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  MEDICAL MANAGEMENT Definition/Description The complex shape of the vertebrae, along with the interaction of central nervous system, the relatively specialized structures of theintervertebral disks and the associated vertebral ligaments has made the description and classification of spinal fractures an ongoing pursuit for the medical community. The current system had its roots in 1963 after Holdsworth proposed classifying spinal fractures by the mechanism of injury (MOI) of compression, flexion, extension, and flexion-rotation. He divided the injuries involvement of the anterior weight bearing c olumn and the posterior “tension bearing” column of facet joints and ligament complex [1] . The 1983 Denis system revision led to a center column comprised of the posterior vertebral body, posterior vertebral disk and posterior ;ongitudinal ligament [2] . In the Denis system it was believed that trauma focused into the middle column was sufficient to cause instability in the spine. The instability was further categorized into three types:    First degree: considered mechanical    Second degree: neurological    Third degree: combined mechanical/neurological This system is still currently the favored method. The main frustration from the Denis method is that the inclusion of the middle column introduced a “virtual landmark” that isn’t really suitable for determining an injury type. A recently developed system by Aebi incorporates the two column method, combined with the method of injury, and the  instability which may result in neurological compromise. This method can result in 27 subgroups of spinal fractures [3] . Obviously the classification of fractures is complicated and ongoing. The American Academy of Orthopedic Surgeons website lists fractures based on the pattern of injury and in a simpler format:    The flexion pattern contains compression fractures, and axial burst fractures.    The extension pattern, which contains flexion/distraction (often called a chance fracture).    The rotation pattern contains transverse process and fracture-dislocation. [4]  While the listed examples above all imply trauma for a spinal fracture, osteoporosis and conditions such as osteogenesis imperfecta are commonly implicated in vertebral fractures as well.  Epidemiology /Etiology Vertebral fractures detected with patients presenting with back pain account for only a third of osteoporitic fractures. [5]   The extension pattern of lumbar fractures:    A chance fracture results from a distraction accident such as stopping quickly and the force from a seatbelt pulling the vertebrae apart. The flexion pattern of lumbar fractures:      Compression fractures are usually caused by an axial load that causes the anterior vertebrae to lose height. [4]  Axial Burst fractures are caused by an axial load of a sudden acceleration or deceleration transmitted through the spine that causes the vertebrae to lose height on all sides.    Burst fractures may result in some retropulsion of the vertebra into the vertebral canal. [6]  Compression and burst fractures are most commonly seen in falls and traffic accidents. [6]   The rotation pattern of lumbar fractures:    Transverse process (TP) fractures are uncommon and result from extreme sideways bending. These do not usually affect stability.    The fracture-dislocation is a fracture in which bone and its accompanying soft tissue will move off an adjacent vertebra. This type is an unstable fracture and may cause severe spinal cord compression. Characteristics/Clinical Presentation Fractures of the lumbar spine and at the thoracolumbar junction are quite common. Per definition, in compression type fractures the anterior column is affected, whereas in burst fractures, anterior and middle column and sometimes the posterior column, are involved. Compression type fractures are predominately caused by indirect hyperflexion and bending forces whereas burst type fractures result from axial loading. [7]  More than 65% of vertebral fractures may not cause recognizable symptoms and may be undiagnosed with radiographs. [5]  Patients could have neurologic involvement, may have low back pain, movement may be impaired, or a combination of all of them. When the spinal cord is also involved, numbness, tingling, weakness, or bowel/bladder dysfunction may occur. [4]  Upon inspection of the spine, the patient typically has a kyphotic posture that cannot be corrected. The kyphosis is caused by the wedge shape of the fractured vertebra; the fracture essentially turns the lateral conformation of the vertebra from a square to a triangle. [8]   Examination  Radiologists should take a proactive role in helping to diagnose spinal fractures. The failure to diagnose vertebral fracture is a worldwide problem due in part to the lack of fracture recognition by radiologists and the use of ambiguous terminology in radiology reports. [9]  Physical therapists can also be more engaged through a thorough exam that includes:    A detailed history    A neurological exam    Palpation, especially midline along the vertebrae [8]      ROM, STR, joint mobility and muscle length assessments    Careful differential diagnosis Medical Management (current best evidence) Operative    When neurological impairments are present, surgical procedures are usually required to repair or relieve the site of injury. [10]  There are several procedures determined by the degree of compromise, the spinal level of the fracture and the patient's previous health status. [8]  Anterior/Posterior Approach:    Often dictated by the severity of compromise or level of injury, a surgeon will make an anterior or posterior approach to the patient's spine in order to stabilize it. Rods, screws and other mechanical devices are inserted through remaining structures to fuse the affected vertebra(e). The anterior approach dominates upper lumbar (L1, L2) fractures due to involvement with the crura of the diaphragm while lower lumbar fractures (L5) are stabilized through a posterior approach method. [11][12]  Kyphoplasty:    A mini-invasive percutaneous procedure that relieves vertebral fracture pain through the heat discharged during bone cement coagulation. The cement also solidifies to further stabilize the site of injury. [13]  During the procedure, a cannula is introduced into the vertebral body followed by a bone expander to regain some vertebral height. Kyphoplasty has been found to be similar in success rate as vertebroplasty, but with greater recovery of vertebral height. [14]  Vertebroplasty:    An effective treatment in the management of vertebral compression fractures, vertebroplasty involves injecting bone fillers such as polymethylmethacrylate (PMMA) bone cement into the fractured vertebral body. [14][15]   Non-operative
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