Thoracic Spine Fracture

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key words:  thoracic, fracture, thoracolumbar, diagnosis, management, treatment, compression, burst

Definition/Description

TYPES OF SPINAL FRACTURES:
- 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, typically from a fall landing on the buttocks or lower extremities. 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. Flexion-distraction fracture usually results 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.
- 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:
   o 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
   o 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.
   o Shear: all three spinal columns are fractured, usually in the AP plane, due to an object falling across the back.

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.

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

Characteristics/Clinical Presentation

Compression Fracture Charateristics include: kyphotic deformity can develop if chronic, common in older patients with osteoporosis. 

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

Differential Diagnosis

 CT scan 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

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Medical Management (current best evidence)

Compression fracture preventative treatment: bisophosphonates, calcium, vitamin D and exercise for patients with osteoporosis.²
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).¹

Physical Therapy Management (current best evidence)

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Key Research

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Clinical Bottom Line

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