Thoracic Spine Fracture

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Databases Searched:  CINHAL plus Full Text

Key Words:  thoracic, fracture, thoracolumbar, diagnosis, management, treatment, compression, burst

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Definition/Description

According to the Denis classification system for spinal injury, there are four types of vertebral fracture^Kandabarow:
Compression – failure of the anterior column of the spine due to compression forces, mainly in flexion. The most common causes of compression fracture 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.
Burst – fracture of the anterior and middle columns of the spine due to axial loading. The concentration of axial forces is to the thoracolumbar junction.
Flexion-distraction – failures of the posterior and middle columns of the spine under tension. The anterior column may be mildly affected, but the annulus fibrosis and anterior longitudinal ligament are intact, preventing dislocation or subluxation.
Fracture-dislocation – failure of all three spinal columns under compression, flexion, rotation, or shear forces. The most instable of all thoracolumbar spine injuries, they are highly associated with neurological deficits. Subsets include:
Flexion-rotation: the spine is dislocated or subluxed in the lateral and AP planes, fracturing the superior articular process on one side of the level below the dislocation
Flexion-distraction: the anterior spinal column is fractured due to a severe flexion force (similar to seat belt injury), and the annulus fibrosis is torn, allowing subluxation or dislocation.
Shear: all three spinal columns are fractured, usually in the AP plane, due to an object falling across the back.

Minor fractures include those of the spinous processes, transverse processes, pars interarticularis, and facet joints^Kandabarow.

NeckandBack.com Text, Video and Graphic Content to Donald Corenman, MD - Spine Surgeon Colorado (http://www.youtube.com/watch?v=7SIry1QXNsA&feature=player_embedded)

Epidemiology /Etiology

Compression fractures can be due to:

1. Trauma- commonly seen in young people from MVA and falls, 25-32% of spinal cord dysfunction.^O'Conner
2. Osteoporosis- risk factors are post-menopausal women and chronic steroid use. Rarely have neurological complications because the wedge deformation is usually anterior part of vertebral body, injury can be spontaneous, sudden onset.^Demir

3. Pathological- Osteomyelitis

Burst fractures:  10-20% of injuries to the thoracolumbar spine are burst fractures^Kalliopi.  Burst fractures are characterized by collapse of the vertebral body due to great axial pressure^Tisot, such as from a fall landing on the buttocks or lower extremities.  The concentration of axial forces is to the thoracolumbar junction (L5-S1)^Kandabarow.

Flexion-Distraction fractures:  occur when the spine is under tension, usually from a trauma involving sudden upper body forward flexion while the lower body remains stationary (also referred to as “seat belt injuries”). With sudden deceleration in a motor vehicle accident, the pelvis and lower extremities remain fixed by the seat belt, and the upper extremities continue forward, shifting the fulcrum of the spine from the disc to the anterior abdominal wall. This creates the excess tension and weakness in the middle and posterior spinal columns. Abdominal trauma usually coexists in this type of injury from abdominal compression in the abdominal cavity. A gap between the spinous processes is often present upon palpation^Kandabarow.

Fracture-dislocation fractures:  can occur with severe flexion forces (similar to seat belt injuries) or an object falling across the back^Kandabarow.

Characteristics/Clinical Presentation

Over 65% of vertebral fractures are asymptomatic^Lentle.  They are sometimes detected via radiograph when a patient is being screened for another injury.  Presentation of symptomatic fractures includes:  chronic back pain, slower gait, decreased range of motion, and impaired pulmonary function.  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^Lentle.

Thoracic spine injuries may have neurologic involvement (25-32%)^O'Connor, attributed to the narrow spinal canal of the thoracic vertebrae.  Anantomical distortion or vertebral fracture fragments in the spinal canal can compromise the spinal cord.^O'Connor

Increased kyphosis can occur with chronic compression fracture, and is common in older patients with osteoporosis.

80% of Patients with thoracic fractures due to osteroporosis had pain only in the lumbar region. ^Friedrich Neurological impairment can present a few weeks to years later.^Demir

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

Differential Diagnosis

 Plain radiographs are currently the "gold standard" for evaluation of fracture to the thoracolumbar spine, although Hauser et al found CT scans had 99% accuracy of detecting an acute thoracic spine fracture comparted to 87% who received radiographs.^Diaz

Clay-Shoveler's Fracture: rare, fatigue fracture of the upper thoracic spinous process. Seen in power lifters or in patients that are involved hard labor causing shear forces on the vertebra, hyperflexed spine, or direct trauma.

Scheuermann Disease: presents as kyphosis, anterior vetebral body extension and schmorl’s nodes.^Masharaui

Examination

In the absence of validated guidelines for traumatic thoracolumbar injury screening, O’Connor and Walsham (2009) performed a literature review evaluating 17 studies of thoracolumbar injury in trauma patients. Their purpose was to form an algorithm of recommended indications for thoracolumbar imaging. One or more of the following criteria present in a patient with blunt multi-trauma is an indication for thoracolumbar spine imaging^O'Connor:

O'Connor & Walsham Clinical Criteria for Thoracolumbar Screening in Blunt Trauma Patients

High-Risk Mechanism of Injury	Motor vehicle accident at speed >70 kph, fall from height >3 m, ejection from motor vehicle or motorcycle, plus any injury outside of these criteria that could cause a thoracolumbar fracture
Painful Distracting Injury	Painful torso or long-bone injury sufficient to distract the patient from noticing the pain of the thoracolumbar injury
New Neurological Signs or Back Pain/Tenderness	Clinical findings suspicious of new vertebral fracture, including back pain, back tenderness, a palpable step in vertebral palpation, midline bruising, neurological signs consistent with spinal cord injury
Cognitive Impairment	Glasgow Coma Score (GCS) < 15, abnormal mentation, clinical intoxication
Known Cervical Spine Fracture	Evidence of a new traumatic cervical spine fracture

These results were derived from low-level evidence; the authors recommend future controlled trials to standardize these definitions and validate the algorithm.^O'Connor

Holmes et al (2003) clinical screening criteria for selective radiograph of blunt trauma patients with thoracolumbar spine injuries (100% negative predictive value):
1. Complaints of TL spine pain
2. TL spine tenderness
3. A decreased level of consciousness
4. Intoxication with ethanol or drugs
5. A neurologic deficit
6. A painful distracting injury

Medical Management (current best evidence)

Compression fracture preventative treatment: bisophosphonates, calcium, vitamin D and exercise for patients with osteoporosis.^Demir
Conservative Treatment: Compression fractures are generally treated with immobilization by a brace or cast and minimal activity suggested. The physician may prescribe NSAIS, narcotics, and muscle relaxants.Compression fractures tend to heal in 8-10wks.
Surgery if indicated: A vetebroplasty or kyphoplasty a complication of these surgeries is cement leakage (7% of kyphoplasty and 23 % in vetebroplasty).^Schofer

Physical Therapy Management (current best evidence)

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References

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Kandabarow A. Clinical excerpts... Injuries of the thoracolumbar spine... reprinted from Alexander Kandabarow, Injuries of the Thoracolumbar Spine, Topics in Emergency Medicine, vol. 19, no. 3, pp. 65-80, (C)1997 Aspen Publishers, Inc. Topics in Clinical Chiropractic [serial online]. September 1999;6(3):57. Available from: CINAHL Plus with Full Text, Ipswich, MA. Accessed April 13, 2011.