Thoracic Spine Injury

By admin Last updated Nov 5, 2023

Ovid: 5-Minute Sports Medicine Consult, The

Karrn Bales

James Bales

Basics

Cautions:

In a traumatic injury suspicious for a thoracic spine fracture, immobilize the patient on a spine board immediately.
Patients with a neurologic deficit should be transported directly to a trauma center.

Description

Thoracic spine fracture:
- Rarely seen in sports but potentially very catastrophic when it occurs: Seen in collision sports such as hockey, football, and wrestling
- The spinal column can be divided into three anatomically distinct columns. If 2 of the 3 columns are disrupted, then the spinal column is unstable.
- Posterior column: Posterior bony arch and interconnecting ligamentous structures
- Middle column: Posterior aspects of the vertebral bodies, posterior annulus fibrosis, and posterior longitudinal ligament
- Anterior column: Anterior longitudinal ligament, anterior annulus fibrosis, and anterior vertebral body
- Fracture types:
  - Isolated articular fracture
  - Transverse process fracture
  - Spinous process fracture
  - Pars interarticularis fracture (more commonly seen in the lumbar spine)
  - Compression fracture (anterior or lateral flexion forces)
  - Fracture of anterior portion of vertebral body with intact middle column of spine: May have posterior column disruption
  - Burst fracture (axial loading forces)
  - Fracture through middle column of spine: May have spreading of posterior elements and lamina fractures
  - Fracture dislocations: Failure of all 3 columns following compression, tension, rotation, or shear forces
Thoracic diskogenic pain:
- The 3 basic structures of normal vertebral disks:
  - Nucleus pulposus: Gelatinous core of the disk, composed mostly of water and proteoglycans
  - Annulus fibrosus: Surrounds the nucleus pulposus, composed of water and concentric layers of collagen; tears in the innervated outer 3rd aspect may be clinically significant.
  - Vertebral endplates: Lie on the superoinferior aspect of the disks adjacent to the vertebral bodies and aid in the diffusion of nutrients into the disks
- Four categories of thoracic disk herniations:
  - Central: May cause spinal cord compression; patients may present with increased muscle tone, hyperreflexia, abnormal gait, and/or urinary/bowel incontinence.
  - Centrolateral: May result in a presentation resembling Brown-Sequard syndrome, with ipsilateral weakness and contralateral pain or sensory disturbances
  - Lateral: May cause nerve root compression and radiculopathy
  - Intradural: Rare, <10% of cases
Muscular contusions: Caused by a direct blow that results in bleeding in the muscle fibers; seen especially in contact sports with potential for falling (football and wrestling)
Muscular strains:
- Stretch tear of at least one of the back muscles or ligaments
- Seen most frequently in sports involving twisting and turning
Facet syndrome:
- Back pain associated with an overriding of the facets
- Usually diagnosed by exclusion when there is no evidence of disk herniation or spinal stenosis
Scheuermann kyphosis (juvenile diskogenic disease):
- Anterior wedging of at least 5 degrees of 3 consecutive thoracic vertebral bodies
- Hyperkyphosis of thoracic spine and hyperlordosis of lumbar spine
Spinal tumors;
- Maintain a high index of suspicion in younger patients with night pain, fevers, and systemic symptoms.
- Primary tumors that occur in posterior elements are usually benign.
- Osteoid osteoma, osteoblastoma, giant cell tumor, hemangioma, aneurysmal bone cyst, eosinophilic granuloma
- Vertebral body tumors are often malignant in the younger population.
- Solitary plasmacytoma, Ewing sarcoma, osteosarcoma, chondrosarcoma, chordoma, lymphoma

Epidemiology

Thoracic spinal fractures:
- 19–50% of fractures in the thoracolumbar spine region are associated with neurologic damage and compression to the spinal cord.
- 15% of spinal fractures are seen in sports, the 3rd most common general cause after motor vehicle accidents (45%) and falls (20%).
  - In sports-related injuries, the most common cause of fracture is water sports (65%).
  - Of the water sports, diving is the most common cause (60%).
- Male-to-Female ratio of spinal fractures 4:1
- Mean age: 24 ± 12 yrs
Scheuermann kyphosis: Seen between the ages of 10 and 15 yrs
Facet syndrome: Up to 40% of back pain is caused by facet inflammation.

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Sport-specific injuries:
- Football players have increased risk of degenerative disk disease, facet degeneration, and chronic back pain that is proportional to their years of involvement in their sport.
- Weight lifting is also associated with degenerative disk disease as well as sprains/strains of the spinal musculature and ligaments.
- Endurance athletes also may be at risk. Butterfly swimmers and rowers are at risk for rib subluxation from the transverse processes of the thoracic spine, usually at the 6th or 7th level.
- Disk herniation is seen in any athletes participating in sports involving axial rotation of the spine, such as golf.

Incidence

Scheuermann kyphosis:

1–8% of the general population
True incidence is probably underreported because the diagnosis is often missed or attributed to poor posture.

Prevalence

Scheuermann kyphosis: Prevalence is approximately equal in males and females.

Etiology

The thoracic spine is very rigid owing to the rib cage and the costovertebral articulations. The spinal canal is narrowest in the thoracic spine
Little flexion-extension motion
Strong flexion-extension forces combined with axial load are not tolerated well biomechanically and may lead to injury.
Cervicothoracic junction and thoracolumbar junction are susceptible to shear and flexion-extension forces.
The thoracic spine, enclosed and protected by the rib cage, has vertically oriented facets to facilitate rotation.
Thoracic spine fracture:
- Most thoracic spine fractures occur in the lower thoracic spine or at the thoracolumbar junction.
- Rotational or extension forces may fracture the pars interarticularis and damage facet joints.
Thoracic diskogenic pain:
- Up to 90% of herniated disks are due to a degenerative process. With aging, water content of the disk decreases, leading to decreased disk height and loss of function of absorbing axial loads.
- Trauma can be implicated in 10–20% of patients, specifically a twisting or torsional movement.
Facet syndrome:
- Overuse of the facet joint
- Spinal osteoarthritis
- Sudden and excessive movement that traumatizes the joint
- Commonly seen in athletes who engage in sports involving excessive spinal movements such as gymnasts and figure skaters
Scheuermann kyphosis:
- Exact etiology unknown
- 74% heritability, indicating a major genetic contribution
- Disorganized enchondral ossification, collagen reduction, increase in mucopolysaccharides in the endplate

Diagnosis

Rapid evaluation of ABCs
Primary and secondary trauma survey
Detailed neurologic exam with specific attention to evidence of spinal cord injury
Thorough spine exam noting any deformity or tenderness
Any midline tenderness elicited on examination, distracting injury, or intoxication mandates plain-film spine radiography (1,2)[A].

History

Thoracic spine fracture:
- Significant force is required to produce thoracic vertebral fractures, so other injuries may obscure those directly related to thoracic fractures.
- Primary symptoms of thoracic vertebral fracture occur from pain at the fracture site or impingement of nearby structures by bone fragments.
- Common signs and symptoms:
  - Localized soft tissue defect
  - Pain or tenderness:
    - Localized—pain and tenderness over spinous process
    - Referred—paraspinal, anterior chest or abdomen
  - Paraspinal muscle spasm
  - Paresthesia or dysesthesia
  - Weakness (focal or global)
  - Distal areflexia, flaccid plegia
  - Bowel or bladder incontinence
  - Priapism
  - Loss of temperature control
  - Spinal shock—hypotension with bradycardia (1)[A]
Thoracic diskogenic pain:
- Most commonly manifests insidiously with no significant history of trauma
- Pertinent historical features: Duration of symptoms, extent of pain/weakness, and presence of bowel or bladder symptoms
- Pain is the most common symptom, the presenting symptom in 60% of patients. It may be dull and localized to the thoracic spine or referred to retrogastric, retrosternal, or inguinal areas.
- Sensory disturbances, presenting symptom in 25% of patients
- Numbness, dysesthesias, paresthesias in a dermatomal distribution
- Weakness is the presenting symptom in 17% of patients, usually lower extremities, occasionally abdominal and intercostal muscles.
- Bladder symptoms are the presenting symptoms in only 2% of patients (3)[B].
Muscular strains: Typically mild pain following a sporting activity
Scheuermann kyphosis:
- Symptoms are typically insidious and slow in onset with no reported history of trauma.
- Often seen in repetitive microtrauma, osteoporosis, osteochondrosis, necrosis of the ring apophysis, and tight hamstrings (2)[A]

Physical Exam

Thoracic spine fracture: Focus on paresthesia and transient weakness, both of which may be indicative of cord involvement.
Thoracic diskogenic pain:
- Musculoskeletal findings often nonspecific but may reveal myofascial pain or patterns of weakness or inflexibility
- Sensory deficits to light touch or pinprick along a dermatomal pattern
- Motor examination should include testing muscle strength, flexibility, and tone.
  - Include abdominal muscles because T9 and T10 lesions can paralyze the lower abdominal muscles but spare the upper abdominal muscles.
  - Lower extremity weakness associated with spasticity or hyperactive reflexes is a serious finding, indicative of myelopathy.
- Reflexes: Hyperactive reflexes signify an upper motor neuron lesion, whereas hypoactive reflexes signify a lower motor neuron lesion.
- In purely thoracic diskogenic pain, upper extremity reflexes should be normal (otherwise suspect cervical pathology) and patellar and Achilles reflexes should be normal (otherwise suspect lumbosacral pathology) (3)[B].
Scheuermann kyphosis:
- Round back deformity that does not correct with passive extension
- Hyperlordosis of the lumbar spine
- Tight hip flexors, hamstrings, and lumbar fascia (2)[B]

Diagnostic Tests & Interpretation

Pain or tenderness, severe motor vehicle accident, or falls from height are indications for anteroposterior (AP) and lateral plain-film views of the spine.
Thin-cut CT scanning is indicated in any patient with evidence of spinal fracture or ligamentous injury on plain films to assess spinal canal integrity or in patients with normal plain films and significant pain or tenderness and mechanism for severe injury (4)[B].

Lab

Spinal tumors:

Rule out tumor when patient has nocturnal back pain or constitutional symptoms.
CBC with differential
ESR
C-reactive protein

Imaging

Thoracic spine fracture:
- CT scan is more sensitive and specific than plain radiographs for the detection of thoracic spine fractures and should be used in any patient with a traumatic injury suspicious for fracture based on history, exam, or initial plain films.
Thoracic diskogenic pain:
- Plain radiographs are used to rule out fracture, tumor, or infection.
- Signs of disk degeneration on x-ray:
  - Disk calcification: Present in up to 70% of patients with thoracic disk herniation and only 4–6% of patients without herniation
  - Osteophyte formation
  - Disk space narrowing
  - Kyphosis
- MRI: Screening test of choice, better visualization of soft tissues, earlier recognition of disk degeneration, and ability to evaluate in the sagittal plane
- CT myelography: Less optimal study than MRI but good for diagnosing lateral herniations and calcification (3,5)[A]
Scheuermann kyphosis: Plain radiographs are usually diagnostic.
- Irregular upper and lower vertebral end plates
- Apparent loss of disk space height
- Wedging of >5 degrees in at least 1 vertebrae
- Presence of hyperkyphosis >40 degrees, apex between T7 and T9 (5)[B]
Spinal tumors: Start with plain radiographs.
- May not show abnormality until there is 30–50% loss of cancellous bone
- Technetium-99m bone scan is sensitive but not specific.
- ¹⁸F positron emission tomography shows improved specificity.
- MRI, especially with gadolinium, demonstrates excellent definition of soft tissue and osseous changes (5)[B].

Differential Diagnosis

Arthritis (degenerative and rheumatoid)
Ankylosing spondylitis
Spina bifida
Congenital malformation
Neoplasm
Pathologic fracture

Treatment

General:
- Most thoracic injuries respond well to rest, NSAIDs, physical therapy, and stretching.
- Limit bed rest to 1 or 2 days.
- Return to play may occur gradually as the athlete achieves painless range of motion (ROM) (1)[A].

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Thoracic spine fracture:
- Stable fractures are often treated with brace immobilization.
- Thoracolumbosacral orthosis immobilizes a stable thoracic compression fracture (<50% loss of height).
- Unstable fractures may be a consideration for surgical stabilization.
Muscular contusions: Conservative treatment:
- Ice to limit bleeding and swelling
- Moist heating pad after 72 hr
- Massage after initial pain has resolved
- Analgesics as needed for pain
- Restrict activity until pain-free.
- Physical therapy consisting of ROM exercises (5)[A]
Muscular strains: Conservative treatment:
- Physical therapy regimen of gradual mobilization as well as stabilization
- NSAIDs
Facet syndrome: Conservative treatment:
- NSAIDs
- Postural correction
- Rest
- If no response to above treatment, consider an intraarticular facet injection of corticosteroid and long-acting local anesthetic
Scheuermann kyphosis:
- Physical therapy (PT) to stretch tight hamstring muscles, hip flexors, and lumbar fascia
- PT to strengthen abdominal and upper back postural musculature
- Consider a brace in a skeletally immature patient with fixed thoracic kyphosis >50 degrees.
- Milwaukee brace for high thoracic curves
- Boston brace with sternal pads for curves with apex below T7
- Surgery is rarely indicated, and indications are unclear.
- Decision for surgery needs to be an individual one based on patient's symptoms and self-perception (2)[B].

ED Treatment

Perform all needed resuscitation and diagnostic tests with the patient in full spinal immobilization.
If spinal cord injury is suspected, administer high-dose steroids and consult a neurosurgeon or orthopedic surgeon.
If spinal fracture or ligamentous injury is suspected without neurologic impairment, arrange CT scan or MRI while simultaneously consulting neurosurgery or orthopedic surgery.
Pain control should be administered as soon as possible. NSAIDs, opiates, and benzodiazepines are the mainstays of treatment.

Medication

Thoracic spine fracture with neurologic deficit:
- High-dose steroid protocol: Solumedrol 30 mg/kg IV bolus within 8 hr of injury, followed by an infusion of 5.4 mg/kg/hr for the next 23 hr (4)[A]
Other causes of back pain: NSAIDs

In-Patient Considerations

Initial Stabilization

Follow the ABCs of trauma resuscitation.
Airway intervention should be done with inline cervical immobilization.
Preserve residual spinal cord function and prevent further injury by stabilizing the spine.

Admission Criteria

Patients with significant spinal cord or column injury should be treated in a regional trauma center.
Unstable spinal column injury
Cord or root injury
Ileus
Pain control
Concomitant traumatic injury

Discharge Criteria

Stable minor fractures after orthopedic or neurosurgical evaluation

References

1. Khan N, Husain S, Haak M. Thoracolumbar injuries in the athlete. Sports Med Arthrosc. 2008;16:16–25.

2. Lowe TG, Line BG. Evidence based medicine: analysis of Scheuermann kyphosis. Spine. 2007;32:S115–S119.

3. Brown CW, Deffer PA, Akmakjian J, et al. The natural history of thoracic disc herniation. Spine. 1992;17:S97–S102.

4. Chiles BW, Cooper PR. Acute spinal injury. N Engl J Med. 1996;334:514–520.

5. Curtis C, d'Hemecourt P. Diagnosis and management of back pain in adolescents. Adolesc Med State Art Rev. 2007;18:140–164, x.

Additional Reading

Diaz J, Cullinane D, Altman D, et al. Practice management guidelines for the screening of thoracolumbar spine fracture. J Trauma. 2007;63:709–718.

Karlson K. Thoracic region pain in athletes. Curr Sports Med Rep. 2004;53–57.

Papagelopoulos P, Mavrogenis A, Savvidou O, et al. Current concepts in Scheuermann's kyphosis. Orthopedics. 2008;31;52–58.

Ye C, Sun T, Li J, et al. Patterns of sports and recreation related spinal cord injuries in Beijing. Spinal Cord. 2009; May 12.

Codes

ICD9

722.11 Displacement of thoracic intervertebral disc without myelopathy
805.2 Closed fracture of dorsal (thoracic) vertebra without mention of spinal cord injury
805.3 Open fracture of dorsal (thoracic) vertebra without mention of spinal cord injury