Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Job Classification

In most duration tables, five job classifications are displayed. These job classifications are based on the amount of physical effort required to perform the work. The classifications correspond to the Strength Factor classifications described in the United States Department of Labor's Dictionary of Occupational Titles. The following definitions are quoted directly from that publication.

Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Fracture, Thoracic Spine (With Spinal Cord Injury)


Related Terms

  • Broken Back
  • Thoracic Spine Fracture with Paraplegia
  • Thoracic Spine Fracture with SCI

Differential Diagnosis

  • Spinal cord infection
  • Thoracic disc herniation

Specialists

  • Neurologist
  • Neurosurgeon
  • Occupational Therapist
  • Orthopedic (Orthopaedic) Surgeon
  • Physiatrist (Physical Medicine and Rehabilitation Specialist)
  • Physical Therapist

Factors Influencing Duration

Factors that may influence the length of disability are the presence of neurological damage, age of the individual, presence of complications, stability of the fracture, type of fracture, treatment, and individual's job requirements.

Disability may be shorter for individuals whose job duties are sedentary in nature (e.g., desk work). Stable fractures with significant deformity may not be compatible with heavy or very heavy work. Unstable fractures requiring internal fixation (surgical treatment) are incompatible with heavy and, perhaps, moderately taxing work. Spinal cord injury, even with partial neurologic recovery, usually precludes moderate and heavy work.

Medical Codes

ICD-9-CM:
806.2 - Closed Fracture of Thoracic Spine with Spinal Cord Injury
806.20 - Closed Fracture of T1-T6 Level of Vertebral Column with Unspecified Spinal Cord Injury
806.21 - Closed Fracture of T1-T6 Level of Vertebral Column with Complete Lesion of Cord
806.22 - Closed Fracture of T1-T6 Level of Vertebral Column with Anterior Cord Syndrome
806.23 - Closed Fracture of T1-T6 Level of Vertebral Column with Central Cord Syndrome
806.24 - Closed Fracture of T1-T6 Level of Vertebral Column with Other Specified Spinal Cord Injury
806.25 - Closed Fracture of T7-T12 Level of Vertebral Column with Unspecified Spinal Cord Injury
806.26 - Closed Fracture of T7-T12 Level of Vertebral Column with Complete Lesion of Cord
806.27 - Closed Fracture of T7-T12 Level of Vertebral Column with Anterior Cord Syndrome
806.28 - Closed Fracture of T7-T12 Level of Vertebral Column with Central Cord Syndrome
806.29 - Closed Fracture of T7-T12 Level of Vertebral Column with Other Specified Spinal Cord Injury
806.3 - Open Fracture of Thoracic Spine with Spinal Cord Injury
806.30 - Open Fracture of T1-T6 Level of Vertebral Column with Unspecified Spinal Cord Injury
806.31 - Open Fracture of T1-T6 Level of Vertebral Column with Complete Lesion of Cord
806.32 - Open Fracture of T1-T6 Level of Vertebral Column with Anterior Cord Syndrome
806.33 - Open Fracture of T1-T6 Level of Vertebral Column with Central Cord Syndrome
806.34 - Open Fracture of T1-T6 Level of Vertebral Column with Other Specified Spinal Cord Injury
806.35 - Open Fracture of T7-T12 Level of Vertebral Column with Unspecified Spinal Cord Injury
806.36 - Open Fracture of T7-T12 Level of Vertebral Column with Complete Lesion of Cord
806.37 - Open Fracture of T7-T12 Level of Vertebral Column with Anterior Cord Syndrome
806.38 - Open Fracture of T7-T12 Level of Vertebral Column with Central Cord Syndrome
806.39 - Fracture, T7-T12 Level of Vertebral Column with Other Specified Spinal Cord Injury, Open

Overview

© Reed Group
Fracture of the thoracic spine is a break (fracture) of one or more of the 12 bones of the thoracic region (vertebrae T1 to T12) in the upper back. The thoracic spine is the longest section of the spine, with smaller vertebrae, a smaller spinal canal, and a less developed vascular system than the lumbar region. However, it is also more stable than other regions because of support from the ribs and ribcage, indicating that a significant force is required to injure the thoracic vertebrae. Major trauma is the most common cause of thoracic fractures, including motor vehicle accidents, falls, sports injuries, and violence. Thoracic spine fractures result in neurologic impairment in 10% to 25% of individuals (Leahy). Minor trauma can also cause a thoracic spine fracture in individuals who have a condition associated with loss of bone mass (e.g., osteoporosis). The majority of thoracic spine fractures occur in the lower thoracic spine, with 60% to 70% of thoraco-lumbar fractures occurring in the T12 to L2 region (Nadalo).

Four major types of thoracic spine injuries are described based on the mechanism of injury: compression, burst, flexion-distraction, and fracture-dislocation. Compression fractures (also called “wedge” fractures) are the most common type of thoracic spine fracture. They occur when the spine is bent forward (forward flexion) or sideways (lateral flexion) at the moment of trauma, causing the front (anterior) or side (lateral) region of the vertebra to be crushed. Burst fractures are similar to compression fractures, except that the entire vertebra is evenly crushed. This "pancaking" of the vertebra often pushes bone fragments into the spinal cord. Burst fractures are uncommon in the upper thoracic region because of the curve to the thoracic spine, but do occur at the junction between the thoracic and lumbar spine (thoraco-lumbar junction). Burst fractures are commonly accompanied by loss of motor, sensory, and reflex functions (neurologic deficit). Compression and burst fractures are usually caused by an axial load, which occurs with a fall from a height onto the buttocks or feet.

Flexion-distraction fractures (seatbelt injury, lap belt injury, Chance fracture) involve the separation (distraction) of the fractured vertebra and are caused by hyperflexion during the traumatic event. Flexion-distraction fractures rarely occur in the thoracic spine but can occur during a motor vehicle accident if the seatbelt is worn high and without a shoulder harness.

Most spinal cord injuries are caused by spinal fracture-dislocations, with one-sixth occurring in the thoracic spine (Arce). Fracture-dislocations, in which vertebral fractures are found in combination with displacement (dislocation) of adjacent vertebrae, are caused by high-energy trauma. Thoracic fracture-dislocations are unstable, resulting in spinal cord injury with paralysis of the lower extremities (paraplegia) in 90% of individuals with fracture-dislocation above the T10 level, and in 60% of those affected below T10 (Goodrich).

Spinal cord injury (SCI) can be classified as complete, which is associated with permanent paralysis, or incomplete, with the potential for neurologic improvement. Nearly 50% of all spinal cord injuries are complete ("Spinal Cord"). A complete SCI will result in total loss of motor and sensory function at and below the level of injury. Most complete spinal cord injuries of the thoracic spine result in paralysis of the lower extremities (paraplegia).

Incomplete SCI shows a variable neurologic deficit. Three major incomplete SCI syndromes can occur in association with thoracic spine fracture: anterior cord syndrome, Brown-Séquard syndrome, and central cord syndrome. Anterior cord syndrome results in loss of motor function and pain and/or temperature sensation from injury to the front (anterior) of the spinal cord. Limbs retain their normal movement and equilibrium because sensory input from muscles and tendons (proprioception) remains intact. Injury to the right or left side of the spinal cord can cause Brown-Séquard syndrome, which may result in loss of proprioception and movement on the injured side and loss of ability to sense pain and temperature on the uninjured side. Central cord syndrome occurs from injury to the center of the spinal cord and results in motor weakness of the upper more than the lower extremities, with variable sensory deficits. It is more common in the cervical spine but can also occur in at the T1 to T5 levels of the upper thoracic spine (Schreiber).

Spinal concussion may also follow trauma, with swelling around the spinal cord causing temporary neurologic symptoms that typically resolve in 1 to 2 days ("Spinal Cord").

Incidence and Prevalence: The incidence of spinal cord injury is 10,000 to 11,000 per year in the US (Reiter), with 44% occurring from motor vehicle accidents, 24% from violent crime, 22% from falls, and 8% from sports injuries, especially football and ice hockey (Arce). Up to 250,000 individuals in the US currently have a spinal cord injury (Reiter).

Source: Medical Disability Advisor



Causation and Known Risk Factors

Accidents are most often responsible for traumatic fractures, placing athletes and those whose work or sports-related activities increase risk of falling at greater risk of thoracic spine fracture. The average age at the time of injury is 32, with more than half of those injured between ages 16 and 30 years old. About 80% of those with vertebral fractures are male (Reiter), which is believed to be due to the greater incidence of sports-related injuries, motor vehicle accidents, and exposure to violent activity among males. Postmenopausal women with osteoporosis are also at increased risk of vertebral fracture.

Source: Medical Disability Advisor



Diagnosis

History: The individual will usually report recent trauma and may report tenderness over a specific part of the spine and pain on movement. Feelings of numbness or tingling in the arms or legs may be reported, as well as complete lack of feeling in the lower extremities. The individual may seem to be completely paralyzed below the waist but reports a period of sensation around the anus (perianal) or in the legs or demonstrates movement of the legs. Subtle signs of neurologic injury may include bladder or bowel dysfunction and changes in sensations of the perianal region. The physician obtains a history of previous spinal injury, prior neurologic deficit, the mechanism of the current injury, and the individual's general state of health. If the individual is unable to respond, an attempt to interview family members or observers may be made.

Physical exam: The back may have cuts (abrasions), bruising, and deformity. Shifting of the vertebral bodies may be detected by touching with the hands (palpation). The individual may have chest or abdominal trauma (e.g., shoulder harness or lap seatbelt markings). The individual may have difficulty moving his or her legs. A rectal exam may reveal changes in voluntary or reflexive anal sphincter contraction. The unconscious or intoxicated individual is difficult to assess in terms of pain and motor sensory function. Careful observation of spontaneous motion of the extremities may be the only information indicating spinal cord function until a detailed exam is performed. Initial neurological evaluation of conscious individuals may include testing reflexes by percussion, muscle function with resisted range of motion, and sensitivity to touch. Examination will include assessment for head injuries and fractures of the extremities as well as possible abdominal or urologic trauma.

Tests: Plain x-rays (anteroposterior and lateral views) are used initially if clinical examination suggests vertebral fracture. CT scans and MRI may help assess the extent of fracture and possible damage to the spinal cord or other soft tissue. CT myelogram may be useful in determining damage caused by bony fragments.

Bone densitometry may help evaluate the presence and extent of osteoporosis and its possible influence on vertebral fracture. Tissue from a pathologic fracture may be examined histologically to identify and stage possible malignancy.

Routine lab studies will include CBC with hematocrit and hemoglobin to assess for internal bleeding or anemia, coagulation tests, blood type and crossmatch to reserve blood for transfusion if needed during surgery, electrolytes and blood chemistry panel, and urinalysis to screen for genitourinary tract injury. Urodynamic studies may be needed to evaluate functioning of the lower urinary tract.

Source: Medical Disability Advisor



Treatment

Nonsurgical treatment is used to treat stable vertebral fractures in the absence of neurologic deficit, including most compression fractures and some burst fractures. Nonsurgical treatment involves wearing a hyperextension orthosis, cast, or brace for 4 to 6 weeks. Longer periods of immobilization may be needed for individuals with more severe injuries and for those with osteoporosis. Bed rest for 1 to 3 weeks is common.

Individuals with unstable fractures, including severe compression fractures, fracture-dislocations, flexion-distraction fractures with ligamentous injuries, and most burst fractures, may be treated surgically. The goals of surgical treatment are to realign the spine, stabilize the spine, and prevent (or improve) neurologic deficit. The treatment method depends on the severity of the fracture, presence of spinal cord injury, overall health of the individual, age of the individual, and surgeon's preference.

Spinal surgery is performed as an open procedure using general anesthesia. All surgical methods involve fusion (arthrodesis) of adjacent vertebrae using metal plates, rods, wires, and/or screws to stabilize the spine. Following surgery, bracing is used as for nonsurgical treatment. Analgesics may be prescribed as needed postoperatively.

Studies have shown that corticosteroids (methylprednisolone) may provide potential benefit to the individual with spinal cord injury, resulting in significant improvement of neurologic function at 6 months postoperatively if treatment is begun within 8 hours of spinal injury (Reiter).

For fractures or fracture-dislocations with incomplete spinal cord injury, the surgical methods described above may be used to realign and stabilize the spine and prevent or improve neurologic deficit. For complete spinal cord injury with irreversible paralysis of the lower extremities, additional abdominal surgeries may be needed to redirect movement of waste from bowel and bladder (ostomy).

Individuals whose fracture is related to reduced bone mass from osteoporosis or other metabolic disease may be treated with medications to enhance bone deposition.

Source: Medical Disability Advisor



Prognosis

With either surgical or nonsurgical treatment, the outcome is variable in the presence of neurological damage. Bone healing is complete between 8 to 16 weeks. The more severe the final deformity, the more likely that pain will persist, or that late-onset pain will be a problem. Surgical treatment can lead to significant improvement of neurological deficit caused by incomplete spinal cord injuries, but below-the-waist paralysis (paraplegia) is likely if complete spinal cord injury occurs, and disability will usually be permanent.

Source: Medical Disability Advisor



Rehabilitation

A thoracic spine fracture with spinal cord injury may severely affect many aspects of the individual's life. Therefore, rehabilitation must address each of these components, including the functional status in all environments (home, work, and community) (Kirshblum).

Rehabilitation guidelines will be based on fracture type, the level and extent of spinal cord involvement, and fracture management (operative, nonoperative) (Bucholz). The stability of the fracture must be ascertained prior to proceeding with rehabilitation.

With spinal cord involvement, a comprehensive multidisciplinary rehabilitation program is indicated to optimize functional abilities (Kirshblum). Some areas that require special attention following a spinal cord injury include motor status (muscle tone), sensory status (proprioception), autonomic functions (bowel and bladder management), psychosocial status, and occupational status (Kirshblum).

Motor rehabilitation includes range of motion of all limbs and the trunk to prevent contractures and control muscle spasticity (Kirshblum). Strengthening of all remaining active muscles is indicated to maximize functional abilities. Sensory rehabilitation focuses on exercises that emphasize motor control and spatial awareness through movement. Independence in bowel and bladder control is the goal when possible, and retraining the muscles that control these functions is another component of rehabilitation (Kirshblum). In some individuals, breathing status may be compromised and must be managed by a respiratory therapist. When possible, in order to prevent pulmonary complications such as atelectasis and pneumonia, breathing exercises must be emphasized during rehabilitation.

As a result of the lifestyle changes imposed by such a condition, the individual may benefit from the support of a psychologist/psychiatrist. Despite severe disability, reemployment is possible, in which case a vocational counselor may be needed to assist the individual. Sexual dysfunction commonly results from a thoracic spinal cord injury and should be addressed by an appropriate health care professional.

An important component of the rehabilitation process is identifying equipment needs and modifying the individual's environment to accommodate special needs; the goal of all rehabilitation is to promote independence as much as possible and to minimize the residual disability (Kirshblum).

Additional information may provide greater insight into the rehabilitation needs of these individuals (Cifu; Kendall; McKinley; Sumida). For more detailed description of the rehabilitation, see Spinal Cord Injury.

FREQUENCY OF REHABILITATION VISITS
Nonsurgical and Surgical
SpecialistFracture, Thoracic Spine (With Spinal Cord Injury)
Physical TherapistUp to daily for 26 weeks
Occupational TherapistUp to daily for 26 weeks
The table above represents a range of the usual acceptable number of visits for uncomplicated cases. It provides a framework based on the duration of tissue healing time and standard clinical practice.

Source: Medical Disability Advisor



Complications

Complications of thoracic fractures include neurologic deficit (including paraplegia), hunchback (kyphosis), disc herniation, and bone healing with faulty alignment (malunion). Thoracic spine fractures sustained from high-impact forces can be associated with cardiac or pulmonary contusions. Complications from spinal cord injuries include an increased risk of deep vein thrombosis, pulmonary embolism, and decubitus ulcers due to immobility. Individuals may also develop ileus or chronic constipation, requiring treatment to prevent impaction. Inability to void the bladder may require repeated catheterization (Lee).

Another complication associated with spinal cord injury occurring above the T6 level is autonomic dysreflexia, which involves severe dysfunction of the autonomic nervous system, resulting in hypertension, peripheral vasodilation, and bradycardia (Schreiber). Autonomic dysreflexia occurs in 48% to 90% of all individuals with SCI at T6 and above, although it can occur in SCI as low as T10. It can be triggered by any painful or irritating stimulus occurring below the level of injury (Campagnolo).

Postoperative complications can include pulmonary difficulties, cardiac complications such as myocardial infarction, anemia from significant blood loss, coagulation problems such as deep vein thrombosis, and electrolyte disturbances from fluid imbalances. Urinary tract infections are common with extended use of Foley catheters after spinal surgeries, and these infections can spread to the spine and implanted hardware.

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

To reduce the risk of complications, the individual may not be allowed to work during the early recovery period. Prolonged sitting, standing, heavy lifting, bending, reaching for something over the head (spine extension), and climbing long flights of stairs may be temporarily restricted. Adjusting work table height and chair height and using footrests are all beneficial for individuals with back problems. The individual may require frequent breaks. It may be necessary to reduce hours worked on a temporary basis. Permanent restrictions may include heavy lifting, carrying moderate to heavy loads, and overhead work. If spinal cord injury is present, the facility will need to be wheelchair-accessible. Additional time off for doctor visits may be necessary. Depending on job duties, the individual may require permanent reassignment, which may necessitate retraining.

Source: Medical Disability Advisor



Failure to Recover

If an individual fails to recover within the expected maximum duration period, the reader may wish to consider the following questions to better understand the specifics of an individual's medical case.

Regarding diagnosis:

  • Did individual report recent trauma?
  • What was the nature of the trauma, and was the mechanism of injury determined?
  • Did individual present with findings consistent with a thoracic spine fracture?
  • Were symptoms consistent with injury to the spinal cord?
  • Was diagnosis confirmed on x-ray?
  • Were CT scans performed to examine fracture in more detail?
  • Was an MRI done to determine if there was associated injury to the spinal cord or soft tissue?

Regarding treatment:

  • Was treatment appropriate for the type of fracture?
  • Was surgical stabilization required?
  • Were analgesics effective in controlling pain?
  • Would individual benefit from consultation with a specialist (neurosurgeon, orthopedic surgeon, physiatrist)?
  • Was the individual compliant with treatment recommendations?
  • Did individual participate in rehabilitation as recommended?
  • Are there barriers preventing individual from participating in rehabilitation (insurance limitations, lack of transportation, lack of motivation, pain)?

Regarding prognosis:

  • Has adequate time elapsed to allow for recovery?
  • Was there associated spinal cord injury?
  • What was the expected outcome?
  • Does individual have any pre-existing conditions that may influence the length of disability?
  • Did individual suffer any complications associated with the injury or with surgery?
  • Have appropriate work accommodations been considered?

Source: Medical Disability Advisor



References

Cited

"Spinal Cord." Neurosurgerytoday.org. Feb. 1999. American Association of Neurological Surgeons. 15 Oct. 2008 <http://www.neurosurgerytoday.org/what/patient_e/spinal.asp>.

Arce, D., P. Sass, and H. Abul-Khoudoud. "Recognizing Spinal Cord Emergencies." American Family Physician 64 4 (2001): 631-638. MD Consult. 15 Aug. 2001. Elsevier, Inc. 15 Oct. 2008 <http://home.mdconsult.com/das/journal/view/41477063-2/N/11964136?sid=288992070&source=MI>.

Bucholz, Robert, and James D. Heckman. Rockwood and Green's Fractures in Adults. 6th ed. Philadelphia: Lippincott, Williams & Wilkins, 2005.

Campagnola, D. "Autonomic Dysreflexia in Spinal Cord Injury." eMedicine. Eds. Milton J. Klein, et al. 5 Oct. 2006. Medscape. 15 Oct. 2008 <http://emedicine.com/pmr/topic217.htm>.

Cifu, D. X., et al. "Age, Outcome, and Rehabilitation Costs after Paraplegia Caused by Traumatic Injury of the Thoracic Spinal Cord, Conus Medullaris, and Cauda Equina." Journal of Neurotrauma 16 9 (1999): 805-815. National Center for Biotechnology Information. National Library of Medicine. 15 Oct. 2008 <PMID 10521140>.

Goodrich, Jacob. "Spinal Dislocations." eMedicine. Eds. James F. Kellam, et al. 20 Feb. 2003. Medscape. 15 Oct. 2008 <http://emedicine.com/orthoped/topic441.htm>.

Kendall, M. B., G. Ungerer, and P. Dorsett. "Bridging the Gap: Transitional Rehabilitation Services for People with Spinal Cord Injury." Disability Rehabilitation 25 17 (2003): 1008-1015. National Center for Biotechnology Information. National Library of Medicine. 15 Oct. 2008 <PMID 12851090>.

Kirschblum, S., and D. Campagnola, eds. Spinal Cord Injury Medicine. Philadelphia: Lippincott, Williams & Wilkins, 2001.

Leahy, Michael, and Mark Rahm. "Thoracic Spine Fractures and Dislocations." eMedicine. Eds. Alexander R. Vaccaro, et al. 12 Dec. 2007. Medscape. 2 Feb. 2009 <http://emedicine.com/orthoped/topic567.htm>.

Lee, T. T., and B. A. Green. "Advances in the Management of Acute Spinal Cord Injury." Orthopedic Clinics of North America 33 2 (2002): 311-315. MD Consult. 1 Apr. 2002. Elsevier, Inc. 9 Oct. 2004 <http://home.mdconsult.com/das/journal/view/41477063-2/N/12602201?sid=288992070&source=MI>.

McKinley, W. O., et al. "Nontraumatic vs. Traumatic Spinal Cord Injury: A Rehabilitation Outcome Comparison." American Journal of Physical Medicine and Rehabilitation 80 9 (2001): 693-699. National Center for Biotechnology Information. National Library of Medicine. 22 Nov. 2004 <PMID 11523972>.

Nadalo, Lennard A., and James A. Moody. "Spinal Stenosis." eMedicine. Eds. Lucien Levy, et al. 20 Mar. 2007. Medscape. 2 Feb. 2009 <http://emedicine.medscape.com/article/344171-overview>.

Reiter, Timothy G., et al. "Vertebral Fracture." eMedicine. Eds. Michael G. Nosko, et al. 8 Jul. 2004. Medscape. 2 Feb. 2009 <http://emedicine.com/med/topic2895.htm>.

Schreiber, Donald. "Spinal Cord Injuries." eMedicine. Eds. Daniel J. Dire, et al. 27 Aug. 2004. Medscape. 2 Feb. 2009 <http://emedicine.com/emerg/topic553.htm>.

Sumida, M., et al. "Early Rehabilitation Effect for Traumatic Spinal Cord Injury." Archives of Physical and Medical Rehabilitation 82 3 (2001): 391-395. National Center for Biotechnology Information. National Library of Medicine. 22 Nov. 2004 <PMID 11245763>.

Source: Medical Disability Advisor






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