Radiological Features of Traumatic Vertebral Endplate Fracture: An Analysis of 194 Cases with 263 Vertebral Fractures
Introduction
Vertebral fractures (VFs) are a significant health concern, particularly in the elderly population, where osteoporosis is a common underlying cause. Osteoporotic vertebral fractures are often associated with poor quality of life, impaired mobility, and increased mortality. The identification of osteoporotic vertebral endplate or cortex fractures (ECFs), which primarily include endplate fractures (EPFs) and vertebral anterior cortex buckling, has gained importance in recent years. However, distinguishing between osteoporotic ECFs and old traumatic ECFs can be challenging, as some old traumatic ECFs with healing processes in the elderly may be mistaken for osteoporotic fractures. This study aims to analyze the radiological features of traumatic EPFs to aid in the differentiation between traumatic and osteoporotic EPFs.
Methods
This retrospective study analyzed 194 spine trauma patients with a total of 263 vertebral fractures. The mean age of the patients was 42.11 ± 9.82 years, with 118 males and 76 females. All patients had traumatic EPFs identified by X-ray, CT, or MRI. The inclusion criteria were consecutive trauma patients with EPFs identified by imaging, with all male subjects less than 56 years old and female subjects less than 51 years old. Patients with malignancy, infectious diseases of the spine, or underlying causes of osteoporosis such as cortisol medication, menopause, and hyperthyroidism were excluded. The causes of trauma included traffic accidents (69.1%), falls from heights greater than 2 meters (16.5%), sports injuries, and heavy subject contusions.
Results
The most commonly involved vertebra was L1 (29.7%), followed by T12 (18.3%) and L2 (12.9%). Except for EPFs involving both superior and inferior endplates (12.6%), only 1.9% involved the inferior endplate alone, with the majority involving the superior endplate. The endplates were divided into five segments of equal lengths (from anterior to posterior: a1, a2, m, p2, p1), and the most depressed point of superior EPFs was mostly at segment-a2 (approximately 45%), followed by segment-a1 (approximately 20%) or segment-m (approximately 20%), and very rarely at segment-p1. The upper 1/3 of the anterior vertebral wall was more likely to fracture, followed by the middle 1/3 of the anterior wall. For posterior vertebral wall fractures, 68.5% broke the bony wall surrounding the basivertebral vein. According to vertebral height loss, 58.6%, 30.0%, and 11.4% of vertebral fractures had 1/3 vertebral body height loss, respectively. As the extent of vertebral height loss increased, the chance of having both superior and inferior EPFs also increased; however, the chance of having inferior EPF alone did not increase.
Discussion
The thoracolumbar junction was the most vulnerable site for traumatic VFs, with L1 being the most commonly involved vertebra, followed by T12 and L2. This distribution is similar to that of osteoporotic VFs. However, traumatic EPFs showed no gender differences, unlike osteoporotic EPFs, which have different features for males and females. In traumatic EPFs, the superior endplate was injured more often than the inferior endplate, with only approximately 1.9% involving the inferior endplate alone. This contrasts with osteoporotic EPFs, where the inferior endplate is more commonly involved, particularly in females.
The in-plane distribution of traumatic EPFs differed from that of osteoporotic EPFs. Traumatic superior EPFs most commonly occurred at segment-a2 (approximately 45%), followed by segment-a1 (approximately 20%) and segment-m (approximately 20%). In contrast, osteoporotic EPFs most commonly occur at segment-m (approximately 70%), followed by segment-a2 (approximately 25%), and rarely at segment-p2 (approximately 5%–10%). Osteoporotic EPFs do not occur at the most anterior and most posterior 1/5 segments of the endplate (segment-a1 or p1), whereas traumatic EPFs can occasionally occur at segment-p1.
The associated posterior vertebral wall fractures in traumatic EPFs often involved the bony wall surrounding the basivertebral vein (68.5%), whereas osteoporotic ECFs generally do not involve the posterior vertebral wall. The upper 1/3 of the anterior vertebral wall was more likely to fracture in traumatic EPFs, followed by the middle 1/3 of the anterior wall.
According to vertebral height loss classification, traumatic VFs were more likely to have EPF even when the extent of vertebral height loss was mild. In contrast, osteoporotic VFs with ECF often have greater vertebral height loss. As the extent of vertebral height loss increased in traumatic VFs, the chance of having both superior and inferior EPFs also increased; however, the chance of having inferior EPF alone remained low.
Limitations
This study has several limitations. It primarily focused on EPF characterization, so vertebral anterior/posterior wall fractures might not have been fully characterized unless they coexisted with EPF. The study only analyzed vertebral anterior and posterior wall fractures, leaving out the left/right lateral wall fractures. The ECF features described were primarily from CT and MRI examinations, while osteoporotic ECF features were based on radiographs. The mean age of traumatic VF study subjects (42.1 years) was younger than that of comparison subjects of osteoporotic VF (72.5 years). Finally, the sample size of this study was modest (194 patients with 263 vertebral fractures), and a larger sample size collected from multiple centers may offer even fuller features of traumatic ECF/EPF.
Conclusion
The features of traumatic EPFs characterized in this study may help differentiate between osteoporotic EPFs and traumatic EPFs. Traumatic EPFs most commonly involve the superior endplate, with the most depressed point often located at segment-a2. In contrast, osteoporotic EPFs most commonly occur at segment-m. Traumatic EPFs can occasionally involve the posterior vertebral wall, particularly the bony wall surrounding the basivertebral vein, whereas osteoporotic ECFs generally do not involve the posterior vertebral wall. The extent of vertebral height loss in traumatic VFs is often mild, and the chance of having both superior and inferior EPFs increases with greater height loss. These distinguishing features can aid in the accurate diagnosis and management of vertebral fractures in clinical practice.
doi.org/10.1097/CM9.0000000000000919
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