Does This Older Patient Have a Spinal Fracture? Evaluation and Management of Spinal Fractures in Older Adults
AUTHORS
Michael Barrie, MD, Assistant Professor, Department of Emergency Medicine, The Ohio State University, Columbus
David Hartnett, MD, Assistant Professor, Department of Emergency Medicine, The Ohio State University, Columbus
Lauren T. Southerland, MD, Assistant Professor, Department of Emergency Medicine, The Ohio State University, Columbus
PEER REVIEWER
Steven M. Winograd, MD, FACEP, Attending Emergency Physician, Mt. Sinai Queens Hospital Center, Assistant Clinical Professor, Emergency Medicine
Older adults present unique challenges for the clinician. Missing a spinal fracture can have devastating consequences for this more fragile population. The authors review the clinical presentation, injury patterns, and unique considerations for imaging and management of spinal fractures in older adults.
— Ann M. Dietrich, MD, Editor
Introduction
Older adults have an increased risk of spinal fractures and require special consideration. These patients are particularly vulnerable to traumatic spinal injury because of many factors, including changes in bone quality with aging, medications, and increased prevalence of spinal stenosis and spinal disease. In combination with this increased risk of fracture, older adults also are at increased risk for trauma. One-third to one-half of community-dwelling older adults report falling in the past year.1,2 While most of these falls are not injurious, a fall from standing height or even a bed or chair can provide enough force to cause a fracture of the spine in this more vulnerable population. Falling from a standing height is the most common mechanism of spinal injury, with motor vehicle collisions (MVCs) a close second.3,4 Older adults also have an increased rate of MVCs per driven mile and the highest fatality rates for pedestrian accidents.4,5 Another frequently undiagnosed source of traumatic force to the spine is elder abuse, which should be considered as a cause in any older adult who presents for a fall or an injury, especially patients who have a delayed presentation.6
In addition to an increased propensity for spinal trauma, older adults have significantly higher morbidity and mortality. In one reported cohort, the mortality from spinal injury was 27.7% in those older than 70 years of age, compared to 3.2% in younger patients.4 Cervical spine fractures, in particular, have poor outcomes, with an in-hospital mortality rate of 38%.7 Spine fractures above C4 have a seven times higher risk of mortality than fractures at lower cervical levels.7 Even stable cervical fractures without spinal cord injury have a one-year death rate similar to the mortality from hip fractures (25%).8
Primary Assessment
It is important to conduct a full trauma evaluation in accordance with Advanced Trauma Life Support (ATLS) algorithms in patients who presents with possible traumatic complaints. For older adults, a fall to the ground or out of a chair may be significant trauma, and a cursory exam may miss important injuries. Frequently, these patients are not treated as trauma patients despite the high rates of injuries and morbidity. Current trauma triage protocols undertriage the geriatric population, resulting in reduced numbers of older adults presenting to trauma centers.9-11 Although efforts are being made to triage these patients more appropriately, undertriage of significant injuries still occurs frequently.10-12
The first step in ATLS is evaluation and management of the airway. This process can present unique challenges in geriatric patients. The cervical spine may be less mobile from degenerative disk disease and complications caused by comorbid conditions. Positioning the head and neck for intubation may cause difficulties with respiration/ventilation or increase stress on the cervical spine.13 Patients with rheumatoid arthritis also are at higher risk for atlantoaxial subluxation when the neck is extended for intubation. Any manipulation of the neck in older trauma patients should be gentle, and a second provider rather than a cervical collar should be used to hold the head steady during manipulation.
The next steps in ATLS are the evaluation of breathing and circulation. It is important to understand that the physiology of aging generally leads to less cardiopulmonary reserve. Thus, critical patients will decompensate rapidly, and providers should intervene early when abnormal vital signs are identified. The newest trauma triage guidelines recommend that a systolic blood pressure below 110 mmHg, rather than the cutoff of 90 mmHg used in younger adults, is a predictor of morbidity in older adult trauma patients.10 Additionally, the provider must consider the effects of comorbidities on the patient’s vital signs and breathing. A comorbidity such as chronic obstructive pulmonary disease can reduce the ability to ventilate if the patient is laid supine for trauma assessment, leading to respiratory distress.14 A cervical collar for spinal immobilization can worsen respiratory status as well.
Currently, ATLS guidelines emphasize early spinal immobilization with a cervical collar. However, controversy has emerged regarding the benefit of cervical spine immobilization with current techniques.15,16 The use of cervical collars is recommended based on historical practice, but current data do not support their use, and studies have shown that cervical collars do not provide significant immobilization. Risks of immobilization include decreased respiratory function, decreased venous return, increased intracranial pressure, and pressure-related wounds.17 Cervical collars also should not be used in patients with penetrating injuries to the neck, since cervical immobilization devices have shown worse outcomes. 18 Both the Eastern Association for the Surgery of Trauma (EAST) and the Congress of Neurological Surgeons guidelines do not recommend empiric cervical collar use in patients who are awake, alert, and do not have neck pain or neurologic deficits. (See Table 1.)
Table 1. Summary of Available Guidelines for the Assessment and Management of Spinal Trauma |
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|
Guideline |
Key Recommendations |
Area |
Year |
Website |
|
EAST Cervical Spine Collar Clearance in the Obtunded Adult Blunt Trauma Patient |
• In obtunded blunt trauma patients, recommend maintaining cervical collar until a negative high-quality cervical spine CT is done. |
Cervical spine |
2015 |
|
|
EAST Cervical Spine Injuries Following Trauma |
• In awake, alert patients without neurologic injury or distracting injury, without neck pain or tenderness, and with full range of motion of the neck, imaging is not necessary and cervical collars may be removed. • CT is the preferred imaging modality for screening for injuries. |
Cervical spine |
2009 |
|
|
Congress of Neurological Surgeons Guidelines |
• A cervical collar is not recommended if the patient is alert, not intoxicated, and without neck pain or neurologic deficits. Steroids are not recommended for the treatment of acute spinal cord injury. |
Cervical spine |
2013 |
|
|
American Academy of Orthopaedic Surgeons Treatment of Symptomatic Osteoporotic Spinal Compression Fractures |
• Treat acute compression fractures (0-5 days since onset) with calcitonin for four weeks. Kyphoplasty is a limited recommendation, but vertebroplasty is not recommended. |
Cervical, thoracic, or lumbar compression fracture |
2010 |
|
|
EAST Screening for Thoracolumbar Spinal Injuries |
• Patients without complaints of thoracolumbar pain and with normal mental status and neurologic and physical exams may be excluded from thoracolumbar imaging by clinical exam alone. If imaging is required, CT is the recommended first-line imaging for possible thoracolumbar spine fractures. • In patients with a cervical spine fracture, the thoracolumbar spine should be imaged to evaluate for noncontiguous fractures. |
Thoracic or lumbar spine |
2012 |
|
|
UK National Institute for Health and Care Excellence Spinal Injury: Assessment and Initial Management |
• Recommend using Canadian C-spine criteria to guide imaging, which has a cutoff of imaging all patients > 65 years of age with blunt trauma. • Imaging is recommended for thoracolumbar spine fractures if > 65 years of age or suspicion for fracture in the cervical spine. • Recommend X-ray as first-line imaging for thoracolumbar spine fractures, and CT if X-ray is abnormal or clinical signs of neurologic injury are present. • No indication for steroids, nimodipine, or naloxone in the setting of spinal cord injury. |
Cervical, thoracic, or lumbar spine |
2016 |
|
Although the controversy about empiric cervical spine immobilization is unlikely to be resolved soon, a clear consensus has recommended against routine use of rigid backboard devices for full spinal immobilization.19 These devices do not immobilize the spine, and they generally are associated with increased morbidity for older adults. The yield also is low, as one review of 5,286 patients transported on long boards for thoracic and lumbar spinal immobilization found that only 4.3% had fractures of the thoracic or lumbar spine and only 0.5% had potentially unstable fractures.20 While these rigid boards can be used for difficult extrications at the scene, they should not be used for ambulance transport. Patients should be transferred immediately to a cushioned cot or mattress. The general principle is to immobilize the patient in a position of comfort and avoid placing the patient in devices that cause an increase in the patient’s pain or distress.
For those patients who require CT imaging of the cervical spine, providers should re-evaluate the patient’s cervical spine following negative imaging to assess for pain and mobility. A suggested approach to spinal clearance after normal imaging is to remove the collar and have the patient gently move his or her neck actively through a complete range of motion, asking the patient to turn the head to each side, look up and down, and to move the ear toward the shoulder. Providers also can re-evaluate the cervical spine for tenderness. A challenging situation occurs when the imaging is normal but the patient has ongoing tenderness or decreased cervical range of motion. A conservative approach would be to obtain either flexion-extension plain films or cervical magnetic resonance imaging (MRI) to evaluate for ligamentous injury. However, more recent guidelines suggest that this approach may have little benefit to detect clinically significant injuries and much higher associated costs.21
The assessment for cervical spine fracture in the intubated or obtunded trauma patient relies heavily on imaging. Current EAST guidelines support discontinuation of cervical spine precautions and removal of cervical collars if CT imaging is negative in the obtunded patient. In an analysis of more than 1,017 patients, CT imaging alone was 100% sensitive for detection of unstable cervical spine injury and 91% sensitive for any stable injury of the cervical spine.21 Although CT imaging alone may miss some stable spinal trauma, such as ligamentous injuries, these injuries generally do not require operative intervention or rigid cervical immobilization. An important exception is in patients who have negative CT imaging but develop a new neurologic deficit that localizes to a cervical level. In these patients, providers should consider obtaining an MRI to evaluate for blunt spinal cord injury.
A final consideration is awareness of how a patient’s arrival, age, or premature closure may cause bias in an initial evaluation. Most older adults with a fall or blunt trauma will be transported privately and not by emergency medical services. This can result in bias, as the “patient was well enough to drive in.” All elderly patients who present for an injury should receive a full history and physical exam irrespective of their mode of arrival or other distracting injury. Non-spinal injuries, such as extremity fractures, do not preclude spinal fractures. Conducting a thorough trauma evaluation will prevent the provider from closing the case prematurely once one injury has been identified. Any patient with a potential spinal injury should be evaluated thoroughly for other traumatic injuries.
Further Assessment
Once the patient has been stabilized (airway, breathing, and circulation), the provider can conduct the secondary exam. Just as in younger patients, any patient with a concerning mechanism or symptoms of a spinal fracture should receive a detailed physical exam, which includes a full neurologic exam and an examination of the skin and vertebrae for pain or signs of trauma. For patients who have an abnormal physical exam with neurologic deficit, it is important to document physical exam findings carefully early in the trauma evaluation. Providers should use a standard grading for spinal cord injury, such as the American Spinal Injury Association worksheet (available at: http://asia-spinalinjury.org/wp-content/uploads/2016/02/International_Stds_Diagram_Worksheet.pdf).
Although the physical exam can increase suspicion for injuries, clinical exam alone is insufficient to exclude spinal injuries. In a prospective evaluation of almost 900 blunt trauma patients of all ages, the site of pain, even in conscious, alert patients, did not correlate with the spinal level of the fracture in 61% of patients.22 Additionally, older adults have a higher risk for C1 and C2 dens fractures, which are nonpalpable. (See Figure 1.) Even in the thoracic and lumbar spine, which can be palpated more easily, clinical exam for significant fractures has a sensitivity of 78.6% and a specificity 83.4%.22 And 21% of older adults with a cervical spine fracture will be asymptomatic initially.23
Figure 1. Dens Fracture |
 |
Cervical Spine Assessment. Several clinical decision tools have been developed. The Canadian C-Spine criteria recommend imaging all adults ≥ 65 years of age with any mechanism of injury, including falls.24 The National Emergency X-Radiography Utilization Study (NEXUS) criteria for cervical spine imaging do not include an age limit and may be applicable to older adults.25 These criteria recommend imaging for any patient who does not meet a set of low-risk criteria, including lack of cervical spinal tenderness, intoxication, or neurologic deficits.
There has been some concern about the use of NEXUS to rule out cervical spinal fractures in older adults, as these patients can have fractures without cervical spinal tenderness and may have comorbidities that decrease cognition and pain response.26 Additionally, some elements of NEXUS are subjective and vulnerable to disagreement between assessors.27 In one cohort of 2,785 blunt trauma patients, NEXUS had a sensitivity of 65.9% in older adults vs. 84.2% in younger adults.28 However, another single-site study noted a sensitivity of 94.8% in older adults with blunt trauma.29 These data suggest that imaging should be performed if the pretest probability for a cervical fracture is high. One proposal to improve the sensitivity of NEXUS is to adjust the definition of normal mental status (currently a Glasgow Coma Scale [GCS] of 15) to exclude any change in cognition from baseline. This could be done by obtaining collateral information from family or friends and by screening for delirium with one of the many cognitive tools validated in the emergency department (ED).30,31 In a prospective study of 800 older patients with ground level falls, using NEXUS and a change from baseline mental status as an indication for imaging resulted in 100% sensitivity for cervical spine fractures.32
Mental status assessment is important for any patient in the ED, but it is especially important for the older trauma patient. Confusion or altered mental status induced by the trauma or pain may impede communication and cause the patient to deny pain. Even older adults without acute cognitive changes often deny pain.33,34 Researchers have found that the current generation of older adults may respond negatively to questions about pain but positively to other descriptors, such as soreness, discomfort, or aching. Therefore, when assessing for neck or back pain in this population, it is important to ask the question again using different terminology, such as “Are you uncomfortable or sore?” Using multiple questions in addition to physical examination and palpation will increase the provider’s ability to identify possible injuries.
Thoracic and Lumbar Spine Assessment. Clinical decision tools for thoracic and lumbar spine imaging after trauma also are controversial. An American Association for the Surgery of Trauma clinical decision tool for imaging of the thoracic and lumbar spine found that any patient ≥ 60 years of age was at high risk and recommended that any older adult receive imaging.35 The GLass intact Assures Safe Spine (GLASS) criteria also indicates that patients ≥ 60 years of age require imaging.36
Some of the complexity in evaluating older adults with potential thoracic or lumbar spinal fractures occurs because the patients may present with abdominal pain or generalized back pain rather than spinal tenderness.26 Additionally, the pain may radiate to other parts of the spine or localize poorly. Currently, clinical decision tools that facilitate clearance of an older adult’s lower spine are not available. In neurologically intact patients (GCS of 15 and no change in mentation from baseline) with a low-velocity mechanism of trauma and no neurologic deficits or spinal, chest, back, or abdominal pain (or discomfort), it likely is safe to clear the thoracic and lumbar spine clinically without imaging.
Imaging Modalities
Once the decision to obtain imaging has been made, the next decision is which type of imaging to acquire. For plain film radiographs, adequate views must be obtained. However, in older adults, X-rays frequently are inadequate because of immobility, osteopenia, or chronic changes in the spine. For these reasons, most providers choose CT imaging for cervical spine injuries in older adults. Plain film X-rays of the thoracic and lumbar spine also can be significantly limited by patient positioning, body habitus, arthritic and degenerative changes, osteopenia, and overlapping bony anatomy. CT is the recommended imaging for evaluation of traumatic injury in the lower spine in this population as well, with 99% accuracy compared with 87% for standard X-rays.37 The EAST guidelines recommend CT as the initial imaging modality, while the UK National Institute for Health and Care Excellence Guidelines for Spinal Injury recommend beginning with standard thoracic and lumbar spine X-rays. (See Table 1.) Although MRI typically is not the initial imaging obtained, it is indicated for neurologic deficits, cauda equina, or central cord syndrome.
If a fracture is found, the patient should return to radiology for imaging of the rest of the spine, according to a recent meta-analysis. In blunt trauma patients (e.g., [MVCs, falls), 26% of those with thoracolumbar spine fractures had concomitant cervical spinal fractures. Similarly, if a cervical spine fracture was identified, 20% of all trauma patients had a secondary fracture in the thoracolumbar spine.38,39 The EAST guidelines endorse imaging the entire spine if a spinal fracture is found in one area.40 Any patient with a spinal fracture also should be assessed carefully and comprehensively for the presence of associated injuries. Spinal fractures can highlight a high-energy mechanism of trauma, and the patient is more likely to have intracranial, thoracic, or abdominal injuries also. Patients found to have spinal fractures should receive a careful tertiary trauma evaluation, and providers should strongly consider additional imaging of the brain, chest, or abdomen as indicated.
Injury Patterns
Compared to injuries in a younger population, spine injuries in older adults are more likely to follow certain injury patterns. For example, geriatric patients are twice as likely to sustain cervical spine fractures as younger patients with similar mechanisms of injury.25 Compression fractures also are far more common in older patients.
Cervical Spine. The most common cervical spine fractures in the geriatric population are at the level of C1 and C2, with more than 50% of cervical fractures occurring at the level of C2.41 Additionally, the incidence of C2 fractures has increased 135% from 2000 to 2011 (Medicare data).42 Fractures in this area are associated with a very high rate of morbidity and mortality.43
C1 or atlas fractures are divided into three types. (See Table 2.) Type I is an isolated anterior or posterior arch, type II is a burst fracture with bilateral fracture of the anterior and posterior arch, and type III is a unilateral mass fracture. Surgery is recommended if there is displacement, cord compression, or adjacent joint instability, but otherwise patients are managed nonoperatively.
C2 is the most frequent spinal fracture location for older adults. C2 or odontoid fractures also are divided into three types. Type I is avulsion of the tip of the odontoid, type II is a fracture through the waist of the odontoid, and type III involves a fracture line that extends into the body of C2. Type II fractures are the most common. Although the majority of C2 injuries are nonoperative, an estimated 15% will require surgery. In type I C2 injuries, it is imperative to evaluate for atlanto-occipital instability. This is done in consultation with a spinal surgeon, who may complete further evaluation with flexion/extension imaging or MRI.
Table 2. Synopsis of Common Cervical Spinal Fractures, Description, Complications, and Treatment44-49 |
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|
Fracture |
Description |
Pearls |
|
|
C1 – Atlas (Jefferson Fracture) |
Type I |
Isolated anterior or posterior arch |
• Rates and cost of care for atlas fractures are increasing50 • Conservative (nonsurgical) treatment is recommended unless evidence of displacement, cord compression, or adjacent joint instability • Halo vest has the highest rate of complications and nonunion (62.5%) |
|
Type II |
Burst fracture with bilateral fractures of anterior and posterior arch |
||
|
Type III |
Unilateral lateral mass fracture |
||
|
C2 – Odontoid |
Type I |
Avulsion of the tip of the odontoid |
• C2 is the most frequent fracture location • 15% require surgical management • Type I must evaluate for atlanto-occipital instability • Type II is the most common cervical fracture in older adults |
|
Type II |
Through the waist of the odontoid |
||
|
Type III |
Extending into the body of C2 |
||
|
Hangman’s Fracture (Traumatic Anterior Spondylolisthesis) |
Type I |
Axial loading and hyperextension — minimally displaced |
• Less common in older adults than in younger patients because of association with high-energy mechanism • Type I typically are nonoperative • Type III are the least common injury type |
|
Type II |
Hyperextension with rebound flexion — disruption of C2-C3 disk |
||
|
Type IIa |
Severe flexion of body fragment with minimal fracture displacement |
||
|
Type III |
Flexion/rebound extension with facet joint dislocations |
||
The hangman’s fracture is a traumatic anterior spondylolisthesis with fracture dislocation of C2 on C3. It is less common in the geriatric population than in younger patients, mainly because it is associated with high-energy mechanisms. The fracture’s moniker comes from judicial hangings when a knot was placed under the chin. When the victim was dropped, the submental knot would cause sudden hyperextension of the neck. This is useful to remember only because it helps highlight the typical mechanism of injury: forceful hyperextension of the neck while being struck under the chin. This can happen with falls when the chin strikes a surface or when an unrestrained passenger strikes the vehicle’s steering wheel or windshield.
Type I injuries have minimal displacement. Type II injuries involve hyperextension with rebound flexion, causing disruption of the C2-C3 disc. Type IIa injuries have severe flexion of body fragment with minimal fracture displacement. Type III injuries involve flexion with rebound extension with facet joint dislocations.
Associated Injuries. Any cervical fractures that involve the facet joints, transverse body, or transverse foramen may cause vertebral artery injuries. (See Figure 2.) A subsequent CT angiogram should be obtained to evaluate the vasculature. Many patients with blunt vertebral artery injury will have no presenting neurologic deficits, but they can progress to have posterior circulation stroke symptoms or death.
Treatment of vertebral artery injuries generally is nonoperative, as the injury locations are inaccessible. Patients should be monitored closely for signs of stroke and should be started on anticoagulation, such as warfarin, aspirin, or heparin, in consultation with a neurovascular surgeon. (See Figure 2.)
Figure 2. Fracture Involving the Transverse Foramen |
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This fracture pattern requires a follow-up CT angiography to evaluate for injury to the vertebral artery.
|
Thoracolumbar Spine. Overall, thoracic fractures are relatively uncommon because of the decreased mobility of the thoracic spine in comparison to the cervical and lumbar spine. The majority of the purely thoracic fractures that do occur are related to osteoporosis and malignancy. More frequently, fractures occur in the thoracolumbar region (T10-L2), given the articulation between the stable thoracic spine and the highly mobile lumbar spine. This area is at high risk for burst fractures and chance fractures. (See Table 3.)
Table 3. Synopsis of Common Thoracolumbar Spinal Fractures, Description, Complications, and Treatment |
|||
|
Type |
Mechanism |
Definition |
Pearls |
|
Compression Fracture |
Commonly osteoporotic |
• > 20% loss of vertebral body height |
• Frequently associated concomitant fractures • Increased kyphosis can decrease pulmonary function • Even asymptomatic compression fractures are associated with increased risk of falls55 |
|
Burst Fracture |
Axial load with flexion |
• Involvement of anterior and middle columns • Retropulsion of bone into the spinal canal |
• 20% have associated concomitant spinal fractures • May be managed nonoperatively if no neurologic deficits and stable fracture pattern |
|
Chance Fracture |
Commonly occurs in motor vehicle collisions in which the patient was wearing only a lap belt |
• Involves all three columns • Flexion of anterior and middle column, distraction of posterior column |
• 50% are associated with an intra- abdominal injury |
A compression fracture, defined as a greater than 20% loss of vertebral body height, is the most frequently diagnosed thoracolumbar spinal injury. The most common underlying etiology is osteoporosis, and patients frequently may have associated concomitant fractures. Although management of thoracolumbar compression fractures generally is nonoperative, the injuries cause significant morbidity, including increased risk of falls and decreased pulmonary function secondary to the resulting spinal kyphosis. In addition, these fractures are associated with cognitive decline, functional decline, and further falls with injury.51-55
A burst fracture is a severe type of compression fracture, with disruption of the vertebral body cortex and retropulsion of the bone into the spinal canal. Unlike more common compression fractures, burst injuries are sustained with higher energy mechanisms with axial loading and flexion, such as falling from a height and landing on the feet. Burst fractures are more likely to require operative management; however, if there are no associated neurologic deficits and the fracture is stable, conservative measures can be considered.
Chance fractures involve all three columns of the spine — anterior, middle, and posterior. A chance fracture can occur when a person wearing a lap belt but no shoulder strap is involved in an MVC and the spine flexes over the low seat belt. The anterior vertebral body fails under compression, and the posterior elements of the spine fracture with distraction. It is important to note that a chance fracture is a marker of a high-energy mechanism of injury and a majority of these patients will have an associated intra-abdominal injury due to the compression of the abdominal compartment.
Spinal Cord Injuries. Acute traumatic central cord syndrome is the most common type of incomplete spinal cord injury.56 The clinical presentation of central cord syndrome is greater extremity weakness in the upper extremities compared to the lower ones and bilateral loss of pain and thermal sensation in a cape-like distribution over the shoulders and upper back. It may be associated with bladder or bowel incontinence. The most common mechanism is hyperextension of the neck, during which the ligamentum flavum protrudes anteriorly and compresses the spinal cord. Spinal stenosis, which is common in the older population, increases the risk of developing a traumatic central cord syndrome. This injury may occur during a fall when the forehead strikes a hard object and the body keeps moving, or during a rear-end MVC. It is proposed that after this injury there is edema predominately in the central cord. This may lead to Wallerian degeneration of the corticospinal tract, which affects the upper extremities more than the lower extremities.
Although more common with penetrating spinal injuries, Brown-Sequard hemiplegia is an injury that results from transection of half of the spinal cord. The clinical exam shows ipsilateral motor weakness with contralateral loss of pain and temperature sensation.57
Cauda equina syndrome may result from any space-occupying lesion within the spinal canal below the termination of the actual spinal cord. The most common types of lesions include disc herniation, spinal stenosis, tumor, burst fracture, epidural hematoma, and epidural abscess. These lesions compress the nerve roots within the spinal canal, causing progressive symptoms and eventual permanent nerve dysfunction. Symptoms include back pain, urinary retention leading to possible overflow incontinence, loss of anal sphincter tone leading to bowel incontinence, saddle anesthesia, impotence, and sensorimotor loss in the lower extremities. Cauda equina syndrome is a surgical emergency and requires immediate decompression to preserve the affected nerve roots. Treatment delay can result in sexual dysfunction, urinary dysfunction, chronic pain, and persistent weakness. Urinary retention should be treated quickly, as this can lead to obstructive nephropathy and renal failure. Patients with suspected cauda equina syndrome should have a documented post-void residual, and if greater than 200 mL, consider placement of a Foley catheter to relieve the obstruction.
Management
Cervical Spine. Management of spinal fractures in older adults is more complicated than in younger adults. The indications for surgical fixation differ because of the higher risk of surgical complications in older patients. Additionally, while surgery for C1 and C2 fractures may be associated with improved radiographic healing, it has not been linked firmly to improved patient outcomes.47 External fixation with a halo and surgical fixation of a cervical spine injury have similar mortality rates.58 The decision to proceed with surgery or conservative therapy (immobilization) is difficult and must take into account the patient’s comorbidities, pre-existing functional status, and current symptoms.
The most common conservative therapy is immobilization with a cervical collar. All patients, but especially older adults, may find the collars limiting and uncomfortable. Cervical collar use is associated with lower respiratory tract infection (the most common complication), delirium, and increased care needs.59 Older adults are at higher risk for falls while wearing these devices, as they cannot flex the neck to view their feet or the floor. Hard cervical collars may not be shaped correctly for an older adult’s cervical spinal lordosis, and soft collars provide minimal immobilization. High cervico-thoracic collars, such as Miami J, Aspen, or Philadelphia collars, are preferred for immobilization but must be fit well.60 Even millimeters of extra space in a cervical collar can result in a significant difference in the degrees of range of motion.
The close fit needed for these collars to function also is the reason for some of the associated complications. Cervical collars can cause skin breakdown, respiratory complications, and falls. The downward pressure placed by a collar can limit the expansion of the upper ribs with inhalation. This results in reduced lung parameters (FEV1) from 98% of predicted for age and weight to 89%, which can be a significant decrease if a patient has underlying pulmonary disease.61 If a collar must be used in an older adult patient with chronic respiratory disease, consider raising the head of the bed to help improve respiratory function and encourage frequent pulmonary toilet. The enforced immobility from a cervical collar combined with respiratory compromise also leads to pneumonia and sepsis, the two most common complications in patients hospitalized with spinal fractures.62
In addition to respiratory effects, cervical collars can cause pressure injuries and skin breakdown. Seventy-five percent of patients transported to a trauma center with cervical immobilization developed stage 1 injuries (non-blanchable redness of the skin) and 2.9% developed stage 2 injuries (partial thickness skin loss or blister) from collars during transport alone.63 Prolonged use increases that risk. In hospitalized trauma patients, 28% will develop a pressure ulcer, and cervical collars are the most common device culprit.64 If long-term use of a collar will be needed, the patient’s caregivers should perform daily skin assessments and follow up closely with the medical team.
Thoracic and Lumbar Fractures. As with cervical spine fractures, the decision to proceed to surgery for thoracic and lumbar spine fractures must weigh the risks and benefits. Age older than 70 years is an independent predictor for mortality (odds ratio, 3.1) in patients undergoing surgery for lumbar fractures.65 If there are no neurologic deficits from the injury, most of these fractures are treated conservatively with bracing, physical therapy, and secondary prevention by managing any underlying osteoporosis.
Patients whose movement is significantly limited by pain may be treated with thoracolumbar sacral orthosis (TLSO) braces. The effects of bracing on long-term outcomes are not clear. Soft or rigid braces for osteoporotic compression fractures do not improve outcomes.51,66 Dynamic braces that provide some stabilization and restricted movement have proven superior in trials.67
Management strategies with good data on outcomes (depending on the type of fracture) include physical therapy, osteoporosis treatment, and kyphoplasty. Early physical therapy is especially important, as functional status is decreased by vertebral fractures.53,54 Physical therapy decreases the risk of chronic pain and improves physical function.68 All patients with vertebral fractures who are cleared for movement should be referred to a physical therapist or physiatrist.
Additionally, older adults with spinal fractures, whether from a low- or high-velocity impact, should be screened and treated for osteoporosis and osteopenia.69,70 This can help with recovery and prevent future fractures. In patients with low vitamin D levels, supplementation has been associated with improved recovery and decreased mortality for patients with distal radius and hip fractures, and also may improve outcomes in spinal fractures.71,72 An initial fracture is the greatest risk factor for subsequent fractures, so it is very important for all older adults to discuss osteoporosis screening and management with their primary care providers.
Final treatment strategies specific to vertebral compression fractures are vertebroplasty and balloon kyphoplasty. Vertebroplasty is an outpatient procedure that involves stabilizing the vertebral body with intraosseous polymethylmethacrylate cement. Kyphoplasty uses an initial balloon device over the injection needle to compress the existing bone and make a discrete bony pocket for cement injection. A recent meta-analysis of these procedures found a complication rate of 4% and an improvement in pain relief in 89% of adults.73 These interventions are cost effective, even in the oldest old patients, as they prevent future spinal compression fractures and improve daily function and quality of life.74-76 This should be discussed with patients at the time of diagnosis, as these procedures are most effective if performed in the acute phase (within two to three weeks of fracture).77,78
Conclusions
Spinal fractures, whether requiring operative or conservative treatment, are high-risk injuries in older adults. Routine spinal immobilization with a cervical collar and rigid backboard is not needed, as these devices increase morbidity. Also, if one spinal fracture is found, remember to obtain imaging of the entire spine to look for concomitant fractures. Finally, consider referral for early physical therapy assessment and osteoporosis screening for any older adult with a fracture.
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Older adults present unique challenges for the clinician. Missing a spinal fracture can have devastating consequences for this more fragile population. The authors review the clinical presentation, injury patterns, and unique considerations for imaging and management of spinal fractures in older adults.
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