation: You'll slowly increase activity with physiotherapy
• Most people heal within 3 months and return to normal activities

Unstable Fracture or Nerve Damage:

• Surgery: Doctors will operate to:
  • Put the bones back in the correct position (reduction)
  • Remove any bone pressing on nerves (decompression)
  • Stabilise the spine with metal screws and rods (fusion)
• Why urgent? If nerves are compressed, surgery within 24 hours gives the best chance of recovery
• After surgery: You'll mobilise quickly (often the next day) with physiotherapy

3. Rehabilitation

If you have nerve damage (spinal cord injury):

• Spinal injury unit: Specialist centres have experts in helping people recover
• Physical therapy: Exercises to strengthen muscles, improve balance, use a wheelchair if needed
• Occupational therapy: Learning to do daily activities (dressing, cooking, working)
• Bladder/bowel management: Techniques to manage toileting
• Psychological support: Adjusting to life after injury
• Adaptation: Home modifications, specialised equipment

Recovery varies:

• Some people recover fully
• Some recover partially (e.g., can walk with aids)
• Some have permanent paralysis but live independently with support

What to expect

Recovery Timeline:

Stable Fracture (No Nerve Damage):

• Week 1-6: Wearing brace, pain improving, gentle activities
• Week 6-12: Brace may come off, return to light activities
• Month 3-6: Return to work (office jobs), most activities
• Month 6-12: Return to sports, manual labour (with clearance)

Unstable Fracture (Surgery, No Permanent Nerve Damage):

• Day 1-2: Out of bed, walking with physiotherapy
• Week 1-2: Discharged home (if no other injuries)
• Week 6-12: Return to office work
• Month 3-6: Return to heavier activities, sports (with clearance)

Spinal Cord Injury:

• Week 1-4: Acute hospital, stabilisation
• Month 1-6: Spinal injury rehabilitation unit, intensive therapy
• Month 6-12: Continued outpatient rehabilitation
• Ongoing: Long-term management, adaptations, follow-up

Follow-Up:

• Regular X-rays to check healing (6 weeks, 3 months)
• Physiotherapy appointments
• Clinic visits with your surgeon

When to seek help

Call 999 (Emergency) immediately if:

• You've had a serious accident or fall and have back or neck pain
• You can't feel or move your arms or legs
• You've lost control of your bladder or bowels
• You have numbness in the "saddle area" (between your legs)
• Your symptoms are getting worse

See your doctor urgently if:

• You have severe back pain after a fall (even a minor fall if you're older)
• You have back pain and new weakness, numbness, or tingling in your limbs
• You have pain that doesn't improve with painkillers

Remember: Spinal fractures are serious, but with prompt, proper treatment, most people recover well. If you have nerve damage, modern rehabilitation can help you live a full, independent life. The key is to get help quickly—if in doubt, call 999.

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12. References

1. Denis F. The three column spine and its significance in the classification of acute thoracolumbar spinal injuries. Spine. 1983;8(8):817-831. doi:10.1097/00007632-198311000-00003

2. Magerl F, Aebi M, Gertzbein SD, Harms J, Nazarian S. A comprehensive classification of thoracic and lumbar injuries. Eur Spine J. 1994;3(4):184-201. doi:10.1007/BF02221591

3. Sekhon LH, Fehlings MG. Epidemiology, demographics, and pathophysiology of acute spinal cord injury. Spine. 2001;26(24 Suppl):S2-S12. doi:10.1097/00007632-200112151-00002

4. Hu R, Mustard CA, Burns C. Epidemiology of incident spinal fracture in a complete population. Spine. 1996;21(4):492-499. doi:10.1097/00007632-199602150-00016

5. Vaccaro AR, Lehman RA Jr, Hurlbert RJ, et al. A new classification of thoracolumbar injuries: the importance of injury morphology, the integrity of the posterior ligamentous complex, and neurologic status. Spine. 2005;30(20):2325-2333. doi:10.1097/01.brs.0000182986.43345.cb

6. Fehlings MG, Vaccaro A, Wilson JR, et al. Early versus delayed decompression for traumatic cervical spinal cord injury: results of the Surgical Timing in Acute Spinal Cord Injury Study (STASCIS). PLoS One. 2012;7(2):e32037. doi:10.1371/journal.pone.0032037

7. Vaccaro AR, Oner C, Kepler CK, et al. AOSpine thoracolumbar spine injury classification system: fracture description, neurological status, and key modifiers. Spine. 2013;38(23):2028-2037. doi:10.1097/BRS.0b013e3182a8a381

8. Kirshblum SC, Burns SP, Biering-Sorensen F, et al. International standards for neurological classification of spinal cord injury (revised 2011). J Spinal Cord Med. 2011;34(6):535-546. doi:10.1179/204577211X13207446293695

9. Old JL, Calvert M. Vertebral compression fractures in the elderly. Am Fam Physician. 2004;69(1):111-116.

10. Chandler CF, Lane JS, Waxman KS. Seat belt sign following blunt trauma is associated with increased incidence of abdominal injury. Am Surg. 1997;63(10):885-888.

11. Holly LT, Kelly DF, Counelis GJ, Blinman T, McArthur DL, Cryer HG. Cervical spine trauma associated with moderate and severe head injury: incidence, risk factors, and injury characteristics. J Neurosurg. 2002;96(3 Suppl):285-291. doi:10.3171/spi.2002.96.3.0285

12. McKinley W, Santos K, Meade M, Brooke K. Incidence and outcomes of spinal cord injury clinical syndromes. J Spinal Cord Med. 2007;30(3):215-224. doi:10.1080/10790268.2007.11753929

13. Ahn UM, Ahn NU, Buchowski JM, Garrett ES, Sieber AN, Kostuik JP. Cauda equina syndrome secondary to lumbar disc herniation: a meta-analysis of surgical outcomes. Spine. 2000;25(12):1515-1522. doi:10.1097/00007632-200006150-00010

14. Westerveld LA, Verlaan JJ, Oner FC. Spinal fractures in patients with ankylosing spinal disorders: a systematic review of the literature on treatment, neurological status and complications. Eur Spine J. 2009;18(2):145-156. doi:10.1007/s00586-008-0764-0

15. Hoffman JR, Mower WR, Wolfson AB, Todd KH, Zucker MI; National Emergency X-Radiography Utilization Study Group. Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma. N Engl J Med. 2000;343(2):94-99. doi:10.1056/NEJM200007133430203

16. Stiell IG, Wells GA, Vandemheen KL, et al. The Canadian C-spine rule for radiography in alert and stable trauma patients. JAMA. 2001;286(15):1841-1848. doi:10.1001/jama.286.15.1841

17. Flanders AE, Spettell CM, Tartaglino LM, Friedman DP, Herbison GJ. Forecasting motor recovery after cervical spinal cord injury: value of MR imaging. Radiology. 1996;201(3):649-655. doi:10.1148/radiology.201.3.8939210

18. Calenoff L, Chessare JW, Rogers LF, Toerge J, Rosen JS. Multiple level spinal injuries: importance of early recognition. AJR Am J Roentgenol. 1978;130(4):665-669. doi:10.2214/ajr.130.4.665

19. Hurlbert RJ, Hadley MN, Walters BC, et al. Pharmacological therapy for acute spinal cord injury. Neurosurgery. 2013;72 Suppl 2:93-105. doi:10.1227/NEU.0b013e31827765c6

20. Ryken TC, Hurlbert RJ, Hadley MN, et al. The acute cardiopulmonary management of patients with cervical spinal cord injuries. Neurosurgery. 2013;72 Suppl 2:84-92. doi:10.1227/NEU.0b013e318276ee16

21. Wood KB, Buttermann GR, Phukan R, et al. Operative compared with nonoperative treatment of a thoracolumbar burst fracture without neurological deficit: a prospective randomized study with follow-up at sixteen to twenty-two years. J Bone Joint Surg Am. 2015;97(1):3-9. doi:10.2106/JBJS.N.00226

22. Geerts WH, Code KI, Jay RM, Chen E, Szalai JP. A prospective study of venous thromboembolism after major trauma. N Engl J Med. 1994;331(24):1601-1606. doi:10.1056/NEJM199412153312401

23. Dai LY, Jiang LS, Jiang SD. Conservative treatment of thoracolumbar burst fractures: a long-term follow-up results with special reference to the load sharing classification. Spine. 2008;33(23):2536-2544. doi:10.1097/BRS.0b013e3181851bc2

24. Bracken MB, Shepard MJ, Collins WF, et al. A randomized, controlled trial of methylprednisolone or naloxone in the treatment of acute spinal-cord injury: results of the Second National Acute Spinal Cord Injury Study. N Engl J Med. 1990;322(20):1405-1411. doi:10.1056/NEJM199005173222001

25. Kramer JL, Minhas NK, Jutzeler CR, et al. Neuropathic pain following traumatic spinal cord injury: models, measurement, and mechanisms. J Neurosci Res. 2017;95(6):1295-1306. doi:10.1002/jnr.23881

26. Bauman WA, Spungen AM, Wang J, Pierson RN Jr, Schwartz E. Continuous loss of bone during chronic immobilization: a monozygotic twin study. Osteoporos Int. 1999;10(2):123-127. doi:10.1007/s001980050206

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13. Viva Preparation

Opening Statement (Perspective)

"Spinal fractures represent a spectrum of vertebral injuries from stable compression fractures to complex unstable fracture-dislocations with neurological compromise. The key principles in management are: early recognition and immobilisation to prevent secondary injury; systematic assessment using validated clinical decision rules and classification systems; distinguishing stable from unstable injuries using the Denis three-column model and TLICS score; comprehensive neurological assessment with the ASIA Impairment Scale; and timely intervention—early decompression within 24 hours improves outcomes in incomplete spinal cord injury with neural compression. Stable fractures (TLICS ≤3) are managed conservatively with bracing, while unstable patterns or those with neurological deficit require surgical stabilisation. This is a time-critical orthopaedic emergency where systematic, evidence-based decision-making optimises patient outcomes."

Common Exam Questions

1. "Classify thoracolumbar spinal fractures for me."

Model Answer: "I use three complementary systems:

Denis Three-Column Model (foundational): Divides spine into anterior column (ALL, anterior two-thirds of VB/disc), middle column (posterior one-third VB/disc, PLL), and posterior column (pedicles, facets, laminae, posterior ligamentous complex). Failure of two or more columns indicates instability.

TLICS Score (treatment-oriented): Three components totalling 10 points:

• Morphology: compression (1), burst (2), translational/rotational (3), distraction (4)
• PLC integrity: intact (0), indeterminate (2), injured (3)
• Neurology: intact (0), nerve root (2), complete SCI (2), incomplete SCI or cauda equina (3)

Score ≤3 → conservative; ≥5 → surgery; 4 → surgeon discretion. This score has been validated with substantial interobserver reliability (kappa 0.71) and guides treatment decisions.

AO Spine Classification (descriptive): Type A (compression), B (distraction), C (displacement), with subgroups and neurological modifiers.

For clinical decision-making, I primarily use TLICS as it incorporates neurological status and has validated treatment thresholds."

2. "How do you assess neurological status in acute spinal cord injury?"

Model Answer: "I use the ASIA (American Spinal Injury Association) Impairment Scale, which is the international standard:

Motor examination: Test 10 key muscles (5 UL, 5 LL) graded 0-5 MRC scale. Total score 0-100.

• UL: C5 biceps, C6 wrist extensors, C7 triceps, C8 FDP middle finger, T1 ADM
• LL: L2 iliopsoas, L3 quads, L4 tib ant, L5 EHL, S1 gastroc/soleus

Sensory examination: Test 28 dermatomes bilaterally for light touch and pinprick (0-2 each). Total 0-112 per modality.

Critical: Assess sacral sparing (S4-5 sensation, voluntary anal contraction, deep anal pressure). Presence defines incomplete injury.

ASIA Grades:

• A (Complete): No motor/sensory below level, no sacral sparing
• B (Sensory incomplete): Sensory but no motor below level, sacral sparing present
• C (Motor incomplete): Motor preserved, >50% key muscles less than 3/5
• D (Motor incomplete): Motor preserved, ≥50% key muscles ≥3/5
• E (Normal)

Sacral sparing is the single best prognostic factor—ASIA B-D have significantly better recovery potential than ASIA A (5-10% vs 50-90% ambulatory)."

3. "What are the indications and timing for surgery in spinal fractures with SCI?"

Model Answer: "Indications:

• Incomplete SCI (ASIA B-D) with neural compression (absolute)
• Cauda equina syndrome (absolute, less than 48h for bladder recovery)
• Progressive neurological deterioration (absolute)
• Unstable fracture pattern (TLICS ≥5)
• Complete SCI (ASIA A): Stabilisation for rehabilitation (no proven neurological benefit)

Timing: The STASCIS trial (2012) showed early decompression (less than 24 hours) in incomplete cervical SCI resulted in 2-grade ASIA improvement in 19.8% vs 8.8% with late surgery (p=0.034), without increased complications. Current guidelines recommend surgery less than 24 hours for incomplete SCI with neural compression.

Surgical goals:

1. Neural decompression (remove bone, disc, haematoma compressing cord)
2. Reduction (restore alignment)
3. Stabilisation (prevent further injury, enable rehabilitation)
4. Fusion (long-term stability)

Approach selection: Depends on fracture pattern and location of compression—posterior for most thoracolumbar fractures; anterior if significant retropulsion or anterior column defect; combined if severe instability."

4. "Do you give steroids in acute spinal cord injury?"

Model Answer: "No. Current AANS/CNS and AOSpine guidelines strongly recommend against routine use of high-dose methylprednisolone in SCI.

Historical context: NASCIS II (1990) and III (1997) suggested marginal benefit if started within 8 hours. However, these trials had significant methodological flaws, post-hoc analyses, and showed increased harm.

Reasons NOT to use:

• No clear neurological benefit in modern meta-analyses
• Significant complications: infection (surgical site, pneumonia), GI bleeding, respiratory failure, increased mortality
• Risk outweighs any marginal benefit
• Not standard of care in 2024

Exception: Some centres offer as off-label treatment with informed consent if patient presents less than 8 hours, recognising lack of evidence and risks. I would not routinely use it."

5. "How do you clinically clear a cervical spine in a trauma patient?"

Model Answer: "I use validated clinical decision rules—either NEXUS or Canadian C-Spine Rule.

NEXUS (simpler): Cervical imaging NOT required if ALL five criteria met:

1. No posterior midline C-spine tenderness
2. No focal neurological deficit
3. Normal alertness (GCS 15)
4. No intoxication
5. No painful distracting injury

Sensitivity 99.6%, NPV 99.8%.

Canadian C-Spine Rule (more specific, preferred):

• Step 1: High-risk factors? (Age ≥65, dangerous mechanism, paraesthesias) → Image
• Step 2: Low-risk factors allowing ROM assessment? (Simple RTA, sitting, ambulatory, delayed pain onset, no midline tenderness) → If NO, image
• Step 3: Can rotate 45° actively? → If YES, clear; if NO, image

Sensitivity 100%, specificity 42.5% (superior to NEXUS).

If rule negative: Clinical clearance If rule positive OR any doubt: CT cervical spine

Cannot clinically clear: Obtunded, intoxicated, or unreliable patient → Image

Practical tip: If high-energy mechanism, polytrauma, or neurological signs, proceed directly to imaging. Clinical rules are for low-moderate risk patients."

Common Mistakes (What Gets You Failed)

❌ Stating steroids are standard treatment for SCI (outdated, harmful)
❌ Not performing full ASIA examination (incomplete assessment of SCI)
❌ Missing sacral sparing assessment (critical for prognosis and classification)
❌ Not appreciating urgency of incomplete SCI decompression (less than 24h improves outcomes)
❌ Confusing spinal shock (physiological) with neurogenic shock (haemodynamic) (different management)
❌ Failing to assess for PLC injury (ligamentous disruption = unstable)
❌ Not recognising Chance fracture associations (50% have abdominal injury with seat belt sign)
❌ Inadequate spinal immobilisation knowledge (how to maintain, when to remove)
❌ Not knowing TLICS score thresholds (≤3 conservative, ≥5 surgery)
❌ Confusing ASIA grades (especially B vs C, importance of sacral sparing)

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Last Reviewed: 2026-01-10 | MedVellum Editorial Team

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Medical Disclaimer: MedVellum content is for educational purposes and clinical reference. Clinical decisions should account for individual patient circumstances. Always consult appropriate specialists and current guidelines. This information is not a substitute for professional medical advice, diagnosis, or treatment. Spinal fractures and spinal cord injuries are time-critical emergencies requiring immediate specialist input.