Managing spinal fractures in primary care

Date: 
Sunday, September 7, 2014

Dr. Hee Hwan Tak

Medical Director and Senior Consultant,
Centre for Spine and Scoliosis Surgery, Singapore
Lower back injuries can result from a variety of causes but spinal fractures are most commonly the result of osteoporosis or blunt trauma. For non-acute back injuries, primary care physicians must be prepared to identify the type of injury or fracture and refer accordingly.
Spinal fractures at any age

Patients with osteoporosis are prone to fractures due to weakened, brittle bones and these frequently occur in the lower spine. Such fractures are more likely to occur in women over 50 years who have a history of osteoporosis and may have been diagnosed as such with bone density scans.

The mechanism of injury can be telling for diagnosing osteoporotic spinal fractures because it was likely minor, without excessive violent motion or trauma. Patients are more likely to complain of a sprain or pain and might not recall a specific fracture-inducing event.

In younger patients, compression fractures are the more common ailment, and are typically the result of a trauma such as a fall or a vehicle accident.

Compression fractures are a minor form of spinal fractures that occur in the anterior portion of the vertebral body. This portion of the bone loses height and becomes depressed. In addition to causing pain, compression fractures alter the mechanics of the spine and can affect the weight-bearing function.

Other types of spinal fractures, e.g. burst fractures, chance fractures, or fracture-dislocations, are rarely seen in the primary care setting as they are usually evacuated to the hospitals.

Look, feel and move

In any instance of spinal injury, GPs should conduct a “Look, Feel and Move” examination of the patient. Looking involves thorough inspection with proper patient exposure. Feeling involves palpating the spine for areas of tenderness, swelling and pain, which would indicate trauma, and larger than normal gaps between the vertebrae, which suggests soft tissue disruption.

Moving involves patient movement and is a good demonstration of spinal stability. If patients can stand and walk without much problem, there is likely a small, stable injury. However, if bearing weight becomes a problem or if a patient stands with great difficulty and pain the moment they load the spine, then the injury is unstable and more serious.

An X-ray is required to find out what type of injury the patient has. Beyond such inspection, there are no formal guidelines for diagnosis. This may present a challenge for a physician, particularly if they only see a few cases of spinal injury.

A comprehensive patient history with emphasis on the mechanism of injury helps to ensure proper diagnosis. For example, if the patient is an elderly woman with lower back pain and no recollection of a traumatic event, an osteoporotic spinal fracture may be the issue. If the patient is a younger adult involved in a high velocity injury, a compression fracture is more likely.

Treating spinal fractures

Specialist involvement is usually indicated almost immediately in cases of spinal injury or fracture. Treatment options such as plaster casts or braces may not be available in GP clinics.

The exception would be for osteoporotic fractures, which are more likely to be trivial, low velocity injuries with background disease, and may be treated and managed initially in an outpatient clinic with rest, pain relievers, calcitonin and supplementary calcium and vitamin D. Osteoporotic patients may still be referred for specialist care if their condition plateaus or deteriorates further.

In diagnosing spinal fractures, it is best to assume that the spine is unstable until proven otherwise though X-ray or other investigation.

In some cases, patients may have a non-contiguous spinal injury, or injuries in more than one place on the spine. Patients could be unaware of this if, for example, one site is significantly more painful than others. This scenario occurs more often in patients with high velocity injuries, typically about 17 percent of cases.

One of the challenges for GPs when it comes to spinal fractures is how to know for sure that it is due to a fracture alone. There are a number of other diseases that can cause bones to weaken and fracture without significant trauma.

Cancers and tumors can mimic osteoporosis and weaken bones. Multiple myeloma, a blood cancer, can cause fractures of the spine and may be determined by an ESR test to determine the erythrocyte sedimentation rate.

Non-pulmonary tuberculosis, which can occur in a variety of organs in the body such as the gastrointestinal tract, and which does not display the classic coughing symptom, can weaken bones and cause spinal fractures. This is an important issue to be alert about particularly in countries such as India and Indonesia with a high tuberculosis burden.

Other contributors to spinal fractures include steroid medications, people with low calcium intake or poor diet, and minimal exposure to sunlight.

Following up spinal fractures

Following assessment and treatment, patients with spinal fractures must be treated for their underlying systemic disease, if any, to prevent the risk of further fragility fractures. Orthopedic patients must be instructed in the condition of their disease and the medications and exercises necessary to prevent bone loss. Pharmacological treatment should be started in established cases of osteoporotic fractures of the spine. A baseline bone mineral density should be ordered prior to the commencement of drug treatment. Optimizing the home environment is also important to prevent falls at home, as most osteoporotic fractures occur due to falls at home. Cancer patients or those with other diseases require appropriate treatment.

GPs must be clear when managing patients with compression fractures about the allowed activity level. The most common questions from younger patients are about when they can resume work, when they can resume sporting activities, and if they have been given a brace to wear, when they can remove it. Recovery in these patients is typically 3-4 months and after initial treatment is over, a gradual return to normal activity levels is possible.

Patients may have some chronic intermittent pain due to the altered shape of the spine. In a compression or osteoporotic fracture, the total height of the spine is reduced and the profile of the spine is off balance.

Conclusion

Spinal fractures are common in elderly osteoporotic patients and younger patients who have sustained a high impact injury, but GPs should use X-ray tests and rule out cancer, tuberculosis or bone-weakening medications to make a definitive diagnosis. Specialist involvement is recommended for all but the most minor of osteoporotic fractures and recovery may take several months. GPs should maintain a high index of suspicion in order to identify these common but painful lower back fractures.