The spinal column is made up of small bones (vertebrae) stacked on top of one another, creating the natural curves of the back. Between the vertebrae are flat, round, rubbery pads (intervertebral disks) that act as shock absorbers and allow the back to flex or bend. Muscles and ligaments connecting the vertebrae allow motion while providing support and stability for the spine and upper body. Each vertebra has an opening (foramen) in the center and these line up to form the spinal canal. Protected by the vertebrae, the spinal cord and other nerve roots travel through the spinal canal. Nerves branch out from the spinal column through vertebral openings, carrying messages between the brain and muscles. Facet joints align at the back of the spinal column, linking the vertebrae together and allowing for rotation and movement. Like all joints, cartilage covers the surface where facet joints meet.
The spine contains three segments: lumbar, thoracic and cervical. The lumbar spine consists of five vertebrae located in the lower back; lumbar vertebrae are larger because they carry more of the body's weight. The thoracic spine consists of 12 vertebrae and begins at the upper chest, extending to the middle back and connecting to the rib cage. The cervical spine includes the neck and consists of seven small vertebrae, beginning at the base of the skull and ending at the upper chest. Disks in the lumbar spine are composed of a thick outer ring of cartilage (annulus) and an inner gel-like substance (nucleus). In the cervical spine, disks are similar but smaller in size.
The most common spinal fractures occur in the thoracic (midback) and lumbar (lower back) spine, or where the two connect (thoracolumbar junction). A spinal fracture is a serious injury, typically caused by an auto crash, fall from height, or other high-velocity accident. The energy required to severely fracture the spine may also cause spinal cord injury or other damage that requires additional treatment. Men experience fractures of the thoracic or lumbar spine four times more often than women, and seniors who have weakened bone due to osteoporosis are also at increased risk.
Fractures of the thoracic and lumbar spine are commonly caused by high-energy trauma, such as an automobile accident, fall from great height, sports accident, or a violent act, such as a gunshot wound. Osteoporosis, tumors, or other underlying conditions that weaken bone can also cause a vertebra to fracture, even during normal, daily activities.
There are several types of thoracic and lumbar spine fractures, and classification is based upon pattern of injury and whether or not the spinal cord has also been injured. Identifying the type of fracture can help your physician determine the most appropriate treatment.
The primary symptom of thoracic and lumbar spine fracture is moderate to severe back pain that worsens with movement. If the spinal cord is involved, numbness, tingling, weakness, or bowel/bladder dysfunction may also occur. Following a high-energy trauma (such as an auto accident), the patient may have a brain injury and experience loss of consciousness, and in some instances, the back pain may be overwhelmed by pain from other injuries (distracting injuries). In these cases, emergency responders must proceed under the assumption that a spinal fracture is present.
During the initial 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 determine if the patient is conscious and check vital signs, including heart rate and ability to breathe. Once these are stabilized, bleeding and injuries demanding immediate attention will be addressed. The patient must be immobilized in a cervical (neck) collar and backboard before being transported to the hospital emergency room, where a complete evaluation will be performed.
An emergency room physician will conduct a thorough, head-to-toe examination of the head, chest, abdomen, pelvis, limbs and spine. Neurological status will be determined by evaluating the patient's ability to move, feel and sense the position of all limbs, and testing the patient's reflexes will help determine if there has been any injury to the spinal cord or individual nerves. Following the physical examination, a radiologic evaluation is required. Depending on the extent of the injuries, this may include X-rays, computed tomography (CT), and magnetic resonance imaging (MRI) scans of multiple areas, including the thoracic and lumbar spine.
Once all other life-threatening injuries have been stabilized, the physician will identify the pattern of the fracture and determine the appropriate plan of treatment. What treatment is best and whether or not surgery is required will depend on the fracture pattern and on the treatment required for any other injuries sustained.
The ultimate goal of surgical treatment for fracture of the thoracic and lumbar spine is to achieve adequate reduction (fitting the bones together), relieve pressure on the spinal cord and nerves, and allow for early movement. Stabilizing the spine may require use of devices, such as metal screws, rods and cages. During surgery, your surgeon may use an anterior (front), lateral (side), or posterior (back) approach, or a combination of all three, depending on what is most appropriate for your fracture pattern and individual situation.
There are several complications associated with fractures of the thoracic and lumbar spine, including pneumonia and pressure sores. Among the most severe complications is a blood clot that develops in the legs, due to patient immobility. These clots can travel to the lungs, resulting in death (pulmonary embolism). Complications can be reduced by early treatment, mechanical methods (lower-leg compression stockings), and medication to protect against clots, as well as proper surgical techniques and postoperative programs.
Regardless of whether the patient receives nonsurgical treatment or surgery, rehabilitation will be necessary after the injury has healed and both inpatient and outpatient physical therapy may be recommended. The goals of rehabilitation are to reduce pain, regain mobility and return the patient to a lifestyle and activities that are as close as possible to those experienced before the injury. Issues with the potential to complicate these goals include: inadequate reduction of the fracture, neurologic injury (paralysis), and progressive deformity. A spine conditioning program or low back exercises may also be recommended.
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