Compression fracture of the thoracic spine - treatment, surgery and rehabilitation

5 February 2020

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3.8 out of 5

Spinal fractures are serious and, unfortunately, not uncommon injuries that can not only lead to disability, but also take a person’s life. One of their common varieties is a compression fracture of the thoracic vertebrae. Among all spinal fractures, they account for about 40%.

The thoracic spine is represented by 12 vertebrae of medium size, gradually increasing. The last thoracic vertebra is the largest in this section, however, this does not make it more resistant to deformation. Compression fractures can occur in any of them. They are characterized by “flattening” of the vertebral bodies, as a result of which the anterior part takes on the shape of a wedge.

Causes

The main cause of compression fractures is osteoporosis. This disease is characterized by calcium deficiency, which leads to a gradual decrease in bone strength. They become loose, and even a slight load can lead to the formation of cracks, destruction or flattening of the vertebra. Most often this happens when lifting heavy objects or making sudden movements. But in some cases, even sneezing or going down the stairs can provoke deformation of the thoracic vertebra.

Due to the characteristics of age, people aged 12–20 years and older than 58 years are most susceptible to compression fractures of the thoracic spine.

Compression fractures can also occur in healthy people with normal calcium levels as a result of:

falling on your back from a height, including at home;
road accident;
diving in reservoirs with uneven bottoms;
blows to the back in the thoracic spine;
falling heavy objects onto your back.

In addition to osteoporosis, there are a number of other diseases that contribute to increased bone fragility and increase the risk of spinal fracture. This:

benign and malignant tumors of the spine and nearby tissues;
formation of metastases in the spine when the malignant neoplasm is localized in another organ;
tuberculosis of bones.

Kinds

Compression fractures are divided into 3 types depending on the severity of the injury:

Grade 1 – the mildest, vertebral height decreases by less than 30%;
2nd degree - the vertebra is flattened by half;
Grade 3 – vertebral height is reduced by more than 50%.

A decrease in vertebral height can be combined with the formation of bone fragments, which pose a serious threat. They can injure surrounding tissues, as well as nerve roots and the spinal cord itself, which is a serious complication. If this is present, the fracture is called complicated. Otherwise, they speak of an uncomplicated injury.

Symptoms

With fractures of the thoracic vertebrae, especially from 1 to 10, the symptoms are not as acute as with injuries to other parts of the spine. This is due to significantly less mobility of the components of the thoracic region; they are little involved in performing usual everyday activities and experience less stress.

Damage to the 12th thoracic vertebra is associated with severe symptoms, since this part of the spine is very mobile. This also leads to frequent occurrence of signs of damage to nerve structures.

The main symptoms of a fracture of the vertebrae of the thoracic spine are:

pain in the chest, back and upper abdomen, which tends to intensify with movement, breathing and changing body position;
irradiation of pain in the groin, abdomen and a significant decrease in their intensity when taking a supine position;
back muscle tension;
limited mobility;
change in posture;
swelling of soft tissues in the affected area;
formation of hematomas;
disruption of the gastrointestinal tract and urinary system.

Compression fractures of the thoracic region are often accompanied by the formation of a small hump in the projection of the injured vertebra. It is formed by the tops of two spinous processes of adjacent vertebrae, which, as a result of a decrease in the height of the anterior part of its body, have shifted from their normal position.

If a spinal fracture causes nerve damage and compression of the spinal cord, you may experience:

difficulty breathing;
dizziness, fainting;
impaired sensitivity and decreased muscle tone of the limbs.

What is a vertebral compression fracture?

The human spine consists of 32-33 vertebrae, the vast majority of which, in addition to the body, also have arches with processes of different sizes. Between the vertebral bodies are cartilages called intervertebral discs. In addition, joints are also formed between the processes of the arches of adjacent vertebrae.

A compression fracture is a situation when the body of one or more adjacent vertebrae is flattened under the influence of a high load perpendicular to them. In such cases, there is a decrease in the height of the vertebra on one side, i.e. it takes on a wedge shape. This may be accompanied by the formation of cracks or even separation of bone fragments, which will provoke injury to soft tissues.

Each of the vertebrae of the spine can suffer from compression fractures. But most often they affect the vertebrae of the thoracic and lumbar spine, especially the 11th and 12th thoracic and 1st lumbar vertebrae.

Thus, the formation of a compression fracture entails not only the development of the inflammatory process, but also provokes a distortion of the shape of the entire spinal column. After all, a wedge-shaped deformation of one, or even more so several, vertebrae provokes a displacement of the overlying ones, which causes stoop, pathological changes in the intervertebral discs, compression of the spinal roots passing through the holes formed by the processes of the vertebral arches, blood vessels and a number of other disorders.

But these are far from the worst consequences of a compression fracture. The main danger lies in the fact that the spinal cord passes inside the spinal canal, formed on one side by the vertebral bodies and on the other by their arches with processes. This is an important part of the central nervous system, the quality of which determines the correct functioning of not only all parts of the body, but also almost all organs. Therefore, if fragments form when a vertebral body is fractured, they can injure the delicate spinal cord. The consequence of this will be complete and irreversible paralysis of the entire body, below the level of damage to the spinal cord.

Complications of a compression fracture can include:

osteochondrosis, intervertebral hernia;
kyphosis, hump formation;
radicular syndrome, accompanied by impaired sensitivity and mobility of certain parts of the body;
spinal stenosis;
formation of vascular malformations, hematomas in the spinal cord;
disturbances in the functioning of internal organs, in particular loss of control over urination and bowel movements;
migraines, stroke;
disability, etc.

Therefore, if you have recently fallen, suffered a blow to your back, or simply have pain in the spine, you should consult a doctor as soon as possible. Timely consultation and examination will make it possible to detect an injury before it has time to provoke complications and lead to loss of performance.

Diagnostics

Patients with back pain are examined by a vertebrologist or traumatologist if the onset of pain was preceded by injury. The doctor will interview the patient, find out under what conditions the pain occurred, and conduct a thorough examination. Based on increased pain when pressing and percussion, reflex muscle tension and a number of other signs, the doctor can assume the presence of a fracture of the thoracic spine and refer the patient to instrumental research methods.

The basis for diagnosing compression fractures of the spine is x-ray in two projections. This is enough to see a change in the height of the vertebra and a violation of the integrity of its components. To get a more complete picture, patients may be prescribed:

CT scan – provides more complete information than classic X-rays;
MRI – allows you to assess the condition of intervertebral discs, ligaments and the degree of spinal cord stenosis;
electromyelography – allows you to evaluate the quality of the conduction of bioelectric impulses from the spinal cord to the muscles.

If osteochondrosis is suspected, especially in people of the older age group, densitometry is performed. The method allows you to determine bone density and diagnose or refute the presence of osteochondrosis.

Treatment

Treatment of compression fractures of the thoracic region is possible conservatively and surgically. Moreover, the choice of tactics depends not on the wishes of the patient, but on the degree of the fracture and the presence of neurological complications. In both cases, the doctors’ tasks are to eliminate pain, restore the anatomically correct position of the vertebra and accelerate regeneration processes.

Conservative treatment of thoracic spine fractures

Compression fractures of the thoracic spine of the 1st degree are successfully treated conservatively. In such situations, skeletal traction is usually initially prescribed. The goal of the procedure is to stretch the spine, allowing the vertebrae to return to their anatomically correct position.

After this, be sure to apply a plaster cast or put on a reclinator. This orthopedic device is a type of corset. It contains a hard platform designed to protect the injured area of the spine. Semi-rigid and at the same time elastic straps are attached to its corners, supporting the spine in the desired position and reducing the load on it.

Initially, all patients must adhere to strict bed rest. At the same time, they need a hard orthopedic mattress or shield. Also mandatory components of conservative treatment are:

drug therapy;
exercise therapy;
massage;
physiotherapy.

Drug therapy

From the very first day of treatment, the patient is prescribed medications. The initial goal is effective pain relief. For this purpose, analgesics from various pharmacological groups, including narcotic ones, are prescribed. To quickly relieve pain, novocaine blockades are performed.

Also assigned:

calcium and vitamin D preparations;
chondroprotectors;
corticosteroids;
immunostimulants.

The length of time you take each drug varies from case to case. Some of them can be administered parenterally to accelerate the onset of the therapeutic effect and increase its severity with the same dose of the drug.

Exercise therapy

If the doctor has allowed the patient to stand up and walk, this should definitely be done, even if adopting a vertical body position causes discomfort. This is due to the fact that in a supine position, calcium is washed out of the body more actively, so walking contributes to a faster recovery after a fracture.

Massage

It is impossible to activate blood flow and maintain muscle tone during a forced sedentary lifestyle without a properly performed therapeutic massage. But it is important that the sessions are conducted by a qualified specialist, whose actions would not provoke a deterioration in the patient’s condition and displacement of the injured vertebrae.

Physiotherapy

Physiotherapeutic procedures potentiate other components of conservative treatment for compression fractures of the thoracic spine. Patients are prescribed courses of 10–12 procedures:

UHF;
reflexology;
ultrasound therapy;
Sollux;
paraffin and ozokerite wraps.

Ultraviolet irradiation and electrophoresis with the introduction of calcium and phosphorus preparations are considered especially effective. The duration of each procedure is on average 10–15 minutes.

Surgical treatment of thoracic spine fractures

Today, neurosurgeons have many minimally invasive techniques in their arsenal for treating compression fractures. They make it possible to return a broken vertebra to its normal position without serious tissue injury and give it the necessary strength. All manipulations are carried out through a special thin needle or cannula, so after the operation there are no rough scars left, and recovery proceeds quickly. Such minimally invasive interventions used for fractures of the thoracic spine include vertebroplasty and kyphoplasty.

But they can only be used for uncomplicated fractures. If there are signs of damage to nerve structures, spinal cord compression, or spinal instability, neurosurgeons resort to other surgical techniques. In such situations, open operations are indicated, during which the anatomy of the spine is restored with special plates, meshes and other fixing elements. Most often, transpedicular fixation is performed, the technique of which is now 100% proven.

In the most difficult cases, when the vertebra cannot be restored or seriously threatens the integrity of the spinal cord, it is partially or completely removed, i.e., a laminectomy is performed. If necessary, the removed vertebra is replaced with artificial implants or autografts.

Verterbroplasty

Vertebroplasty is a microsurgical operation during which a compression fracture of the spine is eliminated by injecting a special composition – bone cement – into the body of the injured vertebra. This substance is supplied to neurosurgery centers in the form of two components, which are mixed immediately before injection into the vertebra.

Vertebroplasty is highly effective and always leads to an improvement in the patient’s condition. Since the vertebrae are formed by porous spongy bone tissue, filling the natural pores with bone cement leads to a manifold increase in their strength. But since the procedure is not able to “straighten” a broken vertebra, they are performed only for those compression fractures that are accompanied by a decrease in the height of the vertebral body by less than 70%.

The essence of the operation is to insert a thin needle into the vertebral body under X-ray control (usually CT or image intensifier). Bone cement is then prepared. Initially it looks like a paste that easily fills all the natural voids of the bone, but within 8-10 minutes it hardens, turning the vertebra into a high-strength conglomerate and eliminating the risk of its fracture in the future. The needle is removed from the patient's body after the bone cement has hardened, and the remaining puncture is covered with a sterile dressing.

Since the bone cement contains an X-ray contrast agent, the neurosurgeon fully controls the process of filling the vertebra with it and avoids the composition leaking beyond its boundaries. The presence of an antibiotic in the composition eliminates the risk of developing an infectious and inflammatory process, therefore vertebroplasty is considered a safe and highly effective operation.

It takes about 40 minutes and is often performed under local anesthesia. But vertebroplasty cannot be performed if you are allergic to the components of bone cement and if you have malignant tumors or metastases in the spine.

Kyphoplasty

Kyphoplasty is a more advanced percutaneous surgery technique that does not have some of the disadvantages of vertebroplasty. The essence of both operations is similar, but with kyphoplasty, an empty balloon is initially inserted into the vertebral body, into which saline solution is injected.

This allows you to “straighten” the vertebra and completely restore its natural size and position. X-ray contrast barium sulfate is dissolved in advance in the injected solution, so the neurosurgeon can accurately see its position and the degree of restoration of the parameters of the vertebral body on the X-ray machine monitor. As soon as it is possible to achieve its normal size, the fluid and balloon are removed, and bone cement is injected into the vertebral body, as with vertebroplasty.

An additional advantage of kyphoplasty is the ability to eliminate kyphotic deformity of the spine, often observed with compression fractures of the thoracic spine. With it, the risks of bone cement getting outside the vertebra are sharply reduced, and the achieved result allows you to avoid not only repeated fractures, but also restore normal posture, and also avoid limitation of mobility.

Unlike vertebroplasty, kyphoplasty can be performed even with compression fractures accompanied by a decrease in vertebral height by more than 70%. But it is performed under general anesthesia, so it requires more serious preparation.

Transpedicular fixation

This type of surgery involves fixing damaged vertebrae with special titanium screws and rods. They are produced in different types and sizes, which allows you to select the optimal type of screws for each patient with vertebral fractures at any level.

Transpedicular fixation is performed for unstable fractures. During the operation, an incision is made over the injured vertebra. The neurosurgeon then separates the spinous processes and vertebral arches. Direct fixation of the vertebra occurs by screwing screws into the intersection points of the transverse and articular processes.

Once all the titanium screws are installed, rods are passed through the holes in them, designed to evenly distribute the load on the entire system. Ultimately, the created structure reliably holds the vertebra in a given position and is not subject to distortion. The postoperative wound is sutured in layers and covered with a sterile bandage.

When performed correctly, transpedicular fixation does not lead to the development of undesirable consequences and complications. But it cannot be performed for certain diseases, including bleeding disorders, decompressed diabetes mellitus, pregnancy and others.

Laminectomy

In some cases, it is necessary to perform one of the most traumatic operations on the spine - laminectomy. It involves making a large incision in the projection of the damaged vertebra and carefully separating the soft tissues from the elements of the spine.

During a laminectomy, the surgeon can remove the spinous processes, vertebral arches, sharp fragments, and the vertebral body. Sometimes it is necessary to remove the entire spinal motion segment, which is subsequently replaced with an artificial implant or graft.

Laminectomy is used for compression and fragmentation fractures complicated by damage to the spinal cord and nerve fibers. But it requires long and complex rehabilitation.

Chest corset

For a compression fracture, one of the main components of the treatment and recovery process is wearing an orthopedic corset. It is prescribed both for conservative treatment and after surgery. It reliably fixes the back in the correct position, minimizes pressure on the spinal membrane and nerve roots, prevents pathological displacement of the vertebrae, and accelerates bone fusion.

One of the corset options.

The rigidity, size and degree of fixation of the product are selected by an orthopedist. Sometimes it is necessary to make it according to individual measurements so that it reproduces as accurately as possible all the physiological curves of the back. The approximate price is about 15 thousand rubles. It will be much more expensive to buy a corset made to measure.

Wearing a corset is just as important as, at certain stages of recovery, undergoing massage, exercise therapy, physiotherapy procedures and other activities prescribed by a doctor. An orthopedic bandage is used from 1 to 6 months for several hours a day (3-6 hours).

Rehabilitation

After an injury to the thoracic spine, it is important to help the body recover fully. As part of rehabilitation, patients are recommended to:

regularly engage in exercise therapy according to a scheme developed by a doctor;
conduct massage sessions;
monitor your diet;
undergo physiotherapeutic procedures.

Particularly important in rehabilitation is exercise therapy. Thanks to them, physiologically normal mobility of the spinal motion segments is restored, muscle tone increases, which provides reliable support for the spine and improves posture. In addition, special exercises help reduce the intensity of pain and improve the patient’s condition.

The intensity and duration of classes are increased gradually. The rehabilitation specialist selects the level of load individually so that it has a positive effect, but does not cause harm to the damaged spine.

At the final stages of rehabilitation, patients with fractures of the thoracic spine can already perform quite complex exercises:

standing, bend forward and backward, make turns with the body, unfolding the shoulder girdle;
perform lateral bends;
do backbends from a position standing on all fours, etc.

To ensure that rehabilitation proceeds quickly and easily, the diet includes foods that are sources of calcium, phosphorus and vitamins, in particular fermented milk products, oatmeal and buckwheat porridge, and vegetables. In this case, you should avoid high-calorie foods, alcohol, strong tea and coffee.

Physiotherapeutic procedures accelerate blood circulation, promote faster bone consolidation and reduce pain. Patients are recommended sessions of magnetic therapy, ultraviolet irradiation, electrophoresis, etc.

Exercise therapy of the thoracic region for a fracture

Therapeutic exercises for compression lesions of the thoracic localization are the most important part of the treatment program. Exercises after a compression fracture are chosen by the rehabilitation specialist together with the main specialist.

The complex is suitable for adults too.

Let's return to the topic of physical therapy. Restorative exercises are supervised by a physical therapy instructor to prevent gross technical errors. Movements should be smooth and calm, without sudden jerks, and have a gentle amplitude. Charging is performed in a lying position. Failure to comply with the time frame, restrictions regarding the physical regime and any attempts to force the load will lead to a deterioration in health, an exacerbation of the disease, and it is possible that a re-fracture.

Continuation.

In the early recovery period, light gymnastics for 10 minutes, breathing techniques and feasible tasks to work out various muscle groups are recommended to prevent their atrophy. Early exercise therapy includes exercises such as:

clenching of fingers and toes;
diaphragmatic breathing;
rotation of the feet and hands;
isometric tension of the thigh, gluteal, calf muscles;
flexion/extension of the upper limbs at the elbows;
bringing the toe of the foot towards you;
bending the legs at the knee joint, sliding the feet along the surface;
tension/relaxation of the spinal muscles.

At the end of the initial stage, more complex elements are included, which allow increasing blood circulation in the problem area, normalizing the functionality of internal organs and, of course, preparing the muscle frame to perform more complex tasks of physical activity. The total time of one full lesson, including a varied set of exercises for CP, will be about 20 minutes. Physical therapy begins and ends with breathing exercises. Approximate complex of the second period:

isometric contractions of the spinal muscles;
flexion/extension, extension of arms;
turning the head to the right/left, combined with hand movements;
bending the lower limbs at the knees followed by straightening the legs in an elevated position;
alternately spreading the lower limbs to the sides;
bending the chest area with support on the elbows;
raising the head and shoulder girdle;
imitation of cycling with legs, etc.

The exercise therapy complex becomes more diverse and the intensity of the load increases. The exercises are still performed while lying on your stomach or back. Training while standing on all fours and on your knees is gradually being introduced. In the final stages of recovery, light weight and resistance tasks are included. In the last stages of rehabilitation, half-squats on toes, measured bends back in a standing position, rolls from heel to toe are prescribed, while you need to hold on to the crossbar with your hands. The duration of the training increases to 30 minutes, they are performed twice a day.

Patients are prohibited from sitting for at least 2 months. The limit is to go after 10 days, and for some only after 1.5-2 months. If one of the cementoplasty technologies was used to augment and consolidate a cracked vertebra, verticalization of the patient is possible on the same day after surgery.

Possible complications

Compression fractures of the thoracic spine, which were not immediately diagnosed and not properly treated, can lead to serious complications that can result in a person’s disability.

The most dangerous complication of a compression fracture is damage to the spinal cord, nerve roots and large blood vessels. If the injury causes a contusion or rupture of the spinal cord, this leads to irreversible paralysis and disability.

Lack of timely treatment of a compression fracture of the thoracic spine can be complicated by:

segmental vertebral instability;
kyphotic deformity of the thoracic spine;
persistent movement disorders;
osteochondrosis, protrusions and hernias of intervertebral discs of the thoracic spine;
persistent disruption of the gastrointestinal tract.

To avoid the development of dangerous complications, patients with back pain, especially those arising after an injury, must immediately contact a vertebrologist or traumatologist and strictly follow his recommendations.

A compression fracture of the thoracic spine is a serious injury, but in most cases, grade 1 fractures heal well and do not lead to disability. For grade 2 and 3 fractures, the prognosis depends on how quickly treatment is started and the correct selection of the period of immobilization, surgical tactics and the quality of its implementation.

Clinical example No. 2

Patient B., 25 years old, as a result of diving in shallow water, hit his head on the bottom of the reservoir, felt acute pain in the neck, lack of sensitivity, and inability to move in both lower extremities. He was admitted to the clinic on the 3rd day after the injury. Computed tomography (CT) and radiography of the cervical spine were performed, and a complicated comminuted fracture of the body and arch of the C6 vertebra with displacement was diagnosed. Lower paraplegia, upper paraparesis. Dysfunction of the pelvic organs.

Upon examination, the neurological status revealed: lower paraplegia, upper paraparesis. Active movements in the shoulder and elbow joints are preserved in full, the strength of the flexor and extensor muscles of the forearm is preserved. Paresis of flexion and extension of the hands 3 b. Paresis of flexion of fingers 2-3 b. Allodynia is noted in the area of innervation of the ulnar nerve of both upper extremities. Tendon reflexes in the upper extremities are symmetrical and reduced. Knee and Achilles reflexes are absent. A mosaic decrease in sensitivity starting from a line 1 cm below the nipples.

On the day of admission, surgery was performed: Subtotal resection of the C6 body, decompression of the spinal cord, installation of a C5-C7 bone replacement implant, fixation of C5-C7 with a plate.

In the neurological status, there is a decrease in the zones of an- and hypoesthesia, starting from a line 1 cm below the nipples, and the appearance of the urge to urinate. Lower left-sided monoplegia. There is the appearance of active movements in the toes of the right foot 2b, dorsal and plantar flexion of the right foot 2 points, an increase in the strength of the flexor muscles of the fingers of both hands. The patient is activated within the ward: stands supported by a walker in splints for the knee and ankle joints, with additional support

After 12 months, complete restoration of motor and sensory functions was noted.