Vertebroplasty

A Patient’s Guide to Vertebroplasty

Introduction

Vertebroplasty

Patients with osteoporosis are prone to compression fractures in the spine bones, or vertebrae. The front of a vertebra cracks under pressure, causing it to collapse in height. More than 700,000 such fractures occur every year in the United States. These fractures often cause poor back posture, debilitating pain, and difficulty completing routine activities.

Vertebroplasty restores the strength of the fractured bone, thereby reducing pain. More than 80 percent of patients get immediate relief of pain with this procedure.

This guide will help you understand

  • why the procedure becomes necessary
  • what surgeons hope to achieve with vertebroplasty
  • what to expect during recovery

Vertebroplasty

Anatomy

What parts of the spine are involved?

The main section of each spine vertebra is a large, round block of bone called a vertebral body. Compression fractures cause this section of bone to collapse.
The collapsed vertebra gives the spine a hunched appearance, called kyphosis, and the loss of vertebral height shortens the muscles on each side of the spine.

Vertebroplasty

This forces the back muscles to work harder, causing muscle fatigue and pain. The vertebral body is the main structure treated in the vertebroplasty procedure.

Related Document: A Patient’s Guide to Thoracic Spine Anatomy

Rationale

What do surgeons hope to achieve?

In the past, surgeons used standard open surgery to fix compression fractures from osteoporosis. Open surgery requires larger incisions to give the surgeon more room to operate. The results of open surgery for this condition have generally been poor, mainly because it is difficult to do surgery on bones that are weak and soft from osteoporosis. In addition, some aging adults with fractures may not be physically able to tolerate such surgery.

Vertebroplasty gives surgeons a way to fix the broken bone without the problems associated with open surgery. Unlike open surgery, vertebroplasty is a minimally invasive procedure. It requires small openings in the skin and small instruments. This lessens the chance of bleeding, infection, and injury to muscles and tissues.

Surgeons fix the bone in place by squeezing special cement into the broken bone. The cement strengthens and stiffens the vertebra, which reduces pain considerably and helps the patient return to normal activities.

This procedure doesn’t restore the original height of the broken vertebra, however. Nor does it prevent the kyphosis (hunchback) deformity that sometimes results from compression fractures.

Related Document: A Patient’s Guide to Spinal Compression Fractures

Preparations

How will I prepare for the procedure?

The decision to proceed with vertebroplasty must be made jointly by you and your surgeon. You should understand as much about the procedure as possible. If you have concerns or questions, talk to your surgeon.

Vertebroplasty is normally done on an outpatient basis, meaning patients go home the same day as the surgery. You shouldn’t eat or drink anything after midnight the night before.

Surgical Procedure

What happens during the procedure?

Vertebroplasty

The patient lies on his or her stomach. To begin, the surgeon cleans the skin on the back with an antiseptic. Then the skin and muscles over the problem area are numbed using an anesthetic. Patients may also receive general anesthesia to put them to sleep during the procedure.

A small incision is made in the skin on each side of the spinal column. A long needle is inserted through each opening. The surgeon slides the needles through the back of the spinal column into the fractured vertebral body.

Vertebroplasty

A fluoroscope is used to guide the needles. This is a special X-ray television camera adjusted above the patient’s back that lets the surgeon see the patient’s spine on a screen. Metal objects show up clearly on X-rays. The needles are easy for the surgeon to see on the fluoroscope screen. This helps the surgeon confirm that the needles reach the correct spot.

Once the needle is in place, special bone cement, called polymethylmethacrylate (PMMA), is injected
through the needle into the fractured vertebra.

View animation of cement injected

A chemical reaction in the cement causes it to harden in about 15 minutes. This fixes the bone so it can heal. Bandages are placed over the small openings where the needles were inserted.

Complications

What might go wrong?

Serious complications from vertebroplasty are rare, involving less than five percent of cases. As with other procedures, however, complications can occur. Some of the most common complications of vertebroplasty include

  • problems with anesthesia
  • thrombophlebitis
  • infection
  • cement leakage
  • ongoing pain

This is not intended to be a complete list of possible complications.

Problems with Anesthesia

Problems can arise when the anesthesia given during surgery causes a reaction with other drugs the patient is taking. In rare cases, a patient may have problems with the anesthesia itself. In addition, anesthesia can affect lung function because the lungs don’t expand as well while a person is under anesthesia. Be sure to discuss the risks and your concerns with your anesthesiologist.

Thrombophlebitis (Blood Clots)

View animation of pulmonary embolism

Thrombophlebitis, sometimes called deep venous thrombosis (DVT), can occur after any operation. It occurs when the blood in the large veins of the leg forms blood clots. This may cause the leg to swell and become warm to the touch and painful. If the blood clots in the veins break apart, they can travel to the lung, where they lodge in the capillaries and cut off the blood supply to a portion of the lung. This is called a pulmonary embolism. (Pulmonary means lung, and embolism refers to a fragment of something traveling through the vascular system.) Most surgeons take preventing DVT very seriously. There are many ways to reduce the risk of DVT, but probably the most effective is getting you moving as soon as possible. Two other commonly used preventative measures include

  • pressure stockings to keep the blood in the legs moving
  • medications that thin the blood and prevent blood clots from forming

Infection

Infection following spine procedures is rare but can be a very serious complication. Some infections may show up early, within the first few days after the procedure. Infections on the skin’s surface usually go away with antibiotics. Deeper infections that spread into the bones and soft tissues of the spine are harder to treat. They may require surgery to treat the infected portion of the spine.

Cement Leakage

The cement used in vertebroplasty is in a liquid form and is squeezed into the fractured vertebra under high pressure. Some of the cement commonly leaks out of the vertebra, but this usually doesn’t cause any problems. Only rarely does a cement leak cause pressure on the spinal cord or nearby nerves. In these cases, surgery may be required to remove the pressure.

Ongoing Pain

Many patients get nearly complete relief of symptoms from vertebroplasty. As with any procedure, however, you should expect some pain afterward. If the pain continues or becomes unbearable, talk to your doctor about treatments that can help control your pain.

After Surgery

What happens after surgery?

Patients are monitored in the recovery room for two to three hours after the procedure before going home. Patients are instructed to move their backs only carefully and comfortably. Some patients who feel extra pain or other problems after the procedure may need to stay in the hospital overnight.

Patients rarely need to wear a brace after vertebroplasty, since bone cement immediately improves the strength and stiffness of the fractured vertebra.

Rehabilitation

What should I expect as I recover?

People often report greater ease with daily activities within a week after vertebroplasty. Pain also decreases rapidly, and most people require less pain medication within two weeks. Despite these quick improvements, most orthopedists consider that it takes about three months for the bone to heal after vertebroplasty.

Patients are encouraged to walk and do moderate activity as they recover. However, patients should avoid strenuous activity until the surgeon approves it.

When the fracture is from osteoporosis, the surgeon will suggest ways to prevent future problems. Patients may be prescribed medications and supplements (calcium and vitamin D) to maximize bone health. Lifestyle changes, such as quitting smoking and taking up exercising, may also be discussed.

Related Document: A Patient’s Guide to Osteoporosis

Patients who continue to have pain or who have lost muscle tone and strength may need the help of a physical therapist. These patients typically attend therapy sessions for four to six weeks.

The goal of therapy is to safely advance strength and function. The therapist may use treatments such as heat or ice, electrical stimulation, or massage to calm pain. Gentle exercise improves the strength of the spine and limbs. Patients learn how to move safely using healthy postures to reduce strain on the healing back. Exercises for the heart and lungs improve stamina and help with pain control.

Vertebroplasty

As the therapy sessions come to an end, the therapist helps patients get back to the activities they enjoy. Ideally, patients are able to resume normal activities. They may be counseled on which activities are safe or how to change the way they go about their activities.

When treatment is well under way, regular visits to the therapist’s office end. The therapist continues to be a resource. But patients are in charge of doing their exercises as part of an ongoing home program.

Thoracic Spine Anatomy

A Patient’s Guide to Thoracic Spine Anatomy

Introduction

Thoracic Spine Anatomy

The section of the spine found in the upper back is called the thoracic spine. It goes from the base of the neck to the bottom of the rib cage. Knowing the main parts of the thoracic spine and how these parts work is important as you learn to care for your back problem.

Two common anatomic terms are useful as they relate to the thoracic spine. The term anterior refers to the front of the spine. The term posterior refers to the back of the spine. The front of the thoracic spine is therefore called the anterior thoracic area. The back of the thoracic spine is called the posterior thoracic area.

This guide gives a general overview of the anatomy of the thoracic spine. It should help you understand

  • what parts make up the thoracic spine
  • how these parts work

Important Structures

The important parts of the thoracic spine include

Thoracic Spine Anatomy

  • bones and joints
  • nerves
  • connective tissues
  • muscles
  • spinal segment

This section highlights important structures in each category.

Bones and Joints

The human spine is made up of 24 spinal bones, called vertebrae. Vertebrae are stacked on top of one another to create the spinal column. The spinal column is the body’s main upright support.

Thoracic Spine Anatomy

From the side, the spine forms three curves. The neck, called the cervical spine, curves slightly inward. The thoracic spine curves outward. The low back, also called the lumbar spine, curves slightly inward. An inward curve in the spine is called lordosis. An outward curve, as in the thoracic spine, is called kyphosis. The kyphosis is shaped like a “C” with the opening in front.

Thoracic Spine Anatomy

The middle 12 vertebrae make up the thoracic spine. Doctors often refer to these vertebrae as T1 to T12. The large bump on the back of the lower part of the neck is the seventh cervical vertebra, called C7. It connects on top of T1. The lowest vertebra of the thoracic spine, T12, connects below the bottom of the rib cage to the first vertebra of the lumbar spine, called L1.

Each vertebra is made of the same parts. The main section of each thoracic vertebra from T1 to T12 is formed by a round block of bone, called the vertebral body. Each vertebra increases slightly in size from the neck down. The increased size helps balance and support the larger muscles that connect to the lower parts of the spine.

Thoracic Spine Anatomy

A bony ring attaches to the back of each vertebral body. This protective ring of bone surrounds the spinal cord, forming the spinal canal. Two pedicle bones connect directly to the back of the vertebral body. Two lamina bones join the pedicles to complete the ring. The lamina bones form the outer rim of the bony ring. When the vertebrae are stacked on top of each other, the bony rings form a hollow tube that surrounds the spinal cord and nerves. The laminae provide a protective roof over these nerve tissues.

Thoracic Spine Anatomy

A bony knob projects out at the point where the two lamina bones join together at the back of the spine. You can feel these projections, called spinous processes, as you rub your fingers up and down the middle of your back. Bony knobs also point out from the side of the bony ring, one on the left and one on the right. These projections are called transverse processes.

Thoracic Spine Anatomy

Between the vertebrae of each spinal segment are two facet joints. The facet joints are located on the back of the spinal column. There are two facet joints between each pair of vertebrae, one on each side of the spine. A facet joint is made of small, bony knobs that line up along the back of the spine. Where these knobs meet, they form a joint that connects the two vertebrae. The alignment of the facet joints of the thoracic spine allows freedom of movement as you twist back and forth or lean side to side.

Thoracic Spine Anatomy

The surfaces of the facet joints are covered by articular cartilage. Articular cartilage is a slick, rubbery material that covers the ends of most joints. It allows the ends of bones to move against each other smoothly, without friction.

Thoracic Spine Anatomy

On the left and right side of each vertebra is a small tunnel called a neural foramen. (Foramina is the plural term.) The two nerves that leave the spine at each vertebra go through the foramina, one on the left and one on the right. The intervertebral disc (described later) sits directly in front of the opening. A bulged or herniated disc can narrow the opening and put pressure on the nerve. A facet joint sits in back of the foramen. Bone spurs that form on the facet joint can project into the tunnel, narrowing the hole and pinching the nerve.

Nerves

Thoracic Spine Anatomy

The hollow tube formed by the bony rings on the back of the spinal column surrounds the spinal cord. The spinal cord is like a long wire made up of millions of nerve fibers. Just as the skull protects the brain, the bones of the spinal column protect the spinal cord.

The spinal cord travels down from the brain through the spinal column. In the thoracic spine, the spinal canal is narrower than in the rest of the spine, giving very little extra space for the spinal cord as it passes through the thoracic spine.

Thoracic Spine Anatomy

Between the vertebrae, two large nerves branch off the spinal cord, one on the left and one on the right. The nerves pass through the neural foramina of each vertebra. These spinal nerves group together to form the main nerves that go to the organs and limbs. The nerves of the thoracic spine mainly control the muscles and organs of the chest and abdomen.

Connective Tissues

Thoracic Spine Anatomy

Connective tissues are networks of fiber that hold the cells of the body together. Ligaments are strong connective tissues that attach bones to other bones. Several long ligaments connect on the front and back sections of the vertebrae. The anterior longitudinal ligament runs lengthwise down the front of the vertebral bodies. Two other ligaments run full length within the spinal canal. The posterior longitudinal ligament attaches on the back of the vertebral bodies. The ligamentum flavum is a long elastic band that connects to the front surface of the lamina bones. Thick ligaments also connect the ribs to the transverse processes of the thoracic spine.

A special type of structure in the spine called an intervertebral disc is also made of connective tissue. The fibers of the disc are formed by special cells, called collagen cells. The fibers may be lined up like strands of nylon rope or crisscrossed like a net.

Thoracic Spine Anatomy

An intervertebral disc is made of two parts. The center, called the nucleus, is spongy. It provides most of the shock absorption in the spine. The nucleus is held in place by the annulus, a series of strong ligament rings surrounding it.

Discs in the thoracic spine are much thinner than in the cervical and lumbar spine. As a result, there is generally less movement between the vertebrae of the thoracic spine.

Muscles

Thoracic Spine Anatomy

The muscles of the thoracic spine are arranged in layers. Those closest to the skin’s surface run from the back of the vertebrae to the shoulder blades. Others wrap around the rib cage and connect to the shoulders. Strap-shaped muscles called erector spinae make up the middle layer of muscles. These muscles run up and down over the lower ribs and thorax (the rib cage), and cross to the low back. The deepest layer of muscles attaches along the back of the spine bones, connecting the vertebrae. Muscles also connect from one rib to the next.

Spinal Segment

Thoracic Spine Anatomy

A good way to understand the anatomy of the thoracic spine is by looking at a spinal segment.

Each spinal segment includes two vertebrae separated by an intervertebral disc, the nerves that leave the spinal column at each vertebra, and the small facet joints that link each level of the spinal column.

Summary

Many important parts make up the anatomy of the thoracic spine. Understanding the regions and structures of the thoracic spine can help you become more involved in your health care and better able to care for your back problem.

Spinal Compression Fractures

A Patient’s Guide to Spinal Compression Fractures

Introduction

Spinal Compression Fractures

Compression fractures are the most common type of fracture affecting the spine. A compression fracture of a spine bone (vertebra) causes the bone to collapse in height.

Compression fractures are commonly the result of osteoporosis. About 700,000 cases of compression fractures due to osteoporosis occur each year in the United States. Spine bones that are weakened from osteoporosis may become unable to support normal stress and pressure. As a result, something as simple as coughing, twisting, or lifting can cause a vertebra to fracture.

An injury to the spine, such as from a hard fall on the buttocks or blow to the head, can cause a spinal compression fracture. Compression fractures may also occur if cancer from other parts of the body spreads to the spine. Cancer weakens the spine bones and makes them prone to fractures.

This guide will help you understand

  • how compression fractures happen
  • how doctors diagnose the problem
  • what treatment options are available

Spinal Compression Fractures

Anatomy

What parts of the spine are involved?

The human spine is made of 24 spinal bones, called vertebrae. Vertebrae are stacked on top of one another to create the spinal column. The spinal column gives the body its form. It is the body’s main upright support.

The main section of each vertebra is a large, round structure called a vertebral body.
Spinal Compression Fractures

Compression fractures cause this section of bone to collapse. When the fracture is due to osteoporosis, it usually occurs in the lower part of the thoracic spine, near the bottom of the rib cage.

A bony ring attaches to the back of each vertebral body. When the vertebrae are stacked on one another, the bony rings form a hollow tube. This tube, or canal, surrounds the spinal cord. The spinal cord is like a long wire made of millions of nerve fibers. Just as the skull protects the brain, the bones of the spinal column protect the spinal cord.

Spinal Compression Fractures

Severe compression fractures from forceful impact on the spine, as can happen in a car accident, can cause fragments of the vertebral body to push into the spinal canal and press against the spinal cord. This can cause damage to the spinal cord that can result in partial or complete paralysis below the waist. It is rare for a typical compression fracture from osteoporosis to cause damage to the spinal cord.

Related Document: A Patient’s Guide to Thoracic Spine Anatomy

Causes

Why do I have this problem?

Strong, healthy bones are able to withstand the forces and strains of normal activity. Compression fractures in the spine happen when either the forces are too great or the bones of the spine aren’t strong enough. The vertebral body cracks under pressure. Fractures from forceful impact on the spine tend to crack the back (posterior) part of the vertebral body. Fractures from osteoporosis usually occur in the front (anterior) part of the vertebral body.

Spinal Compression Fractures

Osteoporosis is a disease that weakens bone. Sometimes the bones in the spine weaken to the point that even mild forces can lead to a compression fracture. A simple action like reaching down to pull on a pair of socks can cause a weakened vertebra to fracture. The front of the vertebra (the part closest to the front of the body) crumbles, causing the round vertebral body to become wedge-shaped. This angles the spine forward, producing a hunch-backed appearance, called kyphosis.

Related Document: A Patient’s Guide to Osteoporosis

Spinal Compression Fractures

Diseases or conditions that affect the parathyroid gland can also weaken bones. Four pea-sized parathyroid glands are located just behind the thyroid gland in the throat. They produce a substance called parathyroid hormone (PTH), which normally regulates the amount of calcium in the blood stream. An overactive parathyroid gland releases too much PTH, causing the body to leach calcium from bones, even when there is more than enough calcium circulating in the blood stream. This disorder is called hyperparathyroidism It occurs when a tumor, called an adenoma, forms in one of the parathyroid glands. Cancers that affect the kidney, skin, or parathyroid gland may also cause the parathyroid gland to malfunction. If the problem isn’t fixed, bones continue to lose calcium and eventually weaken. Weakening in the spine bones makes the vertebrae more prone to crack in front, as is typical with osteoporosis.

Cancers that form in other parts of the body have a tendency to spread, or metastasize, to the spine. When this happens, the cancer weakens the spine bones, making them susceptible to compression fractures. Doctors may suspect unrecognized cancer if a patient has a compression fracture without any particular cause or reason.

Spine trauma can produce mild or severe compression fractures. Compression fractures from trauma usually involve high forces that impact the spine when it is bent forward. This is typically what happens when a person falls onto the buttocks or strikes his head on the windshield in a car accident. Again, these traumatic fractures usually affect the back part of the vertebral body.

Symptoms

What does the condition feel like?

Compression fractures caused by thin, weakened bones may cause little or no pain at first. Sometimes pain is centered over the area where the fracture has occurred. The collapsed vertebra gives the spine a hunched appearance, and the loss of vertebral height shortens the muscles on each side of the spine. This forces the back muscles to work harder, causing muscle fatigue and pain. When pain does occur, it usually goes away after a few weeks. However, back pain sometimes escalates to the point that patients seek medical help.

Traumatic compression fractures can produce intense pain in the back that spreads into the legs. If the fracture severely damages the vertebral body, bone fragments may lodge in the spinal canal, pressing on the spinal cord. This can paralyze muscles and impair sensation in the areas supplied by the damaged nerve tissue. Such a fracture may also cause the spine to become unstable. When this happens, the spine eventually tilts forward into increased kyphosis, and the potential grows for future complications with the spinal cord.

Diagnosis

How do doctors diagnose the problem?

Diagnosis begins with a complete history and physical examination. The doctor asks questions about your symptoms and how your problem is affecting your daily activities. These include questions about where you feel pain and if you have numbness or weakness in your limbs. Your doctor will also want to know what positions or activities make your symptoms worse or better.

Then the doctor examines you to see which back movements cause pain or other symptoms. Your skin sensation, muscle strength, and reflexes are also tested. The doctor uses gentle pressure to feel the tissues over the sore area, since compression fractures often cause soreness and tenderness in the muscles over fractured vertebra.

Spinal Compression Fractures

If the doctor believes there is a compression fracture, X-rays are ordered. X-rays can show fractures of the vertebrae.

When an X-ray confirms a compression fracture, computed tomography (a CT scan) may be ordered. This is a detailed X-ray that lets the doctor see slices of the body’s tissue. The image can show whether the compression fracture has caused the area to become unstable from the injury.

If symptoms suggest problems with the spinal cord, the doctor may combine the CT scan with myelography. To do this, a special dye is injected into the space around the spinal canal (the subarachnoid space). When the CT scan is performed, the dye highlights the spinal cord and spinal nerves. The dye can improve the accuracy of a standard CT scan for diagnosing the health of the spinal cord and spinal nerves.

Magnetic resonance imaging (MRI) can show the doctor problems affecting the nerves or causing pain. The MRI machine uses magnetic waves rather than X-rays to show the soft tissues of the body. It shows problems in other soft tissues such as the discs and spinal cord. This machine creates pictures that look like slices of the area your doctor is interested in. The test does not require special dye or a needle.

Your doctor may order a bone scan to get additional information. This involves injecting chemical tracers into your blood stream. The tracers then show up on special X-rays of your spine. The tracers build up in areas of extra stress to bone tissue. This test can show if there are any old compression fractures, which would alert the doctor to problems with osteoporosis. If you have osteoporosis, the doctor will suggest ways to prevent future problems.

Treatment

What treatment options are available?

Nonsurgical Treatment

The majority of patients with compression fractures are treated without surgery. Most compression fractures heal within eight weeks with simple remedies of medicine, rest, and a special back brace.

Most patients are given medication to control pain. Although medications can help ease pain, they are not designed to heal the fracture. With pain under control, patients find it easier to get up and move about, avoiding the problems that come from remaining immobile in bed.

Patients are usually prescribed a short period of rest. This gives the fracture a chance to heal and aids in pain control. In some cases, the doctor may have a patient stay in bed for up to one week.

Spinal Compression Fractures

Most patients are fit with a special back brace, called an orthosis. This type of brace is molded to the patient’s body. It limits spine movement in general, though the brace is usually fashioned to keep patients from bending forward. This protects the fractured vertebral body so it can heal. Patients who wear a special brace may be advised to move about but to limit strenuous activities, such as lifting and bending

Surgery

Open surgical treatment for spinal compression fractures due to osteoporosis is infrequently needed. (Open procedures require larger incisions to give the surgeon more room to operate.) In rare cases of severe trauma, however, open surgery is sometimes required. Open surgery is done if the spinal segment has loosened and bone fragments have damaged the spinal cord and spinal nerves.

Surgeons have begun using two new procedures to treat compression fractures caused by osteoporosis. Both are considered minimally invasive. Minimally invasive means the incisions used are very small, and there is little disturbance of the muscles and bones where the procedure is done. These two procedures help the fracture heal without the problems associated with more involved surgeries. These new procedures are

  • vertebroplasty
  • kyphoplasty

Vertebroplasty

This procedure is most helpful for reducing pain. It also strengthens the fractured bone, enabling patients to rehabilitate faster.

Spinal Compression Fractures

To perform vertebroplasty, the surgeon uses a fluoroscope to guide a needle into the fractured vertebral body. A fluoroscope is a special X-ray television that allows the surgeon to see your spine and the needle as it moves. Once the surgeon is sure the needle is in the right place, bone cement, called polymethylmethacrylate (PMMA), is injected through the needle into the fractured vertebra. A reaction in the cement causes it to harden within 15 minutes. This fixes the bone so that it does not collapse any further as it heals. More than 80 percent of patients get immediate pain relief with this procedure.

Related Document: A Patient’s Guide to Vertebroplasty

Kyphoplasty

Kyphoplasty is another way for surgeons to treat vertebral compression fractures. Like vertebroplasty, this procedure halts severe pain and strengthens the fractured bone. However, it also gives the advantage of improving some or all of the lost height in the vertebral body, helping prevent kyphosis.

Spinal Compression Fractures

Two long needles are inserted through the sides of the spinal column into the fractured vertebral body. These needles guide the surgeon while drilling two holes into the vertebral body. The surgeon uses a fluoroscope (mentioned above) to make sure the needles and drill holes are placed in the right spot.

View animation of inflating the balloons

The surgeon then slides a hollow tube with a deflated balloon on the end through each drill hole. Inflating the balloons restores the height of the vertebral body and corrects the kyphosis deformity. Before the procedure is complete, the surgeon injects bone cement into the hollow space formed by the balloon. This fixes the bone in its corrected size and position.

Related Document: A Patient’s Guide to Kyphoplasty

Rehabilitation

What should I expect as I recover?

Rehabilitation after traumatic vertebral fractures can be a slow process. In these cases, patients sometimes need to attend therapy sessions for two to three months and should expect full recovery to take up to one year.

Most spinal compression fractures caused by osteoporosis get better within eight weeks. As mentioned, most patients who suffer compression fractures from osteoporosis don’t require surgery. Instead they are treated conservatively.

Patients who were fit with a special brace are usually able to begin increasing their activity level after about one week. However, patients are encouraged to avoid strenuous activity until their doctor approves resuming normal levels of activity.

People who have back pain generally find their pain improves as the fracture heals. However, the fracture changes the way the spine works, so it is not unusual for patients to have some lingering soreness in the muscles and joints near the fractured vertebra. If pain continues, let your doctor know.

After six to eight weeks, doctors may have their patients begin a period of physical therapy. This is especially true when patients lose muscle tone, are deconditioned from having to limit their activities, or have ongoing pain.

At first, treatments help control pain and inflammation. Ice and electrical stimulation treatments are commonly used to help with these goals. Your therapist may also use massage and other hands-on treatments to ease muscle spasm and pain.

Treatments are also used to improve posture. A combination of flexibility, strength, and postural exercise may be all that is needed to help your posture. Sometimes patients may need additional support with either a rigid brace or a fabric corset.

Your therapist also works with you on how to move and do activities. This form of treatment, called body mechanics, is used to help you develop new movement habits. This training helps you keep your back in safe positions and avoid extra strain near the fracture as you go about your work and daily activities. Training includes positions you use when sitting, lying, standing, and walking. You’ll also work on safe body mechanics with lifting, carrying, pushing, and pulling.

Spinal Compression Fractures

The therapist periodically tests your posture, balance, and strength to see how well you are improving. The therapist’s goal for you is to become proficient and safe with your exercises and improve your posture, strength, and flexibility. The therapist gives you tips on how to avoid future problems.

When patients are well under way, regular visits to the therapist’s office end. The therapist continues to be a resource, but patients are in charge of doing their exercises as part of an ongoing home program.

Scheuermann’s Disease

A Patient’s Guide to Scheuermann’s Disease

Introduction

Scheuermann's Disease

The section of spine from below the neck to the bottom of the rib cage is called the thoracic spine. From the side, the thoracic spine appears slightly rounded. Its shape is like the letter “C” with the opening facing the front of the body. This normal curve is called kyphosis. With excessive kyphosis, the thoracic spine takes on a hunchbacked appearance.

Scheuermann’s disease (also called Scheuermann’s kyphosis) is a condition that starts in childhood. It affects less than one percent of the population and occurs mostly in children between the ages of 10 and 12. It affects boys and girls with a slightly higher number of boys affected. Those who do not get proper treatment for the condition during childhood often experience back pain from the spinal deformity as adults. Sometimes Scheuermann’s disease doesn’t develop until adulthood.

This guide will help you understand

  • how the problem develops
  • how doctors diagnose the condition
  • what treatment options are available

Anatomy

Scheuermann's Disease

What parts of the spine are involved?

A healthy human spine has three gradual curves. From the side, the neck and low back curve gently inward. This is called lordosis. The thoracic kyphosis (outward curve) gives the mid back its slightly rounded appearance. These normal curves help the spine absorb forces from gravity and daily activities, such as lifting.

Scheuermann's Disease

The angle of normal kyphosis in the thoracic spine varies. During the growth years of adolescence, a normal curve measures between 25 and 40 degrees. If the curve angles more than 40 degrees, doctors consider the kyphosis a deformity. In general, kyphosis tends to be more exaggerated in girls. The angle increases slightly throughout life both in women and men. Scheuermann’s disease causes the thoracic kyphosis to angle too far (more than 45 degrees).

Scheuermann's Disease

The 12 thoracic vertebrae are known as T1 to T12. The main section of each thoracic vertebra is a round block of bone, called a vertebral body. A ring of bone attaches to the back of the vertebral body. This ring surrounds and protects the spinal cord.

In Scheuermann’s disease, the front of the vertebral body becomes wedge-shaped, possibly from abnormal growth. This produces a triangular-shaped vertebral body, with the narrow, wedged part closest to the front of the body. The wedge puts a bigger bend in the kyphosis of the thoracic spine.

Scheuermann's Disease

The vertebral bodies are separated by a cushion, called an intervertebral disc. Between each disc and vertebral body is a vertebral end plate. Sometimes one or more discs in patients with Scheuermann’s disease squeeze through the vertebral end plate, which is often weaker in patients with Scheuermann’s disease. This forms pockets of disc material inside the vertebral body, a condition called Schmorl’s nodes.

Scheuermann's Disease

A long ligament called the anterior longitudinal ligament connects on the front of the vertebral bodies. This ligament typically thickens in patients with Scheuermann’s disease. This adds to the forward pull on the spine, producing more wedging and kyphosis.

The disease usually produces kyphosis in the middle section of the thorax (the chest), between the shoulder blades. The condition sometimes causes kyphosis in the lower part of the thoracic spine, near the bottom of the rib cage.

Related Document: A Patient’s Guide to Thoracic Spine Anatomy

Causes

Why do I have this problem?

Famed for discovering this disease, Scheuermann himself thought a lack of blood to the cartilage around the vertebral body caused the wedging. Though scientists have since disproved this theory, the root cause of the disease is still unknown.

View animation

Mounting evidence suggests wedging develops as a problem vertebral body grows. During normal growth, the cartilage around the vertebral body turns evenly and completely to bone. If the change from cartilage to bone doesn’t happen evenly, one side of the vertebral body grows at a faster rate. By the time the entire vertebral body turns to bone, one side is taller than the other. This is the wedge shape that leads to abnormal kyphosis.

Other theories of how Scheuermann’s kyphosis starts include

  • genetics
  • childhood osteoporosis
  • mechanical reasons

Genetics

Researchers have suggested that this disease can be passed down in families. Studies have shown multiple families who have passed the disease through inheritance of certain types of genes. The genetic link is uncommon but remains under investigation.

Childhood Osteoporosis

One medical study found that some patients with Scheuermann’s disease had mild osteoporosis (decreased bone mass) even though they were very young. Other studies did not show problems with osteoporosis. More research is needed to confirm the role of osteoporosis in Scheuermann’s disease.

Related Document: A Patient’s Guide to Osteoporosis

Mechanical Reasons

These include strains from bending, heavy lifting, and using poor posture. This theory makes sense because the back braces used in treating kyphosis work. If a back brace can straighten a bent spine, then perhaps mechanical forces could cause more kyphosis than naturally occurs in the spine. (Back braces are discussed in more detail later.) Some experts think that tight hamstring muscles (along the back of the thigh) pull on the pelvis contributing to spinal deformity.

Scientists are not convinced that mechanical reasons cause the disease; rather, these factors likely aggravate the condition. And in some cases, it is difficult to tell which came first: the mechanical changes causing the deformity or the deformity resulting in the anatomical and thus mechanical changes.

Other Reasons

Other theories put forth that might help explain the cause(s) of Scheuermann’s disease include biochemical changes in the collagen that make up the end-plates altering bone growth, above-average disc height, and increased levels of growth hormone.

Symptoms

What does the condition feel like?

Hunched posture or a round back in children usually alerts parents or teachers to the need for a doctor visit. Children don’t typically complain of back pain or other symptoms.

This is not the case in adolescents who are nearing puberty and have kyphosis in the lowest part of the thorax, near the bottom of the rib cage. In these patients, back pain is the overriding problem. This happens most often to young, active males. Doctors suspect this unique form of the disease occurs because the condition is overlooked during childhood, delaying treatment.

Adults who’ve lived with the hunched posture for many years may note worsening pain. They may be disturbed by the physical changes and deformity that develop.The pain and/or the physical changes typically causes them to seek medical help.

Besides having a forward curved spine, most people affected by Scheuermann’s report back pain, stiffness, and loss of flexibility. The neck and low back try to compensate by increasing the natural lordotic curves in these two areas. Since the person cannot straighten the thoracic spine, the cervical and lumbar spines increase their curves to compensate for the round back. All of these changes in posture are usually accompanied by tight shoulder, hip, and leg muscles.

Degenerative spondylosis is also reported as part of the natural history in middle-aged adults with Scheuermann’s kyphosis. Degenerative changes in the spine (usually from aging) can cause bone spurs to form around the spinal joints. The joint spaces start to narrow. This condition is called spondylosis, which can also contribute to pain and stiffness.

Patients of all ages who experience pain generally report feeling discomfort along the sides of the spine, slightly below the main part of the abnormal curve.

Exaggerated kyphosis can lead to an increased lordosis (inward curve) in the low back. This puts extra strain on the tissues of the low back. Over many years, this added wear and tear may produce low back pain. This mainly occurs in adults who have extra lumbar lordosis from years of untreated Scheuermann’s disease.

In rare cases, the spinal cord is affected. A severe kyphosis stretches the spinal cord over the top of the curve. This can injure the spinal cord. Also, patients with Scheuermann’s disease have a greater chance of having a herniated thoracic disc. This is where the disc material from inside the disc begins to squeeze out and press on the spinal cord. Spinal cord symptoms for both situations include sensations of pins and needles and numbness. The leg muscles may feel weak. Symptoms from an injured spinal cord can also include changes in bowel and bladder function.

Related Document: A Patient’s Guide to Thoracic Disc Herniations

When the kyphosis angle exceeds 100 degrees (rare), the sharply bent spine puts pressure on the heart, lungs, and intestines. When this occurs, patients may tire quickly, suffer shortness of breath, feel chest pain, and lose their appetite.

Diagnosis

How do doctors diagnose the problem?

Doctors start with a complete history and physical examination. However, X-rays are the main way to diagnose Scheuermann’s kyphosis. Taken from the side, an X-ray may show vertebral wedging, Schmorl’s nodes, and changes in the vertebral end plates. Doctors use X-ray images to measure the angle of kyphosis. Doctors diagnose Scheuermann’s disease when three vertebrae in a row wedge five degrees or more and when the kyphosis angle is greater than 45 degrees.

Scheuermann's Disease

Scheuermann’s disease or kyphosis is diagnosed as either being typical (Type I) or atypical (Type II). These two forms of the disease affect different parts of the spine. The typical form (most common type) has the thoracic kyphotic pattern described in this section. The lower (lumbar) spine compensates by becoming hyperlordotic. Lordosis is the spinal curve exactly opposite of kyphosis. Hyperlordotic means the curve increases beyond what is considered “normal.”

The atypical form of Scheuermann’s (Type II) affects the low back known as the lumbar spine. The upper lumbar spine (where the thoracic spine transitions to become the lumbar spine) is involved. Type II is seen most often in young boys before puberty who are active in sports activities. They experience pain that goes away with rest and change in position or activity level.

A side-view X-ray can also show if the spine is flexible or rigid. Patients are asked to bend back and hold the position while an X-ray is taken. The spine straightens easily when it is flexible. In patients with Scheuermann’s disease, however, the curve stays rigid and does not improve by trying to straighten up.

From the front, X-rays show if the spine curves from side to side. This sideways curve is called scoliosis and occurs in about one-third of patients with Scheuermann’s kyphosis.

Scheuermann's Disease

X-rays can show signs of wear and tear in adults who have extra lumbar lordosis from years of untreated Scheuermann’s disease.

Computed tomography (a CT scan) may be ordered. This is a detailed X-ray that lets doctors see slices of the body’s tissue.

Myelography is a special kind of X-ray test. For this test, dye is injected into the space around the spinal canal. The dye shows up on an X-ray. This test is especially helpful if the doctor is concerned whether the spinal cord is being affected.

Magnetic resonance imaging (MRI) uses magnetic waves rather than X-rays to show the soft tissues of the body. This machine creates pictures that look like slices of the area the doctor is interested in. The test does not require special dye or a needle.

Treatment

What treatment options are available?

Nonsurgical Treatment

A child or youth with mild kyphosis may simply need to be observed. Unless the curve or pain becomes worse, no other treatment may be needed. Some children who don’t require treatment eventually improve and have no long-term problems. Others may always have a mild thoracic kyphosis but are able to function normally without pain or other problems.

If the doctor is concerned that the curve will worsen, he or she may suggest bracing and exercise. A brace is most effective when used before the skeleton matures at about age 14. Doctors commonly chose a Milwaukee brace, which is designed to hold the shoulders back and gradually straighten the thoracic curve. The brace won’t reverse the curve in a fully developed spine. Nor is it helpful for rigid curves that angle more than 75 degrees.

Scheuermann's Disease

The Milwaukee brace is made of molded plastic that conforms to the waist. On the back, two upright, padded bars line up along the sides of the spine. Pressure from the upright bars straightens the spine. Patients usually remove the brace to shower, but they keep it on at night.

Younger patients (under 15) generally wear the brace all the time. The doctor adjusts the brace regularly as the curve improves. When the thoracic curve has improved enough, the brace is worn part-time (eight to 12 hours per day) until the skeleton is done growing, typically around age 14 or 15.

A physical therapist may show the patient recommended exercises. When used in combination with a brace, exercises appear to maximize the effect of the brace by strengthening muscles that help align the spine. Certain exercises, such as general conditioning and stretching, are also worthwhile for helping patients control pain. Core training for spinal stabilzation is an important part of the pain management program. However, exercises alone don’t reduce kyphosis in Scheuermann’s disease.

Doctors may prescribe anti-inflammatory medication for pain. Younger patients generally use this medicine on a short-term basis, in combination with other treatments. Adults who have ongoing pain sometimes require long-term use of anti-inflammatory medication. Sometimes adults obtain partial correction of the kyphosis and pain relief with bracing even though they have reached full bone growth. Bracing for pain relief in adults is also considered when surgery is not an option.

Surgery

Surgeons rarely recommend fusion surgery for Scheuermann’s disease. Certain situations may require it, however. For example, surgery may be needed if pain becomes severe and doesn’t go away with nonoperative treatment or if pressure on the spinal cord or spinal nerves is causing problems. Some people request surgery if the deformity is severe enough that their appearance causes them considerable psychologic and/or emotional distress.

Patients whose skeletons are done growing may require surgery. Patients with a rigid kyphosis that angles more than 75 degrees may also need surgery. The entire length of the kyphosis is fused.

Two procedures commonly used to treat thoracic kyphosis are

  • posterior fusion
  • combined fusion

Posterior Fusion

In a fusion operation, two or more bones are joined into one solid bone. Surgeons perform posterior fusion for Scheuermann’s disease on the rare patient who prefers not to use a brace and whose spine is still growing, is mildly flexible, and has a kyphosis of less than 65 degrees.

Scheuermann's Disease

This surgery is done through the back (posterior) of the spine. After making an incision in the back, the surgeon applies pressure to straighten the kyphosis. Small strips of bone graft are then laid over the back of the spinal column. These strips encourage the bones to grow together. Metal rods are attached along the spine to prevent the vertebrae from moving. The rods hold the spine in better alignment and protect the bone graft so it can heal better and faster.

The posterior-only approach has the advantage of less blood loss than an anterior approach and does not interfere with major anterior blood supply to the spinal cord. Surgical time is shorter with the posterior-only method. Improved instrumentation and surgical technique has improved results for posterior-only fusions. Many more surgeons are using this approach with fewer problems even with more rigid curves.

Combined Fusion

Combined fusion is actually two fusion surgeries, one from the back (posterior) and one from the front (anterior) of the spine. In the past, two separate operations were needed, but now some surgeons do both fusions in the same operation. This surgery is commonly used if the spine is finished growing and the kyphosis angle is more than 75 degrees.

The surgeon starts with anterior fusion. With the patient on his or her side, the surgeon cuts away a piece of rib to make a small opening on the side of the thorax. The rib opening is spread apart so the surgeon can reach the spine better. The surgeon operates on the front of the spine through the chest cavity.

Scheuermann's Disease

A section of the anterior longitudinal ligament is cut. This makes it easier to straighten the hunched spine. The intervertebral discs in the problem area are taken out, and the spaces between the wedged vertebrae are filled with bone graft. One method is to take a graft of bone from the pelvis and tamp it into the place of each removed disc. This requires another incision over one side of the pelvis. A second method is to grind up the piece of rib that was removed and place it in the disc spaces. As the grafts heal, the vertebrae become fused into solid bone.

The second part of surgery is an involved form of posterior fusion using special rods and hooks. This part of the operation can be done right after the anterior fusion or scheduled for one week later.

First, the surgeon makes an incision over the back of the spine. The skin and muscles are spread apart.

Scheuermann's Disease

Then strips of bone graft are laid across each vertebra to be fused. Long rods are inserted along the sides of the spine. The rods have hooks attached on both ends. Wire is wrapped between the top and bottom hooks. Tightening the wires causes the spine to straighten. The rods help hold the spine steady as the bone grafts heal. The rods are usually left in permanently.

Rehabilitation

What should I expect as I recover?

Nonsurgical Rehabilitation

Children and adolescents treated nonsurgically sometimes work with a physical therapist. Certain exercises are beneficial when used in combination with a brace. Upper back exercises, such as gentle back bends (extension) can improve posture and prevent the spine from slouching forward. Hamstring stretches and pelvis exercises improve posture by preventing extra lordosis in the low back. Aerobic exercise improves heart and lung health and combats pain.

Pain is also addressed by the physical therapist. The therapist may apply heat, cold, ultrasound, and massage treatments. Adults who’ve had kyphosis for many years (and the resulting low back pain from too much lordosis) benefit from postural exercises to reduce the lumbar curve, followed by stabilization exercises to help them keep better posture. Patients benefit most when these exercises are done regularly and for a lifetime.

After Surgery

Rehabilitation after surgery is more complex. Although some patients leave the hospital shortly after surgery, some surgeries require patients to stay in the hospital for a few days. Soon after surgery, a physical therapist may visit patients who stay in the hospital. The treatment sessions help patients learn to move and do routine activities without putting extra strain on the back.

During recovery from surgery, patients should follow their surgeon’s instructions about wearing a back brace or support belt. They should be cautious about overdoing activities in the first few weeks after surgery.

Scheuermann's Disease

Many surgical patients also need physical therapy outside of the hospital. Patients normally wait up to three months before beginning a rehabilitation program after fusion surgery for Scheuermann’s disease. They typically need to attend therapy sessions for eight to 12 weeks. Full recovery may take up to eight months.

Upon completing physical therapy, patients are in charge of doing their exercises as part of an ongoing home program. Final results are overall favorable following surgery. The majority of patients report being satisfied with their cosmetic appearance. Some patients even experience complete relief from their pain. There may be some low back pain or discomfort with strenuous activity. Complications are rare but can include infection, loss of correction, spinal cord injury or other neurologic problems. In a small number of cases, a second surgical procedure may be required.

Kyphoplasty

A Patient’s Guide to Kyphoplasty

Introduction

Kyphoplasty

Patients with osteoporosis are prone to compression fractures in the spine bones, or vertebrae. The bone cracks under pressure, causing it to collapse in height. More than 700,000 such fractures occur every year in the United States.

The fracture angles the spine forward and produces a hunchbacked appearance, called kyphosis. Patients with this condition are subject to debilitating pain, disturbed sleep, decreased lung and intestinal function, and difficulty completing routine activities.

Kyphoplasty restores the size and strength of the fractured vertebra. This realigns the spine and reduces pain. Nearly 95 percent of patients get immediate relief of pain with this procedure.

This guide will help you understand

  • why the procedure becomes necessary
  • what surgeons hope to achieve with kyphoplasty
  • what to expect during recovery

Kyphoplasty

Anatomy

What parts of the spine are involved?

The main section of each spine vertebra is a large, round structure called a vertebral body. Compression fractures cause the front portion of this round bone to collapse in height. Because the back section of the bone stays intact, the damaged vertebral body becomes wedge-shaped.

Kyphoplasty

It is this wedge shape that angles the spine forward into kyphosis. The vertebral body is the main structure treated in the kyphoplasty procedure.

Related Document: A Patient’s Guide to Thoracic Spine Anatomy

Rationale

What do surgeons hope to achieve with this procedure?

In the past, surgeons used standard open surgical procedures to fix compression fractures from osteoporosis. Open procedures require larger incisions to give the surgeon more room to operate. The results of open surgery for this condition have generally been poor, mainly because operating on bones that are weak and soft from osteoporosis is difficult. In addition, some aging adults with fractures may not be physically able to tolerate such a surgery.

Kyphoplasty gives surgeons a way to fix the broken bone without the problems associated with open surgery. Unlike open surgery, which involves an incision and the use of larger instruments, kyphoplasty is a minimally invasive procedure. It requires a small opening in the skin and small instruments. This lessens the chance of bleeding, infection, and injury to muscles and soft tissues.

The goal of kyphoplasty is to return the fractured vertebra as close as possible to its normal height. This is done by inflating a balloon inside the fractured bone to restore the vertebral body to its normal size. Special cement is then injected into the bone, fixing it in place. The cement strengthens the broken vertebra and stiffens it in its original height and position. This reduces pain and spine deformity (kyphosis), enabling patients to get back to normal activities.

Related Document: A Patient’s Guide to Spinal Compression Fractures

Preparations

How will I prepare for the procedure?

The decision to proceed with kyphoplasty must be made jointly by you and your surgeon. You should understand as much about the procedure as possible. If you have concerns or questions, talk to your surgeon.

Kyphoplasty is normally done on an outpatient basis, meaning patients go home the same day as the surgery. You shouldn’t eat or drink anything after midnight the night before.

Surgical Procedure

What happens during the procedure?

The patient lies on his or her stomach. To begin, the surgeon cleans the skin on the back with an antiseptic. Then the skin over the problem area is numbed using an anesthetic. Patients may also receive general anesthesia to put them to sleep during the procedure.

Kyphoplasty

Two small openings are made in the skin on each side of the spinal column. Long needles are inserted through the openings. The needles are passed completely through the back of the spinal column into the fractured vertebral body. These needles serve as guides while the surgeon drills two holes into the vertebral body. The surgeon uses a fluoroscope to make sure the needles and drill holes are placed in the right spot. A fluoroscope is a special X-ray television that allows the surgeon to see your spine on a screen.

The device works like a video, though the images are in the form of an X-ray. Metal objects show up clearly on X-rays. The needle is easy for the surgeon to see on the fluoroscope screen. This helps the surgeon know the needle goes into the correct spot.

Kyphoplasty

A hollow tube with a deflated balloon on the end is then slid through each drill hole. The balloons are inflated with air. This restores the height of the vertebral body and corrects the kyphosis deformity.

View animation

Next, the surgeon removes the balloon and injects bone cement into the hollow space formed by the balloon. A chemical reaction in the cement causes it to harden in about 15 minutes.

Kyphoplasty

This fixes the bone in its corrected height and position. Bandages are then applied over the small incisions.

Complications

What might go wrong?

Serious complications from kyphoplasty are rare, involving less than five percent of cases. As with other procedures, however, complications can occur. Some of the most common complications of kyphoplasty include

  • problems with anesthesia
  • thrombophlebitis
  • infection
  • cement leakage
  • ongoing pain

This is not intended to be a complete list of the possible complications.

Problems with Anesthesia

Problems can arise when the anesthesia given during surgery causes a reaction with other drugs the patient is taking. In rare cases, a patient may have problems with the anesthesia itself. In addition, anesthesia can affect lung function because the lungs don’t expand as well while a person is under anesthesia. Be sure to discuss the risks and your concerns with your anesthesiologist.

Thrombophlebitis (Blood Clots)

View animation of pulmonary embolism

Thrombophlebitis, sometimes called deep venous thrombosis (DVT), can occur after any operation. It occurs when the blood in the large veins of the leg forms blood clots. This may cause the leg to swell and become warm to the touch and painful. If the blood clots in the veins break apart, they can travel to the lung, where they lodge in the capillaries and cut off the blood supply to a portion of the lung. This is called a pulmonary embolism. (Pulmonary means lung, and embolism refers to a fragment of something traveling through the vascular system.) Most surgeons take preventing DVT very seriously. There are many ways to reduce the risk of DVT, but probably the most effective is getting you moving as soon as possible. Two other commonly used preventative measures include

  • pressure stockings to keep the blood in the legs moving
  • medications that thin the blood and prevent blood clots from forming

Infection

Infection following spine procedures is rare but can be a very serious complication. Some infections may show up early, within the first few days after the procedure. Infections on the skin’s surface usually go away with antibiotics. Deeper infections that spread into the bones and soft tissues of the spine are harder to treat. They may require surgery to treat the infected portion of the spine.

Cement Leakage

The cement used in kyphoplasty is squeezed into the fractured vertebra in liquid form. Because it is injected at low pressure, cement leakage during kyphoplasty is rare. If some of the cement happens to leak out of the vertebra, it usually doesn’t cause any problems. Only rarely does a cement leak cause pressure on the spinal cord or nearby nerves. In these cases, surgery may be required to remove the pressure.

Ongoing Pain

Many patients get nearly complete relief of symptoms from kyphoplasty. As with any procedure, however, you should expect some pain afterward. If the pain continues or becomes unbearable, talk to your surgeon about treatments that can help control your pain.

After Surgery

What happens after surgery?

Patients are monitored in the recovery room for two to three hours after the procedure before going home. You are instructed to move your back only carefully and comfortably. Some patients who are feeling extra pain or other problems after kyphoplasty may need to stay in the hospital overnight.

Patients rarely need to wear a brace after kyphoplasty, since bone cement immediately improves the strength and stiffness in the fractured vertebra.

Rehabilitation

What should I expect as I recover?

The cement used to fix the broken vertebra hardens quickly, within about 15 minutes. As a result, people often find it easier to do daily activities within one week. Pain also decreases rapidly, and most people require less pain medication within two weeks. Despite these improvements, most orthopedists consider that it takes about three months for the bone to heal after kyphoplasty.

Patients are encouraged to walk and do moderate activity as they recover. However, they should avoid strenuous exertion until their surgeon approves resuming normal levels of activity.

When the fracture was from osteoporosis, the doctor will suggest ways to prevent future problems. Patients may be prescribed medications and supplements (calcium and vitamin D) to maximize bone health. Lifestyle changes, such as quitting smoking and taking up exercising, may also be discussed.

Related Document: A Patient’s Guide to Osteoporosis

Patients who continue to have problems with posture and pain or who have lost muscle tone and strength may need the help of a physical therapist. These patients typically need to attend therapy sessions for four to six weeks.

The goal of therapy is to safely advance strength and function.
The therapist may use treatments such as heat or ice, electrical stimulation, and massage to help calm pain. Gentle exercise is used to improve strength of the spine and limbs. Patients begin learning how to move safely using healthy postures to reduce strain on the healing back. Exercises for the heart and lungs improve stamina and help with pain control.

As the therapy sessions come to an end, the therapist helps patients get back to the activities they enjoy. Ideally, patients are able to resume normal activities. They may need guidance on which activities are safe or how to change the way they go about their activities.

When treatment is well under way, regular visits to the therapist’s office will end. The therapist will continue to be a resource. But patients are in charge of doing their exercises as part of an ongoing home program.

Thoracic Disc Herniation

A Patient’s Guide to Thoracic Disc Herniation

Introduction

Thoracic Disc Herniation

A rise in the use of magnetic resonance imaging (MRI) has led to the discovery that many people, perhaps as many as 15 percent of Americans, have a thoracic disc herniation. Seeing a herniated thoracic disc on MRI is often incidental, meaning it shows up when the person has MRI testing for another problem.

Few people with a thoracic disc herniation feel any symptoms or have any problems as a result of this condition. In rare cases when symptoms do arise, the main concern is whether the herniated disc is affecting the spinal cord.

Although people often refer to a thoracic disc herniation as a slipped disc, the disc doesn’t actually slip out of place. Rather, the term herniation means that the material in the center of the disc has squeezed out of the normal space. In the thoracic spine, this condition mostly affects people between 40 and 60 years old.

This guide will help you understand

  • how the problem develops
  • how doctors diagnose the condition
  • what treatment options are available

Anatomy

Thoracic Disc Herniation

What parts of the spine are involved?

The human spine is formed by 24 spinal bones, called vertebrae. Vertebrae are stacked on top of one another to create the spinal column. The main section of each vertebra is a round block of bone, called the vertebral body.

The thoracic spine is made up of the middle 12 vertebrae.

Thoracic Disc Herniation

Doctors often refer to these vertebrae as T1 to T12. The thoracic spine starts at the base of the neck. The lowest vertebra of the thoracic spine, T12, connects below the bottom of the rib cage to the first vertebra of the lumbar spine, called L1.

The upper half of the thoracic spine is much less mobile than the lower section, making disc herniations in the upper thoracic spine rare. About 75 percent of thoracic disc herniations occur from T8 to T12, with the majority affecting T11 and T12.

Thoracic Disc Herniation

The intervertebral disc is a specialized connective tissue structure that separates the vertebral bodies. The disc is made of two parts. The center, called the nucleus, is spongy. It provides most of the disc’s ability to absorb shock. The nucleus is held in place by the annulus, a series of ligament rings surrounding it. Ligaments are strong connective tissues that attach bones to other bones.

Healthy discs work like shock absorbers to cushion the spine. They protect the spine against the daily pull of gravity and during activities that put strong force on the spine, such as jumping, running, and lifting.

The spinal canal is a hollow tube inside the spinal column. It surrounds the spinal cord as it passes through the spine. The spinal cord is similar to a long wire made up of millions of nerve fibers. Just as the skull protects the brain, the bones of the spinal column protect the spinal cord. The spinal canal is narrow in the thoracic spine. Any condition that takes up extra space inside this canal can injure the spinal cord.

Thoracic Disc Herniation

Blood vessels that run up and down the spine nourish the spinal cord. However, only one vessel, the anterior spinal artery, goes to the front of the spinal cord in the area between T4 and T9. Doctors call this section of the spine the critical zone. If this single vessel is damaged, as can happen with pressure from a herniated thoracic disc, the spinal cord has no other way to get blood. Left untreated, this section of the spinal cord dies, which can lead to severe problems of weakness or paralysis below the waist.

Related Document: A Patient’s Guide to Thoracic Spine Anatomy

Causes

Why do I have this problem?

View animation of degeneration

Thoracic disc herniations are mainly caused by wear and tear in the disc. This wear and tear is known as degeneration. As a disc’s annulus ages, it tends to crack and tear. These injuries are repaired with scar tissue. Over time the annulus weakens, and the nucleus may squeeze (herniate) through the damaged annulus. Spine degeneration is common in T11 and T12. T12 is where the thoracic and lumbar spine meet. This link is subject to forces from daily activity, such as bending and twisting, which lead to degeneration. Not surprisingly, most thoracic disc herniations occur in this area.

Thoracic Disc Herniation

Less commonly, a thoracic disc may herniate suddenly (an acute injury). A thoracic disc may herniate during a car accident or a fall. A thoracic disc may also herniate as a result of a sudden and forceful twist of the mid-back.

Diseases of the thoracic spine may lead to thoracic disc herniation. Patients with Scheuermann’s disease, for example, are more likely to suffer thoracic disc herniations. It appears these patients often have more than one herniated disc, though the evidence is not conclusive.

Related Document: A Patient’s Guide to Scheuermann’s Disease

The spinal cord may be injured when a thoracic disc herniates. The spinal canal of the thoracic spine is narrow, so the spinal cord is immediately in danger from anything that takes up space inside the canal. Most disc herniations in the thoracic spine squeeze straight back, rather than deflecting off to either side. As a result, the disc material is often pushed directly toward the spinal cord. A herniated disc can cut off the blood supply to the spinal cord. Discs that herniate into the critical zone of the thoracic spine (T4 to T9) can shut off blood from the one and only blood vessel going to the front of the spinal cord in this section of the spine. This can cause the nerve tissues in the spinal cord to die, leading to severe problems of weakness or paralysis in the legs.

Symptoms

What does the condition feel like?

Symptoms of thoracic disc herniation vary widely. Symptoms depend on where and how big the disc herniation is, where it is pressing, and whether the spinal cord has been damaged.

Pain is usually the first symptom. The pain may be centered over the injured disc but may spread to one or both sides of the mid-back. Also, patients commonly feel a band of pain that goes around the front of the chest. Patients may eventually report sensations of pins, needles, and numbness. Others say their leg or arm muscles feel weak. Disc material that presses against the spinal cord can also cause changes in bowel and bladder function.

Thoracic Disc Herniation

Disc herniations can affect areas away from the spine. Herniations in the upper part of the thoracic spine can radiate pain and other sensations into one or both arms. If the herniation occurs in the middle of the thoracic spine, pain can radiate to the abdominal or chest area, mimicking heart problems. A lower thoracic disc herniation can cause pain in the groin or lower limbs and can mimic kidney pain.

Diagnosis

How do doctors diagnose the problem?

Diagnosis begins with a complete history and physical examination. Your doctor will ask questions about your symptoms and how your problem is affecting your daily activities. These include questions about where you feel pain, if you have numbness or weakness in your arms or legs, and if you are having any problems with bowel or bladder function. Your doctor will also want to know what positions or activities make your symptoms worse or better.

Then the doctor examines you to see which back movements cause pain or other symptoms. Your skin sensation, muscle strength, and reflexes are also tested.

X-rays show the bones. They normally don’t show the discs, unless one or more of the discs have calcified. This is significant in the diagnosis of thoracic disc herniation. A calcified disc that appears on X-ray to poke into the spinal canal is a fairly reliable sign that the disc has herniated. It isn’t clear why a problem thoracic disc sometimes hardens from calcification, though past injury of the disc is one possibility.

The best way to diagnose a herniated thoracic disc is with magnetic resonance imaging (MRI). The MRI machine uses magnetic waves rather than X-rays to show the soft tissues of the body. It gives a clear picture of the discs and whether one has herniated. This machine creates pictures that look like slices of the area your doctor is interested in. The test does not require dye or a needle. This test has shown doctors that many people without symptoms have thoracic disc herniations. This has led some doctors to suggest that thoracic disc herniations not causing symptoms are normal.

Before MRI, doctors relied mainly on myelography to diagnose thoracic disc herniations. By itself, myelography only helps diagnose this condition in about half the cases. Myelography is a kind of X-ray test. A special dye is injected into the space around the spinal canal. The dye shows up on an X-ray. It helps a doctor see if the disc is pushing into the spinal canal.

Computed tomography (CT scan) may be ordered. This is a detailed X-ray that lets doctors see the body’s tissue in images that also look like slices. The images provide more information about calcified discs. Doctors may combine the CT scan with myelography. When the CT scan is performed, the myelography dye highlights the spinal cord and nerves. The dye can improve the accuracy of a standard CT scan for diagnosing a herniated thoracic disc.

Doctors rely mostly on MRI for diagnosing thoracic disc herniations. However, they may use myelography and CT scans when preparing to do surgery to fix a herniated thoracic disc.

Treatment

What treatment options are available?

Nonsurgical Treatment

Doctors closely monitor patients with symptoms from a thoracic disc herniation, even when the size of the herniation is small. If the disc starts to put pressure on the spinal cord or on the blood vessels going to the spinal cord, severe neurological symptoms can develop rapidly. In these cases, surgery is needed right away. However, unless your condition is affecting the spinal cord or is rapidly getting worse, most doctors will begin with nonsurgical treatment.

At first, your doctor may recommend immobilizing your back. Keeping the back still for a short time can calm inflammation and pain. This might include one to two days of bed rest, since lying on your back can take pressure off sore discs and nerves. However, most doctors advise against strict bed rest and prefer their patients do ordinary activities, using pain to gauge how much activity is too much. Another option for immobilizing the back is a back support brace worn for up to one week.

Doctors prescribe certain types of medication for patients with thoracic disc herniation. Patients may be prescribed anti-inflammatory medications such as aspirin or ibuprofen. Muscle relaxants may be prescribed if the back muscles are in spasm. Pain that spreads into the arms or legs is sometimes relieved with oral steroids taken in tapering dosages.

Your doctor will probably have a physical therapist direct your rehabilitation program. Therapy treatments focus on relieving pain, improving back movement, and fostering healthy posture. A therapist can design a rehabilitation program for your condition that helps you prevent future problems.

Most people with a herniated thoracic disc get better without surgery. Doctors usually have their patients try nonoperative treatment for at least six weeks before considering surgery.

Surgery

Surgeons may recommend surgery if patients aren’t getting better with nonsurgical treatment, or if the problem is becoming more severe.

When there are signs that the herniated disc is affecting the spinal cord, surgery may be required, sometimes right away. The signs surgeons watch for when reaching this decision include weakening in the arm or leg muscles, pain that won’t ease up, and problems with the bowels or bladder.

Surgical treatment for this condition includes

  • costotransversectomy and discectomy
  • transthoracic decompression
  • video assisted thoracoscopy surgery (VATS)
  • fusion

Costotransversectomy

Thoracic Disc Herniation

Surgeons use costotransversectomy to open a window through the bones that cover the injured disc. Operating from the back of the spine, the surgeon takes out a small section on the end of two or more ribs where they connect to the spine. (Costo means rib.) Then the bony knob on the side of the vertebra (the transverse process) is removed. (Ectomy means to remove.) This opens space for the surgeon to work. The injured portion of the disc that is pressing against the spinal cord is removed (discectomy) with small instruments. Surgeons take extreme care not to harm the spinal cord.

Transthoracic Decompression

Thoracic Disc Herniation

Transthoracic describes the approach used by the surgeon. Trans means across or through. The thoracic region is the chest. So in transthoracic decompression, the surgeon operates through the chest cavity to reach the injured disc. This approach gives the surgeon a clear view of the disc.

With the patient on his or her side, the surgeon cuts a small opening through the ribs on the side of the thorax (the chest). Instruments are placed through the opening, and the herniated part of the disc is taken out. This takes pressure off the spinal cord (decompression).

Video Assisted Thoracoscopy Surgery (VATS)

Thoracic Disc Herniation

Recent developments in thoracic surgery include video assisted thoracoscopy surgery (VATS). This procedure is done with a thoracoscope, a tiny television camera that can be inserted into the side of the thorax through a small incision. The camera allows the surgeon to see the area where he or she is working on a TV screen. Small incisions give passage for other instruments used during the surgery. The surgeon watches the TV screen while cutting and

Thoracic Disc Herniation
removing damaged portions of the disc.

Categorized as minimally invasive surgery, VATS is thought to be less taxing on patients. Advocates also believe that this type of surgery is easier to perform, prevents scarring around the nerves and joints, and helps patients recover more quickly.

Fusion

Thoracic Disc Herniation

After removing part or all of the disc, the spine may be loose and unstable. Fusion surgery may be needed immediately afterward. The medical term for fusion is arthrodesis. This procedure locks the vertebrae in place and stops movement between the vertebrae. This steadies the bones and can ease pain. Fusion surgery is not usually needed if only a small amount of bone and disc material was removed during surgery to fix a herniated thoracic disc.

In this procedure, the surgeon lays small grafts of bone over or between the loose spinal bones. Surgeons may use a combination of screws, cables, and rods to prevent the vertebrae from moving and allow the graft to heal.

Rehabilitation

What should I expect as I recover?

Nonsurgical Rehabilitation

Even if you don’t need surgery, your doctor may recommend that you work with a physical therapist. Patients are normally seen a few times each week for four to six weeks.

The first goals of treatment are to control symptoms, find positions that ease pain, and teach you how to keep your spine safe during routine activities.

As patients recover, they gradually advance in a series of strengthening exercises. Aerobic exercises, such as walking or swimming, can ease pain and improve endurance.

After Surgery

Rehabilitation after surgery is more complex. Some patients leave the hospital shortly after surgery. However, some surgeries require patients to stay in the hospital for a few days. Patients who stay in the hospital may be visited by a physical therapist soon after surgery. The treatment sessions help patients learn to move and do routine activities without putting extra strain on the back.

During recovery from surgery, patients should follow their surgeon’s instructions about wearing a back brace or support belt. They should be cautious about overdoing activities in the first few weeks after surgery.

Many surgical patients need physical therapy outside of the hospital. They see a therapist for one to three months, depending on the type of surgery. At first, therapists may use treatments such as heat or ice, electrical stimulation, massage, and ultrasound to calm pain and muscle spasm. Then they teach patients how to move safely with the least strain on the healing back.

As patients recover, they gradually begin doing flexibility exercises for the hips and shoulders. Mobility exercises are also started for the back. Strengthening exercises address the back muscles. Patients may work with the therapist in a pool. Patients progress with exercises to improve endurance, muscle strength, and body alignment.

Thoracic Disc Herniation

As the rehabilitation program evolves, patients do more challenging exercises. The goal is to safely advance strength and function.

Ideally, patients are able to go back to their previous activities. However, some patients may need to modify their activities to avoid future problems.

When treatment is well under way, regular visits to the therapist’s office will end. The therapist will continue to be a resource. But patients are in charge of doing their exercises as part of an ongoing home program.