Thoracic Spine Fracture

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Original Editors

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Search Strategy

Databases Searched:  CINHAL plus Full Text, Cochrane, PubMed

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

Search Timeline: April 6, 2011 to May 1, 2011

Definition/Description

According to the Denis classification system for spinal injury, there are four types of vertebral fracture:


• Compression
• Burst 
  
• Flexion-distraction 
• Fracture-dislocation - Subsets include Flexion-Rotation, Flexion-Distraction and Shear
  

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

Some other classification systems that are used include:  AO and TLICSS.

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

Permission granted on 4/29/2011.

Crashed mountain bike off ramp: CT scan 

Epidemiology /Etiology

Compression – failure of the anterior column of the spine due to compression forces, mainly in flexion. The most common causes 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.

File:Burst fx axial CT.jpg

NeckandBack.com Text, Video and Graphic Content to Donald Corenman, MD - Spine Surgeon Colorado (http://neckandback.com/conditions/thoraco-lumbar-spine-fractures)

Burst – fracture of the anterior and middle columns of the spine due to axial loading such as from a fall landing on  the buttocks or lower extremities. The concentration of axial forces is to the thoracolumbar junction.  

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.

Fracture-dislocation – 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.

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.

Characteristics/Clinical Presentation

Over 65% of vertebral fractures are asymptomatic . They are sometimes detected via radiograph when a patient is being screened for another injury.

Presentation of symptomatic fractures includes:

• Chronic back pain in thoracic and/or lumbar region
• Slower gait
• Decreased range of motion
• Impaired pulmonary function
• Increased kyphosis especially in osteoporitic patients with compression fractures
  
• Neurological deficits due to narrowing of spinal canal - can present 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 visualize thoracic fractures and an MRI to assess soft tissue damage. 

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

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

Examination

Screening for Fracture

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

O'Connor and Walsham (2009)

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

High-Risk Mechanism of Injury (MOI)	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.

Holmes et al: Screening criteria for radiograph of blunt trauma patients with thoracolumbar injuries (Sn=1.00, Sp=0.039) :
 

• Complaints of thoracolumbar spine pain

• Thoracolumbar spine tenderness

• Decreased level of consciousness

• Intoxication with alcohol or drugs

• Neurologic deficit

• Painful distracting injury

Singh et al: 

Three predictive variables for thoracic spine fracture based on a case control study (Sp=0.93):

• Fall > 2m
• Thoracic pain
• Intoxication

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

Medical Management (current best evidence)

Operative

Indications for surgery include neurological involvement and/or progressive neurological deterioration, >50% spinal canal compromise, >50% anterior vertebral body height loss, >25° to 35° angle of kyphotic deformity, and posterior ligament complex (PLC) compromise. Surgical approaches can be anterior, posterior or a combination. For more information on spine surgery refer to:

• Anterior Surgical Approach
• Cervical Spinal Surgery


Nonoperative

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) 
  File:Jewett & CASH Braces.JPG

  Jewett (left) & CASH (right) Braces - courtesy of Orthotic & Prosthetic Technologies, Inc., San Marcos, TX
• Casting: 8 to 12 weeks
  File:CASH & Jewett Braces on Patients.JPG

  CASH (left) & Jewett (right) Braces - courtesy of Orthotic & Prosthetic Technologies, Inc., San Marcos, TX
• Closed reduction
• Pain medication
• Physical Therapy

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

Wood et al found 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.

Discussion
Alpantaki et al proposed a treatment algorithm for patients presenting with thoracolumbar burst fractures that is based on the patient’s neurological status. Incomplete neurological impairment indicated the need for surgery whereas a patient without neurological deficits could be conservatively managed. Within the surgery category, it’s recommended that patients without PLC compromise receive an anterior surgical approach, those with thoracic kyphosis >35° receive a posterior surgical approach, and those with complete PLC compromise might benefit from a combined anterior and posterior approach.

There is a lack of evidence for the use of conservative treatments in neurologically involved patients as neurological involvement is typically an exclusion criteria in studies on conservative treatment. However, Weninger et al reported positive outcomes for a select group of patients with unilateral radicular symptoms that refused surgery in favor conservative treatment (closed reduction followed by casting). Patients with more serious neurological involvement such as cauda equina symptoms did not respond as well to the same conservative treatment.

Physical Therapy Management (current best evidence)

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 significant decrease in pain in 8-12 weeks. Significant declines in pain (5.9cm on VAS) are experienced 12-24 hours post-surgery .  Therefore, 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 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.

APTA Preferred Practice Patterns:

4B: Impaired Posture

4G:Impaired Joint Mobility, Muscle Performance, and Range of Motion Associated with Fracture 

4I: Impaired Joint Mobility, Muscle Performance, and Range of Motion Associated with Bony or Soft Tissue Surgery

General Exercise Recommendations ^, within a pain free range, progressed as tolerated:

Refer to Bennell et al (2010)
Table 1 Physiotherapy and home exercise program

Trunk mobility in sitting - extension

Scapular retraction with theraband in sitting + Chin tuck + TA

Standing wall pushups

Hip extension in prone

Four-Point Kneeling + TA

Bridging in supine

A major concern is refracture within a year of the initial injury.  Researchers agree that strengthening back-extensor muscles can help decrease the rate of refracture or prolong occurance of refracture ^,.  Studies show significant improvement in reported pain levels and increased function in patients with back-extensor exercises as part of their exercise regimen ^,,,.  Therefore, patient 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.

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
  

Resources

Thoraco-Lumbar Fractures

Thoracic Spine Fractures

AO Foundation

Thoracic Spine Fractures and Dislocation - Medscape Reference

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.

Recent Related Research (from Pubmed)

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References

see adding references tutorial.