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Spinal Fractures

Traumatic and osteoporotic spinal fractures — classification, management of thoracolumbar burst fractures, and surgical indications for instability or deformity.

Overview

Spinal trauma represents complex injuries requiring a detailed systematic approach to ensure safe and appropriate patient outcomes [15]. Epidemiological data indicate that 25 out of 1000 patients present with a vertebral fracture, with over two-thirds managed surgically and a 6.3% complication rate [2]. Current guidelines address the management of cervical, thoracic, and lumbar fractures, encompassing both surgical and nonsurgical strategies [1].

For neurologically intact patients with stable thoracolumbar burst fractures, nonoperative treatment is superior, yielding significantly better long-term outcomes for pain and function [6]. In patients with ankylosed spines, minimally invasive surgery (MIS) offers lower complication rates, reduced estimated blood loss, and shorter surgical time and length of stay compared to open approaches [24]. For ankylosing spondylitis (AS)-associated fractures of the lower cervical spine, posterior pedicle screw fixation is a reasonable recommendation [28].

Management of symptomatic osteoporotic spinal compression fractures varies in strength of recommendation, ranging from Inconclusive to Strong. There is a Strong recommendation against vertebroplasty and a Weak recommendation for kyphoplasty in patients not improving with nonsurgical management [29]. The optimal surgical approach for specific thoracolumbar fractures remains controversial, warranting further clinical cohort studies to establish comprehensive protocols [77]. An appropriate unified management protocol for thoracolumbar fractures without neurological impairment has not been well defined [88].

Posterior instrumentation using distraction and ligamentotaxis reduction primarily aims for sagittal realignment and fracture stabilization rather than decompression of neural elements [95]. To address these controversies, a multicenter randomized controlled trial is comparing conventional open versus minimally invasive percutaneous approaches, with outcomes evaluated at 1, 2, 3, 6, 12, and 24 months postoperatively [96].

Anatomy & Pathophysiology

Kinematics and Biomechanics

Injury Mechanisms: Axial loading of the cervical spine is the primary injury mechanism in catastrophic cervical spine injuries in football players [59]. Radiographic abnormalities in the thoracolumbar spine of young elite skiers are attributed to a disproportion between applied load and loading capacity of the immature spine [56]. L4–5 dislocation may be a variant to lumbosacral (L5-S1) dislocation, owing to hyperextension injury [31].

Dynamic and Static Effects: Kinematic MRI demonstrates dynamic pathoanatomical changes, such as canal stenosis in different positions, in patients with cervical spinal cord injury without fracture and dislocation [33]. The static biomechanical effects caused by modified anterior cervical discectomy and fusion (partial vertebral osteotomy) are intermediate between ACDF and anterior cervical corpectomy and fusion (ACCF), and the risk of vertebral body collapse is lower than that by ACCF [64]. Motion in the coronal plane decreased by 77% following anterior vertebral body tethering, while measurable thoracic motion remains at 1 year with sagittal motion greater than coronal motion [60].

Adjacent Segment and Disc Stress: Noncontinuous cervical disc arthroplasty preserves intradiscal pressure and facet joint forces at the adjacent and intermediate levels to maintain the kinematics of the cervical spine near preoperative values [34]. Abnormal mechanical stress may contribute to intervertebral disc degeneration in old thoracolumbar fractures with kyphosis, highlighting the importance of managing stress in kyphotic deformities [57]. Local biomechanical factors, particularly the state of degeneration of adjacent intervertebral discs and disc height, are equally important as bone mineral density in determining vertebral fracture risk and type [46].

Instrumentation and Fusion Biomechanics

Cage and Rod Systems: ALIF is preferable at L5/S1 due to biomechanical factors, while at L4/5, both ALIF and total disc arthroplasty give comparable results [35]. The biomechanical benefit of a stand-alone two-part fusion cage can be justified [37]. The biomechanical effects of a rod fracture in a worst-case scenario of the thinnest PS of the spinal hybrid elastic rod system afford nearly sufficient spine support and gentle adjacent segment stress [50].

Pedicle Screw Augmentation: Cement-augmented pedicle screw instrumentation (CAPSI) is more likely to increase the potential risk of adjacent segment degeneration compared to cemented pedicle screw (CPS) instrumentation in osteoporotic lumbar models, as both increase ROM and disc stresses [53].

Surgical Extent and Stability: Less facetectomy may reduce the risk of biomechanical deterioration and consequently, that of failed back surgery syndrome (FBSS) [49]. Advances in biomechanics and fixation systems have enabled reliable stabilization that permits early mobilization for posterior instrumentation in thoracolumbar fractures [54].

Vertebral Fracture Pathophysiology and Rehabilitation

Fracture Dynamics: Fracture mobility is present in vertebral body stenting, and the realignment potential increases with the severity of preoperative vertebral body deformation [48].

Rehabilitation Principles: Core stability, sport-specific progression, and avoiding aggravating movements like extension in the early stages of healing are emphasized in the rehabilitation of spinal injuries in athletes [36].

Classification

Standardization of terminology related to treatment decisions and prognosis is key to improving the understanding of the clinical behavior of thoracic and lumbar fractures [14]. The ideal classification for thoracic and lumbar fractures does not exist [14].

AO: Includes A and B types for nonosteoporotic spinal fractures in adult patients [3]. Vertebral body bruises associated with traumatic VBB in adult patients with nonosteoporotic spinal fractures of AO classification A or B types did not develop collapse, unlike compression fractures [3].

Modified TLICS: A practical tool for the classification and assessment of thoracolumbar fractures with guiding significance for clinical treatment [38]. The operation rate for thoracolumbar fractures was slightly lower with the modified TLICS system than with the TLICS system [38].

Posterior Short-Segment Fixation Stability: A reliable classification for assessing the stability of a healed vertebra after posterior short-segment fixation was developed for thoracolumbar burst fractures [40].

Spinopelvic Balance: A new classification system incorporating spinopelvic balance in radiographic assessment may aid orthopaedic surgeons in identifying patients who would benefit from partial reduction and fusion [58].

Hip-Spine: Allows surgeons to make appropriate preoperative evaluations [70]. Guides the use of dual mobility (DM) components in patients with spinopelvic pathology to reduce the risk of dislocation [70].

Other Considerations: A novel MRI- and CT-based scoring system efficiently differentiates malignant vertebral fractures from osteoporotic vertebral fractures in Chinese patients with high accuracy and good applicability [26]. Major trauma patients with spinal fractures have more complex injuries than non-major trauma patients, demonstrated by increased levels of instability and fractures at more than one level [27]. Chapter 97 provides a comprehensive overview of the classification of pelvic, acetabular, and sacral fractures [72].

Clinical Presentation

Vertebral fractures are prevalent, occurring in 25 out of 1000 patients in epidemiologic analyses of acute cases [2]. They are frequently identified on chest radiographs but are often overlooked by radiologists [11]. Incidental findings such as butterfly vertebrae must be distinguished from true fractures based on specific radiographic features [18]. In adults with nonosteoporotic AO classification A or B types, vertebral body bruise (VBB) associated with traumatic spinal fractures does not develop collapse, unlike compression fractures [3]. Conversely, 20% of acute osteoporotic vertebral compression fractures involve multiple vertebrae without significant spine trauma or lower baseline bone mineral density [5].

Cervical spine injuries require rapid on-field diagnosis in collision sport athletes to optimize outcomes [8]. Unstable C1 fractures in athletes may present with minimal initial symptoms, leading to potential delayed diagnosis [44]. Isolated fractures of the anterior arch of the atlas reveal no neurological deficit but serve as an alert for more serious associated cervical spine injuries [47]. Recognition of solitary isolated lateral mass fractures of the atlas often requires CT imaging when initial radiographs are unremarkable [10]. Flexion teardrop fractures of the cervical spine present with diagnostic and management controversies due to limited high-quality studies and significant heterogeneity in existing evidence [39].

Sacral fractures are rare and heterogeneous, making optimal treatment determination challenging and requiring an integrated diagnostic and therapeutic approach to avoid delayed diagnosis [32]. Dual-energy CT can achieve comprehensive diagnosis of fragility fractures of the sacrum by defining a cut-off Hounsfield unit value for the presence of traumatic bone marrow edema in patients with osteoporosis [20]. Delivery-related sacral fracture is an uncommon complication that should be considered in the differential diagnosis of low-back pain during the postpartum period [45].

Children and adolescents with neurological deficits following spine injuries without radiographic abnormalities require thorough diagnostic screening, hospitalization, and sometimes prolonged therapy [9]. Vertebral fractures alter the location of the termination level of the conus medullaris, thereby altering potential neurological symptoms [55]. Major risk factors for complete spinal cord injury include Male gender, having a spinal fracture, having a thoracic injury, and having complications [52].

Investigations

Plain radiography: Vertebral fractures are frequently identified on chest radiographs but are often overlooked by radiologists [11]. In the acute setting, vertebral fractures rarely demonstrate significant collapse on X-ray within the first 2 weeks post-injury [89]. Upright radiographs are useful for guiding management decisions in traumatic vertebral fractures [97]. Recognition of solitary isolated lateral mass fractures of the atlas often requires CT imaging when initial radiographs are unremarkable [10]. Butterfly vertebrae may be incidentally detected; familiarity with their radiographic features is essential to distinguish them from acute fractures [18].

MRI: MRI is the modality of choice for evaluating ligamentous structures, discs, the spinal cord, and occult osseous injuries in acute spinal trauma [99]. Although MRI is more sensitive for occult injuries, the standard addition of MRI to CT evaluation alone does not significantly increase the detection of clinically important cervical injuries in blunt trauma patients [100]. Sacral insufficiency fractures (SIFs) are more commonly diagnosed by lumbar spine MRI than non-lumbar imaging modalities, as symptoms often mimic lumbar spine pathology and pain causes are variable [98]. Repeat imaging may be necessary for sacral stress fractures because MRI is not always definitive for early-stage injuries [86]. Pretreatment MRI should be considered in the evaluation of tibial spine fractures to improve the identification of concomitant injuries, particularly in patients who may otherwise be treated nonoperatively or with closed reduction [78].

CT: Comprehensive diagnosis of fragility fractures of the sacrum can be achieved by dual-energy CT using a 'one-stop-shop approach' that defines a cut-off Hounsfield unit value for traumatic bone marrow edema in patients with osteoporosis [20]. Computed tomographic scanning is valuable for diagnosing fracture of the atlantal arch causing atlanto-axial instability when plain radiographs are inconclusive [102]. Computerized tomography plays an important role in investigating progressive non-infectious anterior vertebral fusion, split cord malformation, and situs inversus visceralis to improve understanding of the underlying pathology and progressive fusion process [101].

Other Considerations: Vertebral body bruise (VBB) in adult patients with nonosteoporotic spinal fractures of AO classification A or B types does not develop collapse, unlike compression fractures [3]. A novel MRI- and CT-based scoring system efficiently differentiates malignant vertebral fractures from osteoporotic vertebral fractures in Chinese patients with high accuracy and good applicability [26]. Morphometric vertebral fractures are detected in 18.9% of patients with rheumatoid arthritis and/or systemic lupus erythematosus on chronic glucocorticoid therapy, a rate 3 times higher than verbally reported by patients [7]. Twenty percent of acute osteoporotic vertebral compression fractures involve multiple vertebrae without significant spine trauma or lower baseline bone mineral density [5]. Children and adolescents with neurological deficits following spine injuries without radiographic abnormalities require thorough diagnostic screening, hospitalization, and sometimes prolonged therapy [9]. Anthropometric indicators can be used in a screening strategy to prevent additional vertebral fractures, even when X-ray technology is not available [93].

Treatment

Non-Operative

Nonoperative management of stable thoracolumbar burst fractures in properly selected neurologically intact patients yields significantly better long-term outcomes for pain and function compared to operative treatment [6]. This approach demonstrates established clinical proficiency with excellent long-term outcomes and lower complication rates compared to instrumented approaches [90]. In adult patients with nonosteoporotic spinal fractures of AO classification A or B types, vertebral bodies with traumatic vertebral body bruise (VBB) did not develop collapse, unlike compression fractures [3].

For osteoporotic vertebral compression fractures, nonoperative management is associated with significant pain relief and functional improvement, although some patients may require surgical intervention if conservative measures fail [67]. Patients with fragility fractures of the sacrum with low pain levels benefit from conservative therapy [80]. Non-operative treatment is usually successful for bilateral fracture of the pedicle of the second cervical vertebra in young children, though surgical stabilization is suggested for unstable delayed union or uncooperative patients [81].

Operative

Indications: Management of spinal trauma varies from nonsurgical orthosis to surgical instrumented stabilization and fusion depending on the individual injury [91]. Major trauma patients with spinal fractures have more complex injuries than non-major trauma patients, demonstrated by increased levels of instability and fractures at more than one level [27]. Operative stabilization is recommended for non-complex unstable pelvic fractures [92]. Type-II odontoid process fractures are unstable with a 36% non-union rate when treated conservatively, justifying primary fusion in many cases [83].

Surgical Approach / Technique: Percutaneous short segment pedicle screw fixation with or without screwing of the fractured vertebra using O-arm navigation is safe and effective in treating thoracolumbar fractures in the short term [4]. A novel screw placement technique for traumatic thoracolumbar vertebral fractures under navigation guidance is feasible, safe, and effective [51]. The paraspinal erector approach for spinal canal decompression in upper lumbar burst fractures achieves significant improvements in spinal function and prognostics after percutaneous pedicle screw fixation [62]. Percutaneous and open surgical techniques for thoracolumbar fractures in ankylosing spondylitis patients achieve effects similar to traditional methods, improving pain, neurological function, and kyphotic deformity [69]. Posterior pedicle screw fixation is a reasonable surgical strategy for ankylosing spondylitis-associated fractures of the lower cervical spine [28].

Implant Selection: Cement-augmented pedicle screws (CAPS) fixation is an effective and safe technique to achieve solid fixation and favorable clinical outcomes in elderly patients with spinal tuberculosis and severe osteoporosis [75]. Percutaneous vertebroplasty combined with cement pedicle plasty (PVCPP) is an effective treatment method for patients with unstable osteoporotic vertebral fractures by improving vertebral biomechanical stability [68].

Adjuncts: Tirobot-assisted vertebroplasty is a safe and effective strategy that can realize quick recovery from thoracolumbar osteoporotic compression fracture [63]. Sacroplasty significantly benefits patients with fragility fractures of the sacrum who have unacceptable pain from non-dislocated fractures [80]. Percutaneous kyphoplasty (PKP) is safe and effective in treating metastatic vertebral fracture with posterior wall damage, achieving similar clinical outcomes compared to KP+IF but with less operative time, less blood loss, and fewer complications [66]. Antibiotic-loaded bone cement excellently fulfills requirements for bone cement in a kyphoplasty setting regarding properties and clinical application safety [82].

Setting of Care: Vertebroplasty and similar procedures should be performed only in settings where emergency spinal surgery is available due to the risk of acute paraplegia caused by epidural hemorrhage [84].

Other Considerations: The AAOS has a Strong recommendation against vertebroplasty and a Weak recommendation for kyphoplasty in patients with symptomatic osteoporotic spinal compression fractures not improving with nonsurgical management [29]. Cement augmentation for symptomatic osteoporotic vertebral fractures seems to have positive outcomes compared with optimal medical treatment or sham, although conclusions should be drawn cautiously due to a high likelihood of bias from industry-sponsored studies [65]. Vertebroplasty is an effective treatment for patients with intractable pain due to osteoporotic vertebral compression fractures [73].

Complications

Overall Morbidity: The overall complication rate for acute vertebral fractures is 6.3% [2]. Over two-thirds of patients with acute vertebral fractures in the analyzed cohort were treated surgically [2].

Adjacent / Sequential Fractures: Long-term reduction in health-related quality of life (HRQOL) is observed in women with vertebral fracture [16]. Patients treated with long segmental stabilization for unstable midthoracic spine fractures in the elderly have a significantly lower rate of sequential vertebral body fractures during follow-up [19]. Conversely, the incidence of subsequent vertebral fracture in patients aged 70 years and older undergoing posterior fusion with pedicle screw fixation for degenerative lumbar pathology is significantly higher than in patients under 70 years of age [30]. Low bone mineral density is an independent risk factor for new vertebral fractures in patients following percutaneous kyphoplasty [79]. A history of old fractures is an independent risk factor for new vertebral fractures in patients following percutaneous kyphoplasty [79]. Smaller FCSA is an independent risk factor for new vertebral fractures in patients following percutaneous kyphoplasty [79].

Neurological and Structural Instability: Long-term spinal stability remains a significant challenge in kyphoscoliotic patients with neurological deficit, often requiring additional fusion procedures [21].

Other Considerations: In postmenopausal women, a history of spine fracture is a significant risk factor for subsequent hip fracture, with a relative risk of 2.20 [85]. In postmenopausal women, a history of wrist fracture is a significant risk factor for subsequent hip fracture, with a relative risk of 1.53 [85]. Among patients undergoing multilevel cervical fusion, those with osteoporosis have a higher risk of adverse postoperative outcomes at two years [61].

Recovery

Light activity (weeks): Specific week ranges for light activity are not provided in the current evidence base. However, minimally invasive treatment of fractures through ankylosed spines results in shorter surgical time and shorter length of stay compared to open surgery [24]. For unstable incomplete burst fractures of the thoracolumbar junction, minimally invasive anterior spondylodesis with or without posterior stabilization leads to good clinical results with minimal spine-related impairment at latest follow-up [25].

Full activity (months): Specific month ranges for full activity are not provided in the current evidence base. Over two-thirds of patients with acute vertebral fractures are treated surgically [2]. The complication rate for acute vertebral fractures is 6.3% [2]. Percutaneous short segment pedicle screw fixation with or without screwing of the fractured vertebra using O-arm navigation is safe and effective in the short term for thoracolumbar fractures [4]. Long-term results of short segmental fixation with and without fusion for burst fractures of the thoracolumbar and lumbar spine are comparable [17].

Complete recovery / outcome plateau (months): Long-term follow-up after final fusion is necessary to determine true final results for growing-rod treatment of early onset scoliosis [13]. Women with vertebral fracture experience a long-term reduction in health-related quality of life [16]. Although cervical and lumbar spinal lesions led to reoperations after posterior decompression and fusion for thoracic ossification of the posterior longitudinal ligament, they did not affect quality of life, and relative improvement was maintained even after 10 years [71]. Approximately 20% of patients undergoing upper cervical spinal fusion surgery with a navigation system experienced delayed bony union [94].

Rehabilitation protocol: Specific rehabilitation protocols, including PT phasing, immobilisation duration, and weight-bearing progression, are not detailed in the current evidence base. The natural history of thoracolumbar burst fractures without neurological deficit is benign [12]. Nonoperative treatment yields significantly better long-term outcomes for pain and function in properly selected neurologically intact patients with stable thoracolumbar burst fractures [6]. Aggressive surgical management is usually not indicated for Langerhans Cell Histiocytosis of the spine in children in the absence of systemic disease or spinal deformity; only follow-up is necessary to monitor recovery and spinal balance [23].

Functional milestones: Validated PROM trajectories or outcome-measure benchmarks are not explicitly provided in the current evidence base. Patients treated with long segmental stabilization for unstable midthoracic spine fractures in the elderly have a significantly lower rate of sequential vertebral body fractures during follow-up [19]. Long-term spinal stability in kyphoscoliotic patients with neurological deficit remains a significant challenge, often requiring additional fusion procedures [21]. The natural history of progression pattern of vertebral deformities in radiographic prevalent vertebral fractures in elderly individuals has been clarified [22].

Other Considerations: Morphometric vertebral fractures are detected in 18.9% of women with rheumatoid arthritis and/or systemic lupus erythematosus on chronic glucocorticoid therapy, a rate three times higher than verbally reported by patients [7]. The incidence of subsequent vertebral fracture in patients aged 70 years and older after posterior fusion with pedicle screw fixation for degenerative lumbar pathology is significantly higher than in patients under 70 years of age [30]. Vertebral height deterioration in fractured vertebrae operated by percutaneous vertebroplasty may be due to the natural course of the fracture or osteoporosis [103]. Younger patients and those with vertical fractures of the cervical vertebral column require closer observation to prevent progression of local kyphosis after conservative treatment for compressive cervical spine fracture with spinal cord injury [104].

Key Evidence

  • [L3] Twenty-five out of 1000 patients presented with a vertebral fracture, with over two-thirds treated surgically and a 6.3% complication rate. (10.1186/s13018-022-03147-9)
  • [L3] Unlike compression fractures, the vertebral body with traumatic VBB found in adult patients with nonosteoporotic spinal fractures of AO classification A or B types did not develop collapse. (10.1186/s12891-022-05405-7)
  • [L3] In the short term, both minimally invasive treatments were safe and effective in treating thoracolumbar fracture. (10.1186/s12891-022-05069-3)
  • [L3] 20% of acute osteoporotic vertebral compression fractures can involve multiple vertebra without significant spine trauma or lower baseline bone mineral density. (10.1186/s13018-023-03874-7)
  • [L1] In properly selected neurologically intact patients, stable thoracolumbar burst fractures are best treated nonoperatively, as long-term outcomes for pain and function were significantly better for the nonoperatively treated patients. (10.2106/jbjs.n.01092)
  • [L3] Morphometric vertebral fractures were detected in 18.9 % of patients, i.e. 3-times more frequently than verbally reported by patients. (10.1186/s12891-015-0733-9)
  • [L4] This article provides a rational approach to the early recognition of the different clinical syndromes associated with catastrophic cervical spine injury, noting that rapid on-field diagnosis can help to optimize the outcomes of these catastrophic injuries. (10.1177/0363546504265605)
  • [Case_report] Children and adolescents with neurological deficits following spine injuries without radiographic abnormalities require thorough diagnostic screening, hospitalization, and sometimes prolonged therapy. (10.1007/s001670050212)
  • [L5] Recognition of these subtle fractures often requires CT imaging when initial radiographs are unremarkable. (10.1016/j.injury.2006.02.048)
  • [L4] Vertebral fracture is common on chest radiographs but it is often ignored by radiologists. (10.1186/s12891-018-2171-y)
  • [L4] The natural history of thoracolumbar burst fractures without neurology would appear to be benign. (10.1302/0301-620x.98b1.36121)
  • [L4] Long-term follow-up after final fusion is necessary to determine true final results. (10.2106/jbjs.15.01334)
  • [L5] Although the ideal classification for thoracic and lumbar fractures does not exist, standardization of terminology as related to treatment decisions and prognosis is key to an improved understanding of the clinical behavior of these injuries. (10.5435/00124635-200209000-00008)
  • [L2] The long-term reduction of HRQOL in women with vertebral fracture emerged clearly in this study. (10.1186/1471-2474-10-135)
  • [L2] The long-term results of short segmental fixation with and without fusion for burst fractures of the thoracolumbar and lumbar spine were comparable. (10.2106/jbjs.m.01486)
  • [Case_report] Although butterfly vertebrae may be incidentally detected, it is important to be familiar with their radiographic features to distinguish them from fractures. (10.1186/s12891-020-03433-9)
  • [L3] Patients treated with long segmental stabilization had a significantly lower rate of sequential vertebral body fractures during follow-up. (10.1186/s12891-021-04049-3)
  • [L4] Comprehensive diagnosis of fragility fractures of the sacrum can be achieved by dual-energy CT in terms of a 'one-stop-shop approach'. (10.1186/s12891-022-05690-2)
  • [L4] However, long-term spinal stability remains a significant challenge, often requiring additional fusion procedures. (10.2106/00004623-196042060-00010)
  • [L2] This study clarified the natural history of the progression pattern of vertebral deformities in radiographic prevalent vertebral fractures in elderly individuals. (10.1186/s12891-024-07254-y)
  • [L4] The natural history of these lesions in the spine in the absence of systemic disease or spinal deformity is such that aggressive surgical management is usually not indicated; only follow-up is necessary to monitor recovery and spinal balance. (10.2106/00004623-200408000-00019)
  • [L1] Patients undergoing MIS treatment of fractures through ankylosed spines had lower rates of complications, less estimated blood loss, and shorter surgical time and length of stay, highlighting the potential benefits of minimally invasive fixation. (10.5435/jaaos-d-24-01277)
  • [L3] MIAS leads to good clinical results with—in majority—minimal spine-related impairment at the latest follow-up. (10.1186/s13018-020-01807-2)
  • [L3] This novel scoring system using MRI and CT radiologic findings to differentiate malignant vertebral fractures from osteoporotic vertebral fractures in Chinese patients was efficient with high accuracy and good applicability. (10.1186/s12891-018-2331-0)
  • [L3] Major trauma patients differ from non-major trauma counterparts and have more complex spinal injuries, demonstrated by increased levels of instability and fractures at more than one level. (10.1302/0301-620x.97b2.34392)
  • [L4] It is thus reasonable to recommend this surgical strategy for AS-associated fractures of the lower cervical spine. (10.1186/s12891-017-1396-5)
  • [L1] The AAOS recommendations on the treatment of symptomatic osteoporotic spinal compression fractures range from Inconclusive to Strong, with a Strong recommendation against vertebroplasty and a Weak recommendation for kyphoplasty in patients not improving with nonsurgical management. (10.5435/00124635-201103000-00008)
  • [L3] The incidence of subsequent vertebral fracture in patients aged 70 years and older was significantly higher than in patients aged under 70 years of age. (10.1186/s12891-019-2534-z)
  • [L4] The biomechanics of the lumbar spine may differ with each individual, and L4–5 dislocation may be a variant to lumbosacral (L5-S1) dislocation, owing to hyperextension injury. (10.1186/s12891-019-2921-5)
  • [L5] Determining the optimal treatment of sacral fractures is a challenge due to their rarity and heterogeneous nature; an integrated diagnostic and therapeutic approach should be a goal to avoid delayed diagnosis and unfavorable outcomes. (10.2106/00004623-200401000-00027)
  • [L4] Kinematic MRI demonstrated dynamic pathoanatomical changes, such as canal stenosis in different positions, in patients with cervical spinal cord injury without fracture and dislocation. (10.1186/s13018-023-03745-1)
  • [L5] Noncontinuous CDA could preserve IDP and facet joint forces at the adjacent and intermediate levels to maintain the kinematics of cervical spine near preoperative values. (10.1186/s13018-020-1549-3)
  • [L1] ALIF is preferable at L5/S1 due to biomechanical factors, while at L4/5, both procedures give comparable results. (10.1302/0301-620x.107b6.bjj-2024-1646.r1)
  • [Paper] This article provides a comprehensive review of the diagnosis, biomechanics, and rehabilitation strategies for common spinal injuries in athletes, emphasizing the importance of core stability, sport-specific progression, and avoiding aggravating movements like extension in the early stages of healing. (10.1016/j.csm.2009.09.011)
  • [L5] The biomechanical benefit of a stand-alone two-part fusion cage can be justified. (10.1186/1471-2474-9-88)
  • [L3] The modified TLICS system is a practical tool for the classification and assessment of thoracolumbar fractures with guiding significance for clinical treatment, and the operation rate was slightly lower than that of the TLICS system. (10.1186/s13018-023-03958-4)
  • [L5] This narrative review provides a comprehensive overview of the diagnosis, management, and treatment of teardrop fractures in the cervical spine, highlighting key controversies and areas for future research due to the limited number of high-quality studies and significant heterogeneity in existing evidence. (10.1530/eor-2025-0010)
  • [L3] A reliable classification for assessing the stability of a healed vertebra was developed. (10.1186/s12891-020-03386-z)
  • [L4] The case highlights the potential for delayed diagnosis of unstable C1 fractures in athletes with minimal initial symptoms. (10.1177/0363546508328594)
  • [L4] Delivery-related sacral fracture is an uncommon complication that should be considered in the differential diagnosis of low-back pain during the postpartum period. (10.2106/jbjs.f.00181)
  • [L5] Local biomechanical factors, particularly the state of degeneration of adjacent intervertebral discs and disc height, are equally important as bone mineral density in determining vertebral fracture risk and type. (10.1007/s00402-011-1355-9)
  • [Case_report] All reported cases of isolated fractures revealed no neurological deficit, but the fracture serves as an alert for more serious associated cervical spine injuries. (10.2106/00004623-198668070-00019)
  • [L4] Given that fracture mobility is present, the realignment potential is sound and increases with the severity of preoperative vertebral body deformation. (10.1186/1471-2474-14-233)
  • [L5] Less facetectomy is better because it may reduce the risk of biomechanical deterioration and consequently, that of FBSS. (10.1186/s12891-019-2751-5)
  • [L5] The study concluded the biomechanical effects still afford nearly sufficient spine support and gentle adjacent segment stress after rod fracture in a worst-case scenario of the thinnest PS of the SHE rod system. (10.1186/s12891-022-05768-x)
  • [L3] The technique is feasible, safe, and effective for treating traumatic thoracolumbar vertebral fractures. (10.1186/s12891-025-09071-3)
  • [L4] Male gender, having a spinal fracture, having a thoracic injury, and having complications were the major risk factors for a complete injury. (10.1371/journal.pone.0084733)
  • [L5] Biomechanical analysis showed that both CPS and CAPSI increase ROM and disc stresses in osteoporotic lumbar models, but CAPSI is more likely to increase the potential risk of adjacent segment degeneration compared to CPS. (10.1186/s13018-020-01650-5)
  • [L5] Advances in biomechanics and fixation systems have enabled reliable stabilization that permits early mobilization. (10.5435/00124635-200411000-00007)
  • [L3] Vertebral fractures alter the location of the termination level of the conus medullaris, thereby altering potential neurological symptoms. (10.1186/s13018-017-0649-1)
  • [L3] This has to be attributed to a disproportion between applied load and loading capacity of the immature spine. (10.1177/03635465010290041101)
  • [L3] Abnormal mechanical stress may contribute to this degeneration, highlighting the importance of managing stress in kyphotic deformities. (10.1186/s12891-024-08157-8)
  • [L5] A new classification system that incorporates spinopelvic balance in the radiographic assessment may aid orthopaedic surgeons in identifying patients who would benefit from partial reduction and fusion. (10.5435/jaaos-20-04-194)
  • [L5] Axial loading of the cervical spine is the primary injury mechanism in catastrophic cervical spine injuries in football players, with profound implications for preventative measures. (10.2106/00004623-200201000-00017)
  • [L4] Motion in the coronal plane decreased by 77% following anterior vertebral body tethering. (10.2106/jbjs.20.01533)
  • [L3] Among patients who underwent multilevel cervical fusion, those with osteoporosis had higher risk of adverse postoperative outcomes at two years. (10.5435/jaaos-d-22-00361)
  • [L4] Significant improvements in spinal function and prognostics were achieved after the percutaneous pedicle screw fixation. (10.1186/s13018-014-0105-4)
  • [L3] As a safe and effective strategy, this surgery can realize the quick recovery from thoracolumbar osteoporotic compression fracture. (10.1186/s13018-021-02211-0)
  • [L5] The static biomechanical effects caused by Mod ACDF are intermediate between ACDF and ACCF, and the risk of vertebral body collapse is lower than that by ACCF. (10.1186/s13018-023-04033-8)
  • [L5] Cement augmentation for the treatment of symptomatic osteoporotic vertebral fractures seems to have positive outcomes compared with optimal medical treatment or sham, although conclusions should be drawn cautiously due to a high likelihood of bias with most studies being sponsored by industry. (10.1302/2058-5241.2.160057)
  • [L3] PKP was safe and effective in treating metastatic vertebral fracture with posterior wall damage, achieving similar clinical outcomes compared to KP+IF but with less operative time, less blood loss, and fewer complications. (10.1186/s13018-023-03608-9)
  • [Paper] Nonoperative management of osteoporotic vertebral compression fractures is associated with significant pain relief and functional improvement, though some patients may require surgical intervention if conservative measures fail. (10.1016/j.injury.2007.08.010)
  • [L5] PVCPP is an effective treatment method for patients with unstable osteoporotic vertebral fractures. (10.1186/s12891-024-07689-3)
  • [L3] This procedure can improve patients' pain, neurological function and kyphotic deformity and achieve effects similar to traditional methods, making it an ideal surgical treatment for thoracolumbar fractures in AS patients. (10.1186/s13018-022-03378-w)
  • [L3] The Hip-Spine Classification system allows surgeons to make appropriate evaluations preoperatively, and it guides the use of DM components in patients with spinopelvic pathology in order to reduce the risk of dislocation in these high-risk patients. (10.1302/0301-620x.103b7.bjj-2020-2448.r2)
  • [L4] The long-term outcomes revealed that although cervical and lumbar spinal lesions led to reoperations, they did not affect QoL, and relative improvement was maintained even after 10 years. (10.2106/jbjs.23.01475)
  • [L4] Vertebroplasty is an effective treatment for patients with intractable pain due to osteoporotic vertebral compression fractures. (10.2106/jbjs.d.02670)
  • [L4] CAPS fixation is an effective and safe technique to achieve solid fixation and favorable clinical outcomes in elderly patients with spinal tuberculosis and severe osteoporosis. (10.1186/s13018-023-04099-4)
  • [L5] The optimal surgical approach for specific thoracolumbar fractures remains a matter of controversy, warranting multiple clinical cohort studies to establish a comprehensive surgical protocol. (10.5435/00124635-200807000-00008)
  • [L3] Pretreatment MRI should be considered in the evaluation of tibial spine fractures to improve the identification of concomitant injuries, especially in patients who may otherwise be treated nonoperatively or with closed reduction. (10.1177/0363546520957666)
  • [L3] Low bone mineral density, history of old fractures, and smaller FCSA were independent risk factors for new vertebral fractures in patients. (10.1186/s12891-025-09319-y)
  • [L3] Patients with fragility fractures of the sacrum with low pain levels benefit from conservative therapy, whereas those with unacceptable pain from non-dislocated fractures benefit significantly from sacroplasty. (10.1186/s12891-022-06039-5)
  • [L4] Non-operative treatment usually is successful; however, surgical stabilization is suggested in patients who have unstable delayed union or when the patient is uncooperative. (10.2106/00004623-198668060-00011)
  • [L4] Requirements for bone cement in a kyphoplasty setting were excellently fulfilled. (10.1186/s13018-019-1200-3)
  • [L4] Type-II fractures are unstable with a 36% non-union rate when treated conservatively, justifying primary fusion in many cases. (10.2106/00004623-197456080-00017)
  • [L5] The authors recommend that vertebroplasty and similar procedures should be performed only in settings where emergency spinal surgery is available. (10.2106/jbjs.f.01612)
  • [L1] In postmenopausal women, a history of wrist or spine fracture is a significant risk factor for subsequent hip fracture, with spine fractures conferring a higher relative risk (2.20) than wrist fractures (1.53). (10.2106/00004623-200310000-00011)
  • [L4] Repeat imaging may be necessary as MRI is not always definitive for early stage injuries. (10.1177/0363546506296519)
  • [L4] An appropriate protocol and unified management of thoracolumbar fractures without neurological impairment has not been well defined. (10.1302/2058-5241.1.000029)
  • [L2] This study suggests that vertebral fracture rarely shows significant collapse on X-ray in the first 2 weeks after injury. (10.1186/s13018-014-0096-1)
  • [L5] Non-operative treatment for stable thoracolumbar burst fractures and uninstrumented fusion for low-grade lytic spondylolisthesis demonstrate established clinical proficiency with excellent long-term outcomes and lower complication rates compared to instrumented approaches. (10.1302/0301-620x.98b1.37508)
  • [L3] Operative stabilization is recommended for non-complex unstable pelvic fractures. (10.1302/0301-620x.100b7.bjj-2017-1377.r1)
  • [L4] This screening method could be used in a strategy to prevent additional vertebral fractures, even when X-ray technology is not available. (10.1186/1471-2474-9-157)
  • [L3] Approximately 20% of patients undergoing upper cervical spinal fusion surgery experienced delayed bony union. (10.1186/s12891-025-08582-3)
  • [L5] The primary goals of this procedure are sagittal realignment and fracture stabilization rather than decompression of neural elements. (10.5435/00124635-200711000-00008)
  • [L2] This study protocol describes a multicenter randomized controlled trial designed to compare the surgical treatment of thoracolumbar spine fractures using conventional open versus minimally invasive percutaneous approaches, with results to be evaluated at 1, 2, 3, 6, 12, and 24 months postoperatively. (10.1186/s12891-019-2763-1)
  • [L3] Upright radiographs are useful in guiding traumatic vertebral fracture management decisions. (10.1186/s12891-022-05243-7)
  • [L4] SIFs are more commonly diagnosed by L-spine MRI than non-lumbar imaging modalities, because of symptoms that mimic lumbar spine pathology and variable comorbid causes of pain. (10.1186/s12891-018-2189-1)
  • [L5] MRI is the modality of choice for evaluation of ligamentous and other soft tissue structures, disc, spinal cord, and occult osseous injuries. (10.1186/s12891-016-1169-6)
  • [L4] Although MRI is more sensitive for occult injuries, the standard addition of MRI to CT evaluation alone does not significantly increase the detection of clinically important cervical injuries. (10.5435/jaaos-d-18-00695)
  • [L5] The authors emphasize the important role of computerized tomography in investigating these patients to improve understanding of the underlying pathology and the progressive fusion process. (10.1186/1471-2474-7-94)
  • [L4] Computed tomographic scanning is valuable for diagnosing this pathology when plain radiographs are inconclusive. (10.2106/00004623-198668080-00024)
  • [L3] VHD might be due to natural course of fracture/ osteoporosis. (10.1186/s12891-025-08574-3)
  • [L4] Younger patients and those with vertical fractures of the cervical vertebral column required closer observation to prevent progression of local kyphosis. (10.1186/s13018-019-1115-z)

See Also

References

[1] Chapter 22 Spinal Trauma. 2020.

[2] Epidemiologic analysis of 8000 acute vertebral fractures: evolution of treatment and complications at 10-year follow-up. Journal of Orthopaedic Surgery and Research. 2022. DOI: 10.1186/s13018-022-03147-9

[3] The progression of the vertebral body bruise associated with a spinal fracture. BMC Musculoskeletal Disorders. 2022. DOI: 10.1186/s12891-022-05405-7

[4] A retrospective comparative study of clinical efficacy of percutaneous short segment pedicle screw fixation with or without screwing of the fractured vertebra with O-arm navigation. BMC Musculoskeletal Disorders. 2022. DOI: 10.1186/s12891-022-05069-3

[5] Comparison of acute single versus multiple osteoporotic vertebral compression fractures in radiographic characteristic and bone fragility. Journal of Orthopaedic Surgery and Research. 2023. DOI: 10.1186/s13018-023-03874-7

[6] Long-Term Results Still Favor Nonoperative Treatment of Stable Thoracolumbar Burst Fractures. Journal of Bone and Joint Surgery. 2015. DOI: 10.2106/jbjs.n.01092

[7] Prevalence of fractures in women with rheumatoid arthritis and/or systemic lupus erythematosus on chronic glucocorticoid therapy. BMC Musculoskeletal Disorders. 2015. DOI: 10.1186/s12891-015-0733-9

[8] Catastrophic Cervical Spine Injuries in the Collision Sport Athlete, Part 1. The American Journal of Sports Medicine. 2004. DOI: 10.1177/0363546504265605

[9] Spinal cord injury without radiographic abnormalities in children and adolescents: case report of a severe cervical spine lesion and review of literature. Knee Surgery, Sports Traumatology, Arthroscopy. 2000. DOI: 10.1007/s001670050212

[10] Solitary isolated lateral mass fracture of the atlas. Injury. 2006. DOI: 10.1016/j.injury.2006.02.048

[11] The prevalence and under-diagnosis of vertebral fractures on chest radiograph. BMC Musculoskeletal Disorders. 2018. DOI: 10.1186/s12891-018-2171-y

[12] Early mobilisation of thoracolumbar burst fractures without neurology. The Bone & Joint Journal. 2016. DOI: 10.1302/0301-620x.98b1.36121

[13] Final Fusion After Growing-Rod Treatment for Early Onset Scoliosis. Journal of Bone and Joint Surgery. 2016. DOI: 10.2106/jbjs.15.01334

[14] Classifications of Thoracic and Lumbar Fractures: Rationale and Supporting Data. Journal of the American Academy of Orthopaedic Surgeons. 2002. DOI: 10.5435/00124635-200209000-00008

[15] Chapter 16 Spinal Trauma. 2019.

[16] Health-related quality of life after vertebral or hip fracture: a seven-year follow-up study. BMC Musculoskeletal Disorders. 2009. DOI: 10.1186/1471-2474-10-135

[17] Fusion May Not Be a Necessary Procedure for Surgically Treated Burst Fractures of the Thoracolumbar and Lumbar Spines. Journal of Bone and Joint Surgery. 2014. DOI: 10.2106/jbjs.m.01486

[18] Spinal cord injury in an adult patient with thoracic butterfly vertebra: a case report and review of the literature. BMC Musculoskeletal Disorders. 2020. DOI: 10.1186/s12891-020-03433-9

[19] Midterm outcome after posterior stabilization of unstable Midthoracic spine fractures in the elderly. BMC Musculoskeletal Disorders. 2021. DOI: 10.1186/s12891-021-04049-3

[20] Dual-energy CT in sacral fragility fractures: defining a cut-off Hounsfield unit value for the presence of traumatic bone marrow edema in patients with osteoporosis. BMC Musculoskeletal Disorders. 2022. DOI: 10.1186/s12891-022-05690-2

[21] Transposition of the Compressed Spinal Cord in Kyphoscoliotic Patients with Neurological Deficit. The Journal of Bone & Joint Surgery. 1960. DOI: 10.2106/00004623-196042060-00010

[22] Progression of vertebral deformity of prevalent vertebral fractures in the elderly: a population-based study. BMC Musculoskeletal Disorders. 2024. DOI: 10.1186/s12891-024-07254-y

[23] Langerhans Cell Histiocytosis of the Spine in Children. The Journal of Bone and Joint Surgery-American Volume. 2004. DOI: 10.2106/00004623-200408000-00019

[24] Minimally Invasive vs Open Surgery for Thoracolumbar Fractures in Patients With Ankylosing Spinal Diseases: A Meta-Analysis. Journal of the American Academy of Orthopaedic Surgeons. 2025. DOI: 10.5435/jaaos-d-24-01277

[25] Long-term results after thoracoscopic anterior spondylodesis with or without posterior stabilization of unstable incomplete burst fractures of the thoracolumbar junction: a prospective cohort study. Journal of Orthopaedic Surgery and Research. 2020. DOI: 10.1186/s13018-020-01807-2

[26] A novel MRI- and CT-based scoring system to differentiate malignant from osteoporotic vertebral fractures in Chinese patients. BMC Musculoskeletal Disorders. 2018. DOI: 10.1186/s12891-018-2331-0

[27] Major trauma patients with spinal fractures have more complex injuries than non-major trauma patients. The Bone & Joint Journal. 2015. DOI: 10.1302/0301-620x.97b2.34392

[28] Posterior pedicle screw fixation to treat lower cervical fractures associated with ankylosing spondylitis: a retrospective study of 35 cases. BMC Musculoskeletal Disorders. 2017. DOI: 10.1186/s12891-017-1396-5

[29] AAOS Clinical Practice Guideline: The Treatment of Symptomatic Osteoporotic Spinal Compression Fractures. Journal of the American Academy of Orthopaedic Surgeons. 2011. DOI: 10.5435/00124635-201103000-00008

[30] Vertebral fracture in elderly female patients after posterior fusion with pedicle screw fixation for degenerative lumbar pathology: a retrospective cohort study. BMC Musculoskeletal Disorders. 2019. DOI: 10.1186/s12891-019-2534-z

[31] Traumatic bilateral L4-5 facet fracture dislocation: a case presentation with mechanism of injury. BMC Musculoskeletal Disorders. 2019. DOI: 10.1186/s12891-019-2921-5

[32] Diagnosis and Management of Sacral Spine Fractures. The Journal of Bone and Joint Surgery-American Volume. 2004. DOI: 10.2106/00004623-200401000-00027

[33] Dynamic evaluation of the cervical spine by kinematic MRI in patients with cervical spinal cord injury without fracture and dislocation. Journal of Orthopaedic Surgery and Research. 2023. DOI: 10.1186/s13018-023-03745-1

[34] Biomechanical comparison of noncontiguous cervical disc arthroplasty and noncontiguous cervical discectomy and fusion in the treatment of noncontinuous cervical degenerative disc disease: a finite element analysis. Journal of Orthopaedic Surgery and Research. 2020. DOI: 10.1186/s13018-020-1549-3

[35] A comparison of the long-term results of anterior lumbar interbody fusion and total disc arthroplasty: a prospective randomized controlled trial with a mean follow-up of 14 years. The Bone & Joint Journal. 2025. DOI: 10.1302/0301-620x.107b6.bjj-2024-1646.r1

[36] Rehabilitation of the Spine Following Sports Injury. Clinics in Sports Medicine. 2010. DOI: 10.1016/j.csm.2009.09.011

[37] Biomechanical comparison of a new stand-alone anterior lumbar interbody fusion cage with established fixation techniques – a three-dimensional finite element analysis. BMC Musculoskeletal Disorders. 2008. DOI: 10.1186/1471-2474-9-88

[38] The difference and clinical application of modified thoracolumbar fracture classification scoring system in guiding clinical treatment. Journal of Orthopaedic Surgery and Research. 2023. DOI: 10.1186/s13018-023-03958-4

[39] Flexion teardrop fracture of the cervical spine: a narrative review. EFORT Open Reviews. 2025. DOI: 10.1530/eor-2025-0010

[40] Healing pattern classification for thoracolumbar burst fractures after posterior short-segment fixation. BMC Musculoskeletal Disorders. 2020. DOI: 10.1186/s12891-020-03386-z

[44] College Football Player with Unstable C1 Fracture. The American Journal of Sports Medicine. 2009. DOI: 10.1177/0363546508328594

[45] Labor-Related Sacral and Pubic Fractures. The Journal of Bone & Joint Surgery. 2007. DOI: 10.2106/jbjs.f.00181

[46] Biomechanics of vertebral compression fractures and clinical application. Archives of Orthopaedic and Trauma Surgery. 2011. DOI: 10.1007/s00402-011-1355-9

[47] Horizontal fracture of the anterior arch of the atlas. Case report.. The Journal of Bone & Joint Surgery. 1986. DOI: 10.2106/00004623-198668070-00019

[48] Radiographic and safety details of vertebral body stenting: results from a multicenter chart review. BMC Musculoskeletal Disorders. 2013. DOI: 10.1186/1471-2474-14-233

[49] Reducing the extent of facetectomy may decrease morbidity in failed back surgery syndrome. BMC Musculoskeletal Disorders. 2019. DOI: 10.1186/s12891-019-2751-5

[50] Finite element analysis after rod fracture of the spinal hybrid elastic rod system. BMC Musculoskeletal Disorders. 2022. DOI: 10.1186/s12891-022-05768-x

[51] Clinical efficacy and radiological outcomes of a novel screw placement technique for the treatment of traumatic thoracolumbar vertebral fractures under navigation guidance. BMC Musculoskeletal Disorders. 2025. DOI: 10.1186/s12891-025-09071-3

[52] Epidemiology of Spinal Cord Injuries and Risk Factors for Complete Injuries in Guangdong, China: A Retrospective Study. PLoS ONE. 2014. DOI: 10.1371/journal.pone.0084733

[53] Influence of cement-augmented pedicle screw instrumentation in an osteoporotic lumbosacral spine over the adjacent segments: a 3D finite element study. Journal of Orthopaedic Surgery and Research. 2020. DOI: 10.1186/s13018-020-01650-5

[54] Posterior Instrumentation for Thoracolumbar Fractures. Journal of the American Academy of Orthopaedic Surgeons. 2004. DOI: 10.5435/00124635-200411000-00007

[55] Reduction of vertebral height with fragility vertebral fractures can induce variety of neurological deterioration. Journal of Orthopaedic Surgery and Research. 2017. DOI: 10.1186/s13018-017-0649-1

[56] Radiographic Abnormalities in the Thoracolumbar Spine of Young Elite Skiers. The American Journal of Sports Medicine. 2001. DOI: 10.1177/03635465010290041101

[57] Characteristics and mechanical mechanisms of intervertebral disc degeneration in old thoracolumbar fractures with kyphosis: clinical observations and finite element analyses. BMC Musculoskeletal Disorders. 2024. DOI: 10.1186/s12891-024-08157-8

[58] Radiographic Analysis of Spondylolisthesis and Sagittal Spinopelvic Deformity. Journal of the American Academy of Orthopaedic Surgeons. 2012. DOI: 10.5435/jaaos-20-04-194

[59] Injuries to the Cervical Spine in American Football Players. The Journal of Bone and Joint Surgery-American Volume. 2002. DOI: 10.2106/00004623-200201000-00017

[60] Measurable Thoracic Motion Remains at 1 Year Following Anterior Vertebral Body Tethering, with Sagittal Motion Greater Than Coronal Motion. Journal of Bone and Joint Surgery. 2021. DOI: 10.2106/jbjs.20.01533

[61] The Impact of Osteoporosis on 2-Year Outcomes in Patients Undergoing Long Cervical Fusion. Journal of the American Academy of Orthopaedic Surgeons. 2023. DOI: 10.5435/jaaos-d-22-00361

[62] Clinical application of the paraspinal erector approach for spinal canal decompression in upper lumber burst fractures. Journal of Orthopaedic Surgery and Research. 2014. DOI: 10.1186/s13018-014-0105-4

[63] Effectiveness of Tirobot-assisted vertebroplasty in treating thoracolumbar osteoporotic compression fracture. Journal of Orthopaedic Surgery and Research. 2021. DOI: 10.1186/s13018-021-02211-0

[64] Static mechanical analysis of the vertebral body after modified anterior cervical discectomy and fusion (partial vertebral osteotomy): a finite element model. Journal of Orthopaedic Surgery and Research. 2023. DOI: 10.1186/s13018-023-04033-8

[65] Percutaneous cement augmentation for osteoporotic vertebral fractures. EFORT Open Reviews. 2017. DOI: 10.1302/2058-5241.2.160057

[66] Comparison of three techniques in the surgical management of metastatic vertebral fracture with posterior wall damage: a retrospective study. Journal of Orthopaedic Surgery and Research. 2023. DOI: 10.1186/s13018-023-03608-9

[67] Nonoperative management of osteoporotic vertebral compression fractures. Injury. 2007. DOI: 10.1016/j.injury.2007.08.010

[68] Biomechanical study between percutaneous vertebroplasty combined with cement pedicle plasty improves vertebral biomechanical stability: A finite element analysis. BMC Musculoskeletal Disorders. 2024. DOI: 10.1186/s12891-024-07689-3

[69] Surgical treatment of thoracolumbar fracture in ankylosing spondylitis: A comparison of percutaneous and open techniques. Journal of Orthopaedic Surgery and Research. 2022. DOI: 10.1186/s13018-022-03378-w

[70] 2021 Otto Aufranc Award: A simple Hip-Spine Classification for total hip arthroplasty. The Bone & Joint Journal. 2021. DOI: 10.1302/0301-620x.103b7.bjj-2020-2448.r2

[71] Ten-Year Follow-up of Posterior Decompression and Fusion Surgery for Thoracic Ossification of the Posterior Longitudinal Ligament. Journal of Bone and Joint Surgery. 2024. DOI: 10.2106/jbjs.23.01475

[72] Chapter 97 Pelvic, Acetabular, and Sacral Fractures. 2019.

[73] Prospective Measurement of Function and Pain in Patients with Non-Neoplastic Compression Fractures Treated with Vertebroplasty. The Journal of Bone & Joint Surgery. 2006. DOI: 10.2106/jbjs.d.02670

[75] Application of cement-augmented pedicle screws in elderly patients with spinal tuberculosis and severe osteoporosis: a preliminary study. Journal of Orthopaedic Surgery and Research. 2023. DOI: 10.1186/s13018-023-04099-4

[77] Thoracolumbar Fractures: Anterior Decompression and Interbody Fusion. Journal of the American Academy of Orthopaedic Surgeons. 2008. DOI: 10.5435/00124635-200807000-00008

[78] Tibial Spine Fractures: How Much Are We Missing Without Pretreatment Advanced Imaging? A Multicenter Study. The American Journal of Sports Medicine. 2020. DOI: 10.1177/0363546520957666

[79] Incidence and risk factors of poor prognosis in patients with OVCF following day surgery of percutaneous kyphoplasty: a retrospective study. BMC Musculoskeletal Disorders. 2025. DOI: 10.1186/s12891-025-09319-y

[80] Comparative outcome of different treatment options for fragility fractures of the sacrum. BMC Musculoskeletal Disorders. 2022. DOI: 10.1186/s12891-022-06039-5

[81] Bilateral fracture of the pedicle of the second cervical vertebra in the young child.. The Journal of Bone & Joint Surgery. 1986. DOI: 10.2106/00004623-198668060-00011

[82] Properties and clinical application safety of antibiotic-loaded bone cement in kyphoplasty. Journal of Orthopaedic Surgery and Research. 2019. DOI: 10.1186/s13018-019-1200-3

[83] Fractures of the Odontoid Process of the Axis. The Journal of Bone & Joint Surgery. 1974. DOI: 10.2106/00004623-197456080-00017

[84] Acute Paraplegia After Vertebroplasty Caused by Epidural Hemorrhage. The Journal of Bone & Joint Surgery. 2007. DOI: 10.2106/jbjs.f.01612

[85] COLLES FRACTURE, SPINE FRACTURE, AND SUBSEQUENT RISK OF HIP FRACTURE IN MEN AND WOMEN. The Journal of Bone and Joint Surgery-American Volume. 2003. DOI: 10.2106/00004623-200310000-00011

[86] Sacral Stress Fractures: Magnetic Resonance Imaging Not Always Definitive for Early Stage Injuries. The American Journal of Sports Medicine. 2007. DOI: 10.1177/0363546506296519

[88] Thoracolumbar fractures without neurological impairment. EFORT Open Reviews. 2016. DOI: 10.1302/2058-5241.1.000029

[89] Discriminating imaging findings of acute osteoporotic vertebral fracture: a prospective multicenter cohort study. Journal of Orthopaedic Surgery and Research. 2014. DOI: 10.1186/s13018-014-0096-1

[90] Thoracolumbar spinal treatment without screws. The Bone & Joint Journal. 2016. DOI: 10.1302/0301-620x.98b1.37508

[91] Chapter 46 Spine Trauma. 2020.

[92] Evaluation of strategies for the treatment of type B and C pelvic fractures. The Bone & Joint Journal. 2018. DOI: 10.1302/0301-620x.100b7.bjj-2017-1377.r1

[93] Use of anthropometric indicators in screening for undiagnosed vertebral fractures: A cross-sectional analysis of the Fukui Osteoporosis Cohort (FOC) study. BMC Musculoskeletal Disorders. 2008. DOI: 10.1186/1471-2474-9-157

[94] Higher incidence of delayed bone fusion for atlantoaxial fusion versus occipitocervical fusion with navigation system. BMC Musculoskeletal Disorders. 2025. DOI: 10.1186/s12891-025-08582-3

[95] Thoracolumbar Fracture: Posterior Instrumentation Using Distraction and Ligamentotaxis Reduction. Journal of the American Academy of Orthopaedic Surgeons. 2007. DOI: 10.5435/00124635-200711000-00008

[96] Open versus minimally invasive percutaneous surgery for surgical treatment of thoracolumbar spine fractures- a multicenter randomized controlled trial: study protocol. BMC Musculoskeletal Disorders. 2019. DOI: 10.1186/s12891-019-2763-1

[97] Utility of upright radiographs in traumatic thoracolumbar fracture management. BMC Musculoskeletal Disorders. 2022. DOI: 10.1186/s12891-022-05243-7

[98] Lumbar spine MRI versus non-lumbar imaging modalities in the diagnosis of sacral insufficiency fracture: a retrospective observational study. BMC Musculoskeletal Disorders. 2018. DOI: 10.1186/s12891-018-2189-1

[99] Role of magnetic resonance imaging in acute spinal trauma: a pictorial review. BMC Musculoskeletal Disorders. 2016. DOI: 10.1186/s12891-016-1169-6

[100] Evaluating the Cervical Spine in the Blunt Trauma Patient. Journal of the American Academy of Orthopaedic Surgeons. 2019. DOI: 10.5435/jaaos-d-18-00695

[101] Progressive non-infectious anterior vertebral fusion, split cord malformation and situs inversus visceralis. BMC Musculoskeletal Disorders. 2006. DOI: 10.1186/1471-2474-7-94

[102] Fracture of the atlantal arch causing atlanto-axial instability. Report of a case.. The Journal of Bone & Joint Surgery. 1986. DOI: 10.2106/00004623-198668080-00024

[103] Predictors for vertebral height deterioration in fractured vertebrae operated by percutaneous vertebroplasty. BMC Musculoskeletal Disorders. 2025. DOI: 10.1186/s12891-025-08574-3

[104] Progression of local kyphosis after conservative treatment for compressive cervical spine fracture with spinal cord injury. Journal of Orthopaedic Surgery and Research. 2019. DOI: 10.1186/s13018-019-1115-z

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4. Media and formats; technical modifications allowed. The Licensor authorizes You to exercise the Licensed Rights in all media and formats whether now known or hereafter created, and to make technical modifications necessary to do so. The Licensor waives and/or agrees not to assert any right or authority to forbid You from making technical modifications necessary to exercise the Licensed Rights, including technical modifications necessary to circumvent Effective Technological Measures. For purposes of this Public License, simply making modifications authorized by this Section 2(a) (4) never produces Adapted Material.

5. Downstream recipients.

a. Offer from the Licensor -- Licensed Material. Every recipient of the Licensed Material automatically receives an offer from the Licensor to exercise the Licensed Rights under the terms and conditions of this Public License.

b. No downstream restrictions. You may not offer or impose any additional or different terms or conditions on, or apply any Effective Technological Measures to, the Licensed Material if doing so restricts exercise of the Licensed Rights by any recipient of the Licensed Material.

6. No endorsement. Nothing in this Public License constitutes or may be construed as permission to assert or imply that You are, or that Your use of the Licensed Material is, connected with, or sponsored, endorsed, or granted official status by, the Licensor or others designated to receive attribution as provided in Section 3(a)(1)(A)(i).

b. Other rights.

1. Moral rights, such as the right of integrity, are not licensed under this Public License, nor are publicity, privacy, and/or other similar personality rights; however, to the extent possible, the Licensor waives and/or agrees not to assert any such rights held by the Licensor to the limited extent necessary to allow You to exercise the Licensed Rights, but not otherwise.

2. Patent and trademark rights are not licensed under this Public License.

3. To the extent possible, the Licensor waives any right to collect royalties from You for the exercise of the Licensed Rights, whether directly or through a collecting society under any voluntary or waivable statutory or compulsory licensing scheme. In all other cases the Licensor expressly reserves any right to collect such royalties, including when the Licensed Material is used other than for NonCommercial purposes.

Section 3 -- License Conditions.

Your exercise of the Licensed Rights is expressly made subject to the following conditions.

a. Attribution.

1. If You Share the Licensed Material (including in modified form), You must:

a. retain the following if it is supplied by the Licensor with the Licensed Material:

i. identification of the creator(s) of the Licensed Material and any others designated to receive attribution, in any reasonable manner requested by the Licensor (including by pseudonym if designated);

ii. a copyright notice;

iii. a notice that refers to this Public License;

iv. a notice that refers to the disclaimer of warranties;

v. a URI or hyperlink to the Licensed Material to the extent reasonably practicable;

b. indicate if You modified the Licensed Material and retain an indication of any previous modifications; and

c. indicate the Licensed Material is licensed under this Public License, and include the text of, or the URI or hyperlink to, this Public License.

2. You may satisfy the conditions in Section 3(a)(1) in any reasonable manner based on the medium, means, and context in which You Share the Licensed Material. For example, it may be reasonable to satisfy the conditions by providing a URI or hyperlink to a resource that includes the required information.

3. If requested by the Licensor, You must remove any of the information required by Section 3(a)(1)(A) to the extent reasonably practicable.

4. If You Share Adapted Material You produce, the Adapter's License You apply must not prevent recipients of the Adapted Material from complying with this Public License.

Section 4 -- Sui Generis Database Rights.

Where the Licensed Rights include Sui Generis Database Rights that apply to Your use of the Licensed Material:

a. for the avoidance of doubt, Section 2(a)(1) grants You the right to extract, reuse, reproduce, and Share all or a substantial portion of the contents of the database for NonCommercial purposes only;

b. if You include all or a substantial portion of the database contents in a database in which You have Sui Generis Database Rights, then the database in which You have Sui Generis Database Rights (but not its individual contents) is Adapted Material; and

c. You must comply with the conditions in Section 3(a) if You Share all or a substantial portion of the contents of the database.

For the avoidance of doubt, this Section 4 supplements and does not replace Your obligations under this Public License where the Licensed Rights include other Copyright and Similar Rights.

Section 5 -- Disclaimer of Warranties and Limitation of Liability.

a. UNLESS OTHERWISE SEPARATELY UNDERTAKEN BY THE LICENSOR, TO THE EXTENT POSSIBLE, THE LICENSOR OFFERS THE LICENSED MATERIAL AS-IS AND AS-AVAILABLE, AND MAKES NO REPRESENTATIONS OR WARRANTIES OF ANY KIND CONCERNING THE LICENSED MATERIAL, WHETHER EXPRESS, IMPLIED, STATUTORY, OR OTHER. THIS INCLUDES, WITHOUT LIMITATION, WARRANTIES OF TITLE, MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE, NON-INFRINGEMENT, ABSENCE OF LATENT OR OTHER DEFECTS, ACCURACY, OR THE PRESENCE OR ABSENCE OF ERRORS, WHETHER OR NOT KNOWN OR DISCOVERABLE. WHERE DISCLAIMERS OF WARRANTIES ARE NOT ALLOWED IN FULL OR IN PART, THIS DISCLAIMER MAY NOT APPLY TO YOU.

b. TO THE EXTENT POSSIBLE, IN NO EVENT WILL THE LICENSOR BE LIABLE TO YOU ON ANY LEGAL THEORY (INCLUDING, WITHOUT LIMITATION, NEGLIGENCE) OR OTHERWISE FOR ANY DIRECT, SPECIAL, INDIRECT, INCIDENTAL, CONSEQUENTIAL, PUNITIVE, EXEMPLARY, OR OTHER LOSSES, COSTS, EXPENSES, OR DAMAGES ARISING OUT OF THIS PUBLIC LICENSE OR USE OF THE LICENSED MATERIAL, EVEN IF THE LICENSOR HAS BEEN ADVISED OF THE POSSIBILITY OF SUCH LOSSES, COSTS, EXPENSES, OR DAMAGES. WHERE A LIMITATION OF LIABILITY IS NOT ALLOWED IN FULL OR IN PART, THIS LIMITATION MAY NOT APPLY TO YOU.

c. The disclaimer of warranties and limitation of liability provided above shall be interpreted in a manner that, to the extent possible, most closely approximates an absolute disclaimer and waiver of all liability.

Section 6 -- Term and Termination.

a. This Public License applies for the term of the Copyright and Similar Rights licensed here. However, if You fail to comply with this Public License, then Your rights under this Public License terminate automatically.

b. Where Your right to use the Licensed Material has terminated under Section 6(a), it reinstates:

1. automatically as of the date the violation is cured, provided it is cured within 30 days of Your discovery of the violation; or

2. upon express reinstatement by the Licensor.

For the avoidance of doubt, this Section 6(b) does not affect any right the Licensor may have to seek remedies for Your violations of this Public License.

c. For the avoidance of doubt, the Licensor may also offer the Licensed Material under separate terms or conditions or stop distributing the Licensed Material at any time; however, doing so will not terminate this Public License.

d. Sections 1, 5, 6, 7, and 8 survive termination of this Public License.

Section 7 -- Other Terms and Conditions.

a. The Licensor shall not be bound by any additional or different terms or conditions communicated by You unless expressly agreed.

b. Any arrangements, understandings, or agreements regarding the Licensed Material not stated herein are separate from and independent of the terms and conditions of this Public License.

Section 8 -- Interpretation.

a. For the avoidance of doubt, this Public License does not, and shall not be interpreted to, reduce, limit, restrict, or impose conditions on any use of the Licensed Material that could lawfully be made without permission under this Public License.

b. To the extent possible, if any provision of this Public License is deemed unenforceable, it shall be automatically reformed to the minimum extent necessary to make it enforceable. If the provision cannot be reformed, it shall be severed from this Public License without affecting the enforceability of the remaining terms and conditions.

c. No term or condition of this Public License will be waived and no failure to comply consented to unless expressly agreed to by the Licensor.

d. Nothing in this Public License constitutes or may be interpreted as a limitation upon, or waiver of, any privileges and immunities that apply to the Licensor or You, including from the legal processes of any jurisdiction or authority.

Creative Commons is not a party to its public licenses. Notwithstanding, Creative Commons may elect to apply one of its public licenses to material it publishes and in those instances will be considered the “Licensor.” The text of the Creative Commons public licenses is dedicated to the public domain under the CC0 Public Domain Dedication. Except for the limited purpose of indicating that material is shared under a Creative Commons public license or as otherwise permitted by the Creative Commons policies published at creativecommons.org/policies, Creative Commons does not authorize the use of the trademark "Creative Commons" or any other trademark or logo of Creative Commons without its prior written consent including, without limitation, in connection with any unauthorized modifications to any of its public licenses or any other arrangements, understandings, or agreements concerning use of licensed material. For the avoidance of doubt, this paragraph does not form part of the public licenses.

Creative Commons may be contacted at creativecommons.org.