vertebral end plate fracture. normal anatomy end plate – thin layer of hyaline cartilage between...
TRANSCRIPT
Vertebral End Plate Fracture
Normal Anatomy
• End Plate– Thin layer of hyaline
cartilage between bone and intervertebral disc
– Prevents highly hydrated nucleus from bulging into adjacent vertebral bone
– Absorbs hydrostatic pressure from mechanical loading of the spine
– Allows diffusion of nutrients between bone and disc
Pathophysiology• With age end plate cartilage
thins and calcifies– Affects distribution of IVD
pressure to vertebral– Affects diffusion of nutrients
• Communication develops between nucleus and highly innervated vertebral marrow
• Schmorls Nodes– Protrusion of nucleus into
vertebral body– Pathological when associated
with fibrovascular bone marrow changes and bone marrow lesion
Pathophysiology
• 3 types described– Avulsion
• Bending motion that causes traction of interface between annulus and end plate
• More common vertebral rim in lower lumbar spine• Greater ROM available so more traction
– Traumatic node• End plate fragment from excessive compression with healthy nucleus
pulposus• More common central end plates upper lumbar and thoracolumbar spine• Trabecular bone density is lower, end plates weaker, subcondral softening is
more severe
– Central End Plate Fracture with Exposed Trabecular• Excessive compression with degenerative pulposus
Pathophysiology
Mechanism Of Injury
• Traumatic– Heavy axial compression– Falling into standing or
seated position– Heavy lifting
• Insidious– Repeated axial
compression– Repetitive
flexion/Extension
Associated Pathologies
• Degenerative Disc Disease
• Disc Herniation• Osteoporosis• Vertebral Fractures
Subjective
• Central Low back Pain• Sudden or insidious • History of axial compression or repetitive
traction (flexion/extension)• Aggravated by standing or walking• Pain with jumping, running, landing• Eases lying down
Objective
• Reduced flexion/extension
• Tenderness palpation soft tissue
• Tenderness and stiffness joint PA’s
Special Tests
• Heel drop from standing– In standing, go onto tip
toes– Drop onto heels– Axial compression
causes pain
Further Investigation
• Discography• MRI• X-ray• Often missed on
imaging
General Management
• Management of symptoms and pain relief• Activity modification• Relative Rest• Nearly always conservative
Conservative - Management
• Pain Relief– NSAID’s, Ice, Massage
• Restore Normal Range of Movement– Hips, Thoracic and Lumbar Spine– Soft tissue techniques, mobilisations
• Restore Normal Muscle Activation– Multifidus, erector spinae, glutes, obliques, trans abs
• Restore Dynamic Stability– Gradually re-expose to axial compression to develop
adequate neuromuscular control to reduce force through vertebrae
Plan B - Management
• Vertebroplasty– Only in very severe cases and in combination with
a fracture of the vertebrae