Thoracic Lumbar

Symptoms and Signs

Injury usually results from an activity that increases the compressive load on the spine (eg, lifting, bending forward, or misstepping while walking). In the elderly, osteoporosis weakens the trabecular bone of the vertebral bodies and leaves the posterior elements relatively unaffected. Excessive loads then compress the vertebral bodies into a wedge-shaped configuration as the trabecular bone impacts into itself.

Patients often present with acute pain that is exacerbated by sitting or standing. Percussion over a specific spinal region reveals well-localized tenderness. Associated neurologic deficits are rare.

Many vertebral-body fractures occur silently, however. Elderly patients often have x-ray evidence of fractures without a history of symptoms or injury.

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Treatment and Prognosis

Vertebral-body compression fractures always heal, because the trabecular bone is only impacted into itself, and the blood supply is not impaired. These fractures are relatively stable because the intact posterior elements prevent translational displacement. Neurologic deficits from bony impingement rarely occur. The primary clinical sign is progressive kyphosis due to wedging and loss of height of the vertebral bodies.

Initially, hospitalization for bed rest may be needed to relieve pain. Analgesics, nonsteroidal anti-inflammatory drugs, and laboratory screening tests for other causes of osteopenia may be indicated. 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 not be able to walk independently for a week or so and may have considerable back pain for 6 to 12 wk. Sometimes, a month or more later, the pain shifts from the fracture site to a higher or lower site, probably because of altered mechanical stresses caused by the deformity.

Bracing probably does little to prevent deformity, but it can help relieve pain and allows a quicker return to activities. Bracing is useful only for fractures of the lumbar and lower thoracic spine because adequate support cannot be achieved above these regions. While hyperextension braces (eg, the Jewett) are the most effective biomechanically, they are not the most comfortable. They 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 in patients with lumbar fractures.

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