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The management of fractures of the vertebrae in the elderly
The EDGAR M. BICK,
Management of Fractures of the Vertebrae in the Elderly M.D.,
Diplomate, American Board of Orthopaedic Surgery, New York, New York
Read before tbe combined meeting of tbe New York and Brooklvn-Pbiladelvbia Reeional Committees on Trauma. American College ;j Surge&s, New York, N. Y., Novem: ber rqtb, 1953.
vertebra, in none of the twenty-five eIderIy patients seen had it been possibIe, without jeopardy to heaIth or even in some cases to Iife, to persist in maintaining a significant degree of hyperextension for a length of time suff%zient to bear any influence whatsoever on the process of reparative osteogenesis at the fracture site. Yet for the most part, these eIderIy patients seemed to have done quite weI1. AI1 patients with uncompIicated cases had returned to their way of Iife, some with persistent or recurrent discomfort and others with no residua1 symptoms. None were seriousIy disabIed. It cannot be too strongIy emphasized that an observation made then has remained vaIid. No case in which symptoms of cord compression were absent immediateIy after injury ever showed subsequent signs of cord invoIvement. This observation heId true even when Iatestage compression of the vertebra1 body exceeded the origina deformity as occasionally occurred with the onset of intra-osseous avascuIar necrosis. A further report by Baab and Howorth appeared in 1931.~ It discIosed that 94 per cent of reduced compression fractures of the dorsoIumbar vertebrae in patients of a11 ages treated with hyperextension casts, braces and exercises subsequentIy coIIapsed. They found, too, that such fractures had “no higher symptom rate ” when not reduced than those which maintained reduction or coIIapsed after reduction. In view of the histories of our earIier cases the regimen of treatment which was seen to have been often demanded by circumstance among elderly patients, without perceptibIe detriment to the outcome, became the method deIiberateIy adopted for a11 subsequent cases in this age group. Over IOO such cases that have been studied proved to be instances of vertebra1 coIIapse in the presence of maIignant metastases or muItipIe coIIapse associated with extensive and advanced osteoporosis. These
RACTURES of the vertebrae have been by an aImost standardized procedure ever since Davis introduced his method of earIy reduction foIlowed by sustained ambuIatory hyperextension in 1927. l This procedure has been endorsed with minor technica variations in textbooks on fracture therapy ever since that time.z-4 In face of the singuIarIy forcefu1 statements of BiihIer and of any disagreement demands Watson-Jones, some intrepidity. Two reports, published independentIy about four years ago, chaIIenged the vaIidity of the principIes upon which this method was based. These principIes stated that fractures of the vertebrae couId be reduced and required reduction to norma contour, and that reduction must be maintained unti1 heaIing is compIete. NicoII in EngIand decided “to examine the validity of the assumption that a good anatomica1 resuIt is indispensibIe to a good functiona resuIt.“6 After observing the resuIts in 165 such fractures in heaIthy, hard-working adults, NicoII found no grounds for the assumption. ApparentIy among his coa1 miners the ability to return to their heavy duties bore IittIe reIationship to the degree of fina compression of the vertebra1 bodies, or to the use or non-use of sustained hyperextension during the course of treatment. The second report, aIready in press when NicoII’s appeared, was an end resuIt study of previousIy treated fractures of the vertebrae in the aged.6 This report aIso questioned the vaIidity of the accepted treatment from a different point of view. With a11 due regard to the theoretic principIes advanced in favor of the method and with proper acknowledgment of the occasionaIIy remarkabIe evidence of immediate restoration of contour of the compressed
F treated
7%
Fractures
of Vertebrae
\yere eliminated from the list as not being pertinent to the present study. The latter have been discussed elsewhere.* Forty-f& cases were chosen for further investigation. Criteria for their inclusion in this series were the foIIowing: (I) The patient was sixty years of age or oIder. (2) The fracture was the result of a specific trauma. (3) The fracture had occurred in a vertebral body, the internal architecture of which was within the normal expected at the patient’s age Ievel. The senescent vertebra and its normal variations had already been described from our laboratory.” (TabIe I.) The conduct of treatment can be very simply stated. The patient is put to bed, preferably with a rigid board under the mattress to prevent sagging at the center. Six-inch bIocks are placed at the head of the bed so that the patient’s visibiIity and interest is not exclusively focused on the ceiIing. No attempt is made to restrain the patient from turning or moving about the bed as comfort permits so Iong as he does not insist upon trying to sit up. The upper third of the bed may be further raised to no more than 30 degrees from the Iine of the mattress for short eating periods. No appliances are worn in bed. During the first few days there may be considerabIe pain and the patient may prefer to lie quietly. Within this period anciIIary care requires meticulous attention. More so than in the younger patient these eIderIy peopIe are prone to iIeus, bIadder atony, decubitus sores and constipation, the frequent concomitants of fractures of the vertebrae at a11 ages. Rectal tubes, the occasiona use of an ampul of pitressin@ or hot stoups to the abdomen, furmethide@ or at times catheterization must be employed without deIay as indicated. Fluid baIance must be carefuIIy managed to avoid dehydration or edema. Common sites of decubitus must be protected. OccasionaIIy, however, especially at the time of accident, the patient of this age group may be aImost unaware of injury and even reject the order to bed. Under such circumstances I now bareIy argue the point. In the appended Iist of cases are severa in which my timidity in the presence of determined oId age has not apparentIy been to their disadvantage. OrdinariIy the first week or so is rather painfu1 and the patient may require carefu1 and sympathetic nursing.
in EIderIy
During the second week the intensity of the local pain recedes, the patient becomes more mobile and his genera1 condition responds to proper diet and proper fluid balance. At this time the patient is measured for a spina support which may be either a Iightweight brace or a reinforced corset. The choice depends upon the physica condition, age, degree of debiIity and probable extent of future activity. Some time between the end of the second week and earIy part of the fourth week the local tenderness greatly subsides, the patient moves about quite freeIy in bed with a minimum of discomfort and is abIe and wilting to get out of bed wearing the support. I have even aIIowed this earIier if symptoms permit. With occasiona exceptions a week or two of bed rest is advisabIe to permit the patient to react to the trauma. The patient gradually resumes activity. The spina support is worn for about three months to maintain an upright stance. By that time reparative osteogenesis has attained its optimum. Beyond that time compression may go on further if the vertebra1 body has undergone avascuIar necrosis; but if so, no known type of external support wiI1 prevent it. Any attempt to supervise postfracture exercises in these eIderIy patients with the object of strengthening their back muscIes would be an attempt to paint the IiIy and giId refined goId. The reason for this wiI1 become apparent in the folIowing paragraphs. In deaIing with fractures of the vertebrae in the eIderIy one must accept the fact that the injury has occurred in a spine aIready afflicted to a greater or Iesser extent with menopausal or senile osteoporosis, ,metaboIic or dietetic osteomaIacia, or invoIved in arthritic or degenerative intervertebral processes, either interarticular or discogenic.lO In the infrequent absence of evidence of bone changes in the Iower ranges of this age group one is stiI1 dealing with spine Iigaments of considerably reduced elasticity. It is common experience that in the lives of elderly peopIe maintained on an even pIane, an advanced extent of osseous aging may go on without noticeabIe symptoms. FolIowing some traumatic episode the natural compensatory factors may be thrown off baIance and backache appears which may remain quite persistent. In a Iarge proportion of the cases in the present group some degree of persistent
Fractures
of Vertebrae TABLE
CIW2
5,s and
NO.
Age
in EIderIy I
-r
I-
>ocation
Compression CIassilied
Final Note
Treatment
2
F, 60 M, 60
LI TIZ-LI
Moderate Moderate
3 4 5
F, 60 F, 60 F, 60
LI TII l-6
Moderate Moderate Moderate
6
M, F, F, M, F,
60 60 61 61 62
Lz
Moderate Moderate Moderate Moderate Moderate
1Hyperextension 1Hyperextension days 1Bed rest, corset 1Bed rest, brace 14ctive 2 mo., for symptoms 1Bed rest 4 wk., 1Bed rest 3 wk., 1Brace 13race 13ed rest 6 wk.,
F, F, F, P, P, F, M, F, F,
62 62 62 64 64 64 65 65 65
Severe Moderate Moderate Moderate Moderate Moderate Severe Moderate Severe
13ed rest, corset 13ed rest, 4 wks., corset 13ed rest, 2 wk., brace, corset Iater 3ed rest, adhesive strap !3ed rest 13ed rest I wk., corset 13radford frame, pIaster, brace 13ed rest IHyperextension, pIaster, bed rest
F, F, F, F, M,
65 66 66 67 67
I
; 9 IO II I2
13 ‘4 15 16 ‘7 18 ‘9 20 21 22
23 24
L3 Trz L3 LI LI
ILI 1LI 1L4, 5 r7
1L4 r7,
1LI
11
l-11,
I2
TII,
12
1Ll 1Lz l-12 T8-L
I
1LI 1Ll T8
Moderate Moderate Moderate
28
F, 68
29 30 31 32 33
F, M, F, F, F,
r9 1L3 r12 1LI 1LI 1LI
Moderate Moderate Moderate Slight Severe Moderate
34 35 36
F, 72 F, 72 F, 73
1LI 1Lz rIo
Moderate Moderate Moderate
37 38 39 40 41 42 43
M, F, M, F, F, F, M,
1Ll L3 LI LI T6 T9 Lz
Severe Moderate Moderate SIight Severe Moderate Moderate
44 45
F, 83 F, 62
Trz TIO
Moderate Moderate
27
69 70 71 7r 72
75 75 76 77 78 78 80
-
then brace
bed
2 I
6 wk.
brace brace
corset
3 days 13ed rest 3 wk., corset I3eIt 13ed rest I wk., brace 13race Ilyperextension plaster, removed 3 wk., bed rest 3ed rest, brace 1; 3ed rest 2 wk., corset II 3ed rest 4 wk., plaster, brace to 4 mo. postfracture 13ed rest 2 wk., corset 13ed rest 2 wk., brace Ilyperextension plaster, brace I3ed rest I wk., corset 13ed rest 8 days, corset Ilyperextension frame (bed)’ 5 days, corset 13ed rest 4 wk., corset 13ed rest, corset 1Hyperextension plaster under anesthesia 13ed rest I wk., brace Kept active, corset Bed rest I wk., brace Bed rest I wk., no further support Bed rest 2 wk., no further support Bed rest, brace 4 wk. active, before diagnosis, moderate pain, brace Kept active, corset Bed rest 335 wk., brace
Moderate Severe SIight Severe Moderate
F, 67 F, 67 F, 68
25 26
pIaster plaster,
-
766
Active; x-ray same as at prereduction Some improvement in x-ray contour maintained; active; minima1 pain Persistent moderate pain Active; moderate pain Active; occasional pain Active; no symptoms Active; minima1 symptoms No symptoms I yr. Iater No symptoms X-ray I yr. later, further compression; no significant symptoms Active; moderate pain Active; no symptoms No symptoms 2 yr. later Active; moderate pain No complaints No symptoms 2 yr. Iater No symptoms I yr. and I I yr. later Active; moderate pain Improvement by x-ray; active; moderate pain Active; occasiona pain Active; moderate pain Active; moderate pain (15 mo. later) Active; minima1 pain, (I yr. later) Active; moderate pain Active; no pain Active; recurrent discomfort Active; constant discomfort; sciatic pain Active; no compIaints Active; no compIaints (8 mo.) Active; moderate discomfort Active OccasionaI low back pain Active; moderate discomfort Active; Active; Active
persistent persistent
pain, lumbar spine pain
No complaints after 6 mo. No complaints Active; moderate pain (I yr.) Active Active; no compIaints (2 yr.) Active; no compIaints Active; no compIaints Active; Active;
occasiona occasional
IocaI pain IumbosacraI
pain
Fractures
of Vertebrae
in EIderIy
became minimal or miIdly recurrent. Again in this Iarger series al1 the patients with uncomof the vertebral bodies plicated fractures resumed their ordinary prefracture way of Iife.
backache has been inevitable whether the fracture was severe or slight and regardless of the length of time of bed rest or the wearability of subsequent spinal support. Postfracture backache in these cases was as often as not directed away from the fracture site. It n-as most often IumbosacraI, or generaIIv Iumbar, less often generally dorsa1. Its intensity varied from minimal to severe. It might be more severe several months after treatment is completed than it was during convalescence. These symptoms may require orthopedic treatment in their own right. It must be repeated that their occurrence, their intensity or their duration cannot be related to the type or severit! of fracture, or to the duration or type of treatment. Thev were the backaches of the disturbed elderly spine, precipitated or aggravated b> the trauma of fracture. After a period of aggravation most of the cases act as though the customary compensatory baIance was re-estabIished; at least the more active symptoms abate to a Iower Ievel of discomfort. During these months analgesic medication and at times IocaI massage to the back furnish pleasant amelioration. In some a moderate degree of pain persists. In most, after a variabIe period of time the pain
REFERENCES I. DAVIS, A. G. Fractures of the spine. J. Bone r’+ Joint Surg., 2: 133, 1929. 2. B~HLER, L. Treatment of Fractures, 4th ed. Bristol, 1935. John Wright & Sons Ltd. 3. WATSOK-JONES, R. Fractures and Joint Injuries. Baltimore, 1943. Williams & Wilkins Co. 4. ti~v. J. A. and CONWELL. H. E. Management of Fractures, Dislocations; and Sprains, 5th ed. St. Louis, 1951. C. V. Mosby Co. 5. NICOLL, E. A. Fractures of the dorso-lumbar spine. J. Bone &+Joint Surg., 31B: 376, 1949. 6. RICK. - E. M. and COPEL. J. W. Fractures in the vertebrae in the aged. Geriatrics, 5: 74, 1950. 7. BAAB, 0. D. and HOWORTH, M. B. Fractures of the dorsal and lumbar vertebrae. J. A. M. A., 146: T
I
97. ‘95’. 8. GERSHON-COHEN,J., RECUTMAN, A. M., ScnnAnn, H. and BLUMBERG. N. Asvmotomatic fractures in osteoporotic spines of the aged. J. A. ‘$4. A., ‘53: 625, 1953. g. BICK, E. M. and COPEL, J. W. The senescent human vertebrae. J. Bone Joint Surg., 34A: I IO, 1952. 10. ASCHOFF. L. Zur normaIen and PathoIoaischen Anatomic des Greisenalters. Med. K1in.T Vols. 33 and 34, 1937 and 1938 (published in these volumes as small notes in each issue).
767
Management of Fractures of the Vertebrae in the Elderly M.D.,
Diplomate, American Board of Orthopaedic Surgery, New York, New York
Read before tbe combined meeting of tbe New York and Brooklvn-Pbiladelvbia Reeional Committees on Trauma. American College ;j Surge&s, New York, N. Y., Novem: ber rqtb, 1953.
vertebra, in none of the twenty-five eIderIy patients seen had it been possibIe, without jeopardy to heaIth or even in some cases to Iife, to persist in maintaining a significant degree of hyperextension for a length of time suff%zient to bear any influence whatsoever on the process of reparative osteogenesis at the fracture site. Yet for the most part, these eIderIy patients seemed to have done quite weI1. AI1 patients with uncompIicated cases had returned to their way of Iife, some with persistent or recurrent discomfort and others with no residua1 symptoms. None were seriousIy disabIed. It cannot be too strongIy emphasized that an observation made then has remained vaIid. No case in which symptoms of cord compression were absent immediateIy after injury ever showed subsequent signs of cord invoIvement. This observation heId true even when Iatestage compression of the vertebra1 body exceeded the origina deformity as occasionally occurred with the onset of intra-osseous avascuIar necrosis. A further report by Baab and Howorth appeared in 1931.~ It discIosed that 94 per cent of reduced compression fractures of the dorsoIumbar vertebrae in patients of a11 ages treated with hyperextension casts, braces and exercises subsequentIy coIIapsed. They found, too, that such fractures had “no higher symptom rate ” when not reduced than those which maintained reduction or coIIapsed after reduction. In view of the histories of our earIier cases the regimen of treatment which was seen to have been often demanded by circumstance among elderly patients, without perceptibIe detriment to the outcome, became the method deIiberateIy adopted for a11 subsequent cases in this age group. Over IOO such cases that have been studied proved to be instances of vertebra1 coIIapse in the presence of maIignant metastases or muItipIe coIIapse associated with extensive and advanced osteoporosis. These
RACTURES of the vertebrae have been by an aImost standardized procedure ever since Davis introduced his method of earIy reduction foIlowed by sustained ambuIatory hyperextension in 1927. l This procedure has been endorsed with minor technica variations in textbooks on fracture therapy ever since that time.z-4 In face of the singuIarIy forcefu1 statements of BiihIer and of any disagreement demands Watson-Jones, some intrepidity. Two reports, published independentIy about four years ago, chaIIenged the vaIidity of the principIes upon which this method was based. These principIes stated that fractures of the vertebrae couId be reduced and required reduction to norma contour, and that reduction must be maintained unti1 heaIing is compIete. NicoII in EngIand decided “to examine the validity of the assumption that a good anatomica1 resuIt is indispensibIe to a good functiona resuIt.“6 After observing the resuIts in 165 such fractures in heaIthy, hard-working adults, NicoII found no grounds for the assumption. ApparentIy among his coa1 miners the ability to return to their heavy duties bore IittIe reIationship to the degree of fina compression of the vertebra1 bodies, or to the use or non-use of sustained hyperextension during the course of treatment. The second report, aIready in press when NicoII’s appeared, was an end resuIt study of previousIy treated fractures of the vertebrae in the aged.6 This report aIso questioned the vaIidity of the accepted treatment from a different point of view. With a11 due regard to the theoretic principIes advanced in favor of the method and with proper acknowledgment of the occasionaIIy remarkabIe evidence of immediate restoration of contour of the compressed
F treated
7%
Fractures
of Vertebrae
\yere eliminated from the list as not being pertinent to the present study. The latter have been discussed elsewhere.* Forty-f& cases were chosen for further investigation. Criteria for their inclusion in this series were the foIIowing: (I) The patient was sixty years of age or oIder. (2) The fracture was the result of a specific trauma. (3) The fracture had occurred in a vertebral body, the internal architecture of which was within the normal expected at the patient’s age Ievel. The senescent vertebra and its normal variations had already been described from our laboratory.” (TabIe I.) The conduct of treatment can be very simply stated. The patient is put to bed, preferably with a rigid board under the mattress to prevent sagging at the center. Six-inch bIocks are placed at the head of the bed so that the patient’s visibiIity and interest is not exclusively focused on the ceiIing. No attempt is made to restrain the patient from turning or moving about the bed as comfort permits so Iong as he does not insist upon trying to sit up. The upper third of the bed may be further raised to no more than 30 degrees from the Iine of the mattress for short eating periods. No appliances are worn in bed. During the first few days there may be considerabIe pain and the patient may prefer to lie quietly. Within this period anciIIary care requires meticulous attention. More so than in the younger patient these eIderIy peopIe are prone to iIeus, bIadder atony, decubitus sores and constipation, the frequent concomitants of fractures of the vertebrae at a11 ages. Rectal tubes, the occasiona use of an ampul of pitressin@ or hot stoups to the abdomen, furmethide@ or at times catheterization must be employed without deIay as indicated. Fluid baIance must be carefuIIy managed to avoid dehydration or edema. Common sites of decubitus must be protected. OccasionaIIy, however, especially at the time of accident, the patient of this age group may be aImost unaware of injury and even reject the order to bed. Under such circumstances I now bareIy argue the point. In the appended Iist of cases are severa in which my timidity in the presence of determined oId age has not apparentIy been to their disadvantage. OrdinariIy the first week or so is rather painfu1 and the patient may require carefu1 and sympathetic nursing.
in EIderIy
During the second week the intensity of the local pain recedes, the patient becomes more mobile and his genera1 condition responds to proper diet and proper fluid balance. At this time the patient is measured for a spina support which may be either a Iightweight brace or a reinforced corset. The choice depends upon the physica condition, age, degree of debiIity and probable extent of future activity. Some time between the end of the second week and earIy part of the fourth week the local tenderness greatly subsides, the patient moves about quite freeIy in bed with a minimum of discomfort and is abIe and wilting to get out of bed wearing the support. I have even aIIowed this earIier if symptoms permit. With occasiona exceptions a week or two of bed rest is advisabIe to permit the patient to react to the trauma. The patient gradually resumes activity. The spina support is worn for about three months to maintain an upright stance. By that time reparative osteogenesis has attained its optimum. Beyond that time compression may go on further if the vertebra1 body has undergone avascuIar necrosis; but if so, no known type of external support wiI1 prevent it. Any attempt to supervise postfracture exercises in these eIderIy patients with the object of strengthening their back muscIes would be an attempt to paint the IiIy and giId refined goId. The reason for this wiI1 become apparent in the folIowing paragraphs. In deaIing with fractures of the vertebrae in the eIderIy one must accept the fact that the injury has occurred in a spine aIready afflicted to a greater or Iesser extent with menopausal or senile osteoporosis, ,metaboIic or dietetic osteomaIacia, or invoIved in arthritic or degenerative intervertebral processes, either interarticular or discogenic.lO In the infrequent absence of evidence of bone changes in the Iower ranges of this age group one is stiI1 dealing with spine Iigaments of considerably reduced elasticity. It is common experience that in the lives of elderly peopIe maintained on an even pIane, an advanced extent of osseous aging may go on without noticeabIe symptoms. FolIowing some traumatic episode the natural compensatory factors may be thrown off baIance and backache appears which may remain quite persistent. In a Iarge proportion of the cases in the present group some degree of persistent
Fractures
of Vertebrae TABLE
CIW2
5,s and
NO.
Age
in EIderIy I
-r
I-
>ocation
Compression CIassilied
Final Note
Treatment
2
F, 60 M, 60
LI TIZ-LI
Moderate Moderate
3 4 5
F, 60 F, 60 F, 60
LI TII l-6
Moderate Moderate Moderate
6
M, F, F, M, F,
60 60 61 61 62
Lz
Moderate Moderate Moderate Moderate Moderate
1Hyperextension 1Hyperextension days 1Bed rest, corset 1Bed rest, brace 14ctive 2 mo., for symptoms 1Bed rest 4 wk., 1Bed rest 3 wk., 1Brace 13race 13ed rest 6 wk.,
F, F, F, P, P, F, M, F, F,
62 62 62 64 64 64 65 65 65
Severe Moderate Moderate Moderate Moderate Moderate Severe Moderate Severe
13ed rest, corset 13ed rest, 4 wks., corset 13ed rest, 2 wk., brace, corset Iater 3ed rest, adhesive strap !3ed rest 13ed rest I wk., corset 13radford frame, pIaster, brace 13ed rest IHyperextension, pIaster, bed rest
F, F, F, F, M,
65 66 66 67 67
I
; 9 IO II I2
13 ‘4 15 16 ‘7 18 ‘9 20 21 22
23 24
L3 Trz L3 LI LI
ILI 1LI 1L4, 5 r7
1L4 r7,
1LI
11
l-11,
I2
TII,
12
1Ll 1Lz l-12 T8-L
I
1LI 1Ll T8
Moderate Moderate Moderate
28
F, 68
29 30 31 32 33
F, M, F, F, F,
r9 1L3 r12 1LI 1LI 1LI
Moderate Moderate Moderate Slight Severe Moderate
34 35 36
F, 72 F, 72 F, 73
1LI 1Lz rIo
Moderate Moderate Moderate
37 38 39 40 41 42 43
M, F, M, F, F, F, M,
1Ll L3 LI LI T6 T9 Lz
Severe Moderate Moderate SIight Severe Moderate Moderate
44 45
F, 83 F, 62
Trz TIO
Moderate Moderate
27
69 70 71 7r 72
75 75 76 77 78 78 80
-
then brace
bed
2 I
6 wk.
brace brace
corset
3 days 13ed rest 3 wk., corset I3eIt 13ed rest I wk., brace 13race Ilyperextension plaster, removed 3 wk., bed rest 3ed rest, brace 1; 3ed rest 2 wk., corset II 3ed rest 4 wk., plaster, brace to 4 mo. postfracture 13ed rest 2 wk., corset 13ed rest 2 wk., brace Ilyperextension plaster, brace I3ed rest I wk., corset 13ed rest 8 days, corset Ilyperextension frame (bed)’ 5 days, corset 13ed rest 4 wk., corset 13ed rest, corset 1Hyperextension plaster under anesthesia 13ed rest I wk., brace Kept active, corset Bed rest I wk., brace Bed rest I wk., no further support Bed rest 2 wk., no further support Bed rest, brace 4 wk. active, before diagnosis, moderate pain, brace Kept active, corset Bed rest 335 wk., brace
Moderate Severe SIight Severe Moderate
F, 67 F, 67 F, 68
25 26
pIaster plaster,
-
766
Active; x-ray same as at prereduction Some improvement in x-ray contour maintained; active; minima1 pain Persistent moderate pain Active; moderate pain Active; occasional pain Active; no symptoms Active; minima1 symptoms No symptoms I yr. Iater No symptoms X-ray I yr. later, further compression; no significant symptoms Active; moderate pain Active; no symptoms No symptoms 2 yr. later Active; moderate pain No complaints No symptoms 2 yr. Iater No symptoms I yr. and I I yr. later Active; moderate pain Improvement by x-ray; active; moderate pain Active; occasiona pain Active; moderate pain Active; moderate pain (15 mo. later) Active; minima1 pain, (I yr. later) Active; moderate pain Active; no pain Active; recurrent discomfort Active; constant discomfort; sciatic pain Active; no compIaints Active; no compIaints (8 mo.) Active; moderate discomfort Active OccasionaI low back pain Active; moderate discomfort Active; Active; Active
persistent persistent
pain, lumbar spine pain
No complaints after 6 mo. No complaints Active; moderate pain (I yr.) Active Active; no compIaints (2 yr.) Active; no compIaints Active; no compIaints Active; Active;
occasiona occasional
IocaI pain IumbosacraI
pain
Fractures
of Vertebrae
in EIderIy
became minimal or miIdly recurrent. Again in this Iarger series al1 the patients with uncomof the vertebral bodies plicated fractures resumed their ordinary prefracture way of Iife.
backache has been inevitable whether the fracture was severe or slight and regardless of the length of time of bed rest or the wearability of subsequent spinal support. Postfracture backache in these cases was as often as not directed away from the fracture site. It n-as most often IumbosacraI, or generaIIv Iumbar, less often generally dorsa1. Its intensity varied from minimal to severe. It might be more severe several months after treatment is completed than it was during convalescence. These symptoms may require orthopedic treatment in their own right. It must be repeated that their occurrence, their intensity or their duration cannot be related to the type or severit! of fracture, or to the duration or type of treatment. Thev were the backaches of the disturbed elderly spine, precipitated or aggravated b> the trauma of fracture. After a period of aggravation most of the cases act as though the customary compensatory baIance was re-estabIished; at least the more active symptoms abate to a Iower Ievel of discomfort. During these months analgesic medication and at times IocaI massage to the back furnish pleasant amelioration. In some a moderate degree of pain persists. In most, after a variabIe period of time the pain
REFERENCES I. DAVIS, A. G. Fractures of the spine. J. Bone r’+ Joint Surg., 2: 133, 1929. 2. B~HLER, L. Treatment of Fractures, 4th ed. Bristol, 1935. John Wright & Sons Ltd. 3. WATSOK-JONES, R. Fractures and Joint Injuries. Baltimore, 1943. Williams & Wilkins Co. 4. ti~v. J. A. and CONWELL. H. E. Management of Fractures, Dislocations; and Sprains, 5th ed. St. Louis, 1951. C. V. Mosby Co. 5. NICOLL, E. A. Fractures of the dorso-lumbar spine. J. Bone &+Joint Surg., 31B: 376, 1949. 6. RICK. - E. M. and COPEL. J. W. Fractures in the vertebrae in the aged. Geriatrics, 5: 74, 1950. 7. BAAB, 0. D. and HOWORTH, M. B. Fractures of the dorsal and lumbar vertebrae. J. A. M. A., 146: T
I
97. ‘95’. 8. GERSHON-COHEN,J., RECUTMAN, A. M., ScnnAnn, H. and BLUMBERG. N. Asvmotomatic fractures in osteoporotic spines of the aged. J. A. ‘$4. A., ‘53: 625, 1953. g. BICK, E. M. and COPEL, J. W. The senescent human vertebrae. J. Bone Joint Surg., 34A: I IO, 1952. 10. ASCHOFF. L. Zur normaIen and PathoIoaischen Anatomic des Greisenalters. Med. K1in.T Vols. 33 and 34, 1937 and 1938 (published in these volumes as small notes in each issue).
767