Spine Fracture — Knowledge Stratification
🔹 Intern Level
Core Concepts
- Definition: Disruption of vertebral body ± posterior elements due to trauma
- Common causes:
- RTA (most common)
- Fall from height
- Osteoporotic collapse (elderly)
Basic Classification (Recognition level)
- Compression fracture
- Burst fracture
- Fracture-dislocation (unstable)
Clinical Red Flags
- Back pain + trauma
- Neurological deficit (weakness, numbness)
- Bladder/bowel involvement → emergency
Initial Management (ATLS mindset)
- Immobilize spine (cervical collar, log roll)
- ABC stabilization
- Avoid unnecessary movement
Basic Imaging
- X-ray: screening
- CT: confirm fracture
- MRI: neurological deficit / ligament injury
🔹 MBBS Doctor Level
Detailed Classification Awareness
- Stable vs unstable fracture
- Denis 3-column theory:
- Anterior column
- Middle column
- Posterior column
- Instability if ≥2 columns involved
Common Injury Patterns
- Compression → anterior column
- Burst → anterior + middle (retropulsion risk)
- Chance fracture → flexion-distraction
- Fracture-dislocation → all 3 columns (highly unstable)
Neurological Correlation
- Cervical → quadriplegia
- Thoracic → paraplegia
- Lumbar → cauda equina syndrome
Indications for Urgent Referral
- Neurological deficit
- Suspected unstable fracture
- Severe pain with deformity
Basic Management Principles
- Analgesia
- Immobilization (brace/collar)
- Early referral to spine/neurosurgery
🔹 Other Discipline Resident Level (Orthopedic/Medicine/EM)
Advanced Classification Systems
- AO Spine Classification:
- Type A: Compression
- Type B: Tension band injury
- Type C: Translation/rotation
Stability Assessment
- Mechanical instability
- Neurological instability
- Ligamentous injury (MRI importance)
Radiological Interpretation
- CT: gold standard for bony injury
- MRI:
- Cord edema/contusion
- Posterior ligament complex (PLC) injury
Management Decision Basics
- Conservative:
- Stable fractures
- No neuro deficit
- Surgical:
- Unstable fracture
- Neuro deficit
- Progressive deformity
Complications
- Neurological deterioration
- Kyphotic deformity
- Chronic pain
🔹 Junior Neurosurgery Resident Level
Comprehensive Classification & Scoring
- AO Spine system (detailed)
- TLICS (Thoracolumbar Injury Classification Score):
- Morphology
- PLC integrity
- Neurology
- Score ≥5 → surgery
Biomechanics & Injury Mechanism
- Axial load → burst fracture
- Flexion → compression
- Flexion-distraction → Chance fracture
- Rotation → fracture-dislocation
Radiological Nuances
- CT:
- Canal compromise (%)
- Pedicle involvement
- MRI:
- PLC disruption (key surgical indicator)
- Cord signal change (prognostic)
Surgical Indications
- Neurological deficit with compression
- Unstable fracture (AO B/C, TLICS ≥5)
- Significant canal compromise
- Progressive deformity / kyphosis
Surgical Options
- Posterior fixation (pedicle screw)
- Anterior decompression (corpectomy)
- Combined approach (severe instability)
Emergency Management
- High-dose steroids (controversial; selective use)
- Early decompression (<24 hrs preferred in SCI)
Postoperative Considerations
- DVT prophylaxis
- Early mobilization
- Rehabilitation
Complications to Anticipate
- Hardware failure
- Non-union
- Post-traumatic kyphosis
- Neuro deterioration
🔑 High-Yield Summary
- Instability = key decision point
- CT → bone, MRI → cord + ligaments
- TLICS ≥5 → surgery
- Neuro deficit = urgent decompression
- Always immobilize first, diagnose later