Abstract
Thoracic vertebral compression fracture is one of the most common causes of dorsal spine pain. Vertebral compression fractures are most often the result of osteoporosis, but they may also occur with trauma to the dorsal spine caused by acceleration-deceleration injuries. In osteoporotic patients or in those with primary tumors or metastatic disease involving the thoracic vertebrae, fracture may occur with coughing (tussive fractures) or spontaneously.
The pain and functional disability associated with fractured vertebrae are determined largely by the severity of the injury (e.g., number of vertebrae involved) and the nature of the injury (e.g., whether the fracture causes impingement on the spinal nerves or spinal cord). The pain associated with thoracic vertebral compression fracture may range from a dull, deep ache (with minimal compression of the vertebrae and no nerve impingement) to severe, sharp, stabbing pain that limits the patient’s ability to ambulate and cough.
Keywords
vertebral compression fracture, osteoporosis, metastatic disease, vertebral plasty, kyphoplasty, dowager’s hump, bone density testing, thoracic spine pain, dorsal spine pain
ICD-10 CODES S22.009A Traumatic
Keywords
vertebral compression fracture, osteoporosis, metastatic disease, vertebral plasty, kyphoplasty, dowager’s hump, bone density testing, thoracic spine pain, dorsal spine pain
ICD-10 CODES S22.009A Traumatic
The Clinical Syndrome
Thoracic vertebral compression fracture is one of the most common causes of dorsal spine pain. Vertebral compression fractures are most often the result of osteoporosis ( Fig. 73.1 ), but they may also occur with trauma to the dorsal spine caused by acceleration-deceleration injuries. In osteoporotic patients or in those with primary tumors or metastatic disease involving the thoracic vertebrae, fracture may occur with coughing (tussive fractures) or spontaneously.
The pain and functional disability associated with fractured vertebrae are determined largely by the severity of the injury (e.g., number of vertebrae involved) and the nature of the injury (e.g., whether the fracture causes impingement on the spinal nerves or spinal cord). The pain associated with thoracic vertebral compression fracture may range from a dull, deep ache (with minimal compression of the vertebrae and no nerve impingement) to severe, sharp, stabbing pain that limits the patient’s ability to ambulate and cough.
Signs and Symptoms
Compression fractures of the thoracic vertebrae are aggravated by deep inspiration, coughing, and any movement of the dorsal spine. Palpation of the affected vertebra may elicit pain and reflex spasm of the paraspinous musculature of the dorsal spine. If trauma has occurred, hematoma and ecchymosis may be present overlying the fracture site, and the clinician should be aware of the possibility of damage to the bony thorax and the intraabdominal and intrathoracic contents. Damage to the spinal nerves may produce abdominal ileus and severe pain, resulting in splinting of the paraspinous muscles, and further compromise to the patient’s pulmonary status and ability to ambulate. Failure to treat this pain and splinting aggressively may result in a negative cycle of hypoventilation, atelectasis, and, ultimately, pneumonia.
Testing
Plain radiographs of the vertebrae are indicated to rule out other occult fractures and other bony disorders, including tumor ( Fig. 73.2 ). Magnetic resonance imaging, radionucleotide bone scanning, and positron emission tomography may help characterize the nature of the fracture and distinguish benign from malignant causes of pain ( Figs. 73.2 and 73.3 ). If trauma is present, radionuclide bone scanning may be useful to exclude occult fractures of the vertebrae or sternum. If no trauma is present, bone density testing to evaluate for osteoporosis is appropriate, as are serum protein electrophoresis and testing for hyperparathyroidism. Based on the patient’s clinical presentation, additional testing may be warranted, including a complete blood count, prostate-specific antigen level, erythrocyte sedimentation rate, and antinuclear antibody testing. Computed tomography of the thoracic contents is indicated if an occult mass or significant trauma is suspected. Electrocardiography to rule out cardiac contusion is indicated in all patients with traumatic sternal fractures or significant anterior dorsal spine trauma. The injection technique described later should be used early to avoid pulmonary complications.
