Fractures of the Thoracic and Lumbar Spine

A spinal fracture is a serious injury.

The most common fractures of the spine occur in the thoracic (midback) and lumbar spine (lower back) or
at the connection of the two (thoracolumbar junction). These fractures are typically caused by high-velocity
accidents, such as a car crash or fall from height.
Men experience fractures of the thoracic or lumbar spine four times more often than women. Seniors are al
so at risk for these fractures, due to weakened bone from osteoporosis.
Because of the energy required to cause these spinal fractures, patients often have additional injuries that
require treatment. The spinal cord may be injured, depending on the severity of the spinal fracture.
Understanding how your spine works will help you to understand spinal fractures. Learn more about your s
pine: Spine Basics
Cause
Fractures of the thoracic and lumbar spine are usually caused by high-energy trauma, such as:
Car crash
Fall from height
Sports accident
Violent act, such as a gunshot wound
Spinal fractures are not always caused by trauma. For example, people with osteoporosis, tumors, or other
underlying conditions that weaken bone can fracture a vertebra during normal, daily activities.
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Types of Spinal Fractures
There are different types of spinal fractures. Doctors classify fractures of the thoracic and lumbar spine bas
ed upon pattern of injury and whether there is a spinal cord injury. Classifying the fracture patterns can hel
p to determine the proper treatment. The three major types of spine fracture patterns are flexion, extension
, and rotation.



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Symptoms
The primary symptom is moderate to severe back pain that is made worse by movement.
When the spinal cord is also involved, numbness, tingling, weakness, or bowel/bladder dysfunction may oc
Rotation Fracture Pattern
Transverse process fracture. This fracture is uncommon and results from rotation or extreme sideways (lateral) bending, and usually does n
ot affect stability.
Fracture-dislocation. This is an unstable injury involving bone and/or soft tissue in which a vertebra may move off an adjacent vertebra (displ
aced). These injuries frequently cause serious spinal cord compression.


Extension Fracture Pattern
Flexion/distraction (Chance) fracture. The vertebra is literally pulled apart (distraction). This can happen in accidents such as a head-on car
crash, in which the upper body is thrown forward while the pelvis is stabilized by a lap seat belt.
Flexion Fracture Pattern
Compression fracture. While the front (anterior) of the vertebra breaks and loses height, the back (posterior) part of it does not. This type of f
racture is usually stable and rarely associated with neurologic problems.
Axial burst fracture. The vertebra loses height on both the front and back sides. It is often caused by a fall from a height and landing on the f
eet.

cur.
In the case of a high-energy trauma, the patient may have a brain injury and may have lost consciousness,
or "blacked-out." There may also be other injuries called distracting injuries which cause pain that ov
erwhelms the back pain. In these cases, it has to be assumed that the patient has a fracture of the spine, e
specially after a high-energy injury (motor vehicle crash).
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Examination



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Treatment
The treatment plan for a fracture of the thoracic or lumbar spine will depend on:
Other injuries and their treatment
The particular fracture pattern
Once the trauma team has stabilized all other life-threatening injuries, the doctor will evaluate the spinal fra
cture pattern and decide whether spine surgery is needed.

Flexion Fracture Pattern
Nonsurgical treatment. Most flexion injuries (compression fractures, burst fractures) can be treated in a brace for 6 to 12 weeks. By graduall
y increasing physical activity and doing rehabilitation exercises, most patients avoid post injury problems.
Surgical treatment. Surgery is typically required for unstable burst fractures that have:
Significant comminution (fracture fragments)
Severe loss of vertebral body height
Excessive forward bending or angulation at the injury site
Significant nerve injury due to parts of the vertebral body or disk pinching the spinal cord
These fractures should be treated surgically with decompression of the spinal canal and stabilization of the fracture. Decompression involves rem
oving the bone or other structures that are pressing on the spinal cord. This procedure is also called a laminectomy.
To perform the decompression, your surgeon may decide to access your spine with an incision either on your side or on your back. Each approac
h allows for safe removal of the structures compressing the spinal cord, while preventing further injury.
Investigation, Tests
Neurological tests. The doctor will also evaluate the patient's neurological status. This includes testing the ability to move, feel, and sense th
e position of all limbs. In addition, the doctor will test the patient's reflexes to help determine injury to the spinal cord or individual nerves.
Imaging tests. After the physical examination, a radiologic evaluation is required. Depending on the extent of injuries, this may include x-rays,
computed tomography (CT ) scans, and magnetic resonance imaging (MRI) scans of multiple areas, including the thoracic and lumbar spine.
Physical Examination
the head, chest, abdomen, pelvis, limbs, and spine.
Emergency Stabilization
At first evaluation, it may be difficult to assess the extent of injuries to patients with fractures of the thoracic and lumbar spine.
At the accident scene, EMS rescue workers will first check vital signs, including the patient's consciousness, ability to breathe, and heart rate.
After these are stabilized, workers will assess obvious bleeding and limb-deforming injuries.
Before moving the patient, the EMS team must immobilize the patient in a cervical (neck) collar and backboard. The trauma team will perform
a complete and thorough evaluation in the hospital emergency room.



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Complications
There are several complications associated with fractures of the thoracic and lumbar spine. One potentially
fatal complication is blood clots in the legs, which may develop from immobility. These clots can travel to t
he lungs and cause death (pulmonary embolism). Pneumonia and pressure sores are also common compli
cations of spinal fractures.
There are also specific surgical complications, including:
Bleeding
Infection
Spinal fluid leaks
Instrument failure
Nonunion
Complications can be reduced by early treatment, mechanical methods (lower leg compression stockings),
and medication to protect against clots, as well as proper surgical technique and postoperative programs.
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Long-Term Outcomes
Regardless of whether the patient is treated with surgery, rehabilitation will be necessary after the injury ha
s healed.
The goals of rehabilitation are to reduce pain, regain mobility, and return the patient to as close to preinjury
state as possible. Both inpatient and outpatient physical therapy may be recommended to meet these goa
ls.
Issues that may complicate these goals include inadequate reduction of the fracture, neurologic injury (par
alysis), and progressive deformity.
Top of pageShe was seen initially at an outside facility, with a reported Glasgow Coma Scale
score of 3 and no visual, verbal, or motor responses. She presented with a transverse abd
ominal ecchymosis (seat-belt sign) but was not injured intraabdominally. In addition, she pr
esented with bruising on her upper chest, particularly around the shoulders. On arrival at th
e trauma center, she underwent radiography and CT of the cervical and thoracic spine that
showed bilateral pulmonary contusions; a paraspinal hematoma; right first and second rib fr
actures; and complex fractures of the upper thoracic spinespecifically, fractures through t
he transverse processes of T1, T2, T4, and T5 on the left as well as bi-lateral transverse pr
ocess fractures of T3, fractures of the pedicle and lamina and posterior facets of T3, and co
mpression fractures of the T4 and T5 vertebral bodies (Figs. 1A, 1B, 1C). Four hours after a
dmission, her state of consciousness improved to a Glasgow Coma Scale score of 11, but
she was insensate below the level of the nipples and was unable to move her legs. MRI lat
er revealed a cord edema from C7 to T4 with spinal canal narrowing at T3 due to a retropul
Surgical Procedure
The ultimate goal for surgery is to achieve adequate reduction (fitting the bones together), relieve pressure on the spinal cord and nerves, and
allow for early movement.
Depending on the fracture pattern, your surgeon may decide to do the procedure through an anterior (front), lateral (side), or posterior (back)
approach, or a combination of all three.
Many types of instruments are used in surgery, including metal screws, rods, and cages to stabilize the spine.
Rotation Fracture Pattern
Nonsurgical treatment. Transverse process fractures are predominantly treated with gradual increase in motion, with or without bracing, bas
ed on comfort level.
Surgical treatment. Fracture-dislocations of the thoracic and lumbar spine are caused by very high-energy trauma. They can be extremely un
stable injuries that often result in serious spinal cord or nerve damage. These injuries require stabilization through surgery. The ideal timing of
these surgeries can often be complicated. Surgery is sometimes delayed because of other serious, life-threatening injuries.
Extension Fracture Pattern
The treatment plan for extension injuries will depend on:
Where the spine fails
Whether the bones can be fit together again (reduction) using a brace or cast
Nonsurgical treatment. Extension fractures that occur only through the vertebral body can typically be treated nonsurgically. These should be ob
served closely in a brace or cast for 12 weeks.
Surgical treatment. Surgery is usually necessary if there is an injury to the posterior (back) ligaments of the spine. In addition, if the fracture falls
through the disks of the spine, surgery should be performed to stabilize the fracture.
sed fragment (Figs. 1D and 1E). Posttraumatic bone marrow edema was also present from
T3 to T7.


View larger version (62K)


Fig
. 1
A
.
18-
ye
ar-
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w
om
an
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h
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ltipl
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au
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ont
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ro
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View larger version (75K)


Fig
. 1
B
.
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om
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an
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View larger version (62K)


Fig
. 1
C
.
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om
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View larger version (68K)


Fig
. 1
D
.
18-
ye
ar-
old
w
om
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h
mu
ltipl
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act
ure
s a
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au
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R i
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ow
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ad
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.


She was seen initially at an outside facility, with a reported Glasgow Coma Scale score of 3
and no visual, verbal, or motor responses. She presented with a transverse abdominal ecc
hymosis (seat-belt sign) but was not injured intraabdominally. In addition, she presented wit
h bruising on her upper chest, particularly around the shoulders. On arrival at the trauma ce
nter, she underwent radiography and CT of the cervical and thoracic spine that showed bila
teral pulmonary contusions; a pparaspinal hematoma; right first and second rib fractures; a
nd complex fractures of the upper thoracic spinespecifically, fractures through the transv
erse processes of T1, T2, T4, and T5 on the left as well as bi-lateral transverse process fra
ctures of T3, fractures of the pedicle and lamina and posterior facets of T3, and compressio
n fractures of the T4 and T5 vertebral bodies (Figs. 1A, 1B, 1C). Four hours after admission
, her state of consciousness improved to a Glasgow Coma Scale score of 11, but she was i
nsensate below the level of the nipples and was unable to move her legs. MRI later reveale
d a cord edema from C7 to T4 with spinal canal narrowing at T3 due to a retropulsed fragm
ent (Figs. 1D and 1E). Posttraumatic bone marrow edema was also present from T3 to T7.


View larger version (62K)


Fig
. 1
A
.
18-
ye
ar-
old
w
om
an
wit
h
mu
ltipl
e fr
act
ure
s a
fter
au
to
mo
bil
e a
cci
de
nt.
Ra
dio
gra
ph
of
up
per
th
ora
cic
spi
ne
sh
ow
s b
ilat
era
l u
pp
er l
ob
e p
ul
mo
nar
y c
ont
usi
on
s a
nd
ple
ura
l ef
fus
ion
s.
Ant
ero
po
ste
rior
vi
ew
is
su
gg
est
ive
of
fra
ctu
re
at r
igh
t p
edi
cle
of
T3
(ar
ro
w).


View larger version (75K)


Fig
. 1
B
.
18-
ye
ar-
old
w
om
an
wit
h
mu
ltipl
e fr
act
ure
s a
fter
au
to
mo
bil
e a
cci
de
nt.
Sa
gitt
al (
B)
an
d c
oro
nal
(C
) C
T r
ec
on
str
uct
ion
s s
ho
w
hor
izo
nta
l fr
act
ure
of
T3
wit
h d
istr
act
ion
of
po
ste
rior
el
em
ent
s (
arr
ow
s).


View larger version (62K)


Fig
. 1
C
.
18-
ye
ar-
old
w
om
an
wit
h
mu
ltipl
e fr
act
ure
s a
fter
au
to
mo
bil
e a
cci
de
nt.
Sa
gitt
al (
B)
an
d c
oro
nal
(C
) C
T r
ec
on
str
uct
ion
s s
ho
w
hor
izo
nta
l fr
act
ure
of
T3
wit
h d
istr
act
ion
of
po
ste
rior
el
em
ent
s (
arr
ow
s).


View larger version (68K)


Fig
. 1
D
.
18-
ye
ar-
old
w
om
an
wit
h
mu
ltipl
e fr
act
ure
s a
fter
au
to
mo
bil
e a
cci
de
nt.
Sa
gitt
al
T1-
(D)
an
d T
2-(
E)
wei
ght
ed
M
R i
ma
ge
s o
f u
pp
er t
hor
aci
c s
pin
e s
ho
w
ant
ero
list
he
sis
at f
rac
tur
e l
ev
el
wit
h s
trip
pin
g o
f p
ost
eri
or l
on
git
udi
nal
lig
am
ent
(bl
ac
k a
rro
w
, D
), d
isr
upt
ion
of
int
ers
pin
ou
s li
ga
me
nt (
whi
te
arr
ow
s),
an
d c
om
pre
ssi
on
of
spi
nal
co
rd
wit
h c
ord
ed
em
a (
arr
ow
he
ad
s
, E)
.




Read More: http://www.ajronline.org/doi/full/10.2214/ajr.183.5.1831475

Read More: http://www.ajronline.org/doi/full/10.2214/ajr.183.5.1831475
Last reviewed: February 2010