Thoracic Spine Fracture

Definition/Description

T9-T10 chance fracture from MVA

Most thoracic spine fractures occur in the lower thoracic spine, with 60% to 70% of thoraco-lumbar fractures occurring in the T11 to L2 region, which is the bio-mechanically weak for stress. The majority of these fractures occur without spinal cord injury. 20 to 40% of the fractures are associated with neurological injuries.

Major (high-energy) trauma, is the most common cause of thoracic fractures such as falls from height or road traffic accidents.[1] Minor trauma can also cause a thoracic spine fracture in individuals who have a condition associated with loss of bone mass such as osteoporosis.

There are two current classification systems that radiographers use for thoracic spine fractures: Magerl[2] and Denis[3]

There are four major types (based on the mechanism of injury):

  1. Compression (wedge fractures)
  2. Burst
  3. Flexion-distraction (seat belt injury/ Chance fracture)
  4. Fracture-dislocation

Epidemiology /Etiology

Over 65% of vertebral fractures are asymptomatic [4]. They are sometimes detected via radiograph when a patient is being screened for another injury.

Compression

Caused by axial compression alone or flexion forces, when the spine is bent forward or in side flexion at the moment of trauma. It is a stable fracture and patients rarely accompanied neurological deficits[5].

The most common causes in younger patients are falls and motor vehicle accidents. In older patients the most common causes are minor incidents during normal activities of daily living secondary to osteoporosis or metabolic bone diseases.[6]

Burst

Similar to compression fractures except that the entire vertebra is evenly crushed. It is a very severe fracture, accompanied with retro-pulsed bone fragments into spinal canal. Neurological injury and posterior column injury can occur more frequently.

The common cause of this fracture is due to axial loading of the anterior spine such as from a fall, landing on the buttocks or lower extremities where the concentration of axial forces is to the thoracolumbar junction.[7][8][5]

Flexion-distraction

Involves the separation (distraction) of the fractured vertebra. It occurs by primary distraction forces on the spine. The axis of rotation is located within or in front of anterior vertebral body.

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 (seat belt injury). 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.[5]

Fracture-dislocation

Found in combination with displacement of adjacent vertebrae. It is caused by various combinations of forces. It is very unstable and can cause complete neurological deficit.

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.[5]

Clay-Shoveler's Fracture

Rare, fatigue fracture of the upper thoracic spinous process. Seen in powerlifters or in people with physically intensive jobs causing shear forces on the vertebra, hyperflexed spine, or direct trauma.[9]

Characteristics/Clinical Presentation

Presentation of symptomatic fractures includes: [4][6][10][11][12][13]

  • Chronic back pain in thoracic and/or lumbar region
  • Slower gait
  • Decreased thoracic and lumbar range of movement
  • Impaired pulmonary function
  • Increased kyphosis - especially in osteoporotic patients with compression fractures
  • Neurological deficits due to narrowing of spinal canal - can occur 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[4].

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.[6]

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 visualise thoracic fractures and an MRI to assess soft tissue damage. [14][10][11]

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

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 with thoracic fractures and the need for imaging have been developed but are not fully validated.[6]

Presence of one or more of the following 5 criteria in a patient with blunt multi-trauma is an indication for thoracolumbar imaging (Sn=0.99):

  1. High Risk Mechanism of Injury (MOI):
    • Motor vehicle accident at speed >70 kph
    • Fall from height >3 m
    • Ejection from motor vehicle or motorcycle
    • Any injury outside of these criteria that could cause a thoracolumbar fracture
  2. Painful Distracting Injury: painful torso/long-bone injury sufficient to distract the patient from noticing the pain of the thoracolumbar injury
  3. New Neurological Signs or Back Pain/Tenderness with Clinical Findings Suspicious of a New Fracture:
    • Back pain
    • Back tenderness on palpation
    • Palpable step in vertebral palpation
    • Midline bruising
    • Neurological signs consistent with a spinal cord injury
  4. Cognitive Impairment:
    • Glasgow Coma Scale (GCS) < 15
    • Abnormal mental state
    • Clinical intoxication
  5. Known Cervical Spine Fracture: evidence of a new traumatic cervical spine fracture

However, as these results were derived from low-level evidence, it is recommended that future controlled trials are needed to standardize these definitions and validate the algorithm.[6]

Other criteria for screening include:

  1. Screening criteria for radiograph of blunt trauma patients with thoracolumbar injuries[12] (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

2. Three predictive variables for thoracic spine fracture based on a case control study[11] (Sp=0.93):

  • Fall > 2m
  • Thoracic pain
  • Intoxication

Medical Management

Operative

The benefits of surgical treatment of thoracolumbar fractures compared to conservative management include avoiding an orthosis in the presence of multiple injuries, skin injuries, immediate mobilization and earlier rehabilitation with better restoration of sagittal alignment[16].

The negatives of surgical intervention are the standard risks of surgery including the risks of general anesthetic. Conventional open surgical techniques may be accompanied by approach-related muscle injury, increased infection rates and higher blood loss.

There is no difference between operative and non-operative treatment regarding neurological recovery and long-term functional outcomes.[17]

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.[8] Recently, minimally invasive techniques have been described in thoracolumbar fractures.

Non-Operative

Compression fractures, stable burst fractures and neurologically intact patients can typically be treated non-operatively:[8][16][17][18][19]

  • Bed rest/activity limitation ranging from days to weeks
  • Bracing: 8 to 12 weeks in Jewett or Cruciform Anterior Spinal Hyperextension (CASH) 
  • Casting: 8 to 12 weeks
  • Pain medication
  • Physical therapy

There is no consensus on the exact duration of treatment.

Preventative treatment for fractures related to osteoporosis include bisophosphonates, calcium, vitamin D and exercise.[9]

There was found to be 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.[20][17]  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 however there is no evidence to say that bracing is effective in the management of these fractures. .[19]
Jewett (left) & CASH (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

Physical Therapy Management

Management of vertebral fractures remains controversial [8] ,[20],[21] 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 [22],[20],[23],[17].
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 a significant decrease in pain in 8-12 weeks. Significant declines in pain (5.9cm on VAS) are experienced 12-24 hours post-surgery [22].  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 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


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 [24].  However, because it was a multimodal approach the effectiveness of each treatment is unclear.

General Exercise Recommendations[24],[25] 

A major concern is re-fracture 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 [23],[24] Studies show significant improvement in reported pain levels and increased function in patients with back-extensor exercises as part of their exercise regimen [23],[26],[27],[24]. 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). [24]

Within a pain-free range, progressed as tolerated:

Technique/Exercise Dosage Duration (weeks) Image
Postural Taping - performed by physiotherapist

Start from anterior aspect of each shoulder and go posteriorly + obliquely towards the opposite rib cage

worn full time 1
Soft Tissue Massage - performed by physiotherapist

Stroking, circular frictions, petrissage to the erector spinae, rhomboids, and upper traps with patient prone

5 minutes 1 - 10
Passive Accessory Postero-anterior Vertebral Mobilisation - performed by physiotherapist

Grade 2-3 mobilisations from T1 down to 2 levels below the most painful vertebral region with patient prone

5 mobilisations at each central level x 2 reps 1 - 10
Supine Lying Over Rolled Up Towel

Towel is placed lengthwise along the back to facilitate thoracic extension

5 - 10 minutes 1 (daily)
Erect Sitting with Transversus Abdominus (TA) Stabilisation

Forward sitting on chair (no back rest) with chin retraction, scapular retraction, and TA contraction

10 second hold x 5 reps 1 - 10 (daily)
Elbows Back in Sitting

Hands placed behind the head with elbows pointing out to the side - press elbows back using scapular retraction

5 second hold x 5 reps 1 - 10 (daily)
Trunk Mobility in Sitting

With hands on shoulders gently rotate to both directions and laterally flex to each side

5 reps in each direction 1 - 10

(daily)

Trunk mobility in sitting - extension
Head to wall in standing

Stand with back and heels against the wall and a rolled up towel behind the head - retract chin

10 second hold x 5 reps 1 -1 0

(daily)

Standing corner stretch

Stand facing a corner and place both hands chest height on each side of the wall - move in closer to stretch anterior chest

10 - 30 second hold x 3 reps 2 - 10

(daily)

Walking hands up wall in standing

Stand facing the wall and walk hands up until arms are up-stretched - then hold hands off wall

5 second hold x 5 reps 3 - 10 (daily)
Shoulder flexion in supine

Arms are outstretched holding onto a cane/towel - then take arms over head and hold at end range

10 second hold x 5 reps 3 - 10 (daily)
Standing wall push ups

Stand facing the wall with arms in front at shoulder height - keeping the body straight bend and straighten elbows

8 - 10 reps x 2 sets 1 - 10

(3x/week)

Standing wall pushups
Seated row with dumbbells

Sitting upright - pull hands up towards chest by bending elbows and then lower

8 - 10 reps x 2 sets 1 - 10 (3x/week)
Seated overhead dumbbell press

Elbows are bent and out to the side - press dumbbells straight up until arms are extended overhead

8 - 10 reps x 2 sets 3 - 10 (3x/week)
Bridging in supine

 Knees bent and feet flat on ground - push through feet to lift back and pelvis off ground

5 - 10 second hold x 5 reps 1 - 2 (3x/week)
Bridge in supine
Hip extension in prone

Raise one leg off the ground and then the other

8 - 10 reps x 2 sets 3 - 10 (3x/week)
Hip extension in prone
Half squats - progress to holding dumbbells

 Stand in front of chair and squat down to touch chair with buttocks - then stand up

8 - 10 reps x 2 sets 1 - 2 (3x/week)
Step ups - progress to holding dumbbells

Step up and down a 10 cm step - alternate legs

8 - 10 reps x 2 sets 3 - 10

(3x/week)

Scapular retraction with theraband in sitting

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

8 - 10 reps x 2 sets 1 - 10 (3x/week)
Scapular retraction with theraband in sitting + chin tuck + TA hold
Four-point kneeling with transversus abdominus

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

5 second hold x 8-10 reps
x 2 sets
2

(3x/week)

Four point kneeling with one arm and leg lift

Perform as above - then lift one arm off ground and progress to lifting and extending the leg on the opposite side off ground at same time

8 - 10 reps x 2 sets 3 - 10 (3x/week)
4 point kneeling + TA hold
Prone lying with arm elevation

With arms at shoulder height and bent at elbows - perform scapular retraction and then lift arms off floor

5 - 10 second hold x 5 reps 2 - 3 (3x/week)
Prone trunk extension

Lift head and shoulders off floor while maintaining chin retraction

5 - 10 second hold x 5 reps 4 - 10 (3x/week)

Complications to Consider [8],[21],[23]

  • 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

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.

Resources

  1. Thoraco-lumbar spine fractures. Corenman DS
  2. Fracture, thoracic spine (without spinal cord injury). MD Guidelines.
  3. Thoracic spine fractures and dislocation. Medscape Reference.

References

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  2. Magerl F, Aebi M, Gertzbein SD, Harms J, Nazarian S. A comprehensive classification of thoracic and lumbar injuries. European Spine Journal. 1994 Aug 1;3(4):184-201.
  3. Denis F. Spinal Instability as Defined by the Three-column Spine Concept in Acute Spinal Trauma, Clinical Orthopedics and Related Research. Oct 1984; 198:65-76
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  11. 11.0 11.1 11.2 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.
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  13. Friedrich M, Gittler G, Pieler-Bruha E. Misleading history of pain location in 51 patients with osteoporotic vertebral fractures. European Spine Journal. 2006 Dec 1;15(12):1797-800.
  14. 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.
  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 Aug 15;34(18):1995-9.
  16. 16.0 16.1 Shen WJ, Liu TJ, Shen YS. Nonoperative treatment versus posterior fixation for thoracolumbar junction burst fractures without neurologic deficit. Spine. 2001 May 1;26(9):1038-45.
  17. 17.0 17.1 17.2 17.3 Wood KB, Buttermann GR, Phukan R, Harrod CC, Mehbod A, Shannon B, Bono CM, Harris MB. Operative compared with nonoperative treatment of a thoracolumbar burst fracture without neurological deficit: a prospective randomized study with follow-up at sixteen to twenty-two years. JBJS. 2015 Jan 7;97(1):3-9.
  18. 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. Archives of orthopaedic and trauma surgery. 2009 Feb 1;129(2):207-19.
  19. 19.0 19.1 Giele BM, Wiertsema SH, Beelen A, van der Schaaf M, Lucas C, Been HD, Bramer JA. No evidence for the effectiveness of bracing in patients with thoracolumbar fractures: a systematic review. Acta orthopaedica. 2009 Jan 1;80(2):226-32.
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  25. Guide to Physical Therapist Practice. 2nd ed. Revised. Alexandria, Va: American Physical Therapy Association; 2003.(LoE:5)
  26. 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.(LoE:1B)
  27. 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.(LoE:2B)