The spine has an amazing ability to not flinch when you expect it should ~ and spine compression fractures are good example of this. It could almost be said, as a broad rule of thumb (and obviously discounting catastrophic fractures) that spinal fractures leave the back in better shape than an injury of similar magnitude that doesn’t break bone. This is simply because the energy absorbed in breaking bone spares the wrenching of the soft tissues and leaves them more juicy and compliant in years to come. The spinal facet joints, in particular, cope better without the traumatic scar formation which is the legacy of massive soft tissue damage.
T12, at high waist level, has suffered a compression fracture
The spine can suffer crush fractures of the vertebral bodies as well as snapping breakages of the various bony fins sprigging from the sides of the vertebrae (these are for muscle attachment) such as the transverse and spinous processes. The sorts of spinal fractures that cause paraplegia and quadriplegia (with paralysis of the legs in the former and arms and legs in the latter) involve traumatic shearing forces across the spine, transecting the soft spinal cord inside the bony column, like slicing through a sausage. Apart from the tragedy of lifetime paralysis, the spine is left mechanically unstable and usually needs surgical stabilisation.
A typical spine compression fracture is a wedge fracture. This is caused by a savage forced bending strain (usually forwards) buckling the spine down on itself at a moment of traumatic impact. The mechanics of the injury are sufficient to crumple the bone of the front (or side) of the vertebral body. Although the pictures on MRI or X-ray can look alarming, there's often surprisingly little pain from this crush fracture. Also, the spine is usually quite stable in the aftermath and does not require internal fixation, or any other surgical procedure.
Spinal joints adjacent to this L4 wedge fracture may cause pain several years later from the altered bio-mechanical forces
Compression fractures illustrate all too clearly the disparity in strength between the vertebrae and the intervertebral discs. Of the two, discs are much stronger. The vertebral endplates are the weakest component part of the spine. They are the fine cartilaginous interfaces between the discs and vertebrae and can be quite easily broken with forces within physiological range. The internal honeycomb bone of the vertebrae, called the spongiosa because of its porous, sponge-like quality, is also less robust than the disc.
A 3D grid of bone creates the internal scaffolding of the vertebral bodies
The spongiosa is made up of fine filaments of bone which form an internal 3D scaffolding of vertical and horizontal struts and spars. This gridwork makes the vertebral bodies lighter and better able to withstand high compressive forces. The tiny internal cavities within the spongiosa act as a blood storage area with the fluid (blood) also making it easier to hydraulically defray compression through the bones. Sudden and savage compression however, can fracture the bony internal scaffolding.
Endplates can be fractured by activities within physiological range
Another typical spine compression fracture results in a central caving-in of the vertebral body, where the endplate is more porous and fragile over the disc's nucleus. The legacy after injury is called a Schmorl's node, which is like an elliptical depression,or scoop, in the top of the vertebra. The initial fracture however, may be quite small-scale; a barely discernible puncture or vent in the cartilage of the endplate surface that later breaks down into the Schmorl's node. Importantly, this type of minor scale spine compression fracture can be caused by exertions within normal physiological range, such as unaccustomed heavy lifting.
A Schmorl's node can develop from a quite minor vent punched into the endplate from sudden compressive forces through the length of the spine
Osteoporosis, or weakening of bone due to demineralisation, is another cause of spine compression fractures as the bones become more brittle with advancing age. Although osteoporosis comes about through hormonal changes, it can also be speeded up by disc degeneration. If the disc has started to lose height, more load will be taken through the facet joints at the back of the spine behind the disc. In this instance, the bone supporting the facet joints becomes more dense, while the converse happens throughout the vertebral body. The picture below describes this well.
The blacker area at the front of the vertebral body indicates
weaker bone from osteoporosis
Vertebroplasty is a more recent approach to compression fractures of the spine. This involves injecting a bone cement under pressure into the collapsed vertebral body, in effect to restore height by forcing the bone fragments into a more pleasing anatomical alignment.
Vertebroplasty is the injection of a sort of cement inside a collapsed vertebra
The long term effects of vertebroplasty are unknown, since even in a somewhat crushed state the vertebral body still houses the rich blood capillary bed from which the intervertebral disc sucks in its vital nutrition. Early studies indicate accelerated breakdown of the adjacent intervertebral disc with this procedure. Bursting the injured vertebra is also a complication, as the picture below shows.
A kyphoplasty is a similar surgical procedure for wedge compression fractures of vertebrae in the thoracic spine and the same limitations apply. As a postural stoop becomes more apparent in advancing years, spontaneous fractures are commonplace in the thoracic spine.
The white matter is escaped cement impinging on the neural matter inside the spinal canal
Less invasive treatment for traumatic compression fractures is bed rest. One cannot restore naturally the height of the crushed vertebra, although with the right management this may modify considerably over time. The main objective during the healing phase of the crushed bone, is preventing any future deformity of the skeleton as a whole. With wedge fractures, it is important to maintain upright alignment of the spine by preventing the upper body tipping forward and becoming fixed in front of the line of gravity.
Keeping the spine straight while a wedge fracture mends is important for the health of the spinal segments both above and below the damaged vertebra. The best approach in the acute post-injury stage is six weeks lying as flat as possible to stop the spine bending while bone bone is uniting. A more old-fashioned approach was using a plaster-of-Paris jacket to encase the body from armpits to hip bones for a similar period. The results were no better, if not worse, from the massive de-conditioning of the muscles when the spine emerged from the plaster jacket.
Similar principles of conservative treatment apply when treating a developing postural problem of a stooped upper back, especially when it is starting to suffer spontaneous compression fractures. This is quite common with the elderly.
This is a case of stooped upper back, known as a postural kyphosis
Apart from the possibility of fractures, a hunched upper back looks unsightly. It can also be the source of great pain in the upper back and around the sides and front of the chest wall. Advanced thoracic kyphosis is a common cause of breathing difficulties and pain associated with breathing. You can read more about it in the page upper back pain with breathing. People with advanced postural kyphosis can avoid getting to the sad juncture of spontaneous fracturing by doing their own thoracic spine decompression on a daily basis.
The first step in conservative management of these conditions is simply spending a couple of minutes per day lying flat on the back on a carpeted floor, with a small pillow only under the head. The harder surface creates an un-buckling decompressive effect on the spinal segments and interrupts the crushing bending forces, in both the thoracic and lumbar spines.
After a period of three months has transpired since the most recent fracture patients can then progress to using a 1.5cm book under both thoracic and lumbar spines and as soon as this becomes comfortable, using the BackBlock. The thoracic BackBlock procedure is described in detail in the Thoracic Spine section of the book 'Body in Action' which is available on Sarah Key Books, together with other important mobilising exercises for this part of the body. It is described more briefly here in using the BackBlock for the upper back. The standard lumbar BackBlock routine is described here in how to do the BackBlock. Watching the downloadable video from the back pain video package at the bottom of this page will carefully take you through how to do the BackBlock for the upper back, and more importantly how to get off the Block without hurting yourself. It will also show you the all important angels' wings exercise.
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