Received: 16 January 2003

Revised: 22 May 2003

Accepted: 1 September 2003
Published online: 7 October 2003
Springer-Verlag 2003
Abstract The purpose of the present
study was to assess incidence, frac-
ture type, and location of spine frac-
tures due to falls. All emergency room
CT requests during a time period of
26 months were reviewed retrospec-
tively. Patients who had fallen or
jumped and were initially examined
with multidetector CT (MDCT) were
included. The MDCT studies were
evaluated by two radiologists for
trauma location, fracture type, and
multiple level involvement. A total of
237 patients (184 males, 53 female,
age range 1686 years, mean age
42 years) met the inclusion criteria.
A total of 203 vertebral fractures
were seen in 127 patients. Burst frac-
ture (n=78) was the most frequent
type of trauma, usually located in the
thoracolumbar junction (50%). Also,
compression fracture (n=52) was
most common in the thoracolumbar
junction (39%). Posterior column
fracture (n=52) was most frequently
detected in the cervical spine (40%).
Multiple-level spine fractures were
seen in 41 (32%) of the injured
patients, of which 12 (29%) had
fractures at noncontinuous levels.
With increasing height the overall
incidence of fractures increased, and
burst fractures and multiple level
spine fractures became more fre-
quent. Age had no effect on fracture
type or location. Spine fractures due
to falls are common. Burst fracture is
the most common fracture type and
most frequently seen in the thoraco-
lumbar junction. Multiple-level frac-
tures were seen in 32% of the cases,
of which 29% were seen at noncon-
tinuous levels. Serious spine frac-
tures are seen in all falling height and
age groups.
Keywords Spine fracture Computed
tomography Trauma Emergency
radiology Burst fracture
Compression fracture
Eur Radiol (2004) 14:618624
DOI 10.1007/s00330-003-2090-6 MUS CULOS KELETAL
Frank V. Bensch
Martti J. Kiuru
Mika P. Koivikko
Seppo K. Koskinen
Spine fractures in falling accidents:
analysis of multidetector CT findings
Introduction
Spine injuries are potentially dangerous and may cause
permanent damage or even death [1, 2]. They are fre-
quently seen in level-one trauma center patients with se-
rious accidents such as traffic, falling, and sports acci-
dents [2, 3, 4, 5, 6]. The annual incidence of spinal cord
injuries is approximately 1540 per million with a male
predominance (8085%), with two-thirds of spinal cord
injuries occurring in patients less than 30 years of age
[4]. More than 50% of patients with a spinal cord injury
die prior to hospitalization [4]. The higher the level of
injury in the cervical spine, the higher is the pre- and in-
hospital mortality. The diagnosis of spine fractures is
based on clinical examination and radiological findings
[3, 7]. In emergency imaging, CT has replaced conven-
tional radiography as the primary imaging modality of
severely traumatized patients due to its higher diagnostic
accuracy and cost-effectiveness [2, 8, 9, 10], although
conventional radiography has been reported to be suffi-
cient in conscious, non-intoxicated patients without clin-
ical symptoms of spinal injury [3].
In level-one trauma centers CT is routinely used for
screening seriously injured patients [2, 11, 12], although
F. V. Bensch M. J. Kiuru
M. P. Koivikko S. K. Koskinen (

)
Department of Radiology,
Tl Trauma Center,
Helsinki University Central Hospital,
Topeliuksenkatu 5, 00029 Helsinki,
Finland
e-mail: seppo.koskinen@hus.fi
Tel.: +35-89-47161307
Fax: +35-89-47187348
619
conventional radiography has been reported sufficient
in conscious, non-intoxicated patients without clinical
symptoms of spinal injury [3]. Due to technical break-
throughs, multidetector CT (MDCT) is faster and has
better temporal, spatial, and contrast resolution due to
smaller isotropic voxels compared with conventional
helical CT [13]. Also, the two-dimensional (2D) refor-
mats (multiplanar reconstructions, MPR) and three-
dimensional (3D) surface renderings, although 3D sur-
face renderings are rarely used for interpretation because
they are time-consuming and provide only occasionally
additional information [14], are of excellent quality, and
due to the fast image processing, they can be made
almost on-line; therefore, where available, MDCT has
become the imaging method of choice in severe emer-
gency trauma.
Due to more effective and successful first aid during
the golden hour on the trauma site and during the
transportation to hospital, the number of more seriously
injured trauma patients surviving at least until admission
to the emergency room has increased during the past
60 years, being almost three times as high in the 1980s
(50 per million) than in the 1940s (17 per million) [4];
therefore, to be able to detect an injury and recommend
the appropriate imaging modality, it is imperative for the
radiologist-on-call to know the most common locations
and injury patterns of spine fractures in different types of
trauma, such as falling accidents. The purpose of the
present study was to assess the acute phase MDCT spine
findings in patients referred to a level-one trauma center
due to a falling accident.
Materials and methods
This retrospective study took place in Tl Hospital Trauma
Center, Helsinki, Finland. It is the only level-one trauma center for
a population of 1.4 million people. Also, the most difficult ortho-
pedic and neurosurgical trauma patients are submitted to this hos-
pital from other parts of Finland.
Using picture archiving and communications system (PACS),
we retrieved all emergency room CT requests since the installation
of the MDCT in August 2000 to the end of September 2002. A to-
tal of 4812 MDCT examinations were performed during these
26 months by the request of the emergency room physicians. All
patients with a falling accident fulfilling the emergency room tri-
age criteria and whose spine was initially examined with MDCT
were included in this study. Pediatric patients, usually under the
age of 16 years, were not included as they are generally taken to
the Childrens Hospital.
All patients underwent routine cervical and body MDCT on a
four-section multi-slice scanner (LightSpeed QX/i, GE Medical
Systems, Milwaukee, Wis.). For the cervical spine, the high-reso-
lution scanning parameters were as follows: 41.25-mm collima-
tion; gantry rotation time 1.0 s; pitch 3; table feed 3.75 mm;
120/140 kV (upper/lower part of the c-spine); 280/330 mA; and
approximate total exposure time 35 s. In sagittal and coronal MPR
slice thickness was 1.5 mm and reconstruction increment 1.5 mm.
Routine body MDCT with intravenous contrast agent was as fol-
lows: 42.5 mm collimation; gantry rotation time 0.8 s; pitch 6;
table feed 15 mm; 140 kV; 280/330 mA (thorax/abdomen); and
approximate total exposure time 30 s. Also, MPR of the spine was
done in sagittal and coronal planes routinely with 2.5-mm slice
thickness and 2.5-mm reconstruction increment.
Two radiologists interpreted MDCT studies by consensus. The
studies were evaluated by trauma location, fracture type, and wheth-
er the fractures were at multiple levels. The spine was divided into
four functional units: (a) C0 to Th1 (cervical spine); (b) Th2 to
Th11 (thoracic spine); (c) Th12 to L1 (thoracolumbar junction); and
(d) L2 to S1 (lumbar spine). The fracture types were also divided
into four categories: (a) burst fracture [15]; (b) compression fracture
[15]; (c) posterior column fracture [15]; and (d) other fractures.
Falling height and whether the subject had jumped or accidentally
fallen was retrieved from each patients file.
Fig. 1a, b Distribution of fractures in a the cervical spine and
b the thoracolumbar spine. The numbers next to the vertebral bod-
ies represent the absolute number of fractures
620
Results
We found 237 patients (184 males, 78%; 53 females,
22%; age range 1686 years, mean age 42 years) who
met the inclusion criteria. A total of 211 patients (89%)
had fallen accidentally, 19 (8%) had jumped, and in
7 cases (3%) the circumstances were unclear. A total of
203 vertebral fractures (Fig. 1) were seen in 127 patients
(54%), of which 71 (56%) required surgical treatment.
Multiple-level spine fractures were seen in 41 patients
(32%), of which 22 (54%) required surgical treatment. In
12 of the 41 patients (29%) the fractures were seen at
noncontinuous levels. In 110 patients (46%) the initial
MDCT of the spine was normal.
Burst fracture (n=78, 38%; Fig. 2) was the most com-
mon fracture type and was most frequently seen in the
Fig. 2a, b Burst fracture of L1
in a 40-year-old man. a Axial
and b sagittal view with typical
retropulsed fragment. Anterior
and middle columns are frac-
tured, the posterior column
remains intact
Fig. 3ac Compression frac-
ture of Th11 in a 31-year-old
man. a Axial view shows the
left anterior compression with
fracture lines (arrowheads).
b Sagittal view. The anterior
column is fractured, resulting
in a wedge-shaped vertebral
body. c Coronal view reveals
lateral compression (arrow)
621
thoracolumbar junction (n=39, 50%), whereas only 10%
(n=8) of burst fractures were seen in the cervical spine
(Table 1). Seventy-one (56%) of the 127 injured patients
had one or more burst fractures.
Compression fracture (n=52, 26%; Fig. 3) was also
most commonly seen in the thoracolumbar junction
(n=20, 39%), and least commonly in the cervical spine
(n=1, 2%). Posterior column fracture (n=52, 26%;
Fig. 4), on the other hand, was most frequently detected
in the cervical spine (n=21, 40%), and was least common
in the thoracolumbar junction (n=2, 4%; Table 1).
Other fractures (n=21, 10%) occurred almost exclu-
sively in the cervical spine (n=19, 91%); ten fracture dis-
locations (48%), one extension teardrop fracture (5%),
one type-II odontoid process fracture (5%), one atlanto-
occipital dissociation (5%), one isolated anterior longitu-
dinal ligament rupture (5%), fracture of C1 lateral mass
in 2 patients (10%) and three bamboo spine fractures
(14%) in 2 patients with ankylosing spondylitis. In addi-
tion, there was one Chance fracture (5%) in Th11, and
one linear fracture (sagittal split; 5%) in L2 (Table 1).
Nineteen (90%) of the 21 other fractures were consid-
ered unstable.
The mean falling height (6.2 m) of patients who had
jumped was higher than in patients who had accidentally
fallen (3.7 m). Spine fractures, however, did not appear
to occur more frequently. There seemed to be no differ-
ence in fracture type or location between patients who
had jumped or fallen. The limited number of patients
who had jumped, however, does not allow statistical
comparison.
With increasing height the overall incidence of frac-
tures increased (p=0.0182, confidential interval (CI)=
5.2120.15, simple linear regression) and burst fractures
became more frequent (Table 2). In contrast, posterior
column and other fractures decreased, whereas the pro-
portion of compression fractures was constant. As the
falling height increased, the proportion of thoracic spine
fractures also increased (Table 2). This tendency was not
observed in the thoracolumbar junction and lumbar spine
fractures. The cervical fractures appeared to become less
frequent as the falling height increased, and the propor-
tion of normal cervical examinations increased. Multi-
ple-level spine fractures occurred more frequently with
increasing height (Table 2).
The ratio between patients with and without spine frac-
tures seemed to be neither dependent on height nor on age
(Table 2, 3). Falling height was reciprocally proportional
to age, but the incidence of spine fractures did not de-
crease with age (p=0.0328, CI=197.23 to 16.51, simple
linear regression; Table 3). The proportion of posterior
column fractures increased with age, but burst and com-
pression fractures as well as the other fracture types and
multiple-level fractures occurred independently of age
(Table 3). Also, age had no effect on the fracture location,
type, or on the amount of normal examinations (Table 3).
Fig. 4a, b Isolated fracture of
the spinous process of CII in a
50-year-old man. a Axial and
b sagittal views demonstrate
the fracture line (arrows)
Table 1 Fracture type by frac-
ture location
Trauma level Fracture type
Burst Compression Posterior column Other Total
C0 to Th1 8 1 21 19 49
Th2 to Th11 13 18 14 1 46
Th12 to L1 39 20 2 0 61
L2 to S1 18 13 15 1 47
Total 78 52 52 21 203
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Discussion
Severe falling accidents are relatively common. During
the 26-month period covered by this study, a total of 237
patients were taken initially to our hospital after falling
accidents, which means such an accident every third day
on average. In our hospital, if a patient has had a falling
accident, a whole-body MDCT including cervical spine
is requested; therefore, it is justifiable to say that our ma-
terial gives a reliable and representative picture of adult
spine fractures in falling accidents. The radiation dose
the patient is exposed to is considered acceptable com-
pared with the possible extreme consequences of a
missed spinal injury [2].
To our knowledge, no studies concerning fracture-
type incidences and patterns in falling accidents have
been published previously. A limitation of the present
study is the small number of cases in some of the sub-
groups, which makes statistical analysis impossible.
Spinal fractures have been classified according to
Denis three-column theory [15]. Other approaches, such
as Magerl et al.s, for example [16], could not have been
utilized in the present study due to the studys retrospec-
tive nature. Magerl et al.s. classification [16] provides
excellent information in the clinical evaluation of spinal
fractures, as it is based on main injury mechanism and
pathomorphological uniformity, in consideration of prog-
nostic aspects regarding healing potential. This, how-
ever, is data which is not always available in a retro-
spective study. Furthermore, the subgroups are too nu-
merous for the purpose of this study. Also, due to the
retrospective nature of this study, the well-known clini-
cal risk factors for spinal fractures [2] could not be
reliably determined.
The most common spine fracture was the burst frac-
ture, located most frequently in the thoracolumbar junc-
tion. This is in agreement with previous studies [15].
Compression as well as posterior column fractures were
less frequently seen than the more serious burst frac-
tures. The most common location for compression frac-
tures was the same as for burst fractures, i.e., the thora-
columbar junction; therefore, as conventional radiogra-
phy has only a limited capacity to reveal all details of a
more complex injury, CT should be used to differentiate
these two fracture types, as the correct diagnosis might
be crucial for the outcome.
In the present study, the incidence of burst and com-
pression fractures increased with height, which may indi-
cate the injury mechanism. From lower heights the pa-
tients probably hit the ground head first, resulting in
hyperflexion or extension injury due to the high mobility
of the cervical spine [17], whereas falling from greater
heights the part of the body that absorbs the first impact
is a matter of chance. This could, at least partly, explain
the increase of burst and compression fracture incidence
with height.
Posterior column fractures were most common in the
cervical spine. These fractures are mostly hyperflexion
injuries [18]. In our study, the proportion of the cervical
fractures decreased with height, probably due to the fact
that increasing falling height results in more severe head
and neck injuries if a subject hits the ground head first,
causing a higher pre-hospitalization mortality. This
might be why there were fewer upper cervical spine inju-
ries in our study than in the NEXUS (National Emergen-
cy X-Radiography Utilization Study) cervical spine inju-
ry cohort [7]. It is not known how many of the acciden-
tally fallen patients had in fact jumped on purpose, but
those who had intentionally jumped seemed to have had
a greater falling height.
Falling height was reciprocally proportional to age;
however, that does not seem to affect the incidence of
spine fractures, which did not decrease with increasing
age. This might be because of the more rigid and weak-
ened bone structure causing a lesser ability to absorb and
withstand impact forces, which makes the occurrence of
a fracture more likely regardless of the falling height
[19].
The ratio of all MDCT examinations with pathologi-
cal findings to those without pathological findings was
approximately constant regardless of falling height or
age. Only the amount of normal cervical MDCT examin-
ations increased with falling height. This is because in
our hospital, if patients have had high-energy accidents,
cervical MDCT is routinely performed with head and
body MDCT to rule out cervical fractures. In our hospi-
tal, as in many other major trauma centers, conventional
lateral cervical radiography is no longer included in the
trauma series of seriously traumatized patients [8, 20].
The low number of normal thoracolumbar MDCT exam-
inations is due to the fact that this region is already
scanned in the body MDCT.
Multiple-level spine fractures were seen in 41 (32%)
patients, of which in 12 patients (29%) the fractures
were at noncontinuous levels. This should be kept in
mind when scanning the patient [21]. Radiographs are of
limited sensitivity, and also, if a too limited scan area is
used in CT, these fractures can be easily missed. When
using the so-called retro-reconstruction technique in
MDCT, where the reformats are, for example, calculated
from the imaging data acquired in body MDCT scan, this
pitfall can be avoided.
Multidetector CT is fast, has fewer motion artifacts,
reduced partial-volume effects, decreased image noise,
better i.v. contrast material opacification of blood ves-
sels, and increased enhancement of parenchymal organs,
high-quality multiplanar reformation (MPR), and isotro-
pic viewing, all of which increases the diagnostic power
of this imaging modality, benefiting the emergency trau-
ma patients [8, 11, 13]. Although replacing the four-sec-
tion MDCT systems with 8-, 16-, or even 32-section
MDCT systems should speed up the imaging process and
623
624
decrease artifacts, the occupied scanner room time per
patient will not significantly decrease in the future, as
the actual scanning time takes up only a minor part of
the occupied scanner room time. The greater part of the
occupied scanner room time is spent with patient prepa-
ration, injector setup, and the programming of the scan-
ner. This is especially the case in seriously injured trau-
ma patients, whose vital signs are continuously being
monitored by emergency room staff and, if necessary,
life-saving therapies are administered while the patient is
in the CT scanner room. Since sagittal and coronal refor-
mations are considered standard in spine CT [8], they are
also routinely included in our institution. In some cases
of spine fracture, 3D surface renderings may give addi-
tional information in the diagnostic interpretation [14].
On the other hand, MDCT technique produces a large
number of images, and, therefore, in emergency trauma
cases at our hospital, the radiologist-on-call reads the CT
images on-line by the scanner console, and the surgeon
is given an immediate preliminary report, followed by a
written report within the next 30 min.
Conclusion
Spine fractures due to falling accidents are common.
Burst fracture is the most common fracture type and
is most frequently seen in the thoracolumbar junction.
Multiple-level fractures were seen in 32% of the cases,
of which 29% were located at noncontinuous levels.
Serious spine fractures were seen in all falling height and
age groups.
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