95

Review Article

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Trauma to the Upper Thoracic Spine:

Anatomy, Biomechanics, and Unique Imaging Features
Georges V. EI-Khoury1 and Camelia G. Whitten

This review summarizes the anatomic and biomechanical Anatomy and Biomechanics of the Thoracic Spine
features of the thoracic spine, which are different from those of
the more mobile segments of the spine, and emphasizes their Gross Anatomy
role in trauma. The distinguishing characteristics of the tho-
racic spine are the presence of the ribs and their articulations. The thoracic spine consists of 12 vertebrae; it has a yen-
The rib cage restricts motion and adds stiffness to the spine. tral curve that develops in utero and is maintained, although
During trauma, it provides the thoracic spine with additional somewhat modified, throughout life. The vertebral bodies
strength and energy-absorbing capacity. Above the T10 level,
anteriorly are primarily load-bearing. The arches posteriorly
most injuries produce a basic pattern consisting of an anterior
act in resisting tension. The antenopostenior diameter of the
fracture-dislocation involving two contiguous vertebrae, often
with associated neurologic impairment. The definition of spinal
vertebral bodies gradually increases from Ti to T12,
instability remains controversial. CT is the imaging technique whereas the transverse width decreases from Ti to T3 and
of choice for evaluation of spine fractures; however, MR imag- then increases progressively down to T12 [1]. Normally, the
ing is superior in the evaluation of spinal cord injury and post- vertical height of the thoracic vertebral bodies is about 2-3
traumatic disk herniation. MR imaging also provides mm less anteriorly than posteriorly, which partially contnib-
prognostic information not obtainable with other imaging utes to thoracic kyphosis. The sides of the bodies are some-
methods. what concave. In the thonacic spine, the laminae are broad
and heavily overlapped. The pedicles project posteriorly
from the superior aspect of the vertebral body. Extending
dorsomedially from the pedicles are the laminae, which fuse
The thoracic spine is the largest segment of the spine, and in the midline to form the dorsal wall of the spinal canal [1,
it is a common site for trauma, especially in its lower portion 2]. The lumen of the spinal canal varies in size throughout its
(T10-T12). The anatomic and biomechanical features of the length, but its narrowest segment is in the thonacic spine.
thoracic spine make its response and tolerance to mechani- Neural elements within the thonacic portion of the spinal
cal stresses different from those of the more mobile portions canal are, therefore, more frequently affected by conditions
of the spine. This review considers the anatomy, biomechan- that result in even minimal narrowing of the spinal canal [3,
ics, and unique imaging features of the normal and trauma- 4]. The articular processes arise from both the superior and
tized upper portion of the thonacic spine. inferior surfaces of the laminae. The articulating facets are

Received July 1 , 1992; accepted after revision July 28, 1992.

authors: Department of Radiology, The University of Iowa Hospitals and Clinics, 200 Hawkins Dr., Iowa City, IA 52242. Address reprint requests to G. Y.
El-Khoury.
AJR 1993;160:95-102 0361-803X/93/1 601-0095 © American Roentgen Ray Society
96 EL-KHOURY AND WHITTEN AJR:160, January 1993

situated on the posterior surface of the superior articular pro- Anteropostenion radiographs can be obtained easily; how-
cess and ventral surface of the inferior process. Throughout even, diagnostic lateral radiographs may be more difficult to
most of the thoracic region (Ti -Ti 0), the facets are in the obtain in patients with multisystem trauma because the
coronal plane, thus providing significant resistance to ante- examination is performed with the patient in the supine posi-
non translation. At Ti 1 and Ti 2, facets begin to change their tion. In cooperative patients, high-quality lateral views of the
orientation to simulate the lumbar pattern (oblique sagittal thoracic spine can be obtained by using a long exposure
orientation), where they limit notation and have less effect on (3-6 sec, 50 mA, and 70 kVp) and breathing technique. A
anterior translation [4]. swimmer’s view of the upper thoracic spine is often benefi-
The most distinguishing features of the thonacic spine are cial when the upper thonacic vertebrae are not adequately
related to the presence of the nibs and their articulations [1, visualized.
2]. Ribs articulate with vertebrae at two sites. Rib heads Antenopostenior radiographs are ideal for the evaluation of
articulate with the vertebrae at the disk, and the rib tubencle the vertebral bodies. The superior and inferior endplates of
articulates with the transverse process at the costotrans- the vertebral bodies are seen as linear horizontal lines. The
verse articulation. lateral margins are concave. Pedidles appear as oval struc-
Demifacets above and below the disk articulate with the tunes projecting over the superior corners of the vertebral
head of the nb to form the costovertebral joint, which is a bodies. Absence of a pedicle, or asymmetry in the size or
synovial joint divided by an intnaarticular ligament into two density of the pedicles, warrants further investigation to rule
separate compartments. The heads of the first, 11th, and out neoplasm. Pedicle thinning, with a slight increase in the
12th ribs articulate with single vertebral facets of the come- intenpediculate distance at the level of the thinning, is non-
sponding vertebrae rather than with two demifacets of adja- mally seen at the thoracolumban junction in 7% of the popu-
cent vertebrae [1 , 2]. The head of the rib is an important lation. The thinned pedicles may even have concave medial
landmark for identifying the intervertebral disk during axial borders [7, 8]. The articular facets and Iaminae are difficult to
imaging. The nib cage restricts motion and adds stiffness to evaluate on the anteropostenior view. The transverse pro-
the spine. This is especially true in extension and to a lesser cesses are visible as lateral extensions of the upper half of
extent in flexion and lateral notation. Biomechanically, the rib the vertebrae, whereas the costotnansverse joints can be
cage is considered part of the structure of the spine, thus detected as two oblique lines close to the ends of the trans-
providing additional strength and energy-absorbing capacity verse processes. Rib heads, which are detected at the level
during trauma. The rib cage and sternum increase the of the intervertebral disks, articulate with the superior and
moment of inertia and therefore stiffen the spine when it is inferior corners of adjacent vertebral bodies. The panaspinal
subjected to rotatory forces [5]. Andniacchi et al. [6] predicted soft tissues of the thoracic spine should be closely applied to
that the compression tolerance of the spinal column in the the vertebral bodies and only minimally visible. No focal
presence of the rib cage is increased by a factor of 4. In din- swelling should be identified in the paraspinal soft tissues of
ical situations, when costovertebral disruption is present, the the normal thonacic spine.
ability of the spine to carry normal physiologic loads should Lateral nadiographs are helpful in assessing vertebral
be questioned. body height, disk height, endplate irregularity, erosions, and
The transverse processes project laterally from the articu- alignment. On the lateral projection, vertebral bodies are
Ian pillars between the superior and inferior articulan facets. seen as rectangular structures. The pedicles extend posteri-
They diminish in length from the top to the bottom of the tho- only from the superior half of the body. Located above and
macic spine. The tip of each transverse process from Ti to below the pedicles are the articular processes. The spinal
Ti 0 bears an oval costal facet. Costotransverse joints are canal and neural foramina are clearly delineated on lateral
formed by the articulation of the rib tubendles and tips of the nadiographs. The inferior portions of the neural fonamina are
transverse processes. Tii and Ti2 transverse processes do occluded by the heads of the ribs [1]. The spinous processes
not articulate with ribs [1 , 2]. are virtually impossible to visualize on the lateral view owing
Compared with the cervical and lumbar spine, the height to the superimposition of the ribs.
of disks in the thonacic spine is decreased, but the annulus
fibrosus is thicker. The disks in the thonacic region seem to
Trauma to the Upper Thoracic Spine
be effective in limiting rotation [4]. The anterior and posterior
longitudinal ligaments, ligamenta flava, and interspinous and Fractures in the upper thoracic spine (Ti-Tb) are not
supraspinous ligaments in the thoracic spine are not signifi- uncommon. Of 2416 patients with acute fractures of the yen-
cantly different from these ligaments at other spinal seg- tebmal column admitted to the Northwestern University Acute
ments. Spine Injury Center between 1 972 and i 986, 1 6% of the 376
fractures involved the upper thonacic spine [9].

Radiographic Anatomy
Fractures of the Upper Thoracic Spine
Conventional radiography continues to be the mainstay of
any diagnostic investigation of the thoracic spine. Plain radi- Historically, fractures of the upper thoracic spine (Ti -Ti 0)
ognaphy should precede any complex imaging procedure, have been grouped with fractures of the thoracolumbar junc-
and the interpretation of these complex studies should be tion and lumbar spine. These regions differ in both their neu-
undertaken only with the plain nadiogmaphs at hand. Antero- nologic and osseous aspects [3]. Bohlman [3] drew attention
posterior and lateral nadiographs are always required. to the unique features of trauma involving the upper thoracic
AJR:160, January 1993 TRAUMA TO UPPER THORACIC SPINE 97

spine and noted the following: (1 ) Because of its stiffness, ratios of 0.80 in males and 0.87 in females (95% confidence
considerable violence is necessary to produce fractures or limits) at the T8 to Ti 2 levels are considered within normal
fracture-dislocations in the upper thonacic spine. (2) #{149} limits [12, 13].
Because of the narrow spinal canal in this region, injuries of The posterior aspects of the vertebral bodies are visible
the spinal cord are frequently associated with injuries of the on lateral nadiognaphs. Disruption, or bulging, of this line into
upper thonacic spine. (3) Most of the osseous injuries occur the spinal canal is a reliable indicator of a burst fracture in
in flexion and axial loading because very little rotatory the spine (Fig. 3). In a study of 114 patients with burst frac-
motion occurs in the upper thonacic spine. tunes, Daffnen et al. [1 4] found disruption of the posterior yen-
Antenopostenon and lateral views of the thoracic spine are tebral body line in all. This line should be carefully scru-
helpful in assessing alignment. An abrupt change in align- tinized in patients with trauma to the thoracic spine.
ment indicates spinal injury (Figs. 1A and 2B). The presence The spinous processes consistently project over the mid-
of abnormal kyphosis, pleural fluid, panaspinal swelling, rib line, and each tubercle (tip) of the spinous process extends
fractures, dislocations at the costovertebral joints, or widen- slightly below the inferior endplate of its respective vertebral
ing of the interpediculate distance also suggests thonacic body. The “double spinous process sign” seen on the antero-
spine injury (Figs. 2A and 2B). posterior radiograph is a reliable indicator of a fracture of the
Rogers et al. [1 0] recognized that fractures of the upper spinous process [15, 16] (Fig. 4).
thonacic spine do not fit easily into the common fracture clas- CT is a useful adjunct to standard radiography when
sifications and thus should be treated separately. In a review assessing trauma of the thonacic spine, particularly in the
of 35 patients with acute injury to the upper thonacic spine evaluation of vertebral fracture and retnopulsed fragments
and associated paraplegia, they found the basic pattern of [17-20] (Fig. 3B). Keene et al. [17] and Bnant-Zawadzki et al.
injury, affecting 32 of 35 patients, consisted of an anterior [1 8] demonstrated that CT combined with standard radiogna-
fracture-dislocation involving two contiguous vertebrae phy is equal on superior to conventional tomography in
(Figs. 2A and 2B). Shanafuddin et al. [ii] described similar assessing the extent of spine trauma. Brant-Zawadzki et al.
radiographic findings in three patients with fractune-disloca- [1 8] reported that conventional tomography added no clini-
tions of the thonacic spine. cally significant information in the acute stage.
Anteriorly wedged vertebrae are usually considered
abnormal in the clinical setting of trauma. However, normal Spinal Cord lnjuiy
wedging of the lower thoracic vertebral bodies, especially in
males, is common [1 2, 13]. Fletcher [1 2] and Laundsen et al. Fractures associated with spinal cord injury most often
[1 3] proposed using a wedging ratio that compares heights occur at C4-C7 and the thoracolumbar junction; however,
of the anterior vs the posterior vertebral bodies. Wedging midthoracic spine fractures account for a sizable portion of

Fig. 1.-Abnormal alignment and noncontig-

uous fractures.
A, Anteroposterior chest radiograph shows
fluidin left pleural space and abnormal align-
ment between T2 and T3(arrowheads), suggest-
Ing a fracture-dislocatIon.
B, Sagittal T2-welghted MR Image shows T3
and T4 vertebral body fractures (white arrows)
and a noncontiguous fracture of odontold
(black arrow).
98 EL-KHOURY AND WHITTEN AJR:160, January 1993

Fig. 2.-Anterior fracture-dislocation of the-

racic spine.
A, Anteroposterior radiograph shows inter-
ruption in outline of pedicles at Tb, left paraspi-
nal swelling (arrowheads), and left costo-
vertebral dislocation at Ti 1 (arrow).
B, Lateral radiograph of thoracic spine shows

4
anterior fracture-dislocation of Ti 0 on Ti 1, with
secondary kyphosis at T10-Tii.
C, Sagittal T2-weighted MR images show

I transection of cord with hemorrhage and edema

‘1 within spinal cord.

‘I -
‘#{188} _____

Fig. 3.-Disruption of posterior vertebral

body line.
A, Lateral radiograph of thoracic spine shows
posterior displacement and bulging of posterior
vertebral body line of Ti0 (arrows), indicating
retropulsed fragments within spinal canal.
B, Axial CT scan through TiO confirms pres-
ence of retropulsed fragment within spinal
canal.
AJR:160, January 1993 TRAUMA TO UPPER THORACIC SPINE 99

fractures with injury to the spinal cord [10]. Owing to the fractures are the upper cervical spine and thoracolumbar
small diameter of the thoracic spinal canal and the sparse junction [10, 34, 35]. The multiplanan capabilities of MR
vascular supply to the thoracic spinal cord, fractures of the imaging facilitate early diagnosis of multilevel trauma, occa-
upper thoracic spine are usually associated with neurologic sionally revealing unsuspected injuries (Fig. 1 B). It is theme-
injury [9, 21]. Meyer [9] reported that 63% of the fractures of fore mandatory to search for other spine fractures whenever
the upper thonacic spine seen at the Northwestern University a fracture is detected in the upper thonacic spine. The pres-
Acute Spine Injury Center between 1972 and 1986 resulted ence of these second-level spinal injuries is further testi-
in complete neunologic injuries to the spinal cord, while the mony to the severity and complicated nature of the forces
thonacic spinal cord escaped injury in only 10%. Clinical involved in injuries of the upper thoracic spine [10].
evaluation has been, until recently, the only method for pre-
dicting outcome in patients with spinal cord injury. Clinical
assessment, however, cannot distinguish between transec- Fracture of the Upper Thoracic Spine vs Aortic Transection
tion, hemorrhage, and edema of the spinal cord, as indicated
by the occasional observation of significant recovery after an Traditionally, mediastinal widening, apical cap, and pleural
apparently complete lesion [22]. MR imaging is capable of fluid have been attributed to aortic transection [36]. How-
showing edema and hemorrhage within the spinal cord. In ever, these findings are also seen in more than half the
addition, several authors [22-29] have recognized a distinct patients with an injury to the upper thomacic spine [3, 37-39]
correlation between the pattern of spinal cord injury on MR (Fig. 4). Dorm et al. [39] found a 36% fmequency of hemotho-
imaging and neurologic recovery. Hemorrhage within the max in patients with injuries to the thomacic spine. In a review
spinal cord suggests that there will be little improvement in of the madiogmaphs of 54 patients with fractures between the
neurologic function. Edema within the spinal cord, particu- C6 and T8 vertebral levels, Dennis and Rogers [38] found
lamly if it is limited to one spinal segment, implies a more that 69% had a wide mediastinum. A spine fracture could be
favorable outcome. The optimum time for prognostic imag- detected on the chest radiograph in half of their patients.
ing is 24-72 hr after the injury. For assessment of spinal These authors concluded that if a fracture of the upper tho-
injury, MR imaging has recently been advocated as the macic spine can be detected to account for the mediastinal
examination of choice, after conventional radiography, par- widening, aortic rupture becomes unlikely in the absence of
ticulamly when a neurologic deficit is present or is progress- clinical signs and symptoms to support such a diagnosis
ing [27] (Fig. 2C). MR imaging also has the added [38].
advantage of showing the cervicothonacic junction in heavy Fractures of the upper thomacic spine and aortic rupture
patients [27]. have an important clinical feature in common: both condi-
Holdsworth [30] in 1 970 and Bohlman [3] in 1 985 stated tions can cause parapamesis on paraplegia [37]. Aortic mup-
that shearing fractures of the upper thoracic spine are tune can cause diminished blood supply to the spinal cord,
always associated with complete paraplegia; however, some resulting in ischemia and necrosis [40]. Therefore, in
reports [ii , 31-33] describe patients with severe fracture patients in whom both aortic rupture and fracture of the
dislocations of the thoracic spine in whom the spinal cord upper thoracic spine are possibilities, the proper sequencing
was not injured. of diagnostic tests and careful handling of the patient are
The “floating laminae” or “floating arches” mechanism essential. Bolesta and Bohlman [37] recommend first ruling
may explain how the spinal cord escapes injury in fracture- out an aortic injury and then localizing the fracture or dislo-
dislocations of the thoracic spine. Bilateral pedicular frac- cation. Such patients should be immobilized and handled
tunes at several levels allow the posterior elements to remain judiciously when they are transported to and from the
aligned while the vertebral bodies displace forward [31-33]. angiography suite.
With the floating arches mechanism, the spinal canal actu-
ally enlarges, in a fashion similar to that seen with spondylo-
listhesis, owing to a defect in the pans interarticulanis. Sternal Fractures
Simpson et al. [33] warned that although plain nadiognaphs
may suggest transection of the spinal cord, they should The sternum is frequently buckled or fractured in patients
never be used to infer the state of the spinal cord in an with trauma to the upper thomacic spine. Radiographically,
obtunded or unconscious patient. Careful handling of the the appearance of this indirect injury to the sternum dLffers
unstable spine in these circumstances should continue until from that of direct trauma to the sternum and should alert
the neunologic status of the patient can be thoroughly evalu- radiologists to severe injury in the thomacic spine [41]. An
ated. indirect sternal injury is identified by the pattern of displace-
ment of the bone fragments. Forces transmitted to the stem-
num through the ribs, as a result of spine fracture or
Multilevel Spinal Injuries
dislocation, posteriorly displace the upper sternal fragment
Up to 17% of fractures of the upper thoracic spine are relative to the lower portion of the sternum (Fig. 5). This pat-
associated with another noncontiguous spinal fracture [10]. tern of displacement is different from that usually seen with
Often, the second level of injury is not recognized early direct trauma to the sternum, where forces applied to the
enough to prevent clinically significant extension of the neu- front of the chest posteriorly displace the lower sternal f rag-
rologic deficit [34]. Common sites for second noncontiguous ment [42].
100 EL-KHOURY AND WHITTEN AJR:160, January 1993

\4 4
d
Fig. 4.-injury to upper thoracic spine vs aor- Fig. 5.-Sternal fracture. Lateral radiograph Fig. 6.-Traumatic thoracic disk hernlatlon.
tic transection. Anteroposterlor chest radiograph of sternum in a patient with T6-.T7 fracture Sagittal Ti-weighted MR Image shows a trau-
obtained with patient supine shows widening of shows characteristic appearance of sternal matic herniation of disk at T8-T9 (arrowheads).
mediastinum and apical pleural capping (arrow- fractures associated with thoracic spine Injury: Note also fracture In vertebral arch (arrows)
heads). These findings are seen in both upper posterior displacement of upper sternal frag- and mild anterior subluxation of T8 on T9.
thoracic spine injury and aortic transection. Na- ment relative to lower fragment.
sogastric tube is not shifted to right, and left
main bronchus is not depressed. Spinous pro-
cesses of Ti and T2 (arrows) are duplicated (dou-
ble spinous process sign), indicating fractures.
Findings on aortic angiogram were normal.

Traumatic Disk Herniation the key to spinal stability. In 1983, Denis [49] reported that
instability did not result from rupture of the posterior column
Intervertebral disk hemniation after injury to the cervical
alone and advanced the clinically based three-column the-
spine is well known [28, 43-45]. Posttmaumatic disk hernia-
ory. He asserted that, for an injury to be unstable, the middle
tiOn in the thomacic spine, however, is not uncommon [46]
column, consisting of the posterior portion of the vertebral
(Fig. 6). Pratt et al. [46] reported that three of their six
body, posterior annulus, and posterior longitudinal ligament,
patients with acute injury to the thomacic spine had disk her-
should be disrupted [49]. He also separated spinal injuries
niations shown by MR imaging. Because the presence of a
into four major types: compression fracture, burst fracture,
herniated disk can significantly alter the surgical manage-
flexion-distmaction (seat-belt) fracture, and fracture-disloca-
ment of a spine injury, radiologists may be asked to address
tion. This three-column concept and fracture classification
this question when evaluating spine trauma [28, 43, 45, 46].
are widely used in the evaluation of thoracolumbam spine
Because MR imaging provides more information than CT
trauma.
regarding the integrity of the spinal cord, disks, and liga-
Some investigators [4, 1 0, 50] have observed that these
ments, it should be the imaging technique of choice in the
concepts do not seem to apply to the rigid portion of the tho-
evaluation of disk hemniation or other soft-tissue injury to the
macic spine. As an alternative, Daffner et aI. [50] proposed
spine [45-48].
radiographic criteria for instability that would apply to the
entire vertebral column. When one or more of the following
Spinal Instability
five radiographic signs are present, the injury is considered
Spinal instability after trauma is an exceedingly important unstable: displaced vertebrae, widened interlaminar or inter-
issue for surgeons, because its presence or absence deter- spinous distance, perched or dislocated facet joints,
mines how the patient is treated. The definition of instability increased intempediculate distance, and disrupted posterior
has been controversial, and no single scheme to determine vertebral body line.
instability is universally accepted. Other investigators think that although the three-column
White and Panjabi [5] defined clinical instability as “the theory is clinically attractive, it is not valid biomechanically.
loss of the ability of the spine under physiologic loads to Studies of kinematics during spinal loading and fracture
maintain relationships between vertebrae in such a way that have shown significant variability in injuries produced with
theme is neither damage nor subsequent irritation to the spi- similar forces [4]. Yoganandan et al. [51] proposed that insta-
nal cord or nerve roots, and in addition, theme is no develop- bility should be considered as a continuum, in which partial
ment of incapacitating deformity on pain due to structural injuries to different structures of the spine may allow patho-
changes.” logic amounts of motion, even if gross failure is not evident
Holdsworth [30] thinks that the integrity of the posterior initially. This continuum of instability may lead to late defor-
column, consisting of the vertebral arch and its ligaments, is mity as well as to neumologic deterioration (Fig. 7).
AJR:160, January 1993 TRAUMA TO UPPER THORACIC SPINE 101

Fig. 7.-Delayed instability.

A, Lateral radiograph of thoracic spine ob-
tamed at admission in a 22-year-old woman In-
volved In a car accident shows vertebral body
compression fractures involving three midtho-
racic vertebrae. She was neurologically Intact
at admission. The injury was judged to be
stable and was treated with a brace.
B, 8 weeks after A, the patient returned with
weakness and neurologic deficits in lower cx-
tremitles. Lateral radiograph shows increased
wedging of bodies of T6 and Ti and progres-
dye kyphosis as compared with A.

A
I B

1_,-.. -

A
Fig. 8.-KUmmell’s disease.
A, Lateral radiograph of thoracoiumbar junction obtained on day of injury shows normal Ti 1 vertebra.
B, Lateral radiograph obtained 2 months after Injury shows collapse of Ti 1 vertebra.
C, Sagittally reconstructed CT scan, obtained at same time as B, shows Intravertebral and intradiskal vacuum phenomena, characteristically associ-
ated with KUmmell’s disease.

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