Thursday, April 26, 2018

Brain & Spine Disorders

Thoracic Spine Fractures

The spine is made up of strong bones called vertebrae. A vertebra can break just like any other bone in the body. When the vertebral body collapses, it is called a vertebral compression fracture. These fractures happen most commonly in the thoracic spine (the middle portion of the spine), particularly in the lower part. Vertebral fractures are usually caused by a condition such as osteoporosis, a very hard fall, or another type of injury.
The vertebral bodies are the round blocks of bone that form the front part of the spinal column. Compression fractures of the spine usually occur at the bottom part of the thoracic spine (T11 and T12) and the first vertebra of the lumbar spine (L1).

Compression fractures of the spine generally occur from too much pressure on the vertebral body. The fracture occurs when the vertebral body collapses, causing the front part of the vertebral body to become wedge shaped. The bone tissue on the inside of the vertebral body is crushed, or compressed.

This can happen when the spine bends forward at the same time downward pressure builds on the spine. For example, falling to the floor in a sitting position causes the spine to bend and the head to be thrust forward. This posture combined with pressure on the buttocks concentrates pressure on the front part of the spine, the vertebral bodies.

There are several causes of compression fractures. If the vertebra is too weak to hold normal pressure, it may take very little pressure to cause it to collapse. Most healthy bones can withstand pressure, and the spine is able to absorb the shock. However, if the forces are too high, one or more vertebrae may fracture.

Osteoporosis is a common cause of compression fractures in the spine. This disease thins bones, often to the point they become too weak to bear normal pressure. They can eventually collapse during normal activity, leading to a spinal compression fracture. Notably, spinal compression fractures are the most common type of fracture from osteoporosis. Forty percent of all women will have at least one by the time they turn 80 years old.

In severe cases of osteoporosis, actions as simple as bending forward can be enough to cause a "crush fracture" in a vertebra. This type of vertebral fracture causes loss of body height and a humped back (kyphosis), especially in elderly women.

Compression fractures due to trauma can come from a fall, a forceful jump, a car accident, or any event that stresses the spine past its breaking point.

Cancer that spreads to the spine weakens the supportive structure of the spine. Metastasis is a term that refers to the spread of cancer cells into other areas of the body. The bones of the spine are a common place for many types of cancers to spread. The cancer may cause destruction of part of the vertebra, weakening the bone until it collapses.

If the fracture is caused by a sudden, forceful injury, you will probably feel severe pain in your back, legs, and arms. You might also feel weakness or numbness if the fracture injures the nerves of the spine. If the bone collapse is gradual, such as a fracture from bone thinning, the pain will usually be milder. There might not be any pain at all until the bone actually breaks.

In very severe compression fractures, parts of the back of the vertebral body may actually protrude into the spinal canal and put pressure on the spinal cord. Fortunately this is not a common occurrence.

Before a doctor can diagnose your condition and design a treatment plan, a complete history and physical exam are necessary. There are many possible internal causes of pain. It is important to determine what is and is not the root of the problem. After your doctor has a better idea of what is causing your discomfort, diagnostic tests may be recommended.
  • An X-ray of the spine will usually show where the vertebra is broken.
  • If the X-ray shows a fracture, your doctor may also suggest a CT scan to make sure that the broken bone is stable and that the nerves are not in danger. The CT scan will be combined with a myelogram if there are any concerns about the spinal cord.
  • An MRI might be recommended if there is a chance that nerves are hurt in the fracture or if there is some question about what is causing the pain.
  • A bone scan might be ordered to help determine the age of a fracture. If the fracture is old and there appear to be other fractures that have healed, this may indicate osteoporosis. This is important in older patients, particularly women. If osteoporosis is a factor, treatment will include preventive measures to try to stop other vertebral fractures from occurring.
A neurological exam will also be given. This includes testing the nerves by checking your reflexes, muscle strength, and sensory perception. Abnormalities in the neurological examination can point to nerve damage. If there is damage to the spinal nerves, your body movement and neurological responses will be affected. Neurological problems are rare- except in younger patients who have experienced a violent injury, such as a car crash.

Conservative Treatment
The most common treatments for a thoracic compression fracture are pain medications, decreasing activity, and bracing. Doctors are also using newer nonsurgical procedures called vertebroplasty and kyphoplasty. These methods are minimally invasive and showing promise in the treatment of vertebral compression fractures. Vertebral fractures usually take about three months to fully heal. X-rays will probably be taken monthly to check on the healing progress. Surgery for compression fractures is rarely needed.

Pain Medications
Mild pain medications may be prescribed. Remember that medications will not help the fracture to heal, but they can help control pain.

Decreasing Activity
You will most likely have to limit your normal activities. Avoid strenuous activity or exercise. Do not lift heavy objects. Stay away from any activity that might place too much strain on your fractured vertebra. If you are elderly, your doctor may put you on bed rest. Older bones take longer to heal than younger bones and are typically thinner and weaker. Treat this fracture as you would any other broken bone-carefully and seriously.

Another common form of treatment for some types of vertebral compression fractures is bracing. Your doctor may prescribe a back support (called an orthosis). The brace supports the back and restricts movement; just as an arm brace would support a fractured arm.

Braces are molded to conform tightly to your body, like a cast for any other fracture. Braces used to treat a compression fracture of the spine are designed to keep you from bending forward. They hold the spine in more extension (straightened). This takes pressure off the fractured vertebral body and allows it to heal. The brace protects the vertebra and stops further collapse of the bone. Learn more about back and neck braces.

Minimally Invasive Methods
Doctors are using two new procedures to treat compression fractures: vertebroplasty and kyphoplasty. Vertebroplasty is a method of injecting special cement inside the broken vertebral body. It is mainly used to ease pain and improve the strength of the vertebral body.  Kyphoplasty provides the additional benefit of restoring some or all of the normal height of the vertebral body. Dr. Aryan routinely performs this procedure and prefers it o vertebroplasty.  In the procedure, Dr. Aryan slides a tube with a deflated balloon inside the broken bone. The balloon is inflated to help restore the height of the broken vertebra. Bone cement is injected into the cavity formed by the balloon to hold the vertebra at its corrected height.

Surgical Treatment
Spinal surgery is a serious undertaking and is only considered to fix vertebral compression fractures if there is evidence of sudden and serious instability of the spine. For instance, if the fracture leads to a loss of 50 percent of the vertebral body's height, surgery might be necessary to prevent the bone from collapsing onto the spinal nerves and causing more serious damage.

If surgery is necessary to remove pressure from the spinal cord, two approaches will be considered, anterior and posterior. Some type of internal fixation may be suggested to hold the vertebra in the proper position while it heals. Due to the risks and complications associated with it, internal fixation is only done in severe spinal compression fractures. Bone fragments may need to be removed if they are pushing into the spinal cord and nerves, causing too much pressure.

Like all surgical procedures, operations on the spine may have complications. Because the surgeon is operating around the spinal cord and nerves, back operations are always considered extremely delicate and potentially dangerous. You should take time to review the risks associated with spine surgery with your doctor. Make sure you are comfortable with both the risks and the benefits of the procedure planned for your treatment.

Complications specifically related to a vertebral compression fracture include:
  • segmental instability
  • kyphotic deformity
  • neurological complications
Segmental Instability
If a fracture leads to a vertebral body collapse of more than 50 percent, there is a risk of segmental instability. Each spinal segment is like a well-tuned part of a machine. The parts work together to allow weight bearing, movement, and support. When one segment deteriorates or collapses to the point of instability, it can produce pain and difficulty doing activities. The instability eventually results in faster degeneration of the spine in this area.

Kyphotic Deformity
Kyphosis is a common disorder in elderly women who have osteoporosis and frequent fractures. The front of the vertebrae will collapse and "wedge" due to the lack of normal vertebral space. Kyphosis leads to a more rounded thoracic spine. Sometimes this deformity is described as "round back posture" or "hunchback".

Pronounced kyphosis can be a source of severe and debilitating pain. The hunchback deformity may also begin to compress the heart, lungs, and intestines. This in turn leads to fatigue, shortness of breath, and loss of appetite.

Neurological Complications
If the fracture causes part of the vertebral body to place pressure on the spinal cord, the nerves and spinal cord can be affected. There is some space between the spinal cord and the edges of the spinal canal. This space can be reduced if the pieces of the broken vertebral body push into the spinal canal.

The narrowing of the spinal canal due to a compression fracture can either lead to immediate injury to the nerves of the spine, or it can cause problems later on from irritation of the nerves. If the irritation on the spinal nerves comes later (even after the fracture has healed), it can cause pain and problems if the nerves are not working right. The lack of space can also lower the supply of blood and oxygen to the spinal cord. When the spine needs more blood flow during increased activity, the blood vessels may not be able to swell to get more blood to the spine. This can lead to numbness and pain in the nerves that are affected. The nerves also lose some of their mobility when the space available to them is reduced. This leads to irritation and inflammation of the nerves.

Mid Back Pain & Disorders (Thoracic Spine)


