CONDITIONS & PROCEDURES

 

What treatments should I consider?

Nonsurgical Treatment



Most cases of thoracic spine fracture are treated without an operation. Most crush fractures of the vertebral body and nearly all avulsion fractures are treated in this way. If the fracture is stable and the risk of progressive nerve damage is small then treatment is directed at pain relief and early mobilization. It is not usually necessary to keep lying down and it is desirable to get up from time to time to prevent the complications of prolonged bed-rest. Pain relief can be obtained by medication and ice packs and by staying still. Braces are often used to reduce the pain. They do not hold the spine still but reduce movement and divert some of the body weight away from the spine.
Within a few days the pain is improved to the point that you can sit up for longer periods and move within the house. It may be sensible to use a walker to reduce the amount of weight put through the spine while you are standing. This is particularly true if there is a risk of another fall. Walking with a walker does not give you full protection however; with every step you have to put full weight through the spine while you move the walker forward. You may find that a bit sore.
Follow-up with your doctor is important to check that your symptoms are improving and to make sure that the fracture position is unchanged. By six weeks there may be signs of healing on x-ray and this would be a signal to increase activity. Bones take three months to heal up to 80% of their strength so there would normally be some restrictions on heavy activity and sports for at least that period.
Prolonged bed-rest was formerly used as treatment for unstable fractures. A support made out of plaster of paris (plaster bed) was also used to keep the spine still and prevent deformity. Nursing the patient to avoid pressure sores must have been a huge problem. Today, most of these fractures will be treated by surgery to stabilize the fracture. However, in some cases surgery is not undertaken and the patient is treated with prolonged bed-rest. Patients with complete paralysis due to spinal cord injury are quite often treated in this way if the bone injury is likely to heal and become stable without intervention. Unfortunately, surgery will not improve the nerve injury in these cases.
Modern hospital may use beds with alternating pressure mattresses. They reduce the risk of pressure sores and it is usually safe to log roll from side to side without bending at the waist. It is common to supplement this treatment with a back brace worn all the time. This tedious type of treatment may continue for 6 weeks or more, until there is evidence of bone healing on X-ray. Bone healing converts an unstable situation into a stable one. Once the risk of the fracture fragments displacing and damaging the nerves, is over you will gradually mobilize and recover strength.

Surgery

The reason for undertaking surgery on a broken back is nearly always the same. In the surgeons opinion, the fracture is unstable and there is a significant risk that the fracture fragments will move and cause (more) nerve damage, unacceptable deformity, continuing pain or any combination. Since all spinal surgery also has risks attached, the surgeon also thinks that the risk of a problem without surgery is greater than the risk of a problem with an operation.
An incomplete spinal cord injury is a common indication for surgery. The fact that the spinal cord has been injured proves that the fracture is dangerous with a high likelihood of making the nerve injury worse if the fragments shift. It may also be possible to take pressure off the nerves and allow for some recovery of nerve function. By contrast, if there is a complete spinal cord injury with no likelihood of nerve recovery, the damage is already done and surgery may not be recommended. If the spine will become stable with bone healing the bony injury may be treated with bed-rest and a brace and a major operation avoided.
The aim of surgery is to take pressure off the nerves and spinal cord, restore stability and hold the fragments securely until they heal. The exact nature of the operation depends on the anatomy of the fracture. If the posterior elements (the spinous processes, arch or joints) are disrupted then the spine may be exposed from the back and a posterior fusion performed.
A fusion is a type of surgical procedure that surgeons use in many parts of the skeleton to allow two separate bones to grow together or fuse into one. A fusion is used to stop abnormal motion between two or more bones. In the spine, a fusion is typically used to control abnormal motion between two or more vertebrae that has resulted from a fractured vertebra. The abnormal motion due to the fractured vertebrae may place the spinal cord and spinal nerves at rick of damage. By fusing the two vertebrae together the spine is stabilized, the abnormal motion is eliminated, and the spinal cord and spinal nerves are safe from damage.
The surgery prepares the way for bone to grow across the gap between two vertebrae. This is done by scraping the surface of the bone to make a raw surface, holding the bones close together and as still as possible, then packing bone graft into the gap. In this way, growth of bone is stimulated and it will form a bridge of bone from one vertebra to the next fusing them together.
When the front portion of the thoracic spine is damaged it may be possible to stabilize it from the back using long strong screws and struts. In other situations the front of the spine must be exposed through the chest and the fragmented bone is supported with a small cage made of metal and filled with bone graft. The aims and details of the surgery differ from case to case and your surgeon will explain them to you.
After a spinal fusion operation it is important for the bone fragments to stay still relative to one another. For this reason a period of bed-rest may needed or the use of a brace. Once bony healing has been established and the bone bridge has formed from one vertebra to another you can put more stress through the area. Putting too much stress too early runs the risk of causing movement, breakage of the metal implant through fatigue failure, or prevention of the formation of new bone. Restrictions on activity after surgery are not imposed for a whim; they are imposed to give the operation the best possible chance of accomplishing its aim.


Very often, spinal surgery for fracture treatment involves metal implants such as screws, rods, or cages fixed into the bone to hold everything still while the bone heals to fuse the fragments together. The intention is to leave the implants in place even after they have performed their function and the bone has healed. Sometimes, especially with large implants, there is some discomfort which can be attributed to the hardware. In these cases the hardware may be removed after the bone has healed. This operation often requires exposure of the spine once more; however the post-operative pain is much less than the original operation and recovery is much quicker. You do not have to wait for the bone to heal.

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