The human spine has four sections. Out of these sections, the thoracic spine that is more commonly referred to as our upper back consists of 12 thoracic vertebral bones. Fractures along these vertebrae can be quite dangerous, with a 15-20% possibility of developing into serious neurological impairments. These are also the most common of the spine fractures. Thoracic fractures are generally a result of high impact accidents. However, they may occur from low impact injuries too, if you are above 50 years of age and/or suffer from osteoporosis. Mainly because osteoporosis makes your bones weak, due to age related changes and calcium deficiency. Individuals suffering from osteoporosis are much more prone to develop compression fractures due to weakened bones of the upper and lower back. Such compression or osteoporotic fractures are a frequent occurrence today; with approximately 700,000 Americans suffering from osteoporotic fractures of the spine every year. Unfortunately, a very small number of these cases are diagnosed clinically.
Despite the fact that osteoporosis could culminate into thoracic fractures, their major causes are high impact accidents, with 45% of them resulting from motor vehicular accidents, 20% from falls, 15% from sports injuries, and another 15 % from violent acts such as gunshot injuries, etc. The remaining 5% are a result of miscellaneous causes that include osteoporosis and other age related changes to the spine. Some of these causes can lead to devastating injuries with permanent neurological impairments.
Men are more likely to suffer from thoracic fractures in general, but the osteoporotic fractures seem to occur more frequently among menopausal women due to hormonal changes and low bone mass. In fact, some statistics suggest that as many as 25% of menopausal women in the United States have had an osteoporotic fracture of the vertebrae. However, if you are above 50 years of age and develop a thoracic fracture, it is most probably an osteoporotic fracture, regardless of its cause and your sex.
Thoracic fractures are of various types, broadly categorized as extension, flexion, and rotation fractures. Your doctor will determine the suitable treatment plan in your case based on the type of thoracic fracture you have. Not just your treatment plan, but also the possibility and extent of the neurological injuries you may experience, depend on the category of your fracture. Hence, it is essential to get yourself treated immediately in the unforeseen event of a thoracic fracture, mainly because a single vertebral fracture often increases the risk of fractures in the rest of the vertebrae, pelvic bones, and wrist joints.
Thoracic fractures are better visualized with a CT scan of the thoracic spine, rather than on an X-ray and that’s why you will be asked to undergo CT scans of your back by your neurosurgeon to rule out a thoracic fracture, or to monitor the progress of an existing one.
Types of thoracic fractures:
Flexion Fractures: These fractures mainly affect the vertebral body leading to a loss of vertebral height and are of two types’ compression, and axial burst fractures. Compression fractures compress the front of the vertebrae or the part facing your chest, whereas axial burst fractures affect the back of the vertebrae or the part facing outwards along your skin.
Extension Fractures: In such fractures, the vertebrae are pulled apart leading to extensive damage.
Rotation Fractures: These fractures are of two types, the transverse process fractures that occur due to trauma from extreme rotation or side ways bending of the waist, and the extremely dangerous dislocation fracture that affect the bones as well as the surrounding soft tissues due to the displacement of a vertebrae. Dislocation fractures can make the spine unstable, and often cause spinal cord compression with consequent neurological injuries.
• Back pain that varies in severity from moderate to severe is usually the first, and the most important symptom indicating a thoracic fracture. The pain generally worsens on movements involving the back, like walking or standing, and is better on lying down.
• Involvement of the spinal cord from accompanying neurological injuries can produce weakness, numbness, tingling, and abnormal bowel movements and urination.
• Osteoporotic or compression fractures can lead to reduction in your height and other spinal deformities.
• High impact traumas that lead to more severe forms of thoracic fractures usually precipitate serious symptoms such as blackouts, loss of consciousness, and sometimes brain injury.
Depending on the extent, site, and the type of your thoracic fracture, your doctor will decide on the most suitable treatment approach. Thoracic fractures that do not affect the stability of your spine and cause minimal neurological defects such as the flexion and compression fractures seldom require surgery. The non-surgical approach for such fractures is as follows:
• Non-steroidal anti-inflammatory drugs such as ibuprofen, naproxen, and aspirin are usually the first line of treatment to counter back pain.
• Most thoracic fractures are better with the use of braces for 6-12 weeks, physiotherapy, and a gradual increase in physical activity. There are different types of braces available for this purpose, and their utility in the treatment of such fractures depends on the extent of the fracture and the level of immobilization of the spine required in individual cases.
Factors indicative of spinal surgery for thoracic fractures include the level of neurological injury and an unstable spine due to the presence of deformities, such as loss of vertebral body, fragments, abnormal bending of the spine at the site of injury, disc displacement, and dislocations. Besides, a kyphosis or abnormal curvature of the spine that exceeds 250 is also an indication for surgery.
The presence of other traumatic injuries may affect your doctor’s decision regarding a surgical or non-surgical approach too. Sometimes, surgery cannot improve the patient’s neurological deficit; however, it is still indicated for the mobilization of the spine. Once, your neurosurgeon has confirmed your eligibility for spine surgery, the next step is to decide the approach.
The ultimate aim of spine surgery in this regard is to fit your bones back together in the best way possible, and reduce the pressure on the surrounding nerves and spine. Your surgeon will use metal screws, rods, and cages to achieve this goal. Depending on the nature of your injuries the site of the incision, i.e. in the front, side, or back is determined.
Decompression or laminectomy surgery performed to remove the structures and bones pressing on to the spinal cord through a side and/or back incision, is the procedure of choice for compression and burst fractures. These incisions allow safe removal of the fractured fragments without causing further nerve injury. However, laminectomy for the fusion of thoracic fractures requires the use of instruments or anchors such as, pedicle screws, wires, and hooks to improve the outcome of such surgeries.
The outcome of thoracic fractures without neurological deficit is very good. Such fractures and even those with minimal nerve involvement, improve with physiotherapy and rehabilitation over time. Neurological injuries, deformities, severe dislocations, spine compressions, and kyphosis exceeding 300 often indicate a poor long-term prognosis. Hence, regardless of a surgical or non-surgical approach your prognosis depends on the presence and extent of the neurological deficit and injuries accompanying your thoracic fracture. Some studies indicate that spinal surgery carried out within 72 hours of trauma can considerably reduce the extent of neurological injury and complications. However, in case of multiple high intensity traumas, the time of spine surgery is often delayed due to the other more pressing life-threatening injuries that require immediate action.
1. Melton L.J. 3rd, “Epidemiology of spinal osteoporosis,” Spine, 1997;22:2S-11S.
2. Harrison’s Principles of internal medicine, 18th edition, chapters 15, 354