Thoracic Spine Fracture

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Search Strategy

Databases Searched:  CINHAL plus Full Text, The Cochrane Library, MEDLINE with Full Text

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

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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 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. (Also site Denis & O’Connor from Heather) Rarely have neurological complications (Denis from Heather)

Burst – fracture of the anterior and middle columns of the spine due to axial loading (Tisot from Heather) such as from a fall landing on the buttocks or lower extremities. The concentration of axial forces is to the thoracolumbar junction.(also site Denis & Kandabarow) These account for 10-20% of injuries to thoracolumbar region (Kalliopi)

Flexion-distraction – 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 (Kandabarow). 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 (Kandabarow).

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. 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).

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.

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 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

Compression Fractures are most often at the lower thoracic spine.^Demir

Crashed mountain bike off ramp: CT scan http://www.youtube.com/watch?v=5rV9LSV9Fm0

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 (Marre 2011). Neurological impairments can present as long as 1.5 year post injury (O’Connor). Anatomical 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. This population may also exhibit pain in the lumbar region.(Friedrich)

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 that are not fully validated 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. (Marre 2011, Diaz 20).

Patients with poly-trauma can have pain and disability in multiple areas.

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)

Operative Treatment
Indications for surgery include 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) damage. Surgical approaches can be anterior, posterior or a combination. (Alpantaki 2010). Neurological impairment is typically considered an indication for surgery Alpantaki 2010) and is used as an exclusion criteria in studies examining non-operative treatments of thoracic fractures (Post 2005, Giele 2009, Alanay 2004, Agus 2005, Wood 2003, Shen 2001) resulting in a lack of evidence for the use of conservative treatments in neurologically involved patients.

Nonoperative Treatment

Compression fractures and stable burst fractures can typically be treated non-operatively (Shaffrey 1997). Conservative, non-operative treatment can include:

• Closed reduction
• Bracing: Typically a Jewett or hyperextension brace (Giele 2009)
• Casting
• Bed Rest/Activity Limitation ranging from 4 to 12 weeks though positive results have been see with as little as 2 days of bed rest when combined with closed reduction and casting (Weninger 2009)
• Pain medication - NSAIDs, narcotics, and muscle relaxants (Schofer)
• Physical Therapy

There is disagreement in the literature over the effectiveness of bracing. Giele et al (2009) found a paucity of high quality research supporting the use of bracing in patients with thoracolumbar fractures. However, Wood et al (2003) found no significant long-term difference in pain, disability and return to work for non-neurologically involved patients that received surgery compared to bracing or casting. The results of this study indicate that the higher risk and cost of surgery may not be justified and that bracing/casting should be the preferred treatment in this patient population. Casting was recommended over bracing, especially in the early stages of fracture healing due to increased patient compliance. This is one of the few studies on this topic that randomized patients to treatment groups. Braces remain a common part of both operative and non-operative thoracic fracture treatment protocols.

Alpantaki et al (2010) 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 conservatory managed. Within the surgery category, it’s recommended that patients without PLC compromise receive an anterior surgical approach, those with thoracic kyphosis over 35° are put into a posterior approach category and patients with complete PLC compromise might benefit from a combined anterior and posterior surgery. In contrast, Weninger et al (2009) reported positive outcomes for a select group of patients (unilateral radicular symptoms) with incomplete neurological deficits that refused surgery in favor a closed reduction followed by casting.

Physical Therapy Management (current best evidence)

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

Key Research

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Clinical Bottom Line

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Recent Related Research (from Pubmed)

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References

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1. Schofer M, Efe T, Timmesfeld N, Kortmann H, Quante M. Comparison of kyphoplasty and vertebroplasty in the treatment of fresh vertebral compression fractures. Archives of Orthopaedic & Trauma Surgery [serial online]. October 2009;129(10):1391-1399. Available from: CINAHL Plus with Full Text, Ipswich, MA. Accessed April 12, 2011.
2. Demir S, Akin C, Aras M, Koseoglu F. Spinal cord injury associated with thoracic osteoporotic fracture. American Journal of Physical Medicine & Rehabilitation [serial online]. March 2007;86(3):242-246. Available from: CINAHL Plus with Full Text, Ipswich, MA. Accessed April 12, 2011.
3. Friedrich M, Gittler G, Pieler-Bruha E. Misleading history of pain location in 51 patients with osteoporotic vertebral fractures. European Spine Journal: Official Publication Of The European Spine Society, The European Spinal Deformity Society, And The European Section Of The Cervical Spine Research Society [serial online]. December 2006;15(12):1797-1800. Available from: MEDLINE with Full Text, Ipswich, MA. Accessed April 12, 2011.
4. Holmes JF et al. Prospective evaluation of criteria for obtaining thoracolumbar radiographs in trauma patients. J Emerg Med. 2003; 24:1-7. Accessed April 28, 2011.
5. Masharawi Y, Rothschild B, Peled N, Hershkovitz I. A simple radiological method for recognizing osteoporotic thoracic vertebral compression fractures and distinguishing them from Scheuermann disease. Spine [serial online]. August 15, 2009;34(18):1995-1999. Available from: CINAHL Plus with Full Text, Ipswich, MA. Accessed April 20, 2011.
6. O'Connor E, Walsham J. Review article: Indications for thoracolumbar imaging in blunt trauma patients: a review of current literature. Emergency Medicine Australasia [serial online]. April 2009;21(2):94-101. Available from: CINAHL Plus with Full Text, Ipswich, MA. Accessed April 20, 2011.
7. Diaz J, Cullinane D, Vaslef S, et al. Practice management guidelines for the screening of thoracolumbar spine fracture. Journal of Trauma [serial online]. September 2007;63(3):709-718. Available from: CINAHL Plus with Full Text, Ipswich, MA. Accessed April 20, 2011.
8. Patel A, Dailey A, Vaccaro A, et al. Thoracolumbar spine trauma classification: the Thoracolumbar Injury Classification and Severity Score system and case examples. Journal of Neurosurgery: Spine [serial online]. March 2009;10(3):201-206. Available from: CINAHL Plus with Full Text, Ipswich, MA. Accessed April 20, 2011.

9. (2)  O'Conner PA, Eustace S, O'Byrne JM: Spinal cord injury following osteoporotic vetebral fractures: case report, Spine 2002;27:413-5.

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.