The thoracic spine is the middle portion of the spine and is made up of 12 vertebrae, labeled T1 through T12. These vertebrae form the structural framework of the chest and protect the spinal cord while supporting the rib cage.
Please review the Thoracic spine anatomy section for more information.
Disorders affecting the thoracic vertebrae may result from trauma, osteoporosis, loss of blood supply, or tumors. Some conditions cause pain without threatening the spinal cord, while others can lead to spinal instability, deformity, or neurologic injury.
Major Diagnosis Types
Below are the major types we see in our clinic. Click on available links to learn about our approach to the problems.
Thoracic Compression Fracture
A thoracic compression fracture occurs when part of a vertebral body collapses under pressure.
These fractures are particularly common in patients with osteoporosis, but they can also occur after trauma or when a vertebra has been weakened by a tumor or other disease.
The front portion of the vertebral body is often affected more than the back, producing a wedge-shaped vertebra.
Symptoms may include:
- Sudden or gradually worsening mid-back pain
- Pain that becomes worse when standing or walking
- Pain with bending or twisting
- Tenderness over the affected vertebra
- Loss of height
- Progressive rounding of the back
Some compression fractures are discovered incidentally and cause little or no pain.
Most stable compression fractures can initially be treated without surgery.
Treatment may include:
- Temporary activity modification
- Pain medications
- Treatment of osteoporosis
- Physical therapy
- Bracing in selected patients
Persistent painful fractures may sometimes be treated with vertebral augmentation, such as kyphoplasty.
Surgery may be necessary when the fracture causes significant instability, progressive deformity, spinal cord compression, or neurologic impairment.
Thoracic Burst Fracture
A burst fracture occurs when a vertebral body is severely compressed and breaks in multiple directions.
Unlike a simple compression fracture, a burst fracture may push fragments of bone backward into the spinal canal.
Burst fractures often result from significant axial loading injuries, such as:
- Falls from a height
- Motor vehicle accidents
- Motorcycle accidents
- High-energy sports injuries
They can also occur after lower-energy trauma in patients with severely weakened bone.
Symptoms may include:
- Severe back pain
- Difficulty standing or walking
- Muscle spasms
- Numbness or weakness
- Difficulty controlling the legs
If bone fragments compress the spinal cord, neurologic injury can range from mild weakness or numbness to paralysis.
Not every burst fracture requires surgery.
Stable fractures in neurologically intact patients may sometimes be treated with bracing and close follow-up.
Surgery may be recommended when there is:
- Significant spinal instability
- Progressive deformity
- Severe vertebral collapse
- Spinal cord compression
- Neurologic injury
- Failure of nonsurgical treatment
Surgical treatment may involve decompression, pedicle screw instrumentation, spinal fusion, or reconstruction of the damaged vertebral body.
Chance Fracture
A Chance fracture is a flexion-distraction injury in which the spine is pulled apart rather than simply compressed.
The injury typically travels through the vertebral body, pedicles, and posterior elements.
Sometimes referred to as seat-belt fractures.
They may be mechanically unstable even if the spinal canal does not appear severely narrowed.
Some purely bony Chance fractures may heal with bracing when alignment is acceptable.
Surgery is more likely to be recommended if there is instability, soft tissue injury, deformity or malalignment.
Osteoporosis
Osteoporosis is a condition in which bones gradually lose strength and become more susceptible to fracture.
The vertebrae are among the most commonly affected bones.
Thoracic compression fractures may sometimes occur after very minor events, such as:
- Bending forward
- Lifting a relatively light object
- Coughing or sneezing
- Minor falls
In severe osteoporosis, fractures may occur without a clearly remembered injury.
Multiple vertebral fractures can cause:
- Chronic back pain
- Loss of height
- Progressive kyphosis
- Reduced mobility
- Difficulty maintaining upright posture
- Increased risk of additional fractures
Osteoporosis also affects the ability of spinal implants to maintain strong fixation.
Treatment should address both the fracture and the underlying bone disease.
Management may include:
- Calcium and vitamin D when appropriate
- Weight-bearing exercise
- Fall prevention
- Bone-density testing
- Prescription osteoporosis medications (examples include Forteo, Tymlos, Evinity)
- Evaluation for secondary causes of bone loss
Improving bone quality can be particularly important before and after spinal fusion surgery.
Minor Diagnosis Types
These terms are often encountered, but are either less often treated or described within one of the above diagnoses.
Flexion-Distraction Injury
A flexion-distraction injury occurs when the spine bends forward while the posterior portion of the spinal column is pulled apart.
A Chance fracture is one type of flexion-distraction injury, but not all flexion-distraction injuries pass directly through bone.
In some patients, the injury primarily tears the ligaments and soft tissues that normally stabilize the spine.
The injury may involve:
- Supraspinous ligament
- Interspinous ligament
- Facet joints
- Facet capsules
- Ligamentum flavum
- Intervertebral disc
- Posterior longitudinal ligament
Disruption of these structures may make the spine unstable.
Treatment depends on whether the injury is primarily bony or ligamentous and whether normal alignment can be maintained.
Ligamentous flexion-distraction injuries are often treated surgically because damaged ligaments may not reliably restore spinal stability.
Thoracic Vertebral Hemangioma
A vertebral hemangioma is a benign vascular growth within a vertebral body.
Hemangiomas are common and are frequently found incidentally on MRI or CT scans obtained for unrelated reasons.
Most never cause symptoms and require no treatment.
Rarely, these lesions can be aggressive and require surgical evaluation.
Tumors – Benign Vertebral Body
Several types of benign tumors can affect the thoracic vertebrae.
Examples include:
- Osteoid osteoma
- Osteoblastoma
- Giant cell tumor
- Aneurysmal bone cyst
- Chondromyxoid fibroma
- Other uncommon benign bone lesions
Although these tumors are not cancerous, some can grow aggressively and damage normal bone.
Possible symptoms include:
- Persistent back pain
- Night pain
- Local tenderness
- Progressive deformity
- Radicular pain
- Weakness or numbness if the spinal canal is involved
Some small benign lesions can be observed.
Others may require:
- Ablation
- Curettage
- Surgical excision
- Spinal stabilization
- Reconstruction of the vertebra
The specific treatment depends heavily on the tumor type.
Tumors – Malignant Vertebral Body
A primary spine tumor begins within the bones or tissues of the spine rather than spreading there from another part of the body.
Primary malignant vertebral tumors are relatively uncommon.
Examples include:
- Chordoma
- Chondrosarcoma
- Osteosarcoma
- Ewing sarcoma
- Plasmacytoma
- Multiple myeloma
Some of these tumors behave very differently from one another, so obtaining an accurate diagnosis is essential.
Symptoms may include:
- Persistent or worsening back pain
- Pain at night
- Pain unrelated to activity
- Unexplained weight loss
- Progressive spinal deformity
- Weakness or numbness
- Difficulty walking
A biopsy is frequently necessary before definitive treatment.
Treatment may involve a combination of:
- Surgery
- Radiation therapy
- Chemotherapy
- Targeted therapy
- Systemic cancer treatment
Some primary tumors require extensive surgical removal when a meaningful oncologic benefit can be achieved.
Tumors – Metastatic
Metastatic spine tumors are cancers that begin elsewhere in the body and spread to the spine.
They are much more common than primary malignant tumors of the spinal column.
Cancers that commonly spread to the spine include:
- Breast cancer
- Prostate cancer
- Lung cancer
- Kidney cancer
- Thyroid cancer
- Melanoma
- Gastrointestinal cancers
The thoracic spine is a common location for spinal metastases.
Metastatic disease may cause:
- Persistent back pain
- Night pain
- Pain with movement
- Vertebral compression fracture
- Spinal instability
- Weakness or numbness
- Difficulty walking
When tumor extends into the spinal canal, it may produce metastatic epidural spinal cord compression, which can be a neurologic emergency.
Treatment is individualized based on:
- Type of cancer
- Extent of disease
- Neurologic function
- Degree of spinal cord compression
- Mechanical stability of the spine
- Overall health and prognosis
Options may include:
- Radiation therapy
- Stereotactic radiation
- Chemotherapy or targeted systemic therapy
- Vertebral augmentation
- Surgical decompression
- Spinal stabilization
- Tumor removal in selected patients
The goal may be to relieve pain, preserve neurologic function, maintain spinal stability, and allow effective cancer treatment to continue.
Vertebral Osteonecrosis
Vertebral osteonecrosis occurs when part of a vertebral body loses its normal blood supply and the bone subsequently weakens or collapses.
A delayed form of vertebral collapse following a compression fracture is sometimes referred to as Kümmell disease.
Patients may initially improve after a fracture and then develop worsening pain or progressive collapse weeks or months later.
Possible symptoms include:
- Persistent back pain
- Pain that initially improves and later returns
- Progressive vertebral collapse
- Increasing spinal deformity
- Difficulty standing upright
More advanced collapse may occasionally narrow the spinal canal and affect the spinal cord.
Imaging may show:
- Progressive vertebral collapse
- An intravertebral vacuum cleft
- Abnormal fluid or gas within the vertebral body
- Kyphotic deformity
CT and MRI can help distinguish osteonecrosis from infection or tumor.
Treatment depends on the amount of collapse, pain, deformity, and instability.
Options may include observation, bracing, vertebral augmentation, or reconstructive spinal surgery in more advanced cases.