FAQ Category: Thoracic Spine

The middle of your back is the section of the spine called the thoracic spine. There are 12 thoracic vertebrae. It’s likely that you are feeling the spinous process (SP) of the thoracic vertebra.

Each vertebra in the spine is made of the same parts. A round block of bone forms the main section of each thoracic vertebra from T1 to T12. This is called the vertebral body.

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 SP is the knob you feel where the two lamina bones join together at the back of the spine. Bony extensions also point out from the side of the bony ring. There’s one on the left and one on the right. These projections are called transverse processes (TP). The TPs are just off to the side of the SPs.

Pain or tenderness at either of these sites can be an indication of infection, tumor, or misalignment of the bones. If you are having any signs of illness (fever, chills, sweats), you should see your doctor right away. This is especially true if you’ve had a recent infection of any kind anywhere in your body.

If you are otherwise healthy, you may want to wait and see if the soreness goes away with a little time. If not, an X-ray may be warranted. If the problem is caused by the way the bones line up, then you may need a chiropractor, osteopath, or physical therapist to adjust the spine and help restore normal motion.

Pain relief is the first goal of treatment. She may be helped by medications for this. If her general health is good, she may alsobe a candidate for a procedure called balloon kyphoplasty.

During this operation, the surgeon inserts a long, thin needle into the vertebral body. There is a deflated balloon on the end of the needle. Once inside the bone, the balloon is inflated and filled with cement. Once the cement hardens, the main body of the vertebra is restored in height and strength.

Older adults confined to bed or with decreased activity after vertebral compression fracture have a poor prognosis. The body becomes deconditioned quickly. Further bone loss occurs and puts them at increased risk for further fracture.

Balloon kyphoplasty is safe and effective even for older adults. The quick pain relief can restore function and improve activity level right away. You may want to ask her doctor if she is a good candidate for this procedure. If not, what other methods of treatment are advised?

There is some concern that the compressed and fractured bone will result in more load being transferred to the adjacent bones. In patients who are osteoporotic, this could create enough force to cause further fractures.

Patients often assume an increased flexed or stooped position after vertebral compression fractures. This posture seems to help reduce their pain. However, a kyphotic (stooped) posture puts additional strain on already weakened bone.

A recent study from the University of California (San Diego) showed no difference in results after balloon kyphoplasty for patients with spinal fractures less than 60 days old compared to fractures older than 60 days.

Results of this same study showed fast pain relief for older fractures. With decreased pain, patients were able to increase activity and function quickly. Most reported an improved quality of life. Your father may want to take advantage of those benefits sooner than later.

OLF stands for ossification of the ligamentum flavum or OLF. The ligamentum flavum is a continuous band of ligamentous tissue along the backside of the spinal canal. It connects the lamina of the vertebra in a vertical fashion. The lamina is the bone that forms the ring around the spinal cord.

As the vertebral bones stack up one on top of the other, the ligamentum flavum runs from top to bottom. OLF is most common in the thoracic spine (middle of the spine) from T9 to T12. People in Japan, Korea, India, the Middle East, and the Caribbean are affected most often. Men ages 40 to 60 are diagnosed most often but women can have OLF, too.

Basically what happens is the ligament starts to thicken as we age. Bits of bone replace the fibrous tissue of the ligament causing it to harden as well. As it thickens and hardens, it takes up some of the space in the spinal canal. This puts pressure on the spinal cord and can cause mild to severe symptoms. Paralysis is even possible.

The most successful treatment seems to be surgery. The ligament is removed in the areas where it is causing the most problems. This operation is called a surgical decompression. Results of treatment vary and remain unpredictable.

OLF is indeed a condition more common amoung people of East Asian origins. It is fairly rare but seems to be on the rise. OLF is a thickening and hardening of the ligament that goes between the lamina of the vertebral bones. The lamina form a bony ring around the spinal cord to protect it.

Doctors are trying to figure out what kind of treatment is best for OLF. More studies are being reported but the results are often in conflict from one study to the next. Most experts agree that surgery is required to remove the affected ligament. The goal is to keep the ligament from putting pressure on the spinal cord, thereby preventing neurologic symptoms.

It’s not clear if the ligament should be removed at all levels where it is thick and hardened — or if just the levels that are causing symptoms should be taken out. Sometimes it’s very difficult to tell just what levels are affected.

Patients with mild symptoms seem to have a better result by having the OLF removed. Some studies show that when more than two segments are affected the results are less favorable. Early treatment does seem to help the most.

Even small amounts of cement leakage can pose significant problems. Some patients have a toxic or allergic reaction that can be very serious. If the cement gets into the veins and blood supply, blood clots to the lungs can occur. The cardiovascular system can become compromised.

Leakage into the disc space or spinal canal where the spinal cord is can cause serious neurologic complications. Paralysis and even death are possible though these events are rare. Some studies report increased vertebral fractures when leaks occur into the disc space.

Detecting leakage isn’t always easy even with standard X-rays or special X-rays called fluoroscopy. CT scans may be needed to find and monitor leaks. The long-term effects of benign leaks (the patient has no symptoms) is unknown.

Research is ongoing to find ways to prevent leakage. Studies to track long-term results may show that this complication isn’t a major concern for most patients. Right now it’s not even clear how often this happens or what causes it to occur.

Bed rest is often the only thing that helps relieve chronic back pain. However, it’s not a very good idea because of all the other effects of inactivity. Activity is needed to keep the blood circulating and to prevent more bone loss caused by inactivity.

There’s also an increased risk of fracture, pressure sores, blood clots, and many other problems with inactivity.

There are ways to treat this problem, even for the aging adult. Nonnarcotic pain medications can help with the painful symptoms. Drugs to prevent further bone loss may be advised.

A surgical procedure called vertebroplasty is also very successful in reducing pain and stabilizing the spine. The surgeon inserts a long, thin needle into the bone and injects cement. Once the cement hardens, the bone is fixed in place and can start to heal.

If there is a concern that collapse of the spine and deformity might occur, then a kyphoplasty can be done. This is similar to the vertebroplasty but instead of just injecting the cement, a deflated balloon is inserted into the bone first. Then the balloon is inflated and cement injected. The kyphoplasty restores the height of the bone and reduces pain.

A visit with your grandmother’s physician is advised. Controlling her pain will increase her function and quality of life.

As you know, Scheuermann’s disease is a forward curvature or kyphosis of the upper back area. Males and females are affected equally. Less than 10 per cent of the population is affected by this condition. The exact cause is unknown.

Studies show a higher rate of disabling back pain in adults with untreated Scheuermann’s disease. Untreated patients with this condition are more likely to be limited in their job choices. They tend to have sedentary jobs or occupations. They are also more likely to remain single and never marry.

Surgery is advised when the curve is more than 75 degrees as measured on X-rays. Pain, neurologic problems, and cardiopulmonary impairment are other reasons to consider surgery. Bone graft is used along with rods and screws to fuse the spine usually from T2 to L2. Bracing is required after surgery but the result is often a near normal spinal curve and appearance.

Paralysis is a major risk after surgery of this type. Unfortunately, there isn’t anything you can do personally to affect the outcome.

Research shows that several factors come into play here. The thoracic spine tends to be slightly flexed or bent forward. This position is called kyphosis. If a laminectomy is done (bone cut away from the spine), then pressure is taken off the ligament. This ligament is the posterior longitudinal ligament. After a thoracic laminectomy, the spinal cord tends to shift backward. This increases the risk of spinal cord compression and paralysis. The ribs also get in the way when doing the surgery.

The surgeon must be very careful not to damage the spinal cord during surgery. Some surgeons advise doing a spinal fusion after laminectomy to keep the thoracic spine in a more erect position. This has been shown to prevent paralysis on a long-term basis.

OPLL stand for ossification of the posterior longitudinal ligament. OPLL is a condition in which the long ligament along the back of the spinal column ossifies or turns to bone. Pressure on the spinal cord from this problem brings the patient to the surgeon for treatment. But removing the ligament isn’t always easy or successful.

The spinal cord can become damaged during the operation. Paralysis can occur if the spine shifts its alignment. Surgeons in Japan report on 51 cases of OPLL treated by one of three operations. They report the best results when the spine was fused after removing the ligament and/or the bone around the spinal cord. Paralysis was rare when fusion was done.

Paralysis was reversed in some patient who had the ligament or bone removed but the spine wasn’t fused. Fusing the spine in a more upright position took the pressure off the spinal cord and returned motor and sensory function in the legs.

In a few cases, reversal of paralysis wasn’t possible. Most of these patients had severe spinal cord compression and damage before the first operation.

Scheuermann’s disease (SD) is a spinal condition that starts in childhood and results in excessive kyphosis. Kyphosis is a forward curvature of the spine. In SD, the child or teenager looks like he or she has a “hunchback.” The section of spine affected is the thoracic spine from below the neck to the bottom of the rib cage.

The orthopedic surgeon will be able to best answer your question. X-ray measurements are taken and angles of curves are calculated in preparation for this operation. Fusion with rods alongside the spine helps stop the forward progression of this condition.

Studies show an average improvement of about 40 percent with fusion. And because a change in one curve can affect the other spinal curves, this correction also improves the low back curve called the lumbar lordosis.

The spine is a dynamic system and seems to automatically rebalance itself after fusion. This is true even in SD. Long-term studies are still needed to see if these changes are permanent.

The best course of treatment and its timing for vertebral fractures remains unknown. Many doctors advise a course of nonoperative treatment first. Pain medications, back braces, bed rest, and exercise are given a good try before using surgery.

The trade off is the strength, function, and motion lost with rest and inactivity. This puts the patient at increased risk for weakness, balance problems, and falls. Side effects from long-term use of medications can also be a problem.

How late is too late for vertebroplasty is an area of ongoing research. Vertebroplasty is the injection of glue into the fractured bone. The goal is to reduce pain while increasing the strength and stiffness of the spine.

In a recent study on this topic, patients with osteoporosis and malignancy were treated with vertebroplasty. The group with osteoporosis had preoperative symptoms for as long as 30 months. The group with cancer had pain for less than four months.

Both groups had good results with vertebroplasty though the malignancy group had more leakage of the cement compared with the osteoporotic group.

Vertebroplasty is the injection of a cement-like substance into the fractured vertebral bone. The goal is to strengthen the bone and reduce pain for the patient. With osteoporotic or brittle bones, the cement can leak out.

Problems can occur when this happens. The first problem is that the surgery may be considered a failure. If the cement doesn’t give at least a partial repair of the fracture, then the patient may continue to suffer from the pain.

Doctors are aware of these problems and have many methods they use to keep it from happening. It’s not a problem if the cement leaks into the disc area. It’s also not a problem if the cement leaks out of the front or side of the bone.

The real issue is when the cement leaks into the epidural space. This is the area behind the bone next to the spinal cord. Cement in this space can harden and then put pressure on the spinal cord or spinal nerves exiting the area.

Sometimes the body just absorbs or breaks down the extra cement and no further problems occur. For now it may be a wait-and-see situation. Follow-up visits with the doctor are important. Encourage your father to keep all of his appointments with the doctor no matter how he’s feeling.

Talk to her doctor about your concerns. If conservative care hasn’t helped in four to six weeks, then surgery may be needed. The fact that she’s losing function is a red flag.

If it hurts to move, the average older adult will stop moving. Motion, function, and strength are quickly lost and can be hard to get back. Any further treatment may be less successful because inactivity and decreased mobility has led to deconditioning.

Your mother may be a good candidate for a procedure called vertebroplasty. A long thin needle is inserted through the spine. A cement or “superglue” is injected through the needle into the bone. It fills in all the cracks of the fracture and helps reinforce the vertebra.

In a similar operation called a kyphoplasty, a tiny balloon is blown up inside the bone to help restore its size and shape. Then the glue is inserted inside the balloon. When the glue dries, the bone is back to its original shape and strength.

Patients have better long-term results with improved function when they go back to the physical therapist after the vertebroplasty. Patient education is a key feature to maintaining independence.

The family can work with the doctor, nurse, and physical therapist to help your mother understand the importance of doing the exercises. There may be a specific reason why she isn’t doing them (e.g., forgets, confused, tired). See if you can’t find out why she’s noncompliant. Closer supervision by the therapist may be needed at first. Friendly reminder phone calls from the family may help, too.

The procedure your father had was most likely called a vertebroplasty. A long thin needle is inserted into the bone. A strong cement or “superglue” is injected into the area. The cement fills in any cracks or fractures that may be present.

New fractures after vertebroplasty are actually fairly common. Doctors aren’t sure if this is just a coincidence or not. The patient may have fractured in the new place even without the first fracture.

Vertebral fractures are common in older adults with osteoporosis. Medications such as corticosteroids taken for other inflammatory conditions put them at an even greater risk for bone fracture. Three of the most common problems patients take long-term steroids for include asthma, lupus, or sarcoidosis.

Vertebroplasty is an operation and any procedure of this type puts the patient at risk for other health concerns. Doing a vertebroplasty as prevention for conditions like osteoporosis just isn’t a good idea. It would be much better if we all work to prevent problems like decreased bone mass from starting in the first place. Lifelong dietary and exercise guidelines are the key to many conditions like this.

Vertebroplasty is the use of cement injected inside the broken bone. It fills up all the cracks of the fracture and hardens to stabilize the bone. The idea was first tried in France in 1984 so it’s been around more than 20 years.

Since then the technique has been improved and modified. Now the surgeon can also do a procedure called a kyphoplasty. In the kyphoplasty, a cavity is formed in the center of the bone. A special balloon is inserted and then inflated. A similar cement is then injected into the hole.

The idea of the kyphoplasty is to restore the natural height of the bone. A collapsed bone changes how the spine works. The kyphoplasty stabilizes and restores the bone.

The surgeon will be able to tell you whether your father-in-law is a good candidate for one of these treatment options. According to studies done, both are safe and effective.

Vertebroplasty is a good treatment option for vertebral fractures. Cement is injected into the bone through a tiny needle. It fills in the cracks of the fracture and helps hold the bone in place until the break can heal with new bone.

There are a few problems though. The cement can leak into the nearby soft tissues. It can put pressure on the spinal cord or spinal nerves. A small piece of cement can enter the blood supply and travel to the lungs causing a blockage like a blood clot.

Not only that but the cement itself is known to be toxic to the heart. It can cause irregular heart beats, cardiac failure, and even death.

Right now doctors suggest limiting the exposure and risk by only doing one or two bones at a time. The doctor takes into consideration the amount of cement needed and the location of the fracture when making this decision.

You may be describing symptoms of a problem called Thoracic Outlet Syndrome (TOS). The major blood vessels and nerves to the arm and hand travel from the neck under the collarbone and down the arm.

Anything that changes the normal anatomy in the neck, shoulder, or upper chest areas can put pressure on these structures. Sometimes there is an extra (cervical) rib contributing to this problem. In other cases fibrous bands of tissue interfere with the nerves’ movement and ability to slide and glide in their coverings called nerve sheaths.

If these symptoms persist you may want to see a doctor or physical therapist. Sometimes posture or muscle weakness can cause these symptoms. An exercise program may be all you need. In other cases, surgery may be the best approach.

We understand your frustration. Thoracic outlet syndrome (TOS) can be very difficult to evaluate and treat. The treatment should match the underlying cause but it’s not always possible to know what the real problem is.

When surgery is indicated the surgeon might take a more conservative approach. Removing part of a rib can’t be undone so rib-sparing surgery is often tried first. If the patient doesn’t improve, then the second more advanced operation is still possible.

It’s thought that the rib pushes up against the bundle of nerves as they leave the neck and go down the arm. In some cases the nerves might naturally dip down toward the first rib. Either way compression is taken off the nerves by removing a section of the bone.

It’s possible. When patients were surveyed in a recent study most reported a traumatic event as the initial cause of the problem. Car accidents and work-related incidents topped the list. Non-work related events are reported but the specifics aren’t really clear.

Being pulled by the arm can put traction on the nerves to the upper extremity and neck. Thoracic outlet syndrome (TOS) is not a traction injury, but rather, a compressive injury. The nerves and blood vessels leaving the neck and traveling down the arm get pushed up against the ribs or squeezed between layers of fibrous tissue. Previous injuries to the neck and shoulders could be contributing factors to these new symptoms.

In 20 percent of the people affected there is no known cause. The symptoms occur without warning and no accident or trauma is involved.

Your concern for your sister is understandable. This might be a good time to gently ask a few questions such as: