Treatment of spinal fracture, rehabilitation measures

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The spine is the main component of the human musculoskeletal system. In addition to providing the ability to maintain an upright body position, it is the main protection for the delicate spinal cord, which is sensitive to the slightest damage. Therefore, spinal injuries pose a serious threat to human life and health.

Among all spinal fractures, lumbar injuries are observed in approximately half of the cases. It is formed by 5 large vertebrae, which contain nerves and the so-called cauda equina, which are responsible for the innervation of the lower half of the body and the functioning of the pelvic organs. Therefore, his injuries require immediate treatment.

Causes

Most often, lumbar spine fractures occur as a result of forced flexion of the spine or a fall from a height onto the buttocks, back, and especially legs.

A sharp flexion of the spine is most often observed during sudden braking or a head-on collision of cars, when a passenger or driver, maintaining the inertia of movement, sharply moves forward after stopping the vehicle.

Also, a fracture of the lumbar spine can be a consequence of:

• direct blow to the back with any object, hand or foot;
• sports injury (boxers, football players, hockey players, wrestlers are most susceptible);
• man-made disasters accompanied by building collapses.

Osteoporosis is not the least important factor in the occurrence of lumbar vertebral fractures. With this disease, most often observed in people over 50 years of age, there is a decrease in the strength and hardness of bones as a result of their loosening. Therefore, even a slight external impact, a careless descent down the stairs, or even a banal cough can provoke a spinal injury.

The following may increase the risk of developing a lumbar spine fracture:

• rickets;
• benign and malignant tumors of the spine;
• metastases in the spine due to malignant neoplasms in other organs;
• tuberculosis;
• osteomyelitis.

Kinds

There are three main types of lumbar vertebral fractures. This:

• Compression fractures are manifested by compression of the vertebrae along the vertical axis and their fragmentation. As a result, the vertebral body takes on a wedge-shaped shape. With such fractures, the arches and articular processes, as a rule, remain intact.
• Comminuted fractures are accompanied by destruction of the vertebral body and wedge its edges into the intervertebral disc and the body of the underlying vertebra. A sharp bone fragment can become dislodged and cause spinal cord injury.
• Fracture-dislocations - as a result of the action of a traumatic factor, the upper parts of the spine are displaced forward, which provokes a shift of the interarticular surfaces and damage to the articular processes or arches. Often such processes provoke compression or rupture of nerve fibers and damage to the spinal cord.

The most common are compression fractures, which vary in severity:

• 1st degree – the height of the vertebral body decreases by no more than 30%;
• 2nd degree – flattening of the vertebral body does not reach 50%;
• Grade 3 – reduction in vertebral height exceeds 50%.

Since the spinal canal, in which the spinal cord is located, passes directly between the vertebral bodies and their arches, fractures can be uncomplicated by damage to the nerve structures or complicated. Fractures of the second type pose the greatest danger, since it is not always possible to eliminate the consequences of their impact on the nerve roots and spinal cord.

MRI

MRI is necessary in cases where there are motor or sensory disturbances in the lower extremities. Radicular pain or suspected spinal cord compression is also an indication for MRI.

Magnetic resonance imaging is important because it provides the best visualization of the neural structures of the spine. In addition, MRI can be performed using contrast, which allows better diagnosis of conditions such as hemorrhage, tumor or infection with greater sensitivity.

Symptoms

The following symptoms typically occur for a lumbar spine fracture:

• aching, severe or moderate pain at the site of injury, spreading to surrounding tissues, legs, buttocks and intensifying with movement;
• back muscle tension;
• limitation of mobility, manifested by the patient’s efforts to avoid straining the damaged area;
• local swelling of soft tissues;
• flatulence, bloating;
• nausea and vomiting;
• constipation.

At the time of injury, there may be a delay in breathing.

In case of fractures resulting from external mechanical impact, redness of the skin and hematoma are observed at the site of impact. If there is a fracture of the lumbar spine complicated by damage to the nervous structures, the corresponding symptoms arise:

• decreased sensitivity;
• weakening of reflexes;
• convulsions;
• muscle weakness, up to complete paralysis;
• urinary disturbance;
• erectile disfunction.

Compression fractures that occur due to osteoporosis, especially in older people, are often asymptomatic or the symptoms are so minor that patients do not attach due importance to them and do not seek medical help. In such cases, complications may occur as a result of compression of the nerves or spinal cord. Although there are cases when compression fractures of the lumbar spine are discovered, so to speak, after the fact.

Compression fractures most often occur in women over 50 years of age.

With comminuted fractures, the clinical picture is more vivid and leaves no doubt about the nature of the injury. Patients complain of abdominal pain, stool retention, nausea, and vomiting. In this case, traumatic shock is often present, in which circulatory disturbance occurs at the site of injury due to strong spastic muscle tension provoked by pain.

Often, fractures of the lumbar vertebrae are accompanied by injuries to the vertebrae of other parts of the spine, as well as fractures of the pelvis, limbs, blunt abdominal trauma, kidney damage and rupture of the bladder. In such cases, there is a combination of symptoms of spinal fractures with signs of other injuries.

Forecast

• Overall, the prognosis for simple compression fractures is good for most patients who recover fully or with minor back pain. Vertebroplasty and kyphoplasty have improved recovery options for patients with chronic back pain who have failed conservative therapy. These procedures have proven their effectiveness and are used quite widely.
• The prognosis for patients with traumatic compression fractures is largely based on neurological symptoms and is related to the degree of impact of the damaged vertebra on the root or spinal cord.
• Patients with compression fractures caused by spinal infections have a generally favorable prognosis. According to statistics, two thirds of patients with fractures associated with purulent osteomyelitis have a good chance of recovery. At the same time, with tuberculous genesis of compression fractures, in some patients, neurological symptoms do not disappear and the patients lose their ability to work.
• Most vertebral compression fractures caused by osteoporosis stabilize within eight weeks. With adequate drug correction and fall prevention, recurrent fractures can be avoided.

Features of fractures of different lumbar vertebrae

The nature of the symptoms and consequences of the injury directly depend on which vertebra was broken:

• L1 is the most vulnerable and easily injured vertebra of the lumbar region, so this is where compression fractures most often occur. They can be a consequence of both mechanical stress and osteoporosis. But if the injury did not damage the spinal cord, properly organized and immediately started treatment leads to a complete recovery.
• L2 - this vertebra is injured only slightly less frequently than the first, but its fractures are more dangerous. When the height of the vertebral body decreases by more than 50%, segmental instability can develop, which, if left untreated, leads to destabilization of the entire lumbar spine.
• L3 – rarely fractures. If they occur, they are usually the result of a direct blow to it, which often requires the intervention of a neurosurgeon. If the operation is not performed on time, spondylopathy, instability of the spinal motion segment and severe chronic pain may develop.
• L4 – injuries to this vertebra are extremely rare; they usually occur simultaneously with fractures of the second and third lumbar vertebrae.
• L5 – the vertebra connected to the sacrum is quite strong and breaks mainly when falling on the buttocks at the same time as the sacrum.

Content

• 1 Spinal fractures in the lumbar region 1.1 Signs of a spinal fracture

Diagnostics

If you suspect a fracture of the lumbar spine, patients should contact a traumatologist or vertebrologist. The doctor will conduct a thorough interview, find out the circumstances of the injury and conduct an examination.

Reasons to suspect the presence of a fracture are the detection of muscle tension during palpation, local soreness and swelling of the soft tissues. Sometimes there is the formation of a slight protrusion in the area of ​​the injured vertebra, caused by a deviation from the normal position of the spinous process. Also, the doctor will not go unnoticed by the patient’s attempts to avoid movements that involve the lower back.

The presence of these signs is a reason to prescribe additional research methods in order to obtain comprehensive information about the condition of the lumbar and sometimes other parts of the spine. Therefore, patients must be prescribed:

• X-ray in two projections - allows you to notice cracks, decreased vertebral height and the formation of fragments;
• CT scan provides more accurate data than classic X-rays;
• MRI – allows you to evaluate the condition of intervertebral discs, nerves and ligaments.

Sometimes electrophysiological studies are indicated. They help determine the quality of bioelectric impulses from the spinal cord, assess the extent of its damage and develop optimal treatment tactics.

Vertebroplasty

This procedure is most useful for reducing pain. It also strengthens damaged bone, allowing patients to recover faster. Using a needle, under X-ray control, a cementing substance, polymethyl methacrylate (PMMA), is injected into the area of ​​the vertebral fracture. The cement hardens within 15 minutes. This fixes the bone and prevents further destruction and reduces pain in more than 80% of patients.

Treatment

For each patient, treatment tactics are selected individually. When choosing it, the doctor must take into account many factors, including the type of fracture of the lumbar spine, its degree, the presence of neurological complications, etc.

For uncomplicated grade 1 compression fractures, treatment is usually carried out using conservative methods. In all other cases, as well as if conservative therapy is ineffective, the spinal fracture is treated surgically.

However, all patients with lumbar vertebral fractures are recommended to:

• bed rest, the duration of which depends on the severity and type of fracture (the mattress is replaced with a hard board, and a cushion is placed under the lower back);
• skeletal traction to restore the normal distance between the vertebrae (carried out under X-ray control);
• immobilization of the lumbar spine with a plaster cast or a special orthopedic corset to eliminate the load on it and create favorable conditions for the consolidation of bone elements (lasts up to 4 months, sometimes longer).

In some cases, after skeletal traction, step-by-step reclination is performed. The method involves forcefully eliminating the curvature of the spine by applying an oppositely directed force. The procedures are carried out on a rigid board with a cushion placed under the lower back, which are gradually replaced with larger ones. Once the desired result is achieved, the patient’s torso is fixed with a plaster or plastic corset.

Conservative treatment of lumbar spine fracture

As part of conservative therapy, patients are prescribed a set of measures aimed at eliminating pain, accelerating regeneration processes, increasing the tone of the back muscles and normalizing the conductivity of bioelectric impulses along nerve fibers. Thus, patients are prescribed:

• drug therapy;
• exercise therapy;
• physiotherapy;
• massage.

Drug therapy

The nature of drug therapy is selected based on the existing symptoms. It may include:

• painkillers, as well as paravertebral novocaine blockades;
• antibiotics;
• corticosteroids;
• chondroprotectors;
• immunomodulators;
• drugs that enhance intestinal motility;
• laxatives;
• calcium and vitamin D supplements.

Some drugs are administered for only a few days, others require long-term use for up to several months.

Exercise therapy

Physical therapy classes begin from the first days of treatment. It plays a significant role, since when forced to maintain a supine position and a low degree of physical activity, the muscles inevitably atrophy, which will subsequently negatively affect the support of the spine by the muscular corset.

Initially, patients are prescribed breathing exercises. It is performed in a lying position under the guidance of an experienced specialist. It accurately calculates the required load, allowing you to effectively stimulate muscles and work out joints, but without causing harm to the damaged spine.

Physiotherapy

To speed up the process of vertebral restoration, patients are prescribed courses of physiotherapeutic procedures. The most effective are:

• Magnetic therapy – helps reduce pain, eliminate swelling and muscle spasms, and strengthen intervertebral discs;
• electrophoresis - used to reduce pain and promotes the penetration of calcium and phosphorus preparations directly into the affected area;
• reflexology – helps to activate blood flow and improve metabolic processes;
• UHF – favors the speedy elimination of the inflammatory process.

Ultrasound therapy, ultraviolet irradiation and Sollux can also be used. The procedures are carried out in courses of 10–12 sessions, each lasting about 10–15 minutes.

However, each of them has its own limitations and contraindications. They must be taken into account by the doctor when prescribing physiotherapy.

Massage

Therapeutic massage is one of the important components of conservative therapy. At the initial stages, the doctor’s task is to improve blood circulation and metabolic processes in the affected area. The first sessions are carried out while the patient is in the hospital, in particular during skeletal traction.

Gradually increase the intensity of the impact and begin to use the back muscles. This helps restore lost mobility of the vertebrae and speed up the rehabilitation process. But to ensure that the massage does not harm the patient, it must be performed by a highly qualified specialist.

Surgical treatment of lumbar spine fracture

A spinal fracture is a serious injury, in which in many cases timely surgery is the key to a full recovery. Indications for surgical intervention are:

• compression fractures of the lumbar spine, grades 2 and 3;
• comminuted fractures;
• spinal instability;
• compression of nerves and spinal cord.

Modern spinal surgeries for fractures differ significantly from those performed previously. These are gentle, often minimally invasive interventions that can completely eliminate the defect resulting from injury and restore the normal anatomy of the spine. Some of them are carried out through a pinpoint puncture of soft tissue with a thin needle, so after them there are no cosmetic defects left, and safety and effectiveness reach extremely high limits. These include vertebroplasty and kyphoplasty.

But these methods have a number of limitations, in the presence of which the patient is prescribed a different type of surgical intervention. In difficult cases, the vertebrae are fixed by installing special plates, systems, meshes, and laminar contractors. Often, transpedicular fixation is performed to eliminate spinal instability and securely fix all damaged elements.

If it is impossible to restore a broken vertebra using any of the methods, partial or complete removal of it is performed through laminectomy, followed by implantation of artificial implants or grafts of the patient’s own bones.

But in any case, after the operation, patients are prescribed antibiotics, as well as a full course of rehabilitation. Since surgical intervention is only a way to achieve consolidation of bone fragments and strengthen the vertebra. Subsequent rehabilitation solves the problems of restoring normal nerve conduction, strengthening the muscle corset and preventing new fractures in the future.

Vertebroplasty

Vertebroplasty is a method of percutaneous surgery that involves filling the natural cavities in the vertebral bodies with special bone cement. Since they are formed by spongy bone tissue, there are cavities in it. Their filling with a hard polymer ensures high strength and hardness of the vertebra and eliminates the risk of re-injury.

Bone cement is a creamy mass that must be prepared immediately before injection into the vertebra. It was specially created to solve the problem of spinal fractures, so the material is highly biocompatible and safe.

Vertebroplasty is performed under local anesthesia. The patient is inserted into the body of the broken vertebra with a thin needle under the control of an image intensifier or CT scan. Once it reaches the desired location, bone cement is prepared by mixing the two components of the product. It is immediately injected into the vertebra, monitoring the quality of filling all pores. This is possible because the bone cement contains an X-ray contrast agent.

The mass hardens within 8–10 minutes, after which the needle is removed and the remaining postoperative puncture is covered with a sterile bandage. The procedure takes about 40 minutes and has an almost instant result. But it is effective only for compression fractures with a decrease in vertebral height up to 70%.

Kyphoplasty

Kyphoplasty is considered a more modern version of vertebroplasty, since it allows not only to significantly increase the strength of the injured vertebra, but also to restore its normal size and position. This is achieved by “straightening” a lumbar vertebra compressed during a compression fracture with a special balloon.

The techniques for performing both microsurgical operations are the same. But with kyphoplasty, a balloon is initially immersed through a thin cannula into the vertebral body, into which a saline solution is gradually injected. Once the vertebra is aligned and in its normal position, bone cement is injected into it. This way it is fixed in the correct position and gains high strength.

Therefore, kyphoplasty is effective even for compression fractures with a decrease in the height of the vertebral body by more than 70%. However, it has the additional advantage of being able to eliminate kyphotic deformity.

Transpedicular fixation

The technique of transpedicular fixation for the treatment of spinal injuries has been used for about a century. And although this operation involves making incisions and exposing the arches and spinous processes of the vertebrae, it is considered quite safe and effective.

Thanks to it, it is possible to reliably fix a broken vertebra in the desired position and achieve good consolidation of its components. Moreover, the technique involves rigid fixation of only a small area of ​​the spine, so after it the patient does not experience significant restrictions on mobility.

It allows you to release pinched nerves and eliminate compression of the spinal cord, which allows you to get rid of neurological symptoms or reduce their severity. Therefore, the method is widely used for unstable and complicated fractures of the lumbar spine.

Transpedicular fixation is performed under general anesthesia and involves screwing titanium screws into the intersection of the transverse and articular processes of the vertebrae. As a rule, fixing the vertebra with 4 screws is sufficient. After they are installed, springy rods are passed through the special holes of the screws, guaranteeing the stability of the structure, and sutures are applied.

When transpedicular fixation is performed correctly, the risk of damage to large blood vessels and nerve roots is minimal.

Laminectomy

Gentle methods of surgical treatment of fractures may not always lead to the desired result. For complex injuries with vertebral fragmentation and in some other cases, neurosurgeons have to resort to laminectomy.

The operation involves the removal of vertebral arches, spinous processes, bone fragments, or even an entire vertebra through a soft tissue incision. But this makes it possible to completely eliminate the consequences of injury that threaten serious complications, since the distance between the vertebrae increases significantly.

During the operation, damaged ligaments, intervertebral discs and other anatomical structures can be additionally resected.

To close the resulting defects, osteosynthesis, installation of artificial implants or autografts are used. But recovery after surgery takes longer than after others, and is sometimes much more painful.

Medicines

Most patients in the acute stage of fractures receive analgesics. With pain control, the patient can get up and move around easily and avoid problems caused by immobilization.

Corseting

Most patients are prescribed the use of a rigid corset, which is selected individually. A corset can dramatically reduce the range of motion and fix a broken vertebra. Patients who wear a special brace are allowed to move, but strenuous activities such as lifting and bending are significantly limited.

Motor activity control

. Bed rest is usually recommended for several days, since prolonged immobilization leads to weakening of the muscular corset, and in the presence of osteoporosis, to further bone loss and progression of osteoporosis.

Correction of osteoporosis

. Bone-strengthening drugs such as bisphosphonates (Actonel, Boniva, and Fosamax) help stabilize or reverse bone loss. This is a critical part of the treatment and helps prevent further fractures when axial loads are placed on the vertebrae.

Rehabilitation after a spinal fracture

During the recovery period, the practice is to use the same methods as in the conservative treatment of spinal fractures, i.e.:

• drug therapy;
• wearing an orthopedic corset;
• gentle lifestyle;
• exercise therapy;
• massage;
• physiotherapeutic procedures.

The doctor determines their nature and duration individually. Therefore, if exercise therapy is initially gentle, then as the patient recovers, they move on to more active physical therapy exercises. The amount of load and duration of exercises are increased gradually, strictly monitoring the patient’s condition. At the final stages of treatment they are offered:

• simultaneously bend your legs at the knee and hip joints while lying on your back;
• lying on your back, raise your straight legs up, spread them to the sides, and then cross them together;
• perform the “bicycle” exercise;
• lift your chest off the floor and raise your arms from a position lying on your stomach;
• walk on your knees, etc.

If you can walk after such injuries on average after a month, then you are not allowed to sit for 4 months or more.

Also, patients with a fracture of the lumbar spine need to make certain changes in their diet. It is recommended to enrich the daily diet with foods that contain large quantities of easily digestible calcium, phosphorus, and B vitamins (fermented milk products, buckwheat, oatmeal, vegetables, etc.).

During treatment you will have to give up alcohol, fatty foods, processed foods and fast food. Yeast baked goods and confectionery products in large quantities are also not indicated, since during the recovery period the patient leads an inactive lifestyle. His energy costs are reduced, so excessive consumption of high-calorie foods can lead to weight gain, which will be difficult for a weakened spine to maintain.

After completing the main stage of recovery, patients are recommended to undergo sanatorium-resort treatment, which will not only have a positive effect on the condition of the spine and muscular frame, but will also help strengthen the entire body.

It is difficult to make prognoses for fractures of the lumbar spine. If the injury is uncomplicated, and the patient strictly adheres to the recommendations received from the doctor, especially regarding the immobilization regime, the fractures heal quickly, and the person’s ability to work is completely restored.

But if the spinal cord is damaged due to injury, especially if its rupture is diagnosed, sensitivity below the site of the injury completely and irrevocably disappears. This leads to paralysis and disruption of the pelvic organs.

Exercise therapy

Physical activity is of great importance in the rehabilitation of a patient after a compression fracture of the spine.

Rehabilitation periods can be divided into 4 stages:

First stage

lasts during the first – second week after injury. The goal of this period is to increase the patient’s motor activity and restore muscles after immobilization.

Second phase

begins a month after the injury. The main goal of rehabilitation is to stimulate blood circulation in the damaged area and increase physical activity. It is possible to include light exercises to restore the muscle corset.

3rd stage

begins several months after the injury. The goal of this stage of rehabilitation is to restore the mobility of the motor segments of the spine. During this period, the intensity and duration of exercise therapy classes increases. Gymnastic exercises can be supplemented with weight-bearing exercises.

4th stage

lasts from the moment the patient resumes independent movements until complete actual recovery. Complexes of exercise therapy are aimed at completely restoring both spinal mobility and posture.

During this rehabilitation period, there is a smooth transition to full axial load of the injured spine.

Rehabilitation after traumatic vertebral fractures can be a fairly lengthy process. As a rule, complete recovery occurs within 6-12 months.

Possible complications

A lumbar vertebral fracture is a dangerous injury that can lead to disability. If left untreated, it can lead to:

• spinal instability;
• spinal canal stenosis;
• inflammatory processes in the area of ​​damage;
• paralysis of the legs;
• persistent erectile dysfunction;
• urinary and fecal incontinence;
• osteochondrosis, the formation of protrusions and intervertebral hernias;
• kyphotic deformities of the spinal column.

after vertebroplasty
Thus, a fracture of the lumbar spine can occur in anyone, but with proper, and most importantly, timely treatment, there is every chance of fully recovering from the injury, avoiding dangerous complications and disability.