1. Vertebral End Plate Fracture

2. 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

3. 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

4. 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

5. Pathophysiology

6. Mechanism Of Injury Traumatic – Heavy axial compression – Falling into standing or seated position – Heavy lifting Insidious – Repeated axial compression – Repetitive flexion/Extension

7. Associated Pathologies Degenerative Disc Disease Disc Herniation Osteoporosis Vertebral Fractures

8. 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

9. Objective Reduced flexion/extension Tenderness palpation soft tissue Tenderness and stiffness joint PA’s

10. Special Tests Heel drop from standing – In standing, go onto tip toes – Drop onto heels – Axial compression causes pain

11. Further Investigation Discography MRI X-ray Often missed on imaging

12. General Management Management of symptoms and pain relief Activity modification Relative Rest Nearly always conservative

13. 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

14. Plan B - Management Vertebroplasty – Only in very severe cases and in combination with a fracture of the vertebrae