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Spinal Compression Fractures

- Atraumatic Compression Frx:
      - diff Dx:
              - osteoporosis
              - osteomalacia
              - pagets disease
              - multiple myeloma;
              - hyperparathyroidism
                    - reference:
                          - Back pain and vertebral crush frxs: an unemphasized mode of presentation for primary hyperparathyroidism.                           
      - labs:
              - sed rate:
              - serum ca:
              - serum phos:
              - alkaline phosphatase:

- Traumatic Compression Frx:
    - determine whether the frx is stable or unstable
           - these frx are normally stable (assumming the dx is correct) & rarely involve neurologic comprimise;
    - diff dx:
           - burst frx of spine
           - Chance frx
                    - be suspicious of "compression" fractures in young patients involved in MVA;
                    - a good quality AP radiograph may help rule out compression frx (absence of posterior element frx);
    - Denis Classification:
           - 4 types of compression frx according to Denis classification;
           - Type A - involvement of both end plates;
           - Type B - involvement of superior end plate;
           - Type C - inferior end plate;
           - Type D - buckling of anterior cortex w/ both end plates intact;
    - Mechanism:
           - compression frx result from anterior or lateral flexion causing failure of the anterior column;
                  - middle column remains intact & may act as hinge;
                  - in some cases there may be disruption of posterior column in tension, as upper segments hinge forward on middle column;

- Radiographic Studies:
    - radiographs: (see radiographs for burst frx)
          - anterior ht of vertebra body is diminished, while posterior ht remains nl;
          - there is no anterior or posterior translation of the vertebral bodies;
          - amount of anterior compression should be no more than 40 % (relative to posterior vertebral body height (otherwise a burst frx may be present);
    - CT Scan:
          - allows good visualization of the posterior elements, which is necessary inorder to rule out the possibility of Chance fracture;
          - visualizes spinal canal, degree of neural compromise, and delineates element involvement, particularly in a burst fracture;
          - disadvantage of axial CT is its inability to detect subtle horizontally oriented fractures of the vertebral bodies, pedicles, or lamina;
          - minimal vertebral body compression fractures may be missed;
          - many of these problems are overcome by frontal & sagittal reformation.

- Non Operative Treatment:
    - non operative treatment remains the standard for compression fx;
    - most pts can be treated symptomatically w/ short period of bed rest until pain is diminished;
           - in some cases an NG tube is required for severe ileus;
           - if bowel sounds and flatus are not present then patient should be made NPO, and should receive IV Fluid;
    - early ambulation is encouranged in a hyperextion orthosis;
    - avoidance of compression overloads for a period of 12 weeks;
    - depending on degree of compression, pt may be treated effectively by hyperextension exercises & avoidance of compression overloads for period of approximately 12 weeks.
    - early ambulation is encouraged in a hyperextension orthosis.

- Treatment of Unstable Frx:
    - definition of unstable frx:
           - loss of 50% of vertebral body height;
           - angulation of thoracolumbar junction > 20 deg;
           - multiple adjacent compression frx;
           -  failure of 2/3 of columns of spine;
    - spinal segment will fail with weight bearing;
    - even w/ spinal instability - may have good response w/ a hyperextsion cast;
           - note: a brace should not be considered a substitute for a well molded hyperextension cast;
    - kyphoplasty:
           - ref: Quality of Life Following Vertebroplasty.
    - post injury care:
          - watch for increasing kyphotic deformity or if pt's pain has not resolved, elective stabilization and arthrodesis should be considered

Anterolateral compression fracture of the thoracolumbar spine. A seat belt injury.

Assessment of the risk of vertebral fracture in menopausal women.

Vertebral fractures without neurological deficit. A long-term follow-up study.

Late outcome of nonoperative management of thoracolumbar vertebral wedge fractures.

Prospective Measurement of Function and Pain in Patients with Non-Neoplastic Compression Fractures Treated with Vertebroplasty.

Guideline on the Treatment of Symptomatic Osteoporotic Spinal Compression Fractures