Thoracic and Lumbar Vertebral Fractures

Thoracic and lumbar vertebral fractures often result from activity that increases the compressive load on the spine (eg, lifting, bending forward, misstepping while walking). However, vertebral fractures occur silently in many elderly persons, who frequently have x-ray evidence of fractures without a history of symptoms or injury.

In thoracic vertebral fractures, the vertebral body is typically compressed into a wedge shape (best seen on lateral x-rays) due to the normal kyphosis of the thoracic region, which concentrates the forces anteriorly. In lumbar vertebral fractures, the vertebral body is generally flattened, sometimes sideways. Collapse may be acute or progressive.

Patients often present with acute pain that is exacerbated by sitting or standing. The primary symptoms are progressive kyphosis and loss of height. Percussion over a specific spinal region reveals localized tenderness. Associated neurologic deficits, manifested by pain radiating into the leg, and bladder or bowel incontinence are rare. Laboratory screening tests for other causes of osteopenia may be indicated.

Prognosis and Treatment

Compression fractures of the vertebral body heal eventually, because the trabecular bone collapses inward and the blood supply is not impaired. Typically, these fractures are relatively stable because the intact posterior elements prevent displacement that is likely to damage the spinal cord. Rarely, a compression fracture that initially appeared benign collapses completely, compromising the spinal canal and leading to neural injury. Surgery may be indicated to decompress the canal.

The goals of treatment include prevention of further collapse, management of symptoms, and resumption of normal function. Initially, institutional care or bed rest may be needed to relieve pain. Physical therapy can help the patient maintain ambulatory ability, improve limb function, and strengthen trunk musculature. Analgesics and nonsteroidal anti-inflammatory drugs help relieve pain. Patients should be encouraged to sit up and walk for short periods as soon as possible to prevent deconditioning and accelerated bone loss. They may be unable to walk independently for up to 1 week and may have considerable back pain for 6 to 12 weeks. Sometimes, after >= 1 month, the pain shifts from the fracture site to a higher or lower level, because the deformity alters mechanical stresses.

Use of a brace may not prevent deformity but can help relieve pain and enable the patient to return to daily activities more quickly. A brace is useful only for fractures of the lumbar and lower thoracic spine because adequate support cannot be achieved above these regions. Although total contact orthoses and hyperextension braces (eg, the Jewett) are most biomechanically effective, they are very confining and not always well tolerated by elderly patients. Hyperextension braces apply three-point stabilization of the spine through an anterior abdominal pad, a chest pad, and a posterior pad at the level of the fracture. Corsets or abdominal binders are effective and better tolerated alternatives for patients with lumbar vertebral fractures.