Thoracic Spine Fractures

Thoracic spine fractures are fractures in the thoracic area of spinal vertebrae. Spine fractures can occur as a result of motor vehicle accidents, falls, sports, acts of violence, and miscellaneous activities. Results can be devastating, often resulting in permanent neurologic injury.

Twelve thoracic vertebrae exist T1-T12. The vertebral bodies are wedge-shaped, larger posteriorly than anteriorly. The kyphosis of the thoracic spine results in a center of gravity anterior to the apical T7 vertebrae, resulting in compression anteriorly and tension posteriorly in the resting state.

Most thoracic spine fractures occur in the lower thoracic spine, with 60% to 70% of thoracolumbar fractures occurring in the T11 to L2 region, which is biomechanically weak for stress.

Thoracic spine fractures, especially those that occur as a result of traumatic, high-energy accidents, can be extremely devastating. They often result in permanent neurological injury. In all injuries involving the spinal column, neurological dysfunction occurs up to 25% of the time, no matter which part of the spine is affected. When the thoracic spine is injured, the neurological deficit occurs up to 20% of the time.

Very few people are able to recover any purposeful motor function when a complete neurological injury occurs. When a thoracic spine fracture occurs in addition to neurological injury, long-term survival is threatened. People younger than 29 years old at the time of this type of injury have a 86% 10-year survival rate, whereas people who are older than age 29 with the same injury have only a 50% 10-year survival rate.

Thoracic spine fractures have been treated for many years. The earliest treatments included manipulation and closed treatment. Early in the 20th century typical treatment included immobilizing the spine in hyperextension.

Reasons

1. Compression. Failure of the anterior column of the spine due to thoracic spine fractures, mainly in flexion. The most common causes of thoracic spine fractures in younger patients are falls and motor vehicle accidents. The most common causes in older patients are minor incidents during normal activities of daily living secondary to osteoporosis or metabolic bone diseases. Associated neurological complications are rare.
2. Burst. Thoracic spine fractures of the anterior and middle columns of the spine due to axial loadings such as from a fall landing on the buttocks or lower extremities. The concentration of axial forces is at the thoracolumbar junction.
3. Flexion-distraction (seat belt injury). Failures of the posterior and middle columns of the spine under tension usually from a trauma involving sudden upper body forward flexion while the lower body remains stationary. Often associated with abdominal trauma due to compression of abdominal cavity during injury. The anterior column may be mildly affected, but the annulus fibrosis and anterior longitudinal ligament are intact, preventing dislocation or subluxation. A gap between the spinous processes is often present upon palpation.
4. Fracture-dislocation. Failure of all three spinal columns under compression, flexion, rotation, or shear forces. The most unstable of all thoracic spine fractures, they are highly associated with neurological deficits. They can be caused by a severe flexion force similar to that of a seat belt injury, or an object falling across the back.
5. Clay-Shoveler’s Fracture. Rare, fatigue fracture of the upper thoracic spinous process. Seen in powerlifters or in patients that are involved in hard labor causing shear forces on the vertebra, hyper-flexed spine, or direct trauma

Risk Factors

Individuals at greatest risk for thoracic spine fractures are those involved in motor vehicle accidents, falls, sports injuries, and acts of violence, including gunshot wounds. Postmenopausal women with Osteoporosis are at increased risk of vertebral fracture. The risk is increased generally in athletes, individuals whose work or recreation places them at risk of falling from a height, and those with osteoporosis or other chronic diseases that may be associated with bone loss (e.g. metastatic bone lesion, tuberculosis, osteoarthritis).

• Maturing: As we age, our bones normally lose some thickness and wind up weaker, so the hazard for injury increases.
• Females: Bone loss is more typical in women, particularly post-menopausal women. Women lose bone mass at a quickened rate in the initial 5-7 years after menopause. Amid menopause, ladies encounter a drop in estrogen, which is a female sex hormone that helps protect bones. At the point when estrogen levels diminish, bones may lose thickness and wind up plainly inclined to fractures.
• Having a previous spinal injury: It sounds self-evident, however having one spinal fracture extraordinarily builds your odds of having another. After some time, various fractures can cause lost in tallness, and you may see your spine beginning to hunch forward. Your specialist may allude to this forward bend as a condition called kyphosis.
• Unhealthy lifestyle: Smoking, drinking, and lack of exercise would all be able to influence sound bone thickness. Smoking and overwhelming alcohol consumption influence your body’s capacity to assimilate calcium. Carrying on with a stationary way of life makes bones frail, making them inclined to bone loss.

Complications

1. Neurologic deficit including the complete deficit, or paraplegia, a hunchback (kyphosis), disc herniations, and bone healing with faulty alignment (malunion).
2. Individuals with flexion-distraction fractures also may have associated intra-abdominal injuries in up to 50% of cases (Goodrich, “Chance Fracture”)
3. Complications of surgical treatment may include allergic reaction to anesthesia, deep vein thrombosis, pulmonary embolism, urinary tract infection, surgical wound infection, and dural tears occurring during the procedure.

Symptoms

Spinal fracture symptoms may fluctuate depending on the location and severity of the damage. They incorporate back or neck pain, numbness, tingling, muscle spasms, weakness, internal changes, and loss of motion. Paralysis is losing control of the arms or legs and may demonstrate spinal cord damage. Not all fractures cause spinal cord damage and once in a while is the spinal cord totally separated.

45% of most spinal fracture symptoms occur due to motor vehicle accidents, 20% are due to falls, 15% are due to sports accidents, 15% are due to acts of violence, and 5% of spinal fracture symptoms are caused by miscellaneous activities.

Spinal fracture symptoms due to acts of violence occur more frequently in urban areas. Spinal fracture symptoms occur more frequently in men; in fact, the ratio (male-to-female) is approximately 4:1

Majority of vertebral fractures are asymptomatic. They are sometimes detected via radiograph when a patient is being screened for another injury.

Presentation of spinal fracture symptoms includes:

• Chronic back pain in thoracic and/or lumbar region
• Slower gait
• Decreased range of motion
• Impaired pulmonary function
• Increased kyphosis especially in osteoporotic patients with compression fractures
• Neurological deficits due to narrowing of the spinal canal

Spinal fracture symptoms may be seen in patients of any age, but in elderly patients, the frequency and severity of thoracic spinal fractures are increased. Fractures of the thoracic spine can occur whenever the spinal column is subjected to forces that exceed its strength and stability. Common causes of thoracic spinal fractures include falling from a height, motor vehicle accidents, violent weather, military and civilian blast injury, and penetrating trauma. Less common injury patterns may be related to sports injuries. Elderly patients present an increased challenge because thoracic spinal fracture symptoms may occur following relatively minor falls. After aortic rupture, severe thoracic spinal cord injuries represent the most serious long-term morbidities resulting from thoracic trauma.

Diagnostic Procedures

History

Recent trauma may be reported. The patient may report tenderness over the area of the fracture and paralysis or numbness and tingling in the legs as spinal fracture symptoms. Movement of the back causes pain. The individual should be specifically questioned as to previous spine injury, prior neurologic deficit, the mechanism of the current injury, and the individual’s general state of health. If the individual is unable to respond, an attempt to interview family members or observers may be made.

Physical exam

The back may have cuts (abrasions), bruising, and deformity. Shifting of the vertebral bodies may be detected by touching with the hands (palpation). The individual may have chest or abdominal trauma (e.g., shoulder harness or lap seat belt markings). The physician may determine neurologic status by testing reflexes and evaluating response to touch and range of motion of extremities. The unconscious or intoxicated individual is difficult to assess in terms of pain and motor sensory function. The physician will assess for the presence of other injuries, including possible head injury and fractures of the extremities.

Imaging

The goals of diagnostic imaging in patients who have sustained thoracic spinal trauma are to correctly identify spinal fracture symptoms, to identify associated injuries to structures that are related to the thoracic spine, to identify injuries to the spinal cord and nerve roots, to aid in surgical planning, and to judge the stability of postoperative fixation.

• X-rays (anteroposterior and lateral views) will be taken initially. Multidetector CT scans with intravenous contrast enhancement are indicated in most patients to exclude intrathoracic vascular injury. In patients who have sustained blunt trauma, multidetector CT has been proposed as a screening study for thoracolumbar fracture.
• MRI of the thoracic spine should be reserved for patients with neurologic deficits or patients with spinal canal compromise who are unable to provide a full neurologic history. MRI of the thoracic region provides important information concerning the spinal cord and the dural structures. Bone densitometry may be ordered to evaluate the presence and extent of osteoporosis. A biopsy and histologic exam may be done if malignancy is suspected.
• CT scans show bones as well as the soft tissues including the nerves. If your doctor suspects that you might have neurological issues due to the spinal fracture symptoms, your doctor will advise you to get CT scan to see if there’s something pressing on the nerve and spinal cord due to the fracture. In addition to that, another benefit of a CT scan is that it can help look at the cross-sections of your spine. Also, by using different views of the CT scan, your doctor will be able to look at your fracture from multiple angles.

Treatment of Compression Fractures of Thoracic Spine

The treatment of compression fractures of thoracic spine’s goals includes preventing deformity, instability, and neurologic deficit.

Non-Surgical Treatment

Nonsurgical treatment of compression fractures of the thoracic spine is used to treat most stable fractures in the absence of neurologic deficit, including most compression fractures and some burst fractures. It begins with pain management and treatment of concomitant injuries. Nonsurgical treatment of compression fractures of thoracic spine involves wearing a hyperextension orthosis, cast, or brace for 4 to 6 weeks. Longer periods of immobilization may be needed for individuals with more severe injuries and for those with osteoporosis. Bed rest for 1 to 3 weeks is common. If the fracture has been caused by Osteoporosis, treatment of compression fractures of thoracic spine may include medications to enhance bone deposition.

Compression fractures of the thoracic spine that remain painful after nonsurgical treatment of compression fractures of thoracic spine (i.e., bracing, bed rest, and medication) may be managed with Vertebroplasty or Kyphoplasty, which are minimally invasive procedures that correct deformity associated with vertebral fractures and help relieve back pain in 90% of individuals (Lane). In Vertebroplasty, bone cement is injected into the collapsed vertebral body to strengthen the spinal bones and prevent further fracture and deformity. In Kyphoplasty, which is performed in individuals whose fracture is a result of Osteoporosis, the height and shape of the vertebrae are restored by inserting a balloon, and bone cement is then injected into the cavity created by the balloon in order to stabilize the fracture. These procedures are performed with visual guidance provided by fluoroscopic imaging.

Physical therapy management

Rehabilitation programs must be designed specifically for the individual based on their physical abilities and impairments. With conservative treatment of compression fractures of the thoracic spine, the majority of fractures heal with the significant decrease in pain in 8-12 weeks. Significant declines in pain are experienced 12-24 hours post-surgery. Therefore, treatment of compression fractures of thoracic spine depends largely on whether the patient chose surgery or conservative treatment. Interventions should always be prescribed and progressed based on patient tolerance.

Physical therapy goals:

• Reduce pain
• Improve posture
• Improve thoracic mobility
• Strengthen torso
• Improve trunk control
• Provide education
• Lower extremity strengthening

Surgical

The indications for surgery for thoracic spine fracture include excessive deformity, the presence of other injuries, and the presence of or threat of neurologic deficit. Individuals with unstable fractures, including severe compression fractures, fracture-dislocations, flexion-distraction fractures with ligamentous injuries, and most burst fractures, may be treated surgically. The goals of surgical treatment of compression fractures of the thoracic spine are to realign the spine, stabilize the spine, and prevent (or improve) neurologic deficit. The treatment of compression fractures of thoracic spine treatment method depends on the severity of the fracture, overall health of the individual, age of the individual, and surgeon’s preference.

Spinal surgery is performed as an open procedure using general anesthesia. All surgical methods involve fusion (arthrodesis) of adjacent vertebrae by using metal plates, rods, wires, and/or screws to stabilize the spine. In fracture-dislocations, the dislocation will first be reduced. An approach from the front (anterior) may be required to remove (corpectomy) and replace a vertebral body with a bone graft or instrumentation. Following surgery, bracing may be used for nonsurgical treatment of compression fractures of the thoracic spine. Corticosteroids may help relieve pain and swelling in the individual with temporary swelling near the spinal cord. Analgesics may be prescribed as needed.

Video-assisted thoracoscopic surgery (VATS) is a minimally invasive procedure being performed for correcting spinal deformity in thoracic spine fractures that may require anterior bone grafting and stabilization. The benefits of the procedure are not yet clearly demonstrated in the literature, but research continues since risks and complications associated with open surgery can be avoided by using this method.

Prevention

Averting spinal fractures caused by injury sounds like an unimaginable task. Is it accurate to say that you should counteract car crashes or wounds? While you can’t control what happens on a few occasions, you can avoid any potential risk that should help ensure you.

Driving

Continuously wear your safety belt when you’re in an automobile. In case you are in an accident, the safety belt and the airbag are intended to secure you, particularly your head, neck, and chest. To get the full security from the safety belt and the airbag, adjust your seat so that there are 10 inches between you and the airbag so that you’ll have enough space without causing other harm.

Falls

In the event that your bones have been weakened by Osteoporosis or another condition like cancer, you may break a bone from even a little fall. Hence, you should “fall-proof” your home by:

• secure floor rugs that you could slip on
• ensure pathways and passageways are dry and free of clutter
• use a non-slip rubber mat in the shower and around the toilet area
• ensuring stairs are sufficiently bright to avoid any accidents