A thoracic compression fracture occurs when one of the vertebral bodies in the middle portion of the spine partially collapses. The thoracic spine is made up of 12 vertebrae, labeled T1 through T12.
Compression fractures are especially common in people with osteoporosis, but they can also occur after trauma or when a vertebra has been weakened by cancer, infection, or another bone disorder.
Most thoracic compression fractures are stable and can be treated without surgery. However, some fractures cause severe pain, progressive deformity, or spinal instability and may require more advanced treatment.
What Is a Thoracic Compression Fracture?
The vertebral body is the large, weight-bearing portion of each vertebra.
In a compression fracture, the vertebral body loses height because part of the bone collapses. The front portion of the vertebra is often affected more than the back, creating a wedge-shaped vertebra.
If several vertebrae become compressed over time, this can contribute to increased rounding of the upper back, called thoracic kyphosis.
Compression fractures are different from more severe injuries such as burst fractures, in which the vertebral body breaks in multiple directions and may push bone fragments toward the spinal canal.
What Causes Thoracic Compression Fractures?
The most common cause is osteoporosis.
Osteoporosis gradually weakens the internal structure of bone. Once the vertebra becomes sufficiently weak, relatively small amounts of force can cause it to collapse.
A compression fracture may occur after:
- A fall
- Lifting an object
- Bending forward
- Twisting
- Coughing or sneezing
- Minor trauma
In severe osteoporosis, a fracture may occur without any obvious injury.
Other causes include:
- High-energy trauma
- Cancer involving the vertebra
- Multiple myeloma
- Spinal infection
- Long-term corticosteroid use
- Other diseases that weaken bone
Identifying the cause of the fracture is important because treatment may need to address more than the fractured vertebra itself.
Symptoms of a Thoracic Compression Fracture
Some compression fractures cause sudden, severe pain. Others develop gradually and may initially be mistaken for muscle or arthritis-related pain.
Symptoms may include:
- Mid-back pain
- Sudden pain after a fall or minor injury
- Pain that worsens with standing or walking
- Pain with bending or twisting
- Pain when changing positions
- Tenderness over the affected vertebra
- Improvement when lying down
- Loss of height
- Increasing forward curvature of the spine
Some fractures cause little or no pain and are discovered incidentally on imaging performed for another reason.
Do Compression Fractures Cause Nerve Damage?
Most routine osteoporotic compression fractures do not compress the spinal cord or nerves.
In a typical wedge compression fracture, the front of the vertebral body collapses while the back portion remains relatively intact.
Neurologic symptoms are therefore uncommon.
However, weakness, numbness, difficulty walking, or bowel and bladder changes may indicate a more serious fracture pattern, spinal canal compromise, or another underlying condition.
These symptoms require prompt evaluation.
Osteoporosis and Compression Fractures
A vertebral compression fracture may be the first sign that a patient has osteoporosis.
Once one osteoporotic vertebral fracture occurs, the risk of additional fractures increases.
Multiple fractures can lead to:
- Chronic back pain
- Progressive loss of height
- Thoracic kyphosis
- Difficulty maintaining upright posture
- Reduced mobility
- Decreased physical activity
- Increased risk of future fractures
For this reason, treatment of the underlying osteoporosis is an important part of managing a thoracic compression fracture.
How Are Thoracic Compression Fractures Diagnosed?
Diagnosis typically begins with a history, physical examination, and imaging.
X-rays
X-rays can demonstrate:
- Loss of vertebral height
- Wedge-shaped deformity
- Multiple old compression fractures
- Thoracic kyphosis
- Changes in spinal alignment
However, an X-ray may not always determine whether a fracture is new or old.
MRI
MRI is particularly helpful when it is important to determine the age of a fracture.
A recent compression fracture often shows swelling or edema within the bone marrow.
MRI can also evaluate:
- The spinal cord
- The spinal canal
- Nerve compression
- Tumor
- Infection
- Multiple fractures
MRI is often useful when pain is severe, the diagnosis is uncertain, or there is concern for a pathologic fracture.
CT Scan
CT provides detailed images of the bone and may be useful when:
- The fracture pattern is complex
- There is concern for a burst fracture
- The posterior wall of the vertebral body may be involved
- Surgery is being considered
- MRI cannot be performed
Bone Density Testing
A DEXA scan may be recommended to evaluate for osteoporosis.
Blood testing may also be used to look for conditions contributing to abnormal bone loss.
Stable Versus Unstable Compression Fractures
Most osteoporotic compression fractures are considered mechanically stable.
A stable fracture generally does not allow dangerous movement between the vertebrae and does not threaten the spinal cord.
Features that may raise concern for a more unstable injury include:
- Significant trauma
- Severe vertebral collapse
- Involvement of the posterior spinal structures
- Abnormal widening between vertebrae
- Progressive deformity
- Injury to the spinal ligaments
- Neurologic symptoms
If instability is suspected, CT, MRI, or additional imaging may be necessary.
Nonsurgical Treatment
Most uncomplicated thoracic compression fractures improve without surgery.
Treatment may include:
- Temporary activity modification
- Pain medications
- Anti-inflammatory medications when appropriate
- Short-term bracing
- Gradual return to activity
- Physical therapy
- Osteoporosis treatment
Prolonged bed rest is generally avoided because inactivity can contribute to muscle loss, blood clots, worsening osteoporosis, and loss of independence.
Patients are often encouraged to begin walking and gradually increase activity as pain allows.
Bracing
A thoracic or thoracolumbar brace may sometimes be used during the early healing period.
A brace may:
- Reduce painful spinal motion
- Provide additional support
- Help patients remain active while the fracture heals
Bracing is not necessary for every patient.
Long-term use may weaken the muscles supporting the spine, so braces are generally used selectively rather than indefinitely.
How Long Does a Compression Fracture Take to Heal?
Pain from an acute osteoporotic compression fracture often improves gradually over several weeks.
Bone healing commonly occurs over approximately 6 to 12 weeks, although recovery varies considerably between patients.
Some patients improve rapidly, while others have persistent pain even after the fracture itself has healed.
Persistent pain should be reevaluated to determine whether there is:
- Continued fracture activity
- Progressive collapse
- Another fracture
- Spinal deformity
- Pseudarthrosis or osteonecrosis
- Another source of back pain
Kyphoplasty
Kyphoplasty is a minimally invasive procedure that may be considered for selected patients with a painful vertebral compression fracture.
During kyphoplasty:
- A small instrument is introduced into the fractured vertebra through the back.
- A balloon or other device is used to create a cavity within the vertebral body.
- Bone cement is placed into the vertebra to stabilize the fracture.
The main goal is to reduce pain by stabilizing the fractured bone.
In some patients, a small amount of vertebral height can also be restored, although complete correction of the deformity is generally not expected.
Who May Benefit From Kyphoplasty?
Kyphoplasty may be considered when:
- The fracture is recent or remains biologically active
- Pain is severe
- Pain appears to arise directly from the fractured vertebra
- Symptoms have not improved adequately with conservative treatment
- Pain is significantly limiting walking or daily activity
Kyphoplasty is not necessary for every compression fracture.
Patients whose pain is already improving often continue to recover without a procedure.
Vertebroplasty
Vertebroplasty is another vertebral augmentation procedure.
Bone cement is injected into the fractured vertebral body without first creating a cavity using a balloon.
Kyphoplasty and vertebroplasty both aim to stabilize the fracture, although the techniques differ.
The decision to use vertebral augmentation should be individualized based on symptoms, imaging findings, fracture age, and overall health.
When Is Larger Spine Surgery Needed?
Most thoracic compression fractures do not require traditional spinal surgery.
More extensive surgery may be necessary when there is:
- Severe spinal instability
- Progressive kyphotic deformity
- Major vertebral collapse
- Spinal cord compression
- Progressive neurologic dysfunction
- Failure of vertebral augmentation
- Multiple fractures causing significant deformity
- Tumor-related destruction of the vertebra
Surgery may include:
- Pedicle screw instrumentation
- Spinal fusion
- Decompression
- Corpectomy
- Vertebral reconstruction
These operations are much less commonly needed than nonsurgical treatment or vertebral augmentation.
Vertebral Osteonecrosis and Delayed Collapse
Occasionally, a fractured vertebra does not heal normally.
Loss of blood supply to part of the vertebral body can lead to vertebral osteonecrosis and delayed collapse.
A delayed form following a compression fracture is sometimes called Kümmell disease.
Patients may initially improve after their injury and then develop recurrent pain weeks or months later.
Imaging may show:
- Progressive collapse
- An intravertebral vacuum cleft
- Fluid or gas within the vertebral body
- Increasing kyphosis
- Abnormal movement within the fractured vertebra
Treatment depends on the amount of pain, collapse, instability, and deformity.
Compression Fractures Caused by Cancer
Not every vertebral compression fracture is caused by osteoporosis.
Cancer can weaken the vertebral body and produce a pathologic compression fracture.
This is particularly important in patients with:
- A known history of cancer
- Unexplained weight loss
- Persistent night pain
- Pain that does not behave like a typical osteoporotic fracture
- Multiple abnormal vertebrae
- Unusual imaging findings
MRI and sometimes biopsy may be necessary to determine the cause.
Treatment may involve radiation, systemic cancer therapy, vertebral augmentation, or surgery depending on the situation.
Preventing Additional Compression Fractures
A compression fracture should prompt evaluation of overall bone health, particularly in older adults.
Prevention may include:
- Bone-density testing
- Osteoporosis medication when appropriate
- Adequate calcium intake
- Adequate vitamin D
- Weight-bearing exercise
- Strength training
- Fall prevention
- Avoidance of tobacco
- Limiting excessive alcohol use
- Evaluation for medical causes of bone loss
Improving bone strength is one of the most important ways to reduce the risk of future fractures.
When Should a Compression Fracture Be Evaluated Urgently?
Prompt medical evaluation is appropriate when back pain is accompanied by:
- New leg weakness
- Numbness in both legs
- Difficulty walking
- Loss of balance
- New bowel or bladder dysfunction
- Severe pain after major trauma
- Fever or signs of infection
- A history of cancer with new severe back pain
These symptoms may indicate a more serious spinal injury or an underlying condition other than routine osteoporosis.
Outlook
Most thoracic compression fractures are stable and gradually improve with nonsurgical treatment.
The goals of treatment are to:
- Control pain
- Maintain mobility
- Allow the fracture to heal
- Prevent progressive deformity
- Identify and treat osteoporosis
- Reduce the risk of additional fractures
Persistent severe pain may sometimes be treated with vertebral augmentation such as kyphoplasty. More extensive surgery is generally reserved for patients with instability, severe deformity, spinal cord compression, or other complex problems.
Treatment should be based on the fracture pattern, severity of symptoms, neurologic examination, bone quality, and underlying cause of the fracture.
Related Topics
- Osteoporosis
- Thoracic Burst Fracture
- Vertebral Osteonecrosis
- Kyphoplasty
- Thoracic Spinal Instability
- Thoracic Kyphosis
- Metastatic Spine Tumors
- Thoracic Pedicle Screw Instrumentation
- Thoracic Spinal Fusion