News Category: Thoracic Spine

Doctors and therapists treating the thoracic spine (middle of the back) have some special challenges. The anatomy of the thoracic spine is different from the cervical spine (neck) and the lumbar spine (low back). The bones of the thoracic spine are the transition units from cervical to lumbar spine.

In this study, physical therapists test a new model for finding the transverse processes (TP) of the thoracic spine. The TP is a bony extension out to the side of the vertebral bone. It connects to the rib on either side of the vertebrae. Restoring normal alignment and motion at this connection is important for some patients with shoulder, neck, or back pain.

But finding the exact spot of the TP can be difficult. It’s not close to the surface of the skin. Some examiners use the spinous process (SP) to help them find the TP. But the shape and direction of the SP changes from the top of the bottom of the thoracic spine. The spinous process is the bump you feel along the middle of your back. Using this landmark to locate the TP may not be reliable.

To find the best way to locate the TPs, researchers dissected 15 cadavers. They removed the soft tissues over the TPs and SPs. They inserted pins into the SPs and TPs of each thoracic vertebra. Then they used a digital caliper to measure the distances between these two points. They took into consideration how far apart the fingers have to be to feel contact points.

The authors report that if you find the SP and palpate (feel) just to the side of it, you’ll be on the TP of the vertebra one level above. This holds true throughout the thoracic spine.

This model replaces the previously used Rule of Threes model. The old model used the SPs to find the TPs. This method tried to adjust for the change in angle of the SP from vertebra to vertebra. The new model shows this is not necessary. However, this new model may not always apply to the last two thoracic vertebrae (T11 and T12) because of how much they vary in position from person to person.

In this study results of kyphoplasty for patients with vertebral compression fractures (VCFs) are reported from 19 treatment centers. It is the first multicenter study to report short and long-term effects of this procedure for osteoporotic fractures in older adults.

Balloon kyphoplasty is done by inserting a long, thin needle into the fractured and compressed vertebral body. A deflated balloon is passed through the needle and inflated inside the bone. A special cement fills the balloon, hardens, and restores the bone height.

Results were very positive in this study. Highly debilitated patients had quick pain relief and improved in function. Improvements were still present at the follow-up two years later. Quality of life (QOL) was greatly improved as patients were able to get out of bed and resume normal activities. X-rays also confirmed improved height of the bone.

The authors conclude that balloon kyphoplasty is safe and effective. Results are quick and last long-term. Kyphoplasty may not protect patients from future VCFs. Patients still need to be monitored and treated for risk factors that could lead to further fractures.

In this review, doctors from the University of South Florida School of Medicine look over the results of 10 years worth of studies. The topic is the results of surgery for patients with thoracic ossification of the ligamentum flavum (OLF). They hoped to find a way to predict results of the surgery.

OLF is a condition in which the ligamentum along the back of the spine thickens and hardens. Bony splinters may replace the fibers of the ligament. The thicker ligament decreases the size of the opening of the spinal canal. These changes can put pressure on the spinal cord causing paralysis. This condition is called myeloradiculopathy. The part of the spine affected most often is T9 to T12.

Surgery may be the only treatment that helps with myeloradiculopathy. By comparing patient factors with outcomes of treatment, researcher may uncover who can be helped the most with surgery for OLF. Here’s what they found so far.

Although men are affected more often, being male doesn’t mean a better or worse outcome after surgery. Increasing age may be linked with worse results but this wasn’t true for every patient. It doesn’t appear that the level of OLF (higher or lower in the spine) makes any difference either.

More recent studies suggest two factors that may have the most predictive value. These include: 1) duration of symptoms and 2) presence of neurologic symptoms. Patients who wait the longest to have surgery may have the worst results. There were different results from study to study when looking at this factor so it wasn’t 100 per cent fool proof.

Patients with a delayed diagnosis and advanced disease were more likely to have irreversible spinal cord damage. In these cases, the presence of neurologic symptoms was a negative predictor of outcome.

OLF is rare but the number of people affected by this condition is increasing. Guidelines for treatment are needed. Surgeons still don’t know if the OLF should be removed completely or just the affected segments. Most experts advise early surgery even in patients with only mild to moderate symptoms.

Vertebroplasty and kyphoplasty are two treatment methods for vertebral spine fractures. During a vertebroplasty procedure, cement is injected into the fractured bone. Once the cement hardens, the bone is held steady and can start to heal. With kyphoplasty, a deflated balloon is inserted inside the body of the bone. It is inflated and cement is injected inside the balloon. Kyphoplasty helps restore the normal heighth of the bone.

How do these two approaches compare? Is one better than the other? Do patients get long-term relief from pain? Are they more or less likely to fracture again? Many questions remain about these two approaches to vertebral compression fractures.

The authors of this study reviewed all of the studies done so far on the use of both treatment methods. They compare the results based on pain relief, mobility, and vertebral body height. They also made note of any new fractures or other complications that developed.

They found that many patients did get pain relief with either type of procedure. Physical function improved in less than half the patients. Different scales were used from study to study so this measure wasn’t easily compared from one study to the next. Correcting the vertebral height was about the same between vertebroplasty and kyphoplasty.

Problems such as cement leakage or vertebral fracture were the most common complications after either procedure. Cement leakage was much higher for vertebroplasty. Most of the studies lacked enough details to really analyze the results based on complications.

The authors propose a new batch of questions to be studied:

Severe forward curvature of the upper spine is called Scheuermann’s disease. Surgery to fuse the spine in a more upright, functional position is often needed. In this study, two methods of spinal fusion for Scheuermann’s disease are compared. The results are reported in terms of X-ray findings and post-operative complications.

Patients were divided into two groups. Group A had the standard fusion using ground up rib bone graft placed into each disc space. Group B had titanium cages packed with bone graft inserted into each intervertebral disc space. Patients in both groups were very similar in age, gender, height, weight, and body size.

The authors were interested to know if loss of correction over time would be a problem. In the past, loss of height has been reported when fusing the spine with bone graft. In this study there was no difference in results between the two methods. Problems such as infection or nerve damage were equal in both groups.

This is the first study to compare titanium cages to rib graft in the surgical treatment of Scheuermann’s disease. The results didn’t show any advantage of one method over the other. Given the extra cost of the cages (about $4,600) and extra steps in surgery, the authors have gone back to using rib grafts for this operation.

In this study, doctors from Japan present the results of surgery for a condition called thoracic myelopathy. Myelopathy is any damage or pressure on the spinal cord. Thoracic refers to the mid-portion of the spine between the cervical (neck) spine and the lumbar (low back) spine.

All cases were caused by ossification of the posterior longitudinal ligament (OPLL). Ossification is the change of soft tissue into bone. The PLL is a band of ligamentous tissue that runs down the length of the spine. Posterior means it’s along the back of the vertebral bones of the spine.

Surgery for thoracic myelopathy removes the back part of the bone called a laminectomy or decompression. Decompressive laminectomy for the thoracic spine doesn’t have as good of results as for cervical myelopathy. There is a major risk of paralysis with this operation.

The reason for this is that the normal thoracic spine is curved forward so it’s difficult to take pressure off the spinal cord. After a decompressive laminectomy, the natural curve keeps the spinal cord pushed backward with a greater chance for continued pressure on the cord. The ribs also tend to get in the way when performing the surgery from behind the spine (posterior).

Over the years the surgeons doing this study have used three different surgical methods to treat OPLL. They describe each operation and the results over time. The three procedures are:

Patients with Scheuermann’s disease (SD) are the focus of this study. In SD there is an increased forward curve of the thoracic (mid to upper) spine. Forward curvature of the spine is called kyphosis. Too much or excessive forward curvature is called hyperkyphosis.

When the upper back curves forward the lower spine extends or bends backwards to keep the person upright. This position of the lumbar spine is called lumbar lordosis. The authors of this study asked two questions.

1) Is there a direct link between Scheuermann’s kyphosis and lordosis? For example, if one curve increases, does the other curve increase, decrease, or stay the same?

2) If the kyphosis is corrected with surgery, is there a predictable change in the lumbar lordosis?

In this study, posterior fusion of the thoracic spine was done with metal rods on either side of the vertebra. Thirty (30) patients with SD were included. The results showed a definite connection between upper spine kyphosis and low back lordosis. The two were even more strongly linked after surgery than before.

The authors suggest the spine’s dynamic system works to keep a balanced standing posture. Once the spine is no longer forced into forward flexion, the anatomy can get into a more normal or physiologic position. Most of the correction occurs in the upper lumbar spine.

Vertebroplasty is an accepted form of treatment for fractures of the vertebral body. A long thin needle is passed into the main part of the bone. A special X-ray called fluoroscopy helps the surgeon guide the needle to the correct spot. Bone cement is injected into the fractured vertebra. Sometimes the cement leaks out of the bone.

In this study the cause of cement leakage into the disc space is investigated. Out of 66 patients treated with vertebroplasty, 41 percent had cement leakage into the disc space. Most cases of cement leakage were caused by a fractured endplate. The vertebral endplate is the fibrocartilage cap on either side of the intervertebral disc.

Cement usually leaks into the epidural space around the spinal cord. This is the first study to show that leakage into the disc space is not as rare as once thought but actually quite common. If the needle tip goes in too far it can break through the endplate.

The authors advise surgeons to avoid pushing the needle in close to the endplate. If the endplate is already fractured, fluoroscopy can be used to make sure the needle tip stays outside the disc. Using thicker cement can also reduce the risk of leakage.

Finally, patient satisfaction with vertebroplasty was not decreased by cement leakage into the disc space. The success rate did not seem affected by leakage.

Bone fractures are common in the aging population. Anyone with osteoporosis or bone tumors is especially at risk. Vertebral (spine) fractures are painful and lead to deformity and reduced quality of life. Injecting cement into the fractured spine called vertebroplasty is one treatment option.

One of the main problems with vertebroplasty is leakage of the cement injected into the bone. Side effects of leakage are uncommon but if the cement leaks, then the bone isn’t repaired. Doctors are looking for ways to prevent leakage.

They’ve tried partially curing the cement before injecting it. This step increases the thickness of the cement and slows down how fast it moves. They have limited how much cement is used to avoid overfilling and overflow. Low-pressure injections with small syringes have been tried. Pulling the needle out slowly to avoid back flow has been used as well.

The use of gelfoam to block venous channels is the focus of this study. Gelfoam is a liquid form of gelatin. It’s made from sponge cut into tiny pieces. When injected into the bone before the cement, the gelfoam temporarily blocks the veins. This type of blockage is called embolization. It prevents cement from getting through.

Once the gelfoam is in place, then the cement can be injected. X-rays and CT scans were used after the surgery to assess the results. Leakage still occurred in about 25 percent of the patients. Leakage occurred more often in cases of malignancy compared to osteoporosis.

The authors conclude routine use of gelfoam embolization is safe when used before vertebroplasty. It’s more likely to be effective when vertebral fractures are caused by highly vascular tumors. Preinjecting gelfoam to prevent cement leakage may give more patients the treatment option of vertebroplasty.

The purpose of this study was to see if vertebroplasty can reduce pain and improve function in patients with compression fractures. Vertebroplasty is the injection of cement into the fractured vertebra to reinforce it. The cause of the fracture was osteoporosis related to aging.

Conservative care was used in all cases for at least four weeks. The hope is to avoid surgery in older adults because of the potential problems that can arise. Pain relievers, exercises, and bracing were all tried first. Despite all this, the patients had severe pain that wouldn’t go away.

The results of this study showed good improvement in pain and function within the first month. Patients were able to get in and out of bed easier and sleep better. Sitting and standing were also improved. The one independent living skill that didn’t change was toileting. No further changes were observed after 30 days. The changes seen in the first month were still present at one year.

This study along with several other studies report new fractures after vertebroplasty. Most of those new fractures were linked to the osteoporosis. Some were caused by steroids that weaken the bone. The authors suggest further study is needed to see if the number of new fractures after vertebroplasty is actually more than would occur otherwise. It may just be that the new fractures would have happened anyway because of the osteoporosis.

Bone or soft tissue in the neck, shoulder, or arm can pinch off major blood vessels and nerves from the neck down the arm. Symptoms of pain, swelling, numbness, tingling, or cold hand and fingers from this problem are called thoracic outlet syndrome (TOS).

In this study from Johns Hopkins University neurosurgeons compare the results of two operations for TOS. One group had a section of the first rib removed. This operation is called a transaxillary first rib resection (TFRR). The second group had a supraclavicular neuroplasty of the brachial plexus (SNBP). This means scar tissue or constricting fibrous bands and muscles were removed from around the nerves.

The goal of both these operations was to take pressure off the blood vessels and nerves. The hope was to relieve pain and other symptoms. The goal of this study was to see which operation worked better. The authors report a significant difference between the two groups.

Three-fourths of the TFRR group (rib resection) reported good-to-excellent results. Less than half the SNBP group had good results. Patients were followed for up to three years and showed the same findings. This is considered a “long-term” result.

Summary: By all measures the TFRR operation was the better treatment for relief of TOS symptoms. The authors conclude the right surgery may be better than letting this problem run its own course.

This study was done by orthopedic surgeons from the Cincinnati Children’s Hospital Medical Center. They report on 19 cases of surgical correction for Scheuermann’s kyphosis.

Scheuermann’s kyphosis is a condition affecting the spine. The vertebrae curve forward in a position called kyphosis. Pressure on the bones causes wedging and forces the disc through the vertebral end-plate.

The operations were done using video-assisted thoracic surgery (VATS). The front (anterior) part of the spine was released. The back (posterior) spine was fused.

The authors review reasons for surgery and the surgical methods used. They followed all 19 patients for at least two years. Most of the patients obtained at least 40 degrees of correction.

There was only a small loss (1.6 degrees) of correction during the follow-up period. Older patients were at greater risk of losing correction.

The authors say this is the first report of using VATS and fusion together for Scheuermann’s kyphosis. The treatment is safe and effective because release of the discs in the front relieves tension on the rods and screws for the fusion.

Disc protrusion or herniation is common in the lumbar spine. Herniations in the thoracic spine aren’t as common. In this study, doctors report the result of surgery to treat 140 cases of herniated thoracic discs.

A subgroup of 20 patients with giant herniated thoracic discs (HTDs) was compared to patients with smaller herniations. A HTD is defined as having a disc that takes up more than 40 percent of the space in the spinal canal.

In this report the doctors describe the location and size of the disc lesion for both groups (with and without giant HTD). They also describe the patients’ symptoms. Choice of surgery depends on these factors.

In the case of giant HTDs, a wide incision is needed to move or remove the disc away from the spinal cord. Care must be taken to avoid pulling on the nerves or the lining around the spinal cord.

The authors report neural changes before and after surgery. They use two cases to help the reader understand some typical patient histories, exams, and results.

When an older adult reports back pain, doctors think a fracture may be a possible cause. X-rays may be taken with the patient lying down on his or her back (supine). Judging by the height of the bones, the angle of the spine, and the patient’s symptoms, the doctor may advise surgery. The goal of the operation is to stabilize the spine and hold it in one place until the fracture heals.

Many patients can be treated without surgery. But doctors in England noticed X-rays taken three months after fracture showed increased deformity in some of these patients’ spines. The authors did a study of 28 patients with vertebral fractures that were treated nonoperatively. X-rays were taken with the patient supine and also in sitting or standing position. The weightbearing X-rays were compared to the supine X-rays.

Twenty-five percent of the patients treated without surgery showed collapsing bones. Putting weight through the spine made the fracture worse. This finding changed the treatment plan from nonoperative to operative.

The authors conclude that even though spine fractures can be treated without surgery, there are some patients who would do better with an operation. These patients will likely have less deformity and compression of the vertebral bones. Weightbearing X-rays can be used to make this decision. Regular supine X-rays don’t always show how much damage is present. Changes occur when the patient sits or stands and puts weight through the spine.

Changes in bone density and bone strength are real problems for us as we age. The medical term for this is osteoporosis. Ten million adults in the United States have osteoporosis. Another 18 million are at risk for osteoporosis and bone fracture.

In this study, chiropractors and engineers worked together to build a computerized model of osteoporosis. They used advanced technology with math equations to predict who’s at risk for vertebral (spine) fracture. The model is based on X-ray studies of real spines. The equations included values for bone stiffness and elasticity.

This model shows the chances of bone fracture at each age under different loads. A normal, healthy spine can withstand high loads. As we age, gravity, body weight, and repeated loading cause forces too great for the bone structure. This is because the bone has become thin, weak, and less stiff.

The authors report that forces on the spine are greatest in the middle of the upper back. By age 90, the vertebrae can only support one-fourth the load that can be supported at age 30. Gravity and weakness cause changes in the adult’s posture. We become more stooped over. This puts pressure on the front part of the vertebral bones. The bone may then fracture or collapse.

When this happens, the bone takes on a wedge shape. The result is a decrease in bone height, resulting in a loss of total body height. The spine curves forward, the head moves forward, and the person becomes more stooped. This posture puts an increased load on the back muscles.

The authors conclude that this model points us in the right direction for treatment. Exercises, bracing, or other rehab methods can be used to reduce stress on the spine. These measures help reduce the risk of osteoporotic fractures.

If you have osteoporosis, don’t wait to treat it. Early treatment can help prevent problems later on. This is the advice of doctors at the Hershey Medical Center in Pennsylvania.

They reviewed many studies of osteoporosis and conducted one of their own. Fractures of the spine from osteoporosis with damage to the spinal cord or nerves were the subject of each study. Most fractures affecting the mid-back from osteoporosis do not cause nerve problems and are safely treated with methods other than surgery. However, the neurologic problems that do occur are hard to treat.

Surgery may be needed to fuse the spine in this area if nerve problems have occurred. With the underlying osteoporosis, more fractures can develop. Often, the pain, weakness, and loss of sensation don’t get better. Some patients are left with permanent symptoms. Some even have loss of bowel or bladder function.

The main problem is that these symptoms don’t show up right away. Patients can be pain-free without even knowing that they have a fracture in one or more of the vertebrae. It isn’t until much later that the bone collapses enough to cause nerve damage. For some patients, by the time symptoms occur, the damage is permanent.

Fortunately, only a small number of older adults have mid-back vertebral fractures with neurologic symptoms. Treatment for more severe injuries like these has up to a 70 percent complication rate.

The authors offer some ideas to help prevent worse problems. First, once the osteoporosis is found, drug therapy is important. If treated early with medications, vertebral collapse can sometimes be avoided. Second, doctors must keep trying to find better operations to fix the fractures. Third, a back brace after surgery is advised for anyone having a spinal fusion who also has osteoporosis. The authors conclude by saying that more studies are needed to find better ways to treat this problem.

Low back pain from disc herniation in the lumbar vertebrae of the spine is a common problem in adults. This same problem in the mid-back (thoracic spine) is much more rare. In fact, only one percent of all disc herniations occur in the thoracic spine.

When it does happen, doctors may have a hard time making the diagnosis. MRIs (magnetic resonance images) are helpful but not fool proof. Sometimes the image looks like a tumor instead of disc material.

This was the case for a 54-year-old man treated at the Jefferson Medical College in Philadelphia. He had a long history of leg weakness, numbness, and pain in his groin. His back problems started in 1992 after an injury at work. He reinjured himself in 1998 while shoveling dirt.

Based on the location of his symptoms and the results of an X-ray and MRI, the doctors thought he had a spinal tumor. When surgery was done, there was a herniated disc with cartilage in it instead of a tumor.

Case studies can be very helpful to doctors. This doctor reported gaining new information from studying the MRI after the surgery. In this case, the doctor saw some specific changes on the MRI. He concludes that looking for these changes will help with a correct diagnosis for future patients.

Children and teenagers with scoliosis seem to avoid aerobic exercise. Scoliosis is an abnormal sideways curve of the spine. When it happens in children between 10 and 18 years of age, it’s called adolescent idiopathic scoliosis (AIS). “Idiopathic” means that the cause is unknown. Activities that are aerobic require increased oxygen. This can put a strain on the lungs and the entire lung system for someone with AIS.

The reasons for avoidance of aerobic exercise aren’t clear. It may be that breathing in and out during exercise is difficult with AIS. When the spine is abnormally curved, the lungs can get pressed together and shifted to one side.

Doctors hope to find ways to improve lung function. The hope is that children and teenagers with AIS can exercise at a higher level. This may allow them to play in many more sports and activities.

One way to treat AIS is with spinal fusion. This operation straightens and joins the problem area of the spine together. It’s known that spinal fusion can improve breathing and lung function. However, the effect of spinal fusion on aerobic capacity hasn’t been studied.

A group of surgeons at the St. Louis Children’s Hospital measured aerobic capacity before and after surgery for AIS. Two different types of spinal fusion were done. It doesn’t seem to matter which method is used to fuse the spine in AIS. The use of oxygen doesn’t change afterward.

Spinal fusion doesn’t improve aerobic capacity for patients with AIS. Breathing is better after surgery, but the ability to use more oxygen isn’t increased. Perhaps an aerobic training program would make a difference. Further studies are needed to decide what works best.

Even simple movements can cause sudden bone fractures in people with osteoporosis. Men and women can both have this condition, although women are affected most often. Osteoporosis is a condition in the aging adult that causes the bones to become brittle.

One area most likely to fracture is the spine. These fractures are called vertebral compression fractures (VCFs). VCFs can be cause a downward spiral of bone health. The bone loses bone material and density. This in turn causes weakness and deformity.

The patient starts to lose height as the bone gets pressed down. Posture commonly becomes more stooped. This puts more pressure on the bones of the spine. The final result can be a VCF.

A new cement can be used to repair these fractures. It’s called calcium phosphate cement (CPC). CPC is injected into the fractured bone. It acts as a substitute for the injured bone. Once inside the vertebra, it hardens. The body absorbs the cement and slowly replaces it with bone tissue. Patients are placed in a cast after the surgery and have to rest during the period of bone formation. Surprisingly, the fractured bone actually gets stronger than nearby bone without CPC.

CPC can be used to prevent bone collapse in the treatment of VCF caused by osteoporosis. In this study, pain relief was immediate with the treatment. The procedure helped with alignment of the spine, too. These results show continued promise for patients who have severe pain after a spinal fracture due to osteoporosis.

Doctors sometimes use screws and metal implants to hold bones together. This is a useful treatment approach for fractures of the spine bones. There are many possible problems with the use of these devices.

Once the bone has healed, the implants are generally left in. This is because there is an equal risk of problems when putting them in and when taking them out. There can be infection, metal toxicity, corrosion, tumor formation, or loss of bone around the implant.

Doctors may consider removing the screws if the patient complains of pain or discomfort. Physicians in Switzerland advise caution in making this decision. Two cases of screw removal resulted in fracture of the spine two or three days later.

Both patients had severe osteoporosis (brittle bones). Both had worse pain after the screws were taken out than before the operation to remove them. Other reports say that mild back pain may continue in patients who have the implants successfully removed.

Some doctors feel that spinal implants shouldn’t be removed without good cause. Mild pain or local discomfort isn’t enough of a reason. Loose or broken screws should be removed or repaired. Imaging studies may be used to make this decision. If there is significant bone disease such as osteoporosis, the implants should probably remain untouched.