Compression Fractures in the Thoracic and Lumbar Spine After Trauma
A compression fracture is a fracture in which the front of a vertebral body collapses under load. It is the most common type of traumatic spine fracture. In the thoracic and lumbar spine, the screening rules are less settled than in the neck, so a crash patient with mid-back or low back pain and midline tenderness needs a careful exam. That is the standard I hold to with patients in Charlotte.
How Common They Are
The American College of Radiology estimates that thoracolumbar fractures occur in 4% to 7% of blunt trauma patients in the emergency department (Beckmann, J Am Coll Radiol 2019). In a German trauma center series of 562 patients with traumatic spine fractures, traffic accidents caused 26.5% and produced significantly more cervical and thoracic fractures than falls did. Compression fractures were the largest group, 54.8% of patients. Most patients, 75.3%, had no neurologic deficit (Leucht, Injury 2009).
How They Are Classified
Denis described the spine as three columns in a 1983 study of 412 thoracolumbar injuries (Denis, Spine 1983). The middle column is the back wall of the vertebral body, the posterior longitudinal ligament, and the back of the disc annulus. He grouped major injuries into four types: compression fractures, burst fractures, seat-belt-type injuries, and fracture-dislocations. How the middle column fails correlated with the fracture type and with neurologic injury.
The Thoracolumbar Injury Classification and Severity Score, TLICS, is the system used to guide treatment now. It scores three features: the shape of the injury on imaging, the integrity of the posterior ligamentous complex, and neurologic status (Vaccaro, Spine 2005). Two compression fractures that look alike on CT can score differently if the ligaments behind them differ.
Why the Ligaments Matter
The posterior ligamentous complex, the supraspinous ligament, interspinous ligament, ligamentum flavum, and facet capsules, holds the back of the spine together. In 45 surgical spinal trauma patients, MRI read by an attending spine surgeon had a sensitivity of 0.83 for injury to these ligaments against surgical findings (Crosby, Spine J 2011). A compression fracture with intact ligaments and one with torn ligaments are different injuries, and the CT alone may not tell them apart.
Seat-Belt Injuries
Denis listed seat-belt-type injuries as one of the four major categories. They are a car accident injury by definition: the lap belt holds the pelvis while the upper body flexes forward over it. I am not including injury rates for seat-belt fractures here because I did not verify a current figure. The practical point is that a belted occupant with mid-back or low back pain after a frontal crash needs the thoracolumbar spine examined, not only the neck.
How I Screen in the Office
The ACR notes that screening criteria for thoracolumbar injury have less validation and acceptance than the cervical rules (Beckmann, J Am Coll Radiol 2019). Without a validated rule, I rely on the exam. Midline tenderness over the thoracic or lumbar spine, pain with gentle axial load, new leg numbness or weakness, or a high-energy mechanism sends a patient for imaging before any manual care.
For an example of how post-collision imaging findings and outcomes are documented in the peer-reviewed literature, read Dr. Justin Dick's published case report on refractory lumbar pain following a motor vehicle accident in a geriatric patient.
Frequently Asked Questions
What is a compression fracture?
A compression fracture is a collapse of the front of a vertebral body under load. It was the most common fracture type, 54.8% of patients, in a series of 562 traumatic spine fractures (Leucht, Injury 2009).
How common are thoracic and lumbar fractures after trauma?
The American College of Radiology estimates thoracolumbar fractures occur in 4% to 7% of blunt trauma patients in the emergency department (Beckmann, J Am Coll Radiol 2019).
What is the three-column model of the spine?
Denis divided the thoracolumbar spine into anterior, middle, and posterior columns. The middle column is the back wall of the vertebral body, the posterior longitudinal ligament, and the back of the disc annulus (Denis, Spine 1983).
Why do ligaments matter in a compression fracture?
The TLICS system scores posterior ligament integrity alongside fracture shape and neurologic status, because torn ligaments change how a fracture is treated (Vaccaro, Spine 2005).
Can a seat belt cause a spinal fracture?
Seat-belt-type injuries are one of the four major thoracolumbar injury categories Denis described. Dr. Justin Dick in Charlotte, NC examines the mid and low back of belted occupants after frontal crashes.
Where can I get evaluated for a back fracture after a car accident in Charlotte, NC?
Dr. Justin Dick, DC, CNMT, ARRT(N)(CT), screens car accident patients for thoracic and lumbar fractures at Clear Life Scoliosis and Chiropractic Center, 8814 Rachel Freeman Way, Suite 103, Charlotte, NC 28278, phone 980-368-0766. Personal injury patients are treated on a lien basis, with no out-of-pocket payment at the time of care.
Sources and Evidence Tiers
- Leucht P, Fischer K, Muhr G, Mueller EJ. Epidemiology of traumatic spine fractures. Injury. 2009;40(2):166-172. PMID 19233356. LinkEvidence tier: Retrospective cohort (562 patients, single trauma center)
- Beckmann NM, West OC, Nunez D, et al. ACR Appropriateness Criteria: Suspected Spine Trauma. J Am Coll Radiol. 2019;16(5S):S264-S285. PMID 31054754. LinkEvidence tier: Evidence-based guideline with expert panel rating (RAND/UCLA and GRADE)
- Denis F. The three column spine and its significance in the classification of acute thoracolumbar spinal injuries. Spine. 1983;8(8):817-831. PMID 6670016. LinkEvidence tier: Retrospective case series (412 injuries) proposing a classification
- Vaccaro AR, Lehman RA, Hurlbert RJ, et al. A new classification of thoracolumbar injuries: the importance of injury morphology, the integrity of the posterior ligamentous complex, and neurologic status. Spine. 2005;30(20):2325-2333. PMID 16227897. LinkEvidence tier: Expert consensus classification system
- Crosby CG, Even JL, Song Y, Block JJ, Devin CJ. Diagnostic abilities of magnetic resonance imaging in traumatic injury to the posterior ligamentous complex. Spine J. 2011;11(8):747-753. PMID 21840264. LinkEvidence tier: Prospective diagnostic accuracy study (45 patients)
About the author. Dr. Justin M. Dick, DC, is the owner and treating clinician at Clear Life Scoliosis and Chiropractic Center in Charlotte, NC. He holds dual imaging credentials as a Certified Nuclear Medicine Technologist (CNMT) and as an ARRT-registered technologist in nuclear medicine and CT, ARRT(N)(CT). He is a Senior Fellow of the CLEAR Institute, holds the ISICO World Masters credential, is a SOSORT provisional member, and is a certified DOT medical examiner on the FMCSA National Registry. He has multiple peer-reviewed publications indexed in PubMed and serves as adjunct faculty at Life, Sherman, and Palmer chiropractic colleges.
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Clear Life Scoliosis and Chiropractic Center sees personal injury and spinal imaging patients from Charlotte NC, Huntersville NC, Ballantyne NC, Matthews NC, Concord NC, Mooresville NC, Rock Hill SC, and Fort Mill SC.
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- Personal injury and car accident spinal care in Charlotte
- Dr. Justin Dick's research
- Case report: refractory lumbar pain after a motor vehicle accident
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Clear Life Scoliosis and Chiropractic Center
8814 Rachel Freeman Way, Suite 103
Charlotte, NC 28278
Phone: 980-368-0766
Email: office@clearlifescoliosis.com
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