Complications

What are the potential complications of this fracture?

Complications are problems with the course of treatment for the injury. They may be the direct result of the injury or may be caused by the treatment – like the side-effects of some medication. Most complications are quite rare, but doctors pay a lot of attention to them and a great deal of effort is directed at avoiding complications or minimizing their consequences. It also explains some of the mystifying things that doctors and nurses do. Patients who would prefer not to be disturbed are roused and moved from one side to another to reduce the risk of developing complications like pressure sores or chest infections.

Spinal Cord Injury (SCI)

This is one of the complications that may be caused by the fracture. At the moment of injury the nerves may be damaged and may not recover. This injury has greater long term consequences than the fracture itself and requires prolonged, complex and skillful management in order to maximize long term function. As such it is outside the scope of this article. Spinal cord injury is very rarely caused by the treatment of thoracic spine fractures but the neurological injury can become worse during the course of recovery from a spinal fracture. One aim of surgery is to stabilize the spine, in order to stop the progression of SCI and to reverse any reversible element.

Pressure sores

The blood supply to an area of the skin is halted when you lie on that area. If you remain immobile for more than a very few hours the tissue in the pressurized area will die for lack of blood. Normally you move quite frequently, even while asleep; but if you are immobilized by pain or by paralysis following a neurological injury regions such as skin over the sacral area, the hips or at the back of the heels may undergo pressure necrosis. The first sign is redness as the dying tissue stimulates extra blood supply and inflammation, then the skin blackens and dries up. An ulcer forms exposing the underlying tissues – fatty layers, bone or tendon. These tissues in turn are vulnerable so a pressure ulcer can be very deep and very damaging. The skin is a barrier to infection so pressure sores can lead to severe infections.

Prevention is the key to pressure sores (sometimes called decubitus ulcers). If the pressure is relieved periodically, the circulation resumes and no tissue dies. The old fashioned way of rubbing areas with surgical spirit was probably more useful shifting the weight off. It had the advantage that nursing staff were frequently inspecting vulnerable areas. Nowadays there are special beds with inflatable mattresses that change the pressure automatically. Patients are frequently rolled from side to side and mobilized as early as possible.

If pressure sores do develop and do not heal when weight is kept off these areas, it may be necessary to undertake surgery to close the ulcers using flaps and other plastic surgery techniques.

Deep Venous Thrombosis (DVT) and Pulmonary Embolism (PE)

Blood clots can form is the veins if the circulation is stagnant. Blocking the veins with clot (Deep Vein Thrombosis DVT) is a problem, causing aching, pain and swelling of the legs. However, the clots can break off and float up the veins into the lungs causing an even more serious problem – Pulmonary Embolism (PE). Large clots can fatally compromise the circulation to the lungs. When people are immobile after an injury the risk of Venous Thrombo-Embolism (VTE) is greatly increased. The mainstay of prevention is early mobilization. Even severely disabled people can be sat up and encouraged to move their legs. The condition is difficult to detect clinically and the first sign may be chest pain due to a PE. There are tests which show impairments of circulation to the legs or the lungs, If these suggest there is a problem the patient may be treated with blood thinning medication. In some situations a filter can be placed in one of the major veins to prevent clots reaching the lungs.

Chest infection

Pneumonia and bronchitis are other complications which are made more likely by immobilization. It is difficult to clear secretions from your lungs if you are lying down all the time. If chest infections do develop they can be treated with physiotherapy and antibiotics but it is better to prevent the problem by sitting up, taking deep breaths and coughing regularly. With a sore, unstable back this may be difficult; sometimes surgery to stabilize the back can be recommended in order to allow for earlier mobilization.

Nonunion

One aim of surgery after thoracic spine fractures is to prepare the way for bone to grow from one vertebra to the next and fuse the two bones together. This makes the injured area stable again. However, it is not always successful. If the scar that forms in the operated area does not transform into bone, the situation is called a non-union. Likely there will still be some motion at the site of surgery and this may be painful or unstable with an increased risk of nerve damage or breakage of the metal implants through fatigue failure. Where the situation is stable it may be advisable to leave it. However, common practice is to repeat the surgery, freshen up the bone surfaces and pack in bone graft to assist the area to heal. When one form of fixation has failed to hold everything still enough for the fusion to develop, it may be necessary to change the fixation and/or the surgical approach.

Hardware Failure

The metal implants used to hold the broken pieces of bone will undergo fatigue if they are loaded too much too soon or if the bone fails to heal. If there is a non-union the implants will always break eventually as there is micro-movement or even quite gross movement between the bone fragments. If you take a piece of wire and bend it repeatedly in the same place it will change mechanical properties quite soon and break. The same is true of any metal object that is subjected to repetitive stress. When the implant breaks there is often a noticeable change in symptoms and the diagnosis is confirmed by an X-ray. If there is non-union the treatment would be based on solving that problem. Sometimes the bone heals anyway even though the implants are broken and in this situation it may be a good idea to leave the implants in place even though they are broken.

Persistent symptoms

The common forms of back pain are usually caused by injuries to joints, muscles, ligaments and disks in the spine – not the bones. However, these ‘soft tissues’ can also be injured when the bone is broken. After the bone has healed there may be residual aching, weakness and discomfort. The space available for the nerves may also be reduced giving rise to leg pain, weakness or numbness. These persistent symptoms would be evaluated and treated like any other form of chronic back problem.