Thoracic Spine Fracture

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Definition/Description

T9-T10 chance fracture from MVA

Most thoracic spine fractures occur in the lower thoracic spine, with 60% to 70% of thoraco-lumbar fractures occurring in the T11 to L2 region, which is bio-mechanically weak for stress. The majority of these fractures occur without spinal cord injury. 20 to 40% of the fractures are associated with neurological injuries.

Major (high-energy) trauma, is the most common cause of thoracic fractures such as falls from height or road traffic accidents. Minor trauma can also cause a thoracic spine fracture in individuals who have a condition associated with loss of bone mass such as osteoporosis.

Etiology

1. Osteoporosis is the most common precipitating factor for vertebral fracture. However, trauma, cancer, chemotherapy, infection, long term steroid use, hyperthyroidism, and radiation therapy are also known to weaken bones that can lead to compression fractures. The etiology of lower bone density can be related to smoking, alcohol abuse, lower levels of estrogen, anorexia, kidney disease, medications, proton pump inhibitors, and other medications. Risk factors include female gender, osteoporosis, osteopenia, age greater than 50, history of vertebral fractures, smoking, vitamin D deficiency, and prolonged use of corticosteroids.
2. Trauma is the second most common cause of spine fracture, and motor vehicle accidents are the number one cause of spinal cord injury.

Types of Fractures

There are four major types of thoracic spine fractures (based on the mechanism of injury) and a 5th rare type

1. Compression (wedge fractures) - Caused by axial compression alone or flexion forces, when the spine is bent forward or in side flexion at the moment of trauma. It is a stable fracture and patients rarely accompanied neurological deficits. The most common causes in younger patients are falls and motor vehicle accidents. In older patients the most common causes are minor incidents during normal activities of daily living secondary to osteoporosis or metabolic bone diseases.
   
2. Burst - Similar to compression fractures except that the entire vertebra is evenly crushed. It is a very severe fracture, accompanied with retro-pulsed bone fragments into spinal canal. Neurological injury and posterior column injury can occur more frequently. The common cause of this fracture is due to axial loading of the anterior spine such as from a fall, landing on the buttocks or lower extremities where the concentration of axial forces is to the thoracolumbar junction.
3. Flexion-distraction (seat belt injury/ Chance fracture) - Involves the separation (distraction) of the fractured vertebra. It occurs by primary distraction forces on the spine. The axis of rotation is located within or in front of the anterior vertebral body. 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 (seat belt injury). Often associated with abdominal trauma due to compression of the 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 - Found in combination with displacement of adjacent vertebrae. It is caused by various combinations of forces. It is very unstable and can cause a complete neurological deficit. Failure of all three spinal columns under compression, flexion, rotation, or shear forces. The most unstable of all thoracolumbar spine injuries, 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 people with physically intensive jobs causing shear forces on the vertebra, hyperflexed spine, or direct trauma.

Characteristics/Clinical Presentation

Presentation of symptomatic fractures includes:

• Chronic back pain in thoracic and/or lumbar region
• Slower gait
• Decreased thoracic and lumbar range of movement
• Impaired pulmonary function
• Increased kyphosis - especially in osteoporotic patients with compression fractures
• Neurological deficits due to narrowing of spinal canal - can occur as long as 1.5 years post injury

Prolonging of these symptoms leads to decreased physical function and performance of activities of daily living, and increased risk of disability.

Vertebral deformities are also associated with significantly increased risk of future fractures, including hip fractures.

Patients with non-compression fractures are usually involved in a multi-trauma, and will have various injuries and sources of pain. Clinicians must use their best judgment and employ clinical screening criteria to determine if the thoracic spine is involved.

Differential Diagnosis

Plain radiographs are historically the "gold standard" for detecting thoracolumbar fractures, although due to the organs and soft tissue in the thoracic region, fractures can be missed on radiographs. A CT scan is recommended to visualise thoracic fractures and an MRI to assess soft tissue damage. 

Multiple Myeloma and other cancers can present as thoracic pain, but will have additional red flag signs such as unexplained weight loss and fever.

Scheuermann Disease presents as exaggerated Thoracic Hyperkyphosis, anterior body extension and schmorl’s nodes; can be distinguished by vetebral body height parameters on radiograph. 

Examination

Screening for Fracture

Algorithms for screening patients with thoracic fractures and the need for imaging have been developed but are not fully validated.

Presence of one or more of the following 5 criteria in a patient with blunt multi-trauma is an indication for thoracolumbar imaging (Sn=0.99):

1. High Risk Mechanism of Injury (MOI):
   • Motor vehicle accident at speed >70 kph
   • Fall from height >3 m
   • Ejection from motor vehicle or motorcycle
   • Any injury outside of these criteria that could cause a thoracolumbar fracture
2. Painful Distracting Injury: painful torso/long-bone injury sufficient to distract the patient from noticing the pain of the thoracolumbar injury
3. New Neurological Signs or Back Pain/Tenderness with Clinical Findings Suspicious of a New Fracture:
   • Back pain
   • Back tenderness on palpation
   • Palpable step in vertebral palpation
   • Midline bruising
   • Neurological signs consistent with a spinal cord injury
4. Cognitive Impairment:
   • Glasgow Coma Scale (GCS) < 15
   • Abnormal mental state
   • Clinical intoxication
5. Known Cervical Spine Fracture: evidence of a new traumatic cervical spine fracture.

Other criteria for screening include:

1. Screening criteria for radiograph of blunt trauma patients with thoracolumbar injuries (Sn=1.00, Sp=0.039)
2. Complaints of thoracolumbar spine pain
   • Thoracolumbar spine tenderness
   • Decreased level of consciousness
   • Intoxication with alcohol or drugs
   • Neurologic deficit
   • Painful distracting injury
3. Three predictive variables for thoracic spine fracture based on a case control study (Sp=0.93):
   • Fall > 2m
   • Thoracic pain
   • Intoxication

Medical Management

Operative

Benefits of surgical treatment of thoracolumbar fractures compared to conservative management

• Avoiding an orthosis in the presence of multiple injuries and skin injuries
• Immediate mobilization
• Earlier rehabilitation
• Better restoration of sagittal alignment.

Negatives of surgical intervention

• Risks of surgery including the risks of general anesthetic.
• Conventional open surgical techniques may be accompanied by approach-related muscle injury, increased infection rates and higher blood loss.

There is no difference between operative and non-operative treatment regarding neurological recovery and long-term functional outcomes.

Indications for surgery

• Neurological involvement and/or progressive neurological deterioration
• >50% spinal canal compromise
• >50% anterior vertebral body height loss,
• >25° to 35° angle of kyphotic deformity
• Posterior ligament complex (PLC) compromise.

Surgical approaches can be anterior, posterior or a combination. Recently, minimally invasive techniques have been described in thoracolumbar fractures.

Non-Operative

Compression fractures, stable burst fractures and neurologically intact patients can typically be treated non-operatively:

• Bed rest/activity limitation ranging from days to weeks
• Bracing: 8 to 12 weeks in Jewett or Cruciform Anterior Spinal Hyperextension (CASH) 
• Casting: 8 to 12 weeks
• Pain medication
• Physical therapy

There is no consensus on the exact duration of treatment.

Preventative treatment for fractures related to osteoporosis include bisophosphonates, calcium, vitamin D and exercise.

There was found to be no significant long-term difference in pain, disability and return to work for non-neurologically involved patients who received surgery compared to those who received bracing or casting.  This indicates that the higher risk and cost of surgery may not be justified and that bracing/casting would be the preferred treatment in this patient population. Braces are a common component of both post-operative and non-operative thoracic fracture treatment protocols however there is no evidence to say that bracing is effective in the management of these fractures. .

Physical Therapy Management

• Management of vertebral fractures remains controversial ^,, and research is limited on identifying physical therapy intervention.
• Until recently, conservative management of fractures consisted of pain medications, rest and bracing to reduce spinal movements ^,,,.
• Rehabilitation programs must be designed specifically for the individual based on their physical abilities and impairments.
• With conservative treatment, the majority of fractures heal with a significant decrease in pain in 8-12 weeks. Significant declines in pain (5.9cm on VAS) are experienced 12-24 hours post-surgery . 
• Interventions depend largely on whether the patient chose surgery or conservative treatment.
• Interventions should always be prescribed and progressed based on patient tolerance.

Physical Therapy Exam

• Thorough history including MOI and previous spine fractures
• Neurological screen
• Assessment of patient's pain level and location
• Palpation of the thoracic spine
• Screen for thoracic fracture
• Identification of impairments in ROM, strength, flexibility

Physical Therapy Goals

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

Bennell et al. found that a multimodal treatment approach over a 10-week period was successful in reducing pain and improving function in patients who suffered from osteoporotic vertebral fractures .  However, because it was a multimodal approach the effectiveness of each treatment is unclear.

General Exercise Recommendations^, 

• A major concern is re-fracture within a year of the initial injury.
• Strengthening back-extensor muscles can help decrease the rate of refracture or prolong occurance of refracture ^,
• Improvement in reported pain levels and increased function in patients with back-extensor exercises.^,,,.
• Should begin strengthening back-extensor muscles as soon as they are physically able.
• When developing a plan of care, the therapist should consider the individual characteristics of a vertebral fracture and possible secondary limitations.

An example of a Physiotherapy and Home Exercise Program Adapted from: Bennell et al (2010). Within a pain-free range, progressed as tolerated:

Technique/Exercise	Dosage	Duration (weeks)	Image
Postural Taping - performed by physiotherapist Start from anterior aspect of each shoulder and go posteriorly + obliquely towards the opposite rib cage	worn full time	1
Soft Tissue Massage - performed by physiotherapist Stroking, circular frictions, petrissage to the erector spinae, rhomboids, and upper traps with patient prone	5 minutes	1 - 10
Passive Accessory Postero-anterior Vertebral Mobilisation - performed by physiotherapist Grade 2-3 mobilisations from T1 down to 2 levels below the most painful vertebral region with patient prone	5 mobilisations at each central level x 2 reps	1 - 10
Supine Lying Over Rolled Up Towel Towel is placed lengthwise along the back to facilitate thoracic extension	5 - 10 minutes	1 (daily)
Erect Sitting with Transversus Abdominus (TA) Stabilisation Forward sitting on chair (no back rest) with chin retraction, scapular retraction, and TA contraction	10 second hold x 5 reps	1 - 10 (daily)
Elbows Back in Sitting Hands placed behind the head with elbows pointing out to the side - press elbows back using scapular retraction	5 second hold x 5 reps	1 - 10 (daily)
Trunk Mobility in Sitting With hands on shoulders gently rotate to both directions and laterally flex to each side	5 reps in each direction	1 - 10 (daily)	Trunk mobility in sitting - extension
Head to wall in standing Stand with back and heels against the wall and a rolled up towel behind the head - retract chin	10 second hold x 5 reps	1 -1 0 (daily)
Standing corner stretch Stand facing a corner and place both hands chest height on each side of the wall - move in closer to stretch anterior chest	10 - 30 second hold x 3 reps	2 - 10 (daily)
Walking hands up wall in standing Stand facing the wall and walk hands up until arms are up-stretched - then hold hands off wall	5 second hold x 5 reps	3 - 10 (daily)
Shoulder flexion in supine Arms are outstretched holding onto a cane/towel - then take arms over head and hold at end range	10 second hold x 5 reps	3 - 10 (daily)
Standing wall push ups Stand facing the wall with arms in front at shoulder height - keeping the body straight bend and straighten elbows	8 - 10 reps x 2 sets	1 - 10 (3x/week)	Standing wall pushups
Seated row with dumbbells Sitting upright - pull hands up towards chest by bending elbows and then lower	8 - 10 reps x 2 sets	1 - 10 (3x/week)
Seated overhead dumbbell press Elbows are bent and out to the side - press dumbbells straight up until arms are extended overhead	8 - 10 reps x 2 sets	3 - 10 (3x/week)
Bridging in supine  Knees bent and feet flat on ground - push through feet to lift back and pelvis off ground	5 - 10 second hold x 5 reps	1 - 2 (3x/week)	Bridge in supine
Hip extension in prone Raise one leg off the ground and then the other	8 - 10 reps x 2 sets	3 - 10 (3x/week)	Hip extension in prone
Half squats - progress to holding dumbbells  Stand in front of chair and squat down to touch chair with buttocks - then stand up	8 - 10 reps x 2 sets	1 - 2 (3x/week)
Step ups - progress to holding dumbbells Step up and down a 10 cm step - alternate legs	8 - 10 reps x 2 sets	3 - 10 (3x/week)
Scapular retraction with theraband in sitting  Hold theraband in both hands with elbows tucked into sides - then perform wrist extension, forearm supination, shoulder external rotation, and scapular retraction	8 - 10 reps x 2 sets	1 - 10 (3x/week)	Scapular retraction with theraband in sitting + chin tuck + TA hold
Four-point kneeling with transversus abdominus Push into floor with hands, knees and feet - then draw navel up and in	5 second hold x 8-10 reps x 2 sets	2 (3x/week)
Four point kneeling with one arm and leg lift Perform as above - then lift one arm off ground and progress to lifting and extending the leg on the opposite side off ground at same time	8 - 10 reps x 2 sets	3 - 10 (3x/week)	4 point kneeling + TA hold
Prone lying with arm elevation With arms at shoulder height and bent at elbows - perform scapular retraction and then lift arms off floor	5 - 10 second hold x 5 reps	2 - 3 (3x/week)
Prone trunk extension Lift head and shoulders off floor while maintaining chin retraction	5 - 10 second hold x 5 reps	4 - 10 (3x/week)

Complications to Consider ^,,

• Cardiorespiratory compromise
• Additional Fractures
• Refractures
• Osteoporosis
• Prolonged Pain
• Limited Range of Motion
• Limited Strength
• Neurological Compromise
• Postural Dysfunction
• General Deconditioning
• Gait/Ambulation Abnormalities
• Loss of Balance

Clinical Bottom Line

• There is a lack of high-quality evidence for the management of thoracic spine fractures.
• Physical therapists should be familiar with screening for thoracic fractures and take an impairment-based approach when treating post-operative or non-operative patients.

Resources

1. Thoraco-lumbar spine fractures. Corenman DS
2. Fracture, thoracic spine (without spinal cord injury). MD Guidelines.
3. Thoracic spine fractures and dislocation. Medscape Reference.