Download PDF
Z Orthop Unfall 2021; 159(04): 373-382
DOI: 10.1055/a-1144-3846
Review/Übersicht

Traumatic Fractures of the Thoracic Spine

Narrative Literature Review Article in several languages: English | deutsch
Ulrich J. A. Spiegl
1   Department of Orthopaedics, Trauma and Reconstructive Surgery, University Hospital Leipzig
,
Klaus John Schnake
2   Centre for Spinal Surgery, Schoen Hospitals, Fürth
,
Frank Hartmann
3   Centre for Trauma and Orthopaedic Surgery, Ev. Stift St. Martin, Community Hospital Mittelrhein, Koblenz
,
Sebastian Katscher
4   Orthopaedic and Trauma Surgery, Sana Hospital Leipziger Land, Borna
,
Marion Riehle
5   Orthopaedic and Trauma Centre, Alb Fils Hospitals, Göppingen
,
Max J. Scheyerer
6   Clinic and Outpatient Department for Orthopaedic and Trauma Surgery, Cologne University Hospital
,
Gregor Schmeiser
7   Spine Centre, Schoen Hospital Hamburg Eilbek
,
Holger Siekmann
8   Trauma Surgery, Halle University Hospital
,
Georg Osterhoff
1   Department of Orthopaedics, Trauma and Reconstructive Surgery, University Hospital Leipzig
› Author Affiliations
› Further Information
Also available at
   Permissions and Reprints

Abstract

The majority of traumatic vertebral fractures occur at the thoracolumbar junction and the lumbar spine and less commonly at the mid-thoracic and upper thoracic spine. In accordance, a high number of articles are dealing with thoracolumbar fractures focusing on the thoracolumbar junction. Nonetheless, the biomechanics of the thoracic spine differ from the thoracolumbar junction and the lumbar vertebral spine. The aim of this review is to screen the literature dealing with acute traumatic thoracic vertebral fractures in patients with normal bone quality. Thereby, the diagnostic of thoracic vertebral body fractures should include a CT examination. Ideally, the CT should include the whole thoracic cage particularly in patients suffering high energy accidents or in those with clinical suspicion of concomitant thoracic injuries. Generally, concomitant thoracic injuries are frequently seen in patients with thoracic spine fractures. Particularly sternal fractures cause an increase in fracture instability. In case of doubt, long segment stabilization is recommended in patients with unstable mid- und upper thoracic fractures, particularly in those patients with a high grade of instability.

Key words

fractures of the thoracic spine - traumatic fractures - posterior stabilization - adjacent injuries


Publication History

Article published online:
11 May 2020

© 2020. Thieme. All rights reserved.

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany

 

  • References/Literatur

  • 1 Verheyden AP, Spiegl UJ, Ekkerlein H. et al. Treatment of fractures of the thoracolumbar spine: recommendations of the spine section of the German Society for Orthopaedics and Trauma (DGOU). Global Spine J 2018; 8 (2 Suppl.): 34S-45S
    CrossrefPubMedSearch in Google Scholar
  • 2 Reinhold M, Knop C, Beisse R. et al. [Operative treatment of traumatic fractures of the thoracic and lumbar spinal column. Part I: epidemiology]. Unfallchirurg 2009; 112: 33-42 44–45
    CrossrefPubMedSearch in Google Scholar
  • 3 Roussouly P, Pinheiro-Franco JL. Sagittal parameters of the spine: biomechanical approach. Eur Spine J 2011; 20 (Suppl. 05) S578-S585
    CrossrefPubMedSearch in Google Scholar
  • 4 Vaccaro AR, Rizzolo SJ, Allardyce TJ. et al. Placement of pedicle screws in the thoracic spine. Part I: morphometric analysis of the thoracic vertebrae. J Bone Joint Surg Am 1995; 77: 1193-1199
    CrossrefPubMedSearch in Google Scholar
  • 5 Reinhold M, Knop C, Beisse R. et al. [Operative treatment of traumatic fractures of the thorax and lumbar spine: Part II: surgical treatment and radiological findings.]. Unfallchirurg 2009; 112: 149-167
    CrossrefPubMedSearch in Google Scholar
  • 6 Deutsche Gesellschaft für Unfallchirurgie. Hrsg. S3-Leitlinie Polytrauma/Schwerverletzten-Behandlung, last access: 07/2016. Online (last access: 17.04.2020): http://www.awmf.org/uploads/tx_szleitlinien/012-019l_S3_Polytrauma_Schwerverletzten-Behandlung_2017-08.pdf
    PubMed
  • 7 Lemburg SP, Frangen TM, Knoop H. et al. [Prognostic pulmonary and thoracic findings in patients with unstable injuries of the thoracic spine]. Pneumologie 2011; 65: 412-418
    Thieme ConnectPubMedSearch in Google Scholar
  • 8 Huang Z, Chen F, Huang J. et al. Treatment of middle-super thoracic fractures associated with the sternum fracture. Int J Clin Exp Med 2015; 8: 9751-9757
    PubMedSearch in Google Scholar
  • 9 Morgenstern M, von Rüden C, Callsen H. et al. The unstable thoracic cage injury: the concomitant sternal fracture indicates a severe thoracic spine fracture. Injury 2016; 47: 2465-2472
    CrossrefPubMedSearch in Google Scholar
  • 10 Reinhold M, Audigé L, Schnake KJ. et al. AO spine injury classification system: a revision proposal for the thoracic and lumbar spine. Eur Spine J 2013; 22: 2184-2201
    CrossrefPubMedSearch in Google Scholar
  • 11 Vaccaro AR, Oner C, Kepler CK. et al. AOSpine thoracolumbar spine injury classification system: fracture description, neurological status, and key modifiers. Spine (Phila Pa 1976) 2013; 38: 2028-2037
    CrossrefPubMedSearch in Google Scholar
  • 12 Kepler CK, Vaccaro AR, Koerner JD. et al. Reliability analysis of the AOSpine thoracolumbar spine injury classification system by a worldwide group of naive spinal surgeons. Eur Spine J 2016; 25: 1082-1086
    CrossrefPubMedSearch in Google Scholar
  • 13 Kandziora F, Schleicher P, Schnake KJ. et al. [The AOSpine classification of thoraco-lumbar spine injuries]. Z Orthop Unfall 2016; 154: 35-42
    Thieme ConnectPubMedSearch in Google Scholar
  • 14 van Middendorp JJ, Sanchez GM, Burridge AL. The Edwin Smith papyrus: a clinical reappraisal of the oldest known document on spinal injuries. Eur Spine J 2010; 19: 1815-1823
    CrossrefPubMedSearch in Google Scholar
  • 15 Capen DA, Gordon ML, Zigler JE. et al. Nonoperative management of upper thoracic spine fractures. Orthop Rev 1994; 23: 818-821
    PubMedSearch in Google Scholar
  • 16 Dai L. Thoracic spine fractures. Chin Med Sci J 2001; 16: 227-230
    PubMedSearch in Google Scholar
  • 17 Bakhsheshian J, Dahdaleh NS, Fakurnejad S. et al. Evidence-based management of traumatic thoracolumbar burst fractures: a systematic review of nonoperative management. Neurosurg Focus 2014; 37: E1
    CrossrefPubMedSearch in Google Scholar
  • 18 Spiegl UJ, Fischer K, Schmidt J. et al. The conservative treatment of traumatic thoracolumbar vertebral fractures. Dtsch Arztebl Int 2018; 115: 697-704
    PubMedSearch in Google Scholar
  • 19 Katscher S, Verheyden P, Gonschorek O. et al. [Thoracolumbar spine fractures after conservative and surgical treatment. Dependence of correction loss on fracture level]. Unfallchirurg 2003; 106: 20-27
    CrossrefPubMedSearch in Google Scholar
  • 20 Stadhouder A, Buskens E, Vergroesen DA. et al. Nonoperative treatment of thoracic and lumbar spine fractures: a prospective randomized study of different treatment options. J Orthop Trauma 2009; 23: 588-594
    CrossrefPubMedSearch in Google Scholar
  • 21 Bailey CS, Urquhart JC, Dvorak MF. et al. Orthosis versus no orthosis for the treatment of thoracolumbar burst fractures without neurologic injury: a multicenter prospective randomized equivalence trial. Spine J 2014; 14: 2557-2564
    CrossrefPubMedSearch in Google Scholar
  • 22 Siebenga J, Leferink VJ, Segers MJ. et al. Treatment of traumatic thoracolumbar spine fractures: a multicenter prospective randomized study of operative versus nonsurgical treatment. Spine (Phila Pa 1976) 2006; 31: 2881-2890
    CrossrefPubMedSearch in Google Scholar
  • 23 Wood KB, Buttermann GR, Phukan R. et al. Operative compared with nonoperative treatment of a thoracolumbar burst fracture without neurological deficit: a prospective randomized study with follow-up at sixteen to twenty-two years. J Bone Joint Surg 2015; 97: 3-9
    CrossrefPubMedSearch in Google Scholar
  • 24 White AA, Panjabi MM. Clinical Biomechanics of the Spine. 2nd ed.. ed. Philadelphia: JB Lippincott Company; 1990
    Search in Google Scholar
  • 25 McCormack T, Karaikovic E, Gaines RW. The load sharing classification of spine fractures. Spine (Phila Pa 1976) 1994; 19: 1741-1744
    CrossrefPubMedSearch in Google Scholar
  • 26 Lazaro BC, Deniz FE, Brasiliense LB. et al. Biomechanics of thoracic short versus long fixation after 3-column injury. J Neurosurg Spine 2011; 14: 226-234
    CrossrefPubMedSearch in Google Scholar
  • 27 Perry TG, Mageswaran P, Colbrunn RW. et al. Biomechanical evaluation of a simulated T-9 burst fracture of the thoracic spine with an intact rib cage. J Neurosurg Spine 2014; 21: 481-488
    CrossrefPubMedSearch in Google Scholar
  • 28 Basaran R, Efendioglu M, Kaksi M. et al. Finite element analysis of short- versus long-segment posterior fixation for thoracolumbar burst fracture. World Neurosurg 2019; 128: e1109-e1117
    CrossrefPubMedSearch in Google Scholar
  • 29 Waqar M, Van-Popta D, Barone DG. et al. Short versus long-segment posterior fixation in the treatment of thoracolumbar junction fractures: a comparison of outcomes. Br J Neurosurg 2017; 31: 54-57
    CrossrefPubMedSearch in Google Scholar
  • 30 Vassal M, Lonjon G, Knafo S. et al. Surgical treatment of thoracic spine fractures. Outcomes on 50 patients at 23 months follow-up. Orthop Traumatol Surg Res 2014; 100: 475-480
    CrossrefPubMedSearch in Google Scholar
  • 31 Watkins R, Watkins R, Williams L. et al. Stability provided by the sternum and rib cage in the thoracic spine. Spine (Phila Pa 1976) 2005; 30: 1283-1286
    CrossrefPubMedSearch in Google Scholar
  • 32 Bransford R, Bellabarba C, Thompson JH. et al. The safety of fluoroscopically-assisted thoracic pedicle screw instrumentation for spine trauma. J Trauma 2006; 60: 1047-1052
    CrossrefPubMedSearch in Google Scholar
  • 33 Payer M. Unstable upper and middle thoracic fractures. Preliminary experience with a posterior transpedicular correction-fixation technique. J Clin Neurosci 2005; 12: 529-533
    CrossrefPubMedSearch in Google Scholar
  • 34 Scoles PV, Linton AE, Latimer B. et al. Vertebral body and posterior element morphology: the normal spine in middle life. Spine (Phila Pa 1976) 1988; 13: 1082-1086
    CrossrefPubMedSearch in Google Scholar
  • 35 Gonzalvo A, Fitt G, Liew S. et al. Correlation between pedicle size and the rate of pedicle screw misplacement in the treatment of thoracic fractures: can we predict how difficult the task will be?. Br J Neurosurg 2015; 29: 508-512
    CrossrefPubMedSearch in Google Scholar
  • 36 Beck M, Rotter R, Gradl G. et al. Reliability and consequences of intraoperative 3D imaging to control positions of thoracic pedicle screws. Arch Orthop Trauma Surg 2012; 132: 1371-1377
    CrossrefPubMedSearch in Google Scholar
  • 37 Schnake KJ, König B, Berth U. et al. [Accuracy of CT-based navitation of pedicle screws in the thoracic spine compared with conventional technique]. Unfallchirurg 2004; 107: 104-112
    CrossrefPubMedSearch in Google Scholar
  • 38 Bianco RJ, Arnoux PJ, Mac-Thiong JM. et al. Thoracic pedicle screw fixation under axial and perpendicular loadings: a comprehensive numerical analysis. Clin Biomech (Bristol, Avon) 2019; 68: 190-196
    CrossrefPubMedSearch in Google Scholar
  • 39 Ohba T, Ebata S, Oba H. et al. Risk Factors for Clinically Relevant Loosening of Percutaneous Pedicle Screws. Spine Surg Relat Res 2019; 3: 79-85
    CrossrefPubMedSearch in Google Scholar
  • 40 Bühren V, Josten C. Chirurgie der verletzten Wirbelsäule. Berlin, Heidelberg: Springer; 2012
    Search in Google Scholar
  • 41 Vougioukas VI, Weber J, Scheufler KM. Clinical and radiological results after parapedicular screw fixation of the thoracic spine. J Neurosurg Spine 2005; 3: 283-287
    CrossrefPubMedSearch in Google Scholar
  • 42 Wang X, Liu Y, Wang X. et al. Beneficial effects of percutaneous minimally invasive surgery for patients with fractures in the thoracic spine. Exp Ther Med 2018; 16: 5394-5399
    PubMedSearch in Google Scholar
  • 43 Kwan MK, Chiu CK, Lee CK. et al. Comparison between percutaneous fluoroscopic-guided and conventional open pedicle screw placement techniques for the thoracic spine: a safety evaluation in human cadavers. Bone Joint J 2015; 97-B: 1555-1561
    CrossrefPubMedSearch in Google Scholar
  • 44 Diniz JM, Botelho RV. Is fusion necessary for thoracolumbar burst fracture treated with spinal fixation? A systematic review and meta-analysis. J Neurosurg Spine 2017; 27: 584-592
    CrossrefPubMedSearch in Google Scholar
  • 45 Lan T, Chen Y, Hu SY. et al. Is fusion superior to non-fusion for the treatment of thoracolumbar burst fracture? A systematic review and meta-analysis. J Orthop Sci 2017; 22: 828-833
    CrossrefPubMedSearch in Google Scholar
  • 46 Spiegl UJ, Jarvers JS, Glasmacher S. et al. [Release of moveable segments after dorsal stabilization: impact on affected discs]. Unfallchirurg 2016; 119: 747-754
    CrossrefPubMedSearch in Google Scholar
  • 47 Sehmisch S, Müller-Färber J. Implantatentfernung nach Osteosynthese. Leitlinien Unfallchirurgie, AWMF-Nr. 012-004. Berlin; 2018. Online (last access: 17.04.2020): https://www.awmf.org/uploads/tx_szleitlinien/012-004l_S1_Implantatentfernung-nach-Osteosynthese_2018-08.pdf
    PubMed
  • 48 Reinhold M, Knop C, Beisse R. et al. Operative treatment of 733 patients with acute thoracolumbar spinal injuries: comprehensive results from the second, prospective, Internet-based multicenter study of the Spine Study Group of the German Association of Trauma Surgery. Eur Spine J 2010; 19: 1657-1676
    CrossrefPubMedSearch in Google Scholar
  • 49 Müller-Färber J. [Removal of metal in traumatology]. Unfallchirurg 2003; 106: 653-668
    CrossrefPubMedSearch in Google Scholar
  • 50 Kaneda K, Abumi K, Fujiya M. Burst fractures with neurologic deficits of the thoracolumbar-lumbar spine. Results of anterior decompression and stabilization with anterior instrumentation. Spine (Phila Pa 1976) 1984; 9: 788-795
    CrossrefPubMedSearch in Google Scholar
  • 51 Schnake KJ, Scholz M, Marx A. et al. Anterior, thoracoscopic-assisted reduction and stabilization of a thoracic burst fracture (T8) in a pregnant woman. Eur Spine J 2011; 20: 1217-1221
    CrossrefPubMedSearch in Google Scholar
  • 52 McDonough PW, Davis R, Tribus C. et al. The management of acute thoracolumbar burst fractures with anterior corpectomy and Z-plate fixation. Spine (Phila Pa 1976) 2004; 29: 1901-1908
    CrossrefPubMedSearch in Google Scholar
  • 53 Sasso RC, Best NM, Reilly TM. et al. Anterior-only stabilization of three-column thoracolumbar injuries. J Spinal Disord Tech 2005; 18 (Suppl.) S7-S14
    CrossrefPubMedSearch in Google Scholar
  • 54 Dai LY, Jiang LS, Jiang SD. Anterior-only stabilization using plating with bone structural autograft versus titanium mesh cages for two- or three-column thoracolumbar burst fractures: a prospective randomized study. Spine (Phila Pa 1976) 2009; 34: 1429-1435
    CrossrefPubMedSearch in Google Scholar
  • 55 Spiegl UJ, Hauck S, Merkel P. et al. [Incomplete cranial burst fracture in the thoracolumbar junction. Results 6 years after thoracoscopic monosegmental spondylodesis]. Unfallchirurg 2014; 117: 703-709
    CrossrefPubMedSearch in Google Scholar
  • 56 Spiegl U, Hauck S, Merkel P. et al. Six-year outcome of thoracoscopic ventral spondylodesis after unstable incomplete cranial burst fractures of the thoracolumbar junction: ventral versus dorso-ventral strategy. Int Orthop 2013; 37: 1113-1120
    CrossrefPubMedSearch in Google Scholar
  • 57 Zhang S, Thakur JD, Khan IS. et al. Anterior stabilization for unstable traumatic thoracolumbar spine burst fractures. Clin Neurol Neurosurg 2015; 130: 86-90
    CrossrefPubMedSearch in Google Scholar
  • 58 Schnake KJ, Stavridis SI, Kandziora F. Five-year clinical and radiological results of combined anteroposterior stabilization of thoracolumbar fractures. J Neurosurg Spine 2014; 20: 497-504
    CrossrefPubMedSearch in Google Scholar
  • 59 Smits AJ, Noor A, Bakker FC. et al. Thoracoscopic anterior stabilization for thoracolumbar fractures in patients without spinal cord injury: quality of life and long-term results. Eur Spine J 2018; 27: 1593-1603
    CrossrefPubMedSearch in Google Scholar
  • 60 Sobottke R, Frangen T, Lohmann U. et al. [The dorsal spondylodesis of rotationally unstable thoracic fractures. Is additional ventral stabilization necessary?]. Chirurg 2007; 78: 148-154
    CrossrefPubMedSearch in Google Scholar
  • 61 Spiegl UJ, Josten C, Devitt BM. et al. Incomplete burst fractures of the thoracolumbar spine: a review of literature. Eur Spine J 2017; 26: 3187-3198
    CrossrefPubMedSearch in Google Scholar
  • 62 Jarraya M, Guermazi A, Lorbergs AL. et al. A longitudinal study of disc height narrowing and facet joint osteoarthritis at the thoracic and lumbar spine, evaluated by computed tomography: the Framingham Study. Spine J 2018; 18: 2065-2073
    CrossrefPubMedSearch in Google Scholar
  • 63 Verheyden AP, Hoelzl A, Lill H. et al. The endoscopically assisted simultaneous posteroanterior reconstruction of the thoracolumbar spine in prone position. Spine J 2004; 4: 540-549
    CrossrefPubMedSearch in Google Scholar
  • 64 Haiyun Y, Rui G, Shucai D. et al. Three-column reconstruction through single posterior approach for the treatment of unstable thoracolumbar fracture. Spine (Phila Pa 1976) 2010; 35: E295-E302
    CrossrefPubMedSearch in Google Scholar
  • 65 Lai O, Hu Y, Yuan Z. et al. Modified one-stage posterior/anterior combined surgery with posterior pedicle instrumentation and anterior monosegmental reconstruction for unstable Denis type B thoracolumbar burst fracture. Eur Spine J 2017; 26: 1499-1505
    CrossrefPubMedSearch in Google Scholar
  • 66 Graillon T, Rakotozanany P, Blondel B. et al. Circumferential management of unstable thoracolumbar fractures using an anterior expandable cage, as an alternative to an iliac crest graft, combined with a posterior screw fixation: results of a series of 85 patients. Neurosurg Focus 2014; 37: E10
    CrossrefPubMedSearch in Google Scholar
  • 67 Leucht P, Fischer K, Muhr G. et al. Epidemiology of traumatic spine fractures. Injury 2009; 40: 166-172
    CrossrefPubMedSearch in Google Scholar
  • 68 Wang H, Zhou Y, Ou L. et al. Traumatic vertebral fractures and concomitant fractures of the rib in Southwest China, 2001 to 2010: an observational study. Medicine (Baltimore) 2015; 94: e1985
    CrossrefPubMedSearch in Google Scholar
  • 69 Battle CE, Hutchings H, Evans PA. Risk factors that predict mortality in patients with blunt chest wall trauma: a systematic review and meta-analysis. Injury 2012; 43: 8-17
    CrossrefPubMedSearch in Google Scholar
  • 70 Bergeron E, Lavoie A, Clas D. et al. Elderly trauma patients with rib fractures are at greater risk of death and pneumonia. J Trauma 2003; 54: 478-485
    CrossrefPubMedSearch in Google Scholar
  • 71 Krinner S, Grupp S, Oppel P. et al. Do low profile implants provide reliable stability in fixing the sternal fractures as a “fourth vertebral column” in sternovertebral injuries?. J Thorac Dis 2017; 9: 1054-1064
    CrossrefPubMedSearch in Google Scholar
  • 72 Labbe JL, Peres O, Leclair O. et al. Fractures of the upper transthoracic cage. J Bone Joint Surg Br 2009; 91: 91-96
    CrossrefPubMedSearch in Google Scholar
  • 73 Oyetunji TA, Jackson HT, Obirieze AC. et al. Associated injuries in traumatic sternal fractures: a review of the National Trauma Data Bank. Am Surg 2013; 79: 702-705
    CrossrefPubMedSearch in Google Scholar
  • 74 Turk EE, Tsokos M. Blunt cardiac trauma caused by fatal falls from height: an autopsy-based assessment of the injury pattern. J Trauma 2004; 57: 301-304
    CrossrefPubMedSearch in Google Scholar
  • 75 Scheyerer MJ, Zimmermann SM, Bouaicha S. et al. Location of sternal fractures as a possible marker for associated injuries. Emerg Med Int 2013; 2013: 407589
    CrossrefPubMedSearch in Google Scholar
  • 76 Vaccaro AR, Rizzolo SJ, Balderston RA. et al. Placement of pedicle screws in the thoracic spine. Part II: an anatomical and radiographic assessment. J Bone Joint Surg Am 1995; 77: 1200-1206
    CrossrefPubMedSearch in Google Scholar