Everywhere there is a bone, there can be a broken bone! Often Broken areas of the vertebrae come with other injuries or damage, so it can be hard to specify the ‘what, where, and why’ without imaging. Especially if there was a lot of trauma.
The neck is part of the back, but for this article, we will stick to the lumbar spine (low back area).
Back pain from a broken bone is likely to be very intense, and right around one spot. Touching or moving that spot in any direction generally makes it worse. Laying down with a cold pack may be the only way to get relief, and that will probably take a while, because you’ll have to find a good spot that doesn’t put pressure in the wrong spot!
The pain might migrate, radiate, shoot through a limb, or make a band on your trunk. These symptoms don’t usually come from the broken bone.
Broken bones are usually complicated because of your body seeking protection and stability with increased muscle tightness (we call muscle guarding). The broken bone can’t provide it’s normal support, so it might allow for important structures like nerves to be pinched, or sharp pieces of bone might contact soft tissue in severe cases.
Let's get down to the brass tax and talk about where and what these breaks are.
Starting with Spondylolysis. We see the Greek root word spondylos (spine) again, together with the word lysis (loosening or dissolution) which is pretty much medical for break. Spine break. This plays a role in some other conditions we discussed earlier.
Spondylolysis occurs in a ‘bridge’ area anywhere between the vertebral body and the facet joints (the pars interarticularis). Usually this will happen in the lower areas of the spine, the ‘lumbar’ region, next most common in the neck (called the cervical spine), and then rarely in the thoracic spine (1).
Spondylolysis will usually occur because the bone is weakened from a defect, repeated mechanical stress, or poor blood flow to the area weakening the bone. Once weakened, the spondylolysis can occur from any big jerky movements, shoveling, or olympic lifts. Anything where someone is pulling something up quick and hard. Rarely, a direct injury or big trauma may also cause this condition, usually involving some kind of twisting. (1,2)
Although this condition looks super painful, often patients mistake the sensation for a bad strain. Pain is often localized in a single area, or in a banded pattern. The muscles here will usually get really tight, and pain may radiate because of this. The spinous process of the back bone (the part you can feel under the skin) will be pushed out slightly further than usual, making a ‘step deformity.’
Lumbar Spondylolysis (a break in the low back) is usually fairly stable, but still needs the attention of a doctor if symptomatic. Imaging will confirm what’s wrong, and that there aren’t more issues at play. Spondylolysis in the trunk will require stabilization, possibly with splints. No twisting! During the healing phase. Isometric exercises will always be needed to start, sense strengthening is required and trunk movement is off the table. If it’s bad enough, solid braces will be ordered. Monitored exercise plans will allow progression after bracing winds down. Only very severe cases will need surgery. (2)
Another of the most common fractures are compression fractures.
For this one, the recipe is in the name. One or more vertebrae experience enough compressive force to be crushed.
As with many breaks, whatever caused enough force to crush your spine probably caused other issues too. Oddly, symptoms don’t always correlate to the severity of injury. Some are so small you can’t even see on x-rays at first, but they hurt like no other! Others are bad enough that the vertebral body gets deformed, but they don’t seem to add many new symptoms. Compression fractures usually come in 3 sub groups, a crush, a wedge, or a burst injury.
Normally a fall or bending and twisting past normal range will be the cause of a compression fracture, but they can occur from any trauma that puts force straight through the body of the vertebrae. Most commonly, this will result in a ‘crush’ injury. In crush injuries, the vertebral body is disrupted, but can still do its job. Crush injuries will most commonly affect people with osteoporosis or osteoporosis (low bone density disorders). Most people have the bone and ligament strength to resist most crush injuries. Strong enough forces, like falls over 10 ft, may still result in these kinds of fractures. (3)
The signs of a crush injury are unhelpfully general; trunk weakness, sensitivity to movement in all directions, and pain at the point of injury. Worse cases will cause ‘catching’ pains which may ‘shoot’ through the trunk or extremities. All symptoms will likely get better with laying down. For all but the most serious cases, symptoms are not progressive after some bracing.
Wedge fractures, or wedge deformities are kind of like a subgroup of crush fractures. For these, we are still dealing with the vertebral body being crushed, but not healing well. Sometimes they can also form over time. These are relatively stable, getting worse over the course of months or years. Usually this results in kyphosis (a forward lean) or scoliosis (a side-to side lean). It’s difficult to predict how fast or slow this might happen. This could occur because of osteoporosis, osteopenia, an untreated crush fracture, muscle imbalances, immobility, or genetic factors.
This can take a long time to resolve. Some times treatment is more of a management game than a ‘make it normal again’ game. (3)
Bracing, prolonged stretches, and changes in activity can help in mild and moderate conditions without a lot of other complications. It is up to a doctor to recommend surgery based on your risk factors. It is very important to note that surgery is a kind of trauma, and will need an extensive recovery process in itself, but you will likely be able to breathe better while doing it!
Last on the list are burst fractures. Burst injuries, or burst fractures, in the spine means that the vertebral body has been totally disrupted, and can provide no structural support. These are not very common, especially in healthy bone. These are very severe and will always need immediate medical attention. Signs will be severe pain and debility, often accompanied by nerve issues in limbs below the injury.
All compression injuries come with added instability, so you don’t want the injured area to move around much.
Pain relief and stabilization are key in the early phases of this injury, which can last for up to 2 months. Stabilization exercises are often done at this stage with a Physical Therapist to help prevent atrophy of your trunk muscles. Usually these are isometric ‘muscle tensing’ exercises that won’t make the affected joint move. Unsteady, they will build stability by resisting movement. (3)
As with most back issues, muscle relaxers should not be taken before any activity. When the condition improves enough that there is no more risk from moving in the area, exercise must begin to stabilize the trunk without the brace. Even following isometric programs, some muscle atrophy is expected. The bulk of weakness comes from your body forgetting how to isolate muscle movement if it doesn’t practice. Many of the exercises at this point won’t be to actually grow muscle, but rather to improve muscle coordination. (3)
Down to a few fractures left!
I’m putting spinous and transverse process fractures together, as they are fairly similar. Spinous process fractures are fractures of the spinous process of the spin (the part you can feel when you touch a persons spine). Transverse process fracture happen to, well, the transverse process!
The spinous and transverse processes are battened down by multiple layers of muscles and ligaments, and are not responsible for weight-bearing. These fractures are not terribly hard to heal, since these structures are mainly used for subtle stabilizing movements. When sore, the body automatically lets these areas rest by compensating with other movements. The spinous and transverse processes are not very close to other important structures either, so symptoms are pretty much soreness in and around the area of the break. Spinous and transverse process fractures are generally caused by a direct trauma. Many patients won’t need bracing for healing. Rest and pain management are the main ‘go to’s’ for treatment. Movement training after pain has decreased will be needed because of those compensations we were discussing. The body will automatically start using compensations to avoid pain and allow healing, but there are no safe guards to ensure the compensation stops. Good training will let the patient avoid long-term issues after the pain goes away.
A quick note on muscle guarding and muscle relaxers. Any injury in the back is likely to be accompanied by muscle pain in the injured region. There may also be muscle damage, but the most common muscle pain in these circumstances is caused by muscle fatigue. Massage, stretching, and pharmaceutical ‘muscle relaxers’ often offer assistance with that pain, by letting target muscles relax and release some metabolites that build up from overuse. This can be very powerful for healing. The problem is, your body may need that guarding to prevent a back fracture from worsening. If you use massage, stretching, or muscle relaxers, be sure to use them when you plan on resting.
I hope this gives you some insight into back fractures! This was a long one! Because of the complex nature of the back and human health, and the high likelihood that other tissues damage occurs when a fracture occurs, always seek the advice of a medical practitioner before determining a plan of care. (4,5)
Works Cited:
Gagnet P, Kern K, Andrews K, Elgafy H, Ebraheim N. Spondylolysis and spondylolisthesis:
A review of the literature. J Orthop. 2018 Mar 17;15(2):404-407. Doi:
10.1016/j.jor.2018.03.008. PMID: 29881164; PMCID: PMC5990218.
Choi JH, Ochoa JK, Lubinus A, Timon S, Lee YP, Bhatia NN. Management of lumbar
spondylolysis in the adolescent athlete: a review of over 200 cases. Spine J. 2022
Oct;22(10):1628-1633. doi: 10.1016/j.spinee.2022.04.011. Epub 2022 Apr 30.
PMID: 35504566.
Yetman, D., & Carteron, N. (2023). Vertebral Wedging: What You Should Know. Health
Line. https://www.healthline.com/health/vertebral-wedging
Nagasawa DT, Bui TT, Lagman C, Lee SJ, Chung LK, Niu T, Tucker A, Gaonkar B, Yang I,
Macyszyn L. Isolated Transverse Process Fractures: A Systematic Analysis.
World Neurosurg. 2017 Apr;100:336-341. doi: 10.1016/j.wneu.2017.01.032. Epub
2017 Jan 18. PMID: 28108423.
Dillon, A. (2022). Spinous Process: Definition, Function & Fracture Treatment. Study.com.
https://study.com/learn/lesson/spinous-process-fracture-treatment-function.html
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