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.

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 – 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 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) 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) 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. 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. 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.

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 (Lentle). They are sometimes detected via radiograph when a patient is being screened for another injury.

Presentation of symptomatic fractures includes: (Lentle)

• 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 ADLs, and increased risk of disability. Vertebral deformities are also associated with significantly increased risk of future fractures, including hip fractures (Lentle).

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. 

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

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: Presence one or more of the following criteria a patient with blunt multi-trauma is an indication for thoracolumbar spine imaging:

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.

Holmes et al: Screening criteria for radiograph of blunt trauma patients with thoracolumbar spine injuries - consistent with O’Connor and Walsham:
 

• 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 progressive neurological deterioration, >50% spinal canal compromise, >50% anterior vertebral body height loss, >25° to 35° angle of kyphotic deformity. Surgical approaches can be anterior, posterior or a combination.


Nonoperative

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

• Closed reduction
• Bracing: Typically a Jewett or hyperextension brace
• 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
• Pain medication
• Physical Therapy

Wood et al 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. Braces remain a common part of both 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 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.

Neurologically Involved Patients
Since neurological impairment is typically used as an exclusion criteria in studies examining non-operative treatments of thoracic fractures, there is a lack of evidence for the use of conservative treatments in neurologically involved patient. However, Weninger et al reported positive outcomes for a select group of patients with unilateral radicular symptoms that refused surgery in favor a closed reduction followed by casting. However patients with more serious neurological involvement such as cauda equina syndrome did not respond as well to conservative treatment.

Neurologically Intact Patients
There is some disagreement over when surgery is indicated for those who are neurologically intact. Some authors recommend surgery even in this patient group and have seen significantly better improvements in pain and return to work in these patients when treated operatively compared to nonoperative treatment.

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

Physical Therapy Management (current best evidence)

The management of vertebral fractures remains controversial ,, and research is limited on identifying the most appropriate physical therapy intervention. Until recently, conservative management of vertebral fractures consisted of pain meds, bed rest and bracing to reduce spinal movements and stabilize the fracture ,,,.
Rehabilitation programs must be designed specifically for the individual and be based on the physical abilities of that individual. Because of this, an impairment based exam and intervention is most likely warranted.

The majority of vertebral fractures heal after 8-12 weeks of conservative treatment with a decline in pain and 12-24 hours post-surgery with a decline in pain. Therefore, physical therapy interventions depend largely on whether the patient is post-surgery or conservative. Either way, interventions should always be prescribed and progressed based on the patient’s tolerance.

Physical Therapy Goals should address patient limitations and include improvements to pain, stability, balance, strength and range of motion. Bennell et al. found that a multimodal treatment approach over a 10-week period was successful in reducing pain and improving physical function in patients who suffered from osteoporotic vertebral fractures. However, because it was a multimodal approach it was unclear which individual treatment was more or less effective.

Although evidence or specific therapeutic exercise regimens for the treatment of vertebral fractures is limited, preferred practice patterns 4B: Impaired Posture; 4G: Impaired Joint Mobility, Muscle Performance, and Range of Motion Associated with Fracture; and 4I: Impaired Joint Mobility, Muscle Performance, and Range of Motion Associated with Bony or Soft Tissue Surgery are offered by The Guide to Physical Therapist Practice 2nd edition to assist physical therapists in managing patients who fit these patterns.

General Exercise Recommendations ^,: (all within a pain free range and progressed as tolerated)
Supine:

• Bilateral Shoulder Flexion
• Marching
• Alternating Knee Extension

Bicep Curl
Seated:

• Shoulder Shrugs
• Chin Tucks
• Scapular Retraction
• Rows with T-Band
• Deep breathing exercises to promote full chest expansion

Standing:

• Wall Push-Ups
• Corner Stretch
• Step-ups
• Single Leg Stance

Prone:

• Trunk Extension
• Alternating Arm Extension
• Alternating Leg Extension

Other:

• General Aerobic Conditioning
• Education in Proper Body Mechanics
• Ergonomic/Posture Education

Patient should begin back-extension exercises as soon as they are able to tolerate. Studies show significant improvement in pain and increased function ^, as well as decreased risk of refracture when back-extension exercises were utilized ^,,,.

When developing a Plan of Care, the individual characteristics of a fracture and the many secondary limitations that can be involved should be considered.

Complications to Consider ^,,:

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

Key Research

add links and reviews of high quality evidence here (case studies should be added on new pages using the case study template)

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 treated post-operative or non-operative patients.

Recent Related Research (from Pubmed)

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References

see adding references tutorial.