Thoracic Spine Fracture

Original Editors - Tre Hinojosa, Heather Hughes, Erin Locati, and Melissa Osti as part of the Texas State University Evidence-based Practice Project

Lead Editors - Your name will be added here if you are a lead editor on this page. 

Contents

Definition/Description

According to the Denis classification system for spinal injury, there are four types of vertebral fracture[1]:


  • 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.[1]

Some other classification systems that are used include:[2] AO and TLICSS.

Normal Thoracic Spine MRI

[3]

Permission granted on 29 Apr 2011.

CT scan of a Compression fracture of the Thoracic Spine


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.[4] Associated neurological complications are rare[1].

Burst

Fracture of the anterior and middle columns of the spine due to axial loading[5] such as from a fall landing on  the buttocks or lower extremities. The concentration of axial forces is to the thoracolumbar junction. [6][1] 

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.[1]

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.[1]

Clay-Shoveler's Fracture

Rare, fatigue fracture of the upper thoracic spinous process. Seen in power lifters or in patients that are involved in hard labor causing shear forces on the vertebra, hyperflexed spine, or direct trauma.[7]

Characteristics/Clinical Presentation

Over 65% of vertebral fractures are asymptomatic [8]. They are sometimes detected via radiograph when a patient is being screened for another injury.

Presentation of symptomatic fractures includes: [8][4][9][10][11][12]

  • Chronic back pain in thoracic and/or lumbar region
  • Slower gait
  • Decreased range of motion
  • Impaired pulmonary function
  • Increased kyphosis especially in osteoporotic 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[8].

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.[4]

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. [13][9][10]

Multiple Myeloma and other cancers can present as thoracic pain, but will have additional signs such as unexplained weight loss and fever.[14]

Scheuermann Disease presents as exaggerated kyphosis, anterior body extension and schmorl’s nodes; can be distinguished by vetebral body height parameters on radiograph. [15]

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) [4]

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.[4]

Holmes et al. (2003)[11]

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. (2011) [10]

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.[6] For more information on spine surgery refer to:

Non-operative

Compression fractures, stable burst fractures and neurologically intact patients can typically be treated non-operatively:[6][17][18][19][20]

  • Bed rest/activity limitation ranging from days to weeks
  • Bracing: 8 to 12 weeks in Jewett or Cruciform Anterior Spinal Hyperextension (CASH) 
    Jewett (left) & CASH (right) Braces - courtesy of Orthotic & Prosthetic Technologies, Inc., San Marcos, TX
    Jewett (left) & CASH (right) Braces - courtesy of Orthotic & Prosthetic Technologies, Inc., San Marcos, TX
  • Casting: 8 to 12 weeks
    CASH (left) & Jewett (right) Braces - courtesy of Orthotic & Prosthetic Technologies, Inc., San Marcos, TX
    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.[7]

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.[18]  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.[20]

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.[6]


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.[18][6][20] 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.[19]

Physical Therapy Management (current best evidence)

Management of vertebral fractures remains controversial [6],[21],[22] 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 [23],[21],[24],[18].
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 [23].  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 [25].  However, because it was a multimodal approach the effectiveness of each treatment is unclear.

APTA Preferred Practice Patterns[26]:

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 [25],[26] 

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 [24],[25].  Studies show significant improvement in reported pain levels and increased function in patients with back-extensor exercises as part of their exercise regimen [24],[27],[28],[25].  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.

Physiotherapy and Home Exercise Program

Adapted from: Bennell et al (2010). [25]

Within a pain free range, progressed as tolerated:

Technique/Exercise Dosage Weeks

Postural taping*

 - From anterior aspect of each shoulder, posteriorly and obliquely to opposite rib cage

Worn full time 1

Soft tissue massage*

 - In prone, to erector spinae, rhomboids, upper traps - stroking, circular frictions, petrissage

5 mins 1-10

Passive accessory postero-anterior vertebral moblisation*

 - In prone from T1 down to 2 levels below most painful vertebral region (Grd 2-3)

5 mobilising movements
at each
central level
x2 reps
1-10

Supine lying over rolled up towel

 - Towel placed lengthways along the back to facilitate thoracic extension

5-10 mins 1 daily

Erect sitting with transversus abdominus stabilising

 - Sit forward on chair (no back rest), chin retraction, scapular retraction and TA contraction

10 sec hold
x 5 reps
1-10 daily

Elbows back in sitting

 - Hands befind head, elbows pointing out to side. Press elbows back by scapular retraction

Trunk mobility in sitting - extension
Trunk mobility in sitting - extension
5 sec hold
x5 reps
1-10 daily

Trunk mobility in sitting

 - Hands on shoulders, gentle rotation in both directions and lateral flexion to each side

5 reps in
each direction
1-10 daily

Head to wall in standing

 - Back and heels agaist wall with rolled up towel behind head. Chin retraction

10 sec hold
x 5 reps
1-10 daily

Standing corner stretch

 - Face corner, both hands chest height on wall and moving in closer to stretch anterior chest

10-30 sec hold
x 3 reps
2-10 daily

Walking hands up wall in standing

 - Facing wall, walking hands up wall until arms upstretched then holding hands off wall

5 sec hold
x5 reps
3-10 daily

Shoulder flexion in supine

 - Arms outstretched holding onto cane/towel and taking arms over head to hold at end of range

10- sec hold
x5 reps
3-10 daily

Standing wall push ups

 - Face wall, arms in front, shoulder height. Keep body straight, bend and straighten elbows

Standing wall pushups
Standing wall pushups
8-10 reps
x2
1-10 3x/week

Seated row with dumbbells

 - Upright sitting and pull hands up towards chest by bending elbows and then lowering

8-10 reps
x2
1-10 3x/week

Seated overhead dumbbell press

 - With elbows bent and out to side, press dumbbells straight up until arms extended overhead

8-10 reps
x2
3-10 3x/week

Bridging in supine

 - Knee bent and feet flat on ground. Pushing through feet to lift back and pelvis off ground

Bridging in supine
Bridging in supine
5-10 sec hold
x5
1-2 3x/week

Hip extension in prone

 - Raising one leg off the ground and then the other

Hip extension in prone
Hip extension in prone
8-10 reps
x2
3-10 3x/week

Half squats - progress to holding dumbbells

 - Standing in front of chair and squatting down to touch chair with buttocks then standing up

8-10 reps
x2
1-2 3x/week

Step ups - progress to holding dumbells

 - Stepping up and down a 10 cm step. Alternate legs

8-10 reps
x2

3-10

3x/week

Scapular retraction with theraband in sitting

 - Holding theraband in both hands with elbows tucked into sides and performing wrist extension, supination and shoulder external rotation then scapular retraction

Scapular retraction with theraband in sitting + Chin tuck + TA
Scapular retraction with theraband in sitting + Chin tuck + TA
8-10 reps
x2
1-10 3x/week

Four-point kneeling with transversus abdominus

 - Push into floor with hands, knees and feet then draw navel up and in, hold 5 secs

8-10 reps
x2

2

3x/week

Four point kneeling with one arm and leg lift

 - As above; lift one arm off ground. Progress to also lifting extended leg off ground at same time

Four-Point Kneeling + TA
Four-Point Kneeling + TA
8-10 reps
x2
3-10 3x/week

Prone lying with arm elevation

 - Arms at shoulder height and bent at elbows. Scapular retraction then lift arms off floor

5-10 sec hold
x5
2-3 3x/week

Prone trunk extension

 - Lift head and shoulders off floor while maintaining chin retraction

5-10 sec hold
x5
4-10 3x/week
*performed by the therapist


Complications to Consider [6],[22],[24]

  • 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

  1. Corenman DS. Thoraco-lumbar spine fractures. Available from: http://neckandback.com/conditions/thoraco-lumbar-spine-fractures (accessed 20 Sep 2011).
  2. MD Guidelines. Fracture, thoracic spine (without spinal cord injury). Available from: http://www.mdguidelines.com/fracture-thoracic-spine-without-spinal-cord-injury (accessed 20 Sep 2011).
  3. AO Foundation, Available from: http://www.aofoundation.org(accessed 20 Sep 2011).
  4. Leahy M and Gellman H. Thoracic spine fractures and dislocation. Medscape Reference. Available from: http://emedicine.medscape.com/article/1267029-overview (accessed 20 Sep 2011).

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.


Presentations

https://http://www.youtube.com/watch?v=SdhFe8OKb-I&noredirect=1
Diagnosis and Management of Thoracic Spine Fractures

This presentation, created by Caughey Richardson, Jacquelyne Rodriguez, James Rodriguez, and JohnPaul Rodriguez; Texas State DPT Class.

View the presentation

https://http://www.youtube.com/watch?v=i0FL-Ce8qAg
Diagnosis and Management of Thoracic Spine Fractures

This presentation, created by Jason Moreno, Elaine Tsay, Chris Webb; Texas State Class of 2014, Evidence-based Practice projects for PT7539 Ortho Spine course.

View the presentation

Recent Related Research (from Pubmed)

References

  1. 1.0 1.1 1.2 1.3 1.4 1.5 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.
  2. Wood K, Khanna G, Vaccaro A, Arnold P, Harris M, Mehbod A. Assessment of two thoracolumbar fracture classification systems as used by multiple surgeons. J Bone Joint Surg (Am) 2005;87A(7):1423-9.
  3. Corenman DS. Understanding an MRI of the Normal Thoracic Spine (Mid Back) from www.neckandback.com Available from: http://www.youtube.com/watch?v=7SIry1QXNsA (accessed 20 Sep 2011).
  4. 4.0 4.1 4.2 4.3 4.4 O'Connor E, Walsham J. Indications for thoracolumbar imaging in blunt trauma patients: a review of current literature. Emerg Med Australas 2009;21(2):94-101.
  5. Tisot R, Avanzi O. Laminar fractures as a severity marker in burst fractures of the thoracolumbar spine. J Orthop Surg (Hong Kong) 2009;17(3):261-4.
  6. 6.0 6.1 6.2 6.3 6.4 6.5 6.6 Alpantaki K, Bano A, Pasku D, Mavrogenis AF, Papagelopoulos PJ, Sapkas G, et al. Thoracolumbar burst fractures: a systematic review of management. Orthopedics 2010;33(6):422-9.
  7. 7.0 7.1 Demir S, Akin C, Aras M, Koseoglu F. Spinal cord injury associated with thoracic osteoporotic fracture. Am J Phys Med Rehabil 2007;86(3):242-6.
  8. 8.0 8.1 8.2 Lentle BC, Brown JP, Khan A, Leslie WD, Levesque J, Lyons DJ, et al. Recognizing and reporting vertebral fractures: reducing the risk of future osteoporotic fractures. Can Assoc Radiol J 2007;58(1):27.
  9. 9.0 9.1 Marre B, Ballesteros V, Martinez C, Zamorano JJ, Ilabaca F, Munjin M, et al. Thoracic spine fractures: Injury profile and outcomes of a surgically treated cohort. Eur Spine J 2011;20(9):1427-33.
  10. 10.0 10.1 10.2 Singh R, Taylor DM, D’Souza D, Gorelik A, Page P, Phal P. Mechanism of injury and clinical variables in thoracic spine fracture: a case control study. Hong Kong J Emerg Med. 2011;18(1):5-12.
  11. 11.0 11.1 Holmes JF et al. Prospective evaluation of criteria for obtaining thoracolumbar radiographs in trauma patients. J Emerg Med. 2003; 24:1-7.
  12. Friedrich M, Gittler G, Pieler-Bruha E. Misleading history of pain location in 51 patients with osteoporotic vertebral fractures. Eur Spine J 2006;15(12):1797-800.
  13. Diaz J, Cullinane D, Vaslef S, et al. Practice management guidelines for the screening of thoracolumbar spine fracture. J Trauma 2007;63(3):709-18.
  14. PubMed Health: Multiple myeloma Web site. Available at: http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001609/. Accessed April 29, 2001.
  15. 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 2009;34(18):1995-9.
  16. Harding IJ. Anterior spinal surgery. Available from: https://www.ianjharding.com/uploads/anterior_spinal_approaches.pdf (accessed 20 Sep 2011).
  17. Shaffrey CI, Shaffrey ME, Whitehill R, Nockels RP. Surgical treatment of thoracolumbar fractures. Neurosurg Clin N Am 1997;8(4):519-40.
  18. 18.0 18.1 18.2 18.3 Wood K, Butterman G, Mehbod A, Garvey T, Jhanjee R, Sechriest V. Operative compared to nonoperative treatment of thoracolumbar burst fracture without neurological deficit: a prospective, randomized study. J Bone Joint Surg Am 2003;85-A(5):773-81.
  19. 19.0 19.1 Weninger P, Schultz A, Hertz H. Conservative management of thoracolumbar and lumbar spine compression and burst fractures: functional and radiographic outcomes in 136 cases treated by closed reduction and casting. Arch Orthop Trauma Surg 2009;129:207-19.
  20. 20.0 20.1 20.2 Giele BM, Wiertsema SH, Beelen A, va der Schaaf M, Lucas C, Been HD, et al. No evidence for the effectiveness of bracing in patients with thoracolumbar fractures: a systematic review. Acta Orthopaedica 2009;80(2):226-32.
  21. 21.0 21.1 Van Leeuwen PJ, Bos RP, Derksen JC, de Vries J. Assessment of spinal movement reduction by thoraco-lumbar-sacral orthoses. J Rehabil Res Dev 2000;37(4):395-403.
  22. 22.0 22.1 Dai LY, Jiang LS, Jiang SD. Posterior short-segment fixation with or without fusion for thoracolumbar burst fractures. A five to seven-year prospective randomized study. J Bone Joint Surg Am 2009;91:1033-41.
  23. 23.0 23.1 Rousing R, Hansen KL, Andersen M, Jespersen SM, Thomsen K, Lauritsen JM. Twelve-months follow-up in forty-nine patients with acute/semiacute osteoporotic vertebral fractures treated conservatively or with percutaneous vertebroplasty. Spine 2010;35(5):478-82.
  24. 24.0 24.1 24.2 24.3 Cahoj PA, Cook JL, Robinson BS. Efficacy of percutaneous vertebral augmentation and use of physical therapy intervention following vertebral compression fractures in older adults: a systematic review. J Geriatr Phys Ther 2007;30(1):31-40.
  25. 25.0 25.1 25.2 25.3 25.4 Bennell KL, Matthews B, Greig A, Briggs A, Kelly A, Sherburn M, et al. Effects of an exercise and manual therapy program on physical impairments, function and quality of life in people with osteoporotic vertebral fracture: a randomised, single-blind controlled pilot trial. BMC Musculoskeletal Disorders 2010;11(36):1-11.
  26. 26.0 26.1 Guide to Physical Therapist Practice. 2nd ed. Revised. Alexandria, Va: American Physical Therapy Association; 2003.
  27. Huntoon EA, Schmidt CK, Sinaki M. Significantly fewer refractures after vertebroplasty in patients who engage in back-extensor-strengthening exercises. Mayo Clin Proc 2008;83(1):54-7.
  28. Sinaki M, Itoi E, Wahner HW, Wollan P, Gelzcer R, Mullan BP, et al. Stronger back muscles reduce the incidence of vertebral fractures: a prospective 10 year follow-up of postmenopausal women. Bone 2002;30(6):836-41.


The Movement System

Learn about the movement system with Shirley Sarhmann & Mark Comerford in this month's members learn topic.

Become a member