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Spinal Fractures – Current Treatment Options and Perspectives

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Slavisa Zagorac

Submitted: 11 September 2025 Reviewed: 25 November 2025 Published: 04 March 2026

DOI: 10.5772/intechopen.1014132

Current Fracture Management - Techniques and Challenges IntechOpen
Current Fracture Management - Techniques and Challenges Edited by Mazen Ahmad Almasri

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Current Fracture Management - Techniques and Challenges [Working Title]

Dr. Mazen Ahmad Almasri and Dr. Sedeek M. Sedeek Mosaid

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Abstract

Spinal trauma is a complex injury that often requires a multidisciplinary approach and treatment. It is frequently associated with spinal cord injury and neurologic deficit. Spinal column injuries are most often caused by the action of a force of great intensity (traffic accidents, falls from a height, blows with a hard object) or the effect of a minor trauma (based on a previously altered vertebra, most often due to osteoporosis or tumor). This chapter will focus on providing a summary of steps in the initial evaluation of spinal trauma, spinal cord injuries, classification systems, and modern patterns of treatment.

Keywords

  • spinal trauma
  • spinal cord injuries
  • neurologic deficit
  • primary evaluation
  • modern treatment

1. Introduction

The spinal column consists of 33–34 vertebrae connected to each other by joints, ligaments, and muscles. Of these, 24 vertebrae are motile and are called true vertebrae (vertebrae verae) and include 7 cervical (vertebrae cervicales), 12 thoracic (vertebrae thoracicae), and 5 lumbar (vertebrae lumbales) vertebrae. In contrast, the sacral and coccygeal vertebrae are false vertebrae (vertebrae spuriae), which are fused together to form the sacrum (os sacrum) and the coccyx (os coccyges) [1–3]. The spinal vertebrae, connected to each other, form a spinal canal that extends along the entire length of the spinal column, and in this canal is located the spinal cord (medulla spinalis) with its sheaths – meninges, blood vessels, and the beginnings of spinal nerves (nn. spinales) [4, 5]. The spinal column is characterized by the increasing height of the vertebral bodies and disks from the cervical to the lumbar region. The largest width of the spinal column corresponds to the base of the sacrum because the entire weight of the upper body is transferred to the lower extremities through the joint of the sacrum with the pelvic bones [1, 2, 6].

The vertebra belongs to the type of short bones, irregular in shape. A typical vertebra has a body, an arch, a spinal opening, and seven processes [1, 7, 8].

There are four physiological curvatures in the spinal column. Thoracic kyphosis extends from Th2 to Th12, and sacral kyphosis extends from the lumbosacral articulation to the apex of the coccygeal bone. Cervical lordosis is formed when a newborn begins to raise its head [2, 9–11]. Lumbar lordosis extends from Th12 to the lumbosacral articulation [1, 2, 12]. With the activity of the erector spinae, which pulls the erect lumbar spine to achieve the position necessary for walking, lumbar lordosis is formed. Around the age of six, all four sagittal curves are definitively formed [13].

The movements that take place in the spinal column are movements of flexion, extension, lateral flexion, rotation, and circumduction. The intervertebral disks, as well as the facet articulations, allow and limit the movements of two adjacent vertebrae. The disks are thicker in the cervical and lumbar spine, so the movements in these regions are greater [1–3, 6].

2. Epidemiology of spinal column injuries

Spinal column injuries are characterized by a bimodal distribution: they are most common in younger people (from 15 to 30 years old) and in the elderly (over 65 years old). Injuries are most often caused by the action of a force of great intensity (traffic accidents, falls from a height, blows with a hard object) or the effect of a small trauma (based on a previously altered vertebra, most often due to osteoporosis or a tumor). In 10%–50% of cases of spinal column injury, neurological impairment occurs (quadriplegia or paraplegia) [14, 15].

The basic mechanisms of injury are defined by the direction and intensity of the force acting on the spinal column, and these are: flexion, extension, rotation, lateral flexion, compression (axial force), and distraction (stretching) [16–18].

3. Initial evaluation and management

Treatment of spinal cord injuries is based on three basic principles. The first step is initial prehospital treatment (stabilization and immobilization of the injured person), the second step is early hospital treatment (clinical examination, assessment of the neurological condition, diagnostics), and the third step is definitive treatment (conservative or surgical).

3.1 Clinical presentation and prehospital treatment of spinal column injuries – primary and secondary survey, and resuscitation

Spinal column injuries can manifest in a variety of ways, depending on which level is injured, which structure is affected, and to what extent. Most often, there is pain and spasm of the paravertebral musculature, and if there is an injury to the spinal cord, a neurological outburst may occur.

The first rule of initial treatment is to ensure vital functions, according to the ABCDE system (A-airway, B-breathing, C-circulation, D-disability, E-environment) [19–21].

After that, it is necessary to determine the possible existence of an injury to the spinal column. Any individual involved in a trauma is assumed to have cervical spine injuries until ruled out otherwise. So, the treatment of potential spinal injury begins at the accident scene with proper immobilization [22–25]. If the injured person is unconscious, always assume that there is an injury to the spinal column and then place an immobilization device – a rigid cervical collar or a firm spine board [26–28]. In sport-related injuries, the player’s helmet or shoulder pads should be left in place until arrival at the hospital, where experienced personnel can remove them safely. Inadequate initial immobilization can contribute to further neurologic deterioration in a patient with an acute SCI and worsen the outcome [22, 29].

If the injured person is conscious, make eye contact and ask them if they have pain in the cervical or thoracolumbar spine, if they can move their head, and if they have preserved movement and sensation in their arms and legs. If there is any confirmation of these symptoms, assume that there is a spinal injury and immediately apply immobilization. What is important is that the immediate absence of signs of neurological failure does not eliminate the possibility of spinal cord injury [30–33].

Polytraumatized patients should undergo a visual and manual inspection of the back. Motorcyclists are more likely to sustain thoracic spinal injuries. Flexion-distraction injuries should be suspected in the setting of abdominal ecchymoses or abrasions from a seat belt [17].

3.2 Early inpatient treatment – clinical examination, assessment of neurological status, diagnostics

After the initial treatment and ensuring vital functions, it is necessary to carefully take an anamnesis (data on the mechanism of injury) and conduct a clinical examination. If the patient is conscious and there is an injury to the spinal column, the injured person will complain of pain in the area of the injury. If there is also a neurological deficit, the injured person will complain of numbness, weakness in the arms and legs, or complete anesthesia from the level of the injury, as well as urinary retention [30–32].

Then a clinical examination is performed, which involves turning the injured person on their side (with the help of three people, where one simultaneously turns the head of the injured, another the torso, and the third the legs), followed by an inspection (to notice any deformity or the existence of abrasions or bruises), and then performing palpation to identify painful sensitivity and deformity [25].

This is followed by a detailed assessment of the neurological condition of the injured person, which is crucial for further treatment in the case of spinal injury. A neurological examination should include an assessment of muscle strength, sensitivity, and deep reflexes in the upper and lower extremities. A neurological status assessment protocol called the American Spinal Injury Association Score (ASIA score) has been introduced [34] (see Figure 1).

Figure 1.

ASIA Standard Neurological Classification of Spinal Cord Injury (from International Standards for Neurological Classification of Spinal Cord Injury). (Reproduced with permission from http://asia-spinalinjury.org.).

Cervical spine clearance in trauma patients remains controversial. Prolonged immobilization in polytrauma patients is known to be associated with numerous complications, including increased risk of aspiration, limitation of respiratory function, development of ulcers in the occipital and mandibular areas, and an increase in intracranial pressure [26, 27, 29].

Injuries can be ruled out via the National Emergency X-radiography Utilization Study (NEXUS) or Canadian Cervical Spine Rule (CCR) criteria in asymptomatic patients [35, 36] (see Figures 2 and 3).

Figure 2.

NEXUS criteria for c-spine injury.

Figure 3.

The Canadian C-spine rule diagram.

After initial stabilization, ATLS (Advanced Trauma Life Support) measures, and clinical examination, diagnostics follow:

  1. Conventional radiography – In a stable patient with a suspected spinal injury, it is necessary to perform an AP image, a profile (the most important, as it detects up to 80% of injuries), and, in the case of a suspected cervical spine injury, an additional image of the odontoid through the mouth and optionally two oblique shots. Adequate radiography involves visualizing all seven cervical vertebrae, including the first thoracic vertebra. If the patient is conscious, there are two important algorithms based on which we assess whether the injured person needs radiographs, that is, when we are sure that there is no serious injury to the cervical spine (previously mentioned: the NEXUS criteria and the Canadian C-Spine Rule; see Figures 4–7).

Figure 4.

Normal x ray of the cervical spine – lateral view (reproduced with permission from www.radiologymasterclass.co.uk).

Figure 5.

AP odontoid view from the study by Mettler FA: Essentials of Radiology.

Figure 6.

Normal x ray of the thoracic spine – AP and lateral view (reproduced with permission from www.radiologymasterclass.co.uk).

Figure 7.

Normal X ray of the lumbosacral spine – lateral view (from Standring S. Gray’s Anatomy: The Anatomical Basis of Clinical practice. 41st ed. Philadelphia, PA: Elsevier; 2016. Fig. 43.44).

  1. Computed tomography – CT scan – It is today the gold standard in the evaluation of bone-articular injuries of the spine in a polytraumatized or unconscious injured person, as well as in cases where radiographs are not usable. A CT scan of the whole body is often performed as part of the trauma protocol. Modern CT machines enable 3D and dynamic reconstruction of the injured segment. If the clinical findings are normal and the radiography is adequate, a CT scan should be avoided due to the high dose of radiation (see Figure 8–10)

Figure 8.

Cervical spine CT scan with normal findings: (a) Power’s ratio and (b) Basion-dens interval and Harris method. (Available from: https://www.researchgate.net/figure/cervical-spine-ct-scan-with-normal-findings-a-powers-ratio-and-b-basion-dens_fig2340020462 [accessed 7 Sept 2025]).

Figure 9.

A 19-year-old woman sustained a C6–C7 injury in a motor vehicle accident. (a) and (b) Show a CT scan of a completely dislocated vertebra. The ASIA score was A, and after surgery, the patient was moving her left arm. (c) and (d) Show RTG postoperatively with fixation of the C5, C6, C7, and Th1.

Figure 10.

A 34-year-old man sustained a fracture of the L1 vertebra with dislocation in a motor vehicle accident. (a) Shows CT scan after injury. (b) Shows RTG postoperatively with fixation of Th11, Th12, L2 and L3. The patient was paraplegic.

  1. Nuclear magnetic resonance imaging (NMR) – It is indicated in cases where there is a neurological deficit, and radiographs and CT scans are normal. It is invaluable in the detection of soft tissue injuries, in the suspicion of traumatic herniation of the disk (especially if there is a dislocation of the vertebrae), and in the suspicion of the existence of hematomas (see Figure 11).

Figure 11.

Incomplete spinal cord lesions.

  1. Myelography – Nowadays, it is rarely performed. It involves the injection of a contrast agent into the spinal canal, followed by an X-ray or CT scan. It is indicated in cases where there is a suspicion of intradural or epidural pathology (such as traumatic disk herniation or hematoma) and in cases where NMR is contraindicated.

  2. Electromyeloneurography – EMNG – This method is important for monitoring the neurological recovery of the injured person and is not valid in the first weeks following the injury.

3.3 Definitive treatment (conservative or surgical) – the principles of modern treatment and surgical techniques

It is important to determine whether it is a stable or unstable fracture. Stable (minor) fractures without neurological deficit are treated conservatively by administering analgesics, wearing appropriate immobilization (neck: Philadelphia collar for 6 to 12 weeks, TLS orthosis for 12 weeks), and regular monitoring of the injured person. If it is an unstable injury, then surgical treatment is indicated, which has two goals: stabilization of the spinal column and decompression of the spinal canal [37–39].

Skeletal traction of the cervical spine (Crutchfield skull traction) is a very common procedure in the initial treatment of injuries to the cervical spine, especially dislocations [40, 41]. With the help of traction, first of all, further displacement of the vertebrae is prevented, which would lead to a deterioration of the neurological status. In addition, with this method, a closed reposition can sometimes be achieved with a special maneuver. Skeletal traction placement technique: skeletal traction is placed under conditions of local anesthesia. Then, a small incision is made with a scalpel 1 cm above the earlobe. A pair of pliers is used to enter the tabula externa as much as 1 mm. Weights of a certain amount are then hung (a rough rule is to add a minimum of 2 kg to the injured segment. Example: if the C4 is luxated, then the load is 4 + 2 kg, a total of 6 kg).

The type of surgical treatment depends on the type of injury. If it is an unstable fracture, stabilization of this segment is indicated, which is achieved by using special screws and inserts that are usually made of titanium. In addition to stabilizing the fracture, decompression is necessary – relieving the spinal cord or nerve from pressure, which is achieved by removing a bone fragment or hematoma that leads to compression and, therefore, to a neurological deficit. This is done using one of the following techniques: corpectomy, laminectomy, laminoplasty, foraminotomy, or diskectomy.

Standard indications for the surgical treatment of thoracolumbar fractures include incomplete neurological deficit, progressive neurological deficit, spinal cord compression, fracture with luxation, kyphosis greater than 30 degrees, and associated injuries requiring early mobilization [42–44].

Modern spinal surgery involves two basic principles: classical and minimally invasive surgery. Whenever possible (depending primarily on the indication), the principles of minimally invasive surgery should be applied, as it aims at minimal trauma for the injured and faster postoperative recovery. Today’s minimally invasive surgery for spinal cord injuries includes percutaneous placement of screws (with the help of X-rays or navigation), strengthening (augmentation) of the vertebrae with special bone cement, and thoracoscopically assisted decompression and fixation of the thoracic part of the spinal column [45–48].

There are three basic approaches: back (the most common), front, and combined front-back approach. Which approach will be used depends on the type of fracture, the existence of comorbidities and associated injuries, and the training of the surgeon.

3.3.1 Surgical approaches in injuries of the cervical spine

In the case of injuries to the cervical spine, the anterior approach is most often used. The anterior approach allows visualization of the subaxial cervical spine (C3–C7). Indications for the anterior approach include excision of the traumatic disk hernia, intervertebral fusion, tumor treatment, stabilization of a possible pathological fracture, stabilization of the traumatic fracture, and decompression of the spinal canal. The patient is positioned in supination, with the head in extension and facing the opposite side of the planned incision. The incision can be made on either the left or right side of the neck and can be transverse (from the midline of the neck to the anterior edge of the m. sternocleidomastoideus) or longitudinal (along the anterior edge of the same muscle). During anterior access to the neck, the most important structure at risk of injury is the n. laryngeus recurrens. Due to the specific anatomy of the right and left n. laryngeus recurrens, an incision is usually made on the left side because the right nerve is more exposed to injury [49–51].

The posterior approach allows visualization, in addition to the subaxial cervical spine, of C1 and C2, which cannot be accessed through the front of the neck. Indications for this approach include stabilization of fractures of C1 and C2, decompression of the spinal canal, intervertebral fusion, and treatment of tumors. The patient is positioned prone, with their head in flexion. The incision extends from the central prominence of the occipital bone (protuberantia occipitalis) down the midline for 6 to 8 cm. With this approach, injury to the occipital nerves and the vertebral artery (a. vertebralis) is possible [49, 52].

3.3.2 Surgical approaches in injuries of the thoracolumbar spine

The posterior approach is the most common form of surgical treatment for thoracolumbar spine injuries. In addition to providing access to the cauda equina and intervertebral disks, it can also reveal the posterior elements of the spinal column: spinous processes, laminae, facet joints, and pedicles. Access is through the midline and can be extended proximally and distally. The indications are as follows: excision of the traumatic disk hernia, intervertebral fusion, treatment of tumors, stabilization of a possible pathological fracture, stabilization of the traumatic fracture, and decompression of the spinal canal. The patient is in a prone position. Supports are placed longitudinally under the chest, hips, and legs. Underneath the chest and hips, struts are placed to allow the abdomen to be completely free, reducing the filling of the venous plexus around the spinal cord and allowing the venous plexus to drain directly into the inferior vena cava. The patient’s shoulders are positioned at an angle of no more than 90 degrees of abduction and should be slightly bent forward to relax the plexus brachialis. The head and neck are placed in a relaxed, neutral position, without pressure on the eyes. Avoid keeping the head lower than the rest of the body to reduce the risk of postoperative blindness (due to the high hydrostatic pressure in the eyes leading to reduced perfusion). If the approach is used for decompression, the hips are bent to increase the interlaminar or interspinous distance. By placing a brace under the ankle joint, the knees are bent without putting pressure on the proximal fibula-region of the common peroneal nerve [49, 53–56].

In addition to the posterior–posterior access, the thoracic spine can be accessed anteriorly (transthoracically) and postero-laterally, and the lumbar spine can be accessed anteriorly (transperitoneal and retroperitoneal) and posterolaterally (retroperitoneal) [49].

3.3.3 Minimally invasive stabilization of spinal fractures

Minimally invasive surgery is a modern approach to the treatment of spinal fractures, which is based on a well-established indication, a good choice of patients, and the necessity of special equipment. This implies the presence of a C-arc (movable X-ray machine) and the existence of a special instrument for placing screws. Sometimes, it is necessary to have neuromonitoring in order to monitor neurological functions during surgery, and lately, it has been used in more equipped centers for navigation. The concept of minimally invasive surgery involves minimal incision in the skin and minimal damage to subcutaneous tissue, muscles, and bone tissue. If it is a last resort, special needles and AP and profile X-rays are used to identify the target vertebrae. After that, special screws are placed over these needles, which are perforated (hollow) in the middle so that they can be placed over the previously placed needles. After X-ray confirmation of the good position of the screws, two rods are placed over two additional small cuts to connect the screws. In most minimally invasive surgery systems, there is also the possibility of placing bone cement through screws with the aim of further strengthening the vertebrae, and this is especially important in cases of osteoporosis or metastasis [46, 49].

4. Spinal cord injuries

4.1 Background

The spinal cord is the caudal part of the central nervous system and lies entirely in the spinal canal (canalis vertebralis). It extends rostrally to the upper edge of the anterior arch of the atlas, where it continues to the medulla (medulla oblongata) and ends caudally at the L2 level. It has the shape of an elongated cylinder, 42–45 cm long. The terminal part of the spinal cord, 1–2 cm long, is called the conus medullaris. From the top of the cone starts the final thread (filum terminale). The spinal cord is made up of gray and white matter. The gray matter is made up of nerve cell bodies, dendrites, and glial cells. White matter is a set of axons and dendrites (myelinated nerve tract fibers, unmyelinated axons, and glial cells). The spinal cord is enveloped by three sheaths that separate it from the bone-connective structures of the walls of the spinal canal: on the outside is the dura mater, on the inside is the arachnoidea, and directly adjacent to the spinal cord is the soft membrane (pia mater). The space between the arachnoid and the pia mater is referred to as the subarachnoid space, which is filled with cerebrospinal fluid [4, 5, 57, 58].

The spinal cord has 31 pairs of spinal nerves. These are 8 cervical, 12 thoracic, 5 lumbar, 5 sacral, and 1 coccygeal. Spinal nerves exit the spinal canal through the intervertebral openings (foramen intervertebrale). Due to the unevenness in the length of the spinal cord and the spinal canal, the spinal nerves starting from the lumbar and sacral segments are almost parallel to the spinal cord, surround the cone, and form the final bundle of nerves – the cauda equina [57]. Each spinal nerve has an anterior and posterior root. The surface of the skin innervated by sensitive fibers of one spinal nerve is called a dermatome. The portion of muscle mass that corresponds to one spinal nerve is called the myotome.

The blood supply to the spinal cord is quite poor, given the importance of this tissue. Ischemia of the spinal cord can easily occur even after the slightest injury. Ischemia is particularly common at the levels of Th4 and L1. The arterial blood vessels of the spinal cord originate from the vertebral arteries (aa. vertebrales) and from the segmental arteries (a. cervicalis profunda, a. cervicalis ascendens, a. intercostales posteriores, a. lumbales, a. iliolumbalis, a. sacrales laterales) [5].

The annual incidence of SCI is approximately 17,700 new cases per year. Motor vehicle accidents and falls together are responsible for 69.9% of SCI, with gunshot wounds accounting for 13.8% and sports injuries for 8.2%. Fifty-four percent of SCI injuries occur in the cervical spine. Neurologically, most patients (45.8%) sustain incomplete quadriplegia, followed by incomplete paraplegia (21%), complete paraplegia (20%), and complete quadriplegia (17.5%) [4, 57].

4.2 Spinal cord injuries

Spinal cord injuries can be complete or incomplete. A complete lesion implies a complete loss of function below the level of injury. It is manifested by flaccid paralysis (atony), loss of reflexes (areflexia), flexed elbows, vasomotor paralysis with hypotension, hypothermia, bradycardia, priapism (parasympathetic paralysis), and, if the injury is above C4, the diaphragm is compromised, so patients with this level of injury most likely require intubation.

4.2.1 Incomplete lesions of the spinal cord are

  1. “Central cord” syndrome, which occurs in hyperextension injuries of the cervical spine in individuals with pre-existing stenosis of the spinal canal, is manifested by greater motor damage to the upper extremities than to the lower extremities [59–61]; (see Figure 12).

  2. “Anterior cord” syndrome, which has a vascular etiology and is manifested by loss of motor skills, sense of pain, and temperature; this injury carries the worst prognosis of incomplete injuries, with only 10% to 20% of patients recovering functional motor control [59, 62, 63] (see Figure 12)

  3. “Brown-Séquard” syndrome, which occurs due to lateral hemisection of the spinal cord in penetrating injuries, is manifested by ipsilateral hemiparesis and loss of deep and vibrational sensitivity, as well as contralateral loss of pain and temperature. This injury carries the best prognosis for recovery of functional motor activity and sphincter control [59, 64, 65] (see Figure 12)

  4. “Posterior cord” syndrome is a rare, incomplete spinal cord injury that selectively affects the posterior (dorsal) columns, leading to a loss of proprioception (body position sense) and vibration sense, as well as an ataxic gait [59, 66] (see Figure 12).

Figure 12.

A 23-year-old man sustained an injury to the cervical spine during diving. He suffered a C2 fracture with neurologic deficit (ASIA score was A). NMR at T2 sequence shows a spinal cord lesion at the level of the second cervical vertebra. After surgery, the patient recovered well enough to be reclassified as an ASIA D within nine months.

Early neurological findings may be confounded by spinal shock, which is a reversible functional impairment of the spinal cord. As a result of spinal shock, there is a temporary inhibition of the reflex functions of the spinal cord. At the stage of spinal shock, there is flaccid paralysis, loss of reflexes, loss of all modalities of sensation, urinary retention, distension of the intestine with constipation, and vasomotor paralysis with hypotension and hypothermia. This phase can last 24–72 hours, and sometimes longer. After exiting the phase of spinal shock, the sign of recovery is the induction of the bulbocavernosus reflex [59, 67, 68].

4.2.2 Treatment of acute spinal cord injury

It must be carried out within eight hours of the onset of the injury, and preferably within the first three hours, in order to improve post-injury outcomes and prevent secondary spinal cord damage.

  1. Neuroprotective and pharmacological strategies – NASCIS III protocol

    Specific therapy involves the administration of methylprednisolone intravenously at an initial dose of 30 mg/kg bolus, followed by an intravenous infusion of 5.4 mg/(kg h) for the next 23 hours. For patients presenting 3 to 8 hours after injury, the 30 mg/kg bolus is followed by 5.4 mg/(kg h) for the next 47 hours [69].

  2. Surgical management

    The Surgical Timing in Acute Spinal Cord Injury Study (STASCIS) recommends spinal cord decompression within 24 hours in patients with SCI. This early decompression results in an increase of a two-grade ASIA impairment score improvement [70].

5. Cervical fractures

5.1 Classification of injuries of the cervical spine

The most recent classification that has found application in clinical practice is the AO Spine Injury Classification System, which provides a specific classification of injuries of the upper (C1–C2) and subaxial cervical spine (C3–C7), and also includes the neurological condition of the patient [71, 72] (see Figure 13).

Figure 13.

AO Spine Classification System (reproduced with permission from https://www.aofoundation.org/).

5.1.1 Occipital condyle fractures

Incidence is 3% to 16%. Typical clinical presentation can include high cervical pain, torticollis, headaches, and impaired mobility. It should be considered a marker for potentially lethal trauma because it is associated with an 11% mortality rate from associated injuries [73–75].

The Anderson and Montesano system is used to classify occipital condyle fractures [76] (see Figure 14).

Figure 14.

Anderson and Montesano classification of occipital condyle fractures.

Treatment includes cervical orthosis for type 1, type 2, and stable type 3 fractures [75].

5.1.2 Atlanto-occipital dislocation

A highly unstable injury, the most common mechanism of injury is hyperextension with distraction, which occurs most often during traffic accidents. It’s incompatible with life. Diagnosis on plain radiography is challenging [77, 78].

Powers ratio – divides the distance from the basion to the posterior arch by the distance from the anterior arch to the opisthion. A ratio greater than 1 suggests possible anterior dislocation.

The Harris basion-axial interval and basion-dental interval are the most sensitive radiographic measurements. They measure two parameters: the distance from the basion to a line drawn tangentially to the posterior border of C2 (>12 mm or <4 mm is abnormal), and the distance from the basion to the odontoid (>12 mm is considered abnormal).

The Traynelis classification and Harborview classification are commonly used to classify atlanto-occipital dislocation [79].

Treatment includes light traction of about 5 lbs in type 1 and type 3 injuries. In patients with survivable injuries, an occipitocervical fusion is recommended [77, 78].

5.1.3 Atlas (C1) fractures

They are typically seen in younger age groups and constitute 2% to 13% of cervical spine fractures.

Jefferson fracture of both arches of C1 (Jefferson) is a compression fracture that occurs during a direct impact on the head, such as diving or falling from a height. This injury does not cause a neurological outburst because the C1 ring is very wide. The fracture is unstable, and surgical treatment or halo immobilization is indicated [80, 81] (see Figure 15).

Figure 15.

Fracture of the C1 vertebra (reproduced with permission from https://www.ebmconsult.com).

Treatment for isolated anterior or posterior arch fractures, lateral mass fractures, and transverse process fractures can be nonsurgical – using a cervical collar for 6 to 12 weeks. This approach is also applicable in burst fractures involving both anterior and posterior arches with an intact transverse ligament (less than 7 mm of combined lateral overhang of lateral masses). Treatment for unstable injuries (combined lateral mass displacement greater than 7 mm) includes bed rest with traction; additionally, surgical treatment has become widely accepted [81].

5.1.4 Odontoid fractures

A frequent fracture, which is caused by the mechanism of hyperflexion, occurs when falling on the head or in a traffic accident. In people over 70 years of age, these are the most common fractures of the cervical spine. They result in neurological failure in more than 50% of cases [82, 83].

The Anderson and d’Alonzo classification is used for odontoid fractures, and the Roy-Camille classification [82] (Figure 16).

Figure 16.

Anderson and D’Alonzo classification of the C2 fracture from modern Techniques in Spine Surgery, Chapter 14: Technique of Odontoid Screw Fixation for type 2 Odontoid Fractures; DOI: 10.5005/jp/books/1,2509_15.

Treatment is conservative for type 1 and type 3 – cervical collar for 6 to 12 weeks, or operative in type 2, depending on fracture characteristics and the patient population. The high nonunion rate – 32% – and the poor tolerance of halo vests by elderly patients mean these patients should be considered for early C1–C2 fusion [83].

5.1.5 Traumatic spondylolisthesis of the axis (“hangman’s fracture”)

The most common fracture of the upper cervical spine occurs due to hyperextension of the neck, whereby, due to a bilateral fracture of the pars interarticularis of C2, the vertebral body of C2 slips in relation to the vertebral body of C3. It is most often caused by traffic accidents, injuries in contact sports, or when jumping on the head (diving). There is usually no neurological outburst, or it is minimal [84, 85].

Modified Effendi classification by Levine and Edwards is used [86] (see Figure 17).

Figure 17.

Modified Effendi classification by Levine and Edwards A study on management of Hangman’s fracture – scientific figure on ResearchGate. Available from: https://www.researchgate.net/figure/classification-of-hangmans-fracture_tbl1_331792182 [accessed 9 Sept 2025]

Treatment is surgical in type 2 fractures with severe angulation and type 3 fractures with disruption of the C2–C3 disk and/or facet dislocation. Surgical options include anterior C2–C3 fusion, posterior C1–C3 fusion, and bilateral C2 pars interarticularis screws [84, 85].

5.1.6 Fractures of the subaxial spine (C3–C7)

There are several classifications of injuries to the subaxial cervical spine. The simplest division of injuries is into fractures (here the simpler – compressive – and more complex – explosive “burst” fractures are distinguished) and dislocations (which can be unilateral, if there is a slip of up to 25% of the length of the vertebral body, and bilateral, if it is a slip over 25% of the length of the vertebral body) [87].

The Allen–Ferguson Classification is one of the generally accepted classifications, which divides all injuries of the subaxial cervical spine into six types: compression-flexion, vertical compression, distraction-flexion, compression-extension, distraction-extension, and lateral-flexion [88].

The most recent classification is the Subaxial Injury Classification and Severity Scale (SLICS). This classification takes into account three factors: the morphology of the fracture (0–4 points), the integrity of the disko-ligamentous complex (0–2 points), and the neurological status of the injured person (0–4 points). If the number of points is greater than 5, then surgical treatment is indicated [89].

  1. A compressive “wedge” fracture of the subaxial cervical spine is caused by the action of a moderate axial force. Then, there is a lowering of the front part of the vertebral body. The posterior elements are intact, and spinal cord injuries are rare, so therapy is conservative – immobilization for 6 to 12 weeks.

  2. An explosive “burst” fracture is caused by the action of an axial force of very high intensity, whereby an “explosion” of the vertebral body occurs. Bone fragments move in all directions, and, due to damage to the posterior longitudinal ligament, the spinal cord is compressed, and neurological failure occurs. In this case, the treatment is operative.

  3. Teardrop fracture is a flexion axial load injury characterized by a fracture of the anterior-inferior portion of a vertebra as it is driven caudally and into flexion, causing retropulsion of the remaining vertebral body into the spinal canal.

  4. Facet fracture-dislocation of the subaxial cervical spine involves the loss of contact between the articular surfaces. It can be unilateral if there is a slip of up to 25% of the length of the vertebral body, or bilateral if the slip is greater than 25%. The injury is unstable, especially in the flexion position, so surgery is indicated. Due to the instability and high risk of spinal cord injury, it is necessary to provide initial treatment for such an injury, which is skeletal traction.

  5. Fracture of the spinous process of C7 (Clay-shoveler fracture) can be caused by a direct force in the region of the spinous process, or indirectly by a strong contraction of the paravertebral musculature. It’s mostly an isolated injury. It is not accompanied by spinal cord injuries. Therapy is conservative.

6. Thoracolumbar fractures

6.1 Classification of injuries of the thoracolumbar spine

The first serious classification is the one based on the concept of three pillars: the anterior pillar (involving the anterior half of the vertebral body), the middle pillar (involving the posterior half of the vertebral body and the spinal canal), and the posterior pillar (involving the laminae, pedicles, facet joints, transverse and spinal processes). A combination of injuries to either two pillars is considered an unstable injury, where surgical treatment is indicated.

In practice, the following classification is the most popular:

  1. Compressive fracture – The lower lumbar region has a greater ability to tolerate flexion moments, so anterior column failure should raise the suspicion of posterior ligamentous injury, especially when more than 50% loss of vertebral height is seen.

  2. Explosive “burst” fracture – are more common than compressive fractures, and most injuries occur with the spine in a neutral position, resulting in axial loading of the anterior and middle columns. The incidence of neurological deficit is much lower in the lower lumbar spine because the spinal cord ends above this level, and the cauda equina and nerve roots are more tolerant of compression.

  3. “Chance” fracture – represents a horizontal avulsion fracture. It is an unstable spinal injury, most often at the thoracolumbar junction (T12–L2), caused by a rapid flexion-distraction mechanism, such as in a car accident with a lap belt. It is a horizontal fracture through the posterior elements (spinous process, pedicles) and the vertebral body, often involving ligaments as well.

  4. Flexion –distraction injuries – For the lumbar spine, these fractures are most common at L2 and L4.

  5. Translational injuries (luxation fractures)

It is worth mentioning another classification that has found application in clinical practice, and that is the Thoracolumbar Injury Classification System (TLICS). This classification takes into account three factors: the morphology of the fracture (0–4 points), the integrity of the disko-ligamentous complex (0–2 points), and the neurological status of the injured person (0–4 points). If the number of points is greater than 5, then surgical treatment is indicated [90].

The AO Classification System has largely replaced the TLICS and Denis classification scale [91, 92]. Figure 18.

Figure 18.

AO Spine Classification System (reproduced with permission from https://www.aofoundation.org/).

6.2 Treatment of thoracolumbar fractures

Treatment for patients who are neurologically intact, who have less than 25 degrees of kyphosis, less than 50% loss of vertebral height, and less than 50% canal compromise, and who have an intact posterior ligamentous complex is nonsurgical – orthosis for three months.

Surgical treatment is indicated for unstable fractures and/or patients with neurological deficits. Patients with unstable burst fractures, including failure of the posterior ligamentous complex, fracture-dislocation, and fractures with significant rotational displacement, should undergo initial posterior stabilization [42, 43, 45].

7. Sacral fractures

Due to its unique anatomical location, injuries to the sacrum may result in deformity, neurologic deficit, and altered neurological function of the bowel/bladder and lower extremities.

Initial evaluation of high-energy suspected sacral fractures involves log-rolling during the secondary survey, with inspection and palpation of the spinal column up to the coccyx. Additionally, neurological examination of the lower extremities and bowel/bladder function is required. Sacral fractures are often associated with root deficits [93].

The Denis classification, or AO Sacral Injury Classification System, is used for sacral fractures [94, 95]; seeFigure 19 and Figure 20.

Figure 19.

The Denis classification of sacral fractures. (a) The three zones (zone I, alar region fracture; zone II, foraminal region fracture; zone III, central canal region fracture). (b) Zone II fracture going through the sacral foramina. (c) Image showing normal sacral anatomy with reference to the L-5 nerve root (left) and a zone II fracture causing compression of the L-5 nerve root (right). (d) Sagittal views of normal sacrum (left), a zone III burst fracture (middle), and a zone III fracture dislocation (right). Reproduced with permission from Denis F., Davis S., Comfort T. Sacral fractures: An important problem: Retrospective analysis of 236 cases. Clin Orthop Relat Res 227:67–81, 1988.

Figure 20.

AO Spine Classification System (reproduced with permission from https://www.aofoundation.org/).

7.1 Treatment of sacral fractures

Treatment depends on the location and pattern of the fracture, the presence of impaction, the integrity of the L5–S1 facet, associated pelvic fractures, and neurologic deficit.

Treatment of Zone 1 and Zone 2 displaced fractures is followed by percutaneous iliosacral screw fixation; however, in Zone 2, to avoid further injury to the sacral root, the iliosacral screw should not be placed in compression.

Zone 3 injuries commonly involve open-book pelvic fracture patterns with diastasis anteriorly and gapping at the sacral fracture posteriorly. Initial treatment should address the anterior pelvic ring disruption, followed by posterior screw fixation if necessary.

Indications for spinopelvic fixation include the presence of vertical shear or disruption of the L5–S1 facets.

8. Postoperative care and rehabilitation

Early rehabilitation is crucial to preventing thromboembolic and other complications, especially in patients with neurological deficits.

When it comes to patients who have an injury that is treated non-operatively and do not have a neurological deficit, early rehabilitation treatment is started immediately after obtaining adequate immobilization. When it comes to minor injuries such as fractures of the transverse processes and spinous processes (according to the AO classification, they are AOA0), after six weeks, the immobilization is removed, and rehabilitation treatment begins in inpatient conditions or on an outpatient basis. When it comes to vertebral body fractures that are treated non-operatively, and neurological findings are normal, after three months, the immobilization is removed, and rehabilitation treatment begins. While wearing immobilization, it is advised to avoid lifting loads and sudden movements, as well as prolonged sitting and standing due to the heavy load on the spinal column. At the regular controls after two weeks, one month, and six weeks, the healing of the fracture is monitored by X-ray.

When it comes to patients treated operatively, early rehabilitation treatment is started either on the same day of surgery or the next day in the ward. Patients undergoing minimally invasive surgery (lumbar diskectomy, percutaneous vertebroplasty, vertebra biopsy) are verticalized on the same day of the intervention and go home the next day with behavioral advice (avoidance of heavy lifting and sudden movements). Considering that these patients have an operative wound, after removing the sutures, usually two weeks after the operation, rehabilitation treatment begins in inpatient conditions or as an ambulatory type.

A special challenge is presented by patients with neurological impairment (quadriplegia, paraplegia, quadriparesis, paraparesis). In these patients, operative treatment is almost always indicated within 24 to 48 hours of the injury, and immediately after the operative treatment, they are included in early intensive rehabilitation treatment both in the ward and then in institutions that specialize in these conditions. This includes intensive physical therapy, exercises, and prevention of decubitus. Regular follow-ups include checks 2 weeks after discharge, 1 month, 6 months, and 12 months [96–98].

9. Conclusion

Spinal trauma, with associated injuries to other organs and with spinal cord injury, presents a great challenge for both diagnosis and treatment. It is crucial to recognize spinal injury in a polytraumatized patient, as well as to diagnose it in a timely manner.

Take-home messages are: Patients with ankylosing spondylitis have an increased risk of spinal fractures as a result of minor trauma; Brown-Séquard syndrome has the best prognosis after SCI; Abdominal visceral injuries occur in 50% of patients with flexion-distraction injuries in the thoracolumbar spine; Early decompression significantly improves ASIA score; In patients with SCI, hypotension should be avoided, and mean arterial blood pressure should be maintained at 85 to 90 mm Hg to prevent secondary SCI; Most lower lumbar spine fractures can be treated nonsurgically.

Conflict of Interest

The author declares no conflict of interest.

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Written By

Slavisa Zagorac

Submitted: 11 September 2025 Reviewed: 25 November 2025 Published: 04 March 2026

© 2026 The Author(s). Licensee IntechOpen. This content is distributed under the terms of the Creative Commons Attribution 4.0 International License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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