Transverse Process Fractures. A Broken Spine From Crashing

Recently I saw a patient who crashed his mountain bike in a race, tumbling over the handlebars at speed and rolling on impact. He managed to get up afterwards and although he couldn’t finish the race, he was able to drive himself home at which point getting out of the car was difficult. His pain steadily rose until any movement at all was extremely painful by nightfall. My recommendation was for an immediate MRI or CT scan as his examination indicated that he had likely sustained structural damage that required investigation.

In some crashes a cyclist may suffer from a spinal fracture known as a transverse process fracture. Each vertebrae has two protrusions (one on each side) called a transverse process, and when these are cracked or broken the injury is called a transverse process fracture. This fellow did 3 of these! One way of looking at this injury is that the athlete has torn the back and abdominal muscles off the spine so hard that it has pulled parts of the spinal bones off. There will be significant muscle damage and weakness requiring professional rehabilitation from your Physiotherapist.

Causes of transverse process fractures:

· Falls / crashes, esp. at higher speeds

· Severe or sudden rotation or side bending of the spine (he rolled on impact)

· A blow to the spine (eg fall onto an object – think of a multi-rider crash in the peloton)

· Collisions

Risk Factors:

There are several things that increase the risk of sustaining a fracture:

· Low bone density or osteoporosis

· Low muscle mass

· Age

· Diseases that weaken bone (eg tumors, cysts)

Symptoms:

· Back pain – often primarily on the side of the fracture

· Spasm

· Tenderness, +/- bruising

· Restricted or painful movement of the spine or hip

· Possible referred pain or tingling / numbness into the lower limb

· Possible loss of bladder / bowel function – this is an emergency so don’t delay seeking medical assessment

The large back muscles such as quadratus lumborum can tear the transverse processes off the spinal column during trauma

Diagnosis:

Requires imaging and professional assessment. CT scan is regarded as the best choice as it detects more fractures than plain Xrays. MRI is also suitable.

Treatment & Recovery:

The good news is that most transverse process fractures are stable and recover well with rest and short term use of a lumbar brace / support. Being a stable fracture means that they generally don’t require surgery.

Fractures of the transverse process are associated with other injuries as major forces are usually involved (about 35% also suffer injury to the liver, spleen, diaphragm or genitourinary system such as a torn ureter). Anyone having symptoms involving the abdomen, bladder or bowel needs urgent medical assessment.

Healing time varies with age and how healthy you were to begin with. Patients who, prior to injury, had low bone density or low muscle tone causing poor support for the spine and likely to take longer to recover. Healing time is a minimum of 6 weeks, but may take significantly longer to enable a return to high impact sports.

Physiotherapy rehab is critical since you will always have significant muscle damage and asymmetrical muscle wasting and weakness. With the expert help of your Physiotherapist rehab can start early, providing a low load approach is used. This will need progression based on individual assessment, healing, pain levels and compliance with the strengthening program. It certainly cannot be done properly by using the internet! Usually rehab begins within a week of the injury with the low back remaining in a neutral position, with later stages focusing on progressively higher loads, rotational movements and speed prior to return to sport. For cyclists a return to the stationary trainer occurs well before getting off-road or onto the tarmac.

Comment by Dr Toby Loch-Wilkinson (Neurosurgeon – Spine Brain Nerve Neurosurgery, Brisbane)

Thanks for this excellent summary Dave. These types of fractures were easily missed in the era before CT scans and can be all too easily dismissed as a trivial or unimportant fracture of a part of the spine that is not essential for stability. What is not appreciated as you say is the extent of the muscle injury. TP fractures are essentially an avulsion injury of the large muscles and can be extremely painful for a prolonged period of time. Fortunately most patients with this diagnosis do not need prolonged hospitalisation and can be managed with an appropriate period of rest, simple analgesics and an early physiotherapy based rehabilitation program