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 (Without Spinal Cord Injury)


Related Terms

  • Broken Back
  • Thoracic Vertebral Fracture

Differential Diagnosis

Specialists

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

Comorbid Conditions

Factors Influencing Duration

Factors that may influence the length of disability are the age of the individual, presence of complications, presence of chronic illness, type of fracture, and stability of the fracture.

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 heavy work.

Medical Codes

ICD-9-CM:
805 - Fracture of Vertebral Column without Mention of Spinal Cord Injury
805.2 - Closed Fracture of Thoracic Spine without Mention of Spinal Cord Injury
805.3 - Open Fracture of Thoracic Spine without Mention of Spinal Cord Injury

Overview

© Reed Group
Fracture of the thoracic spine is a break (fracture) of one or more of the 12 bones of the thoracic spine (vertebrae T1 through 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. It is also the most stable spinal section due to support from the ribs and ribcage; significant force is needed to injure thoracic vertebrae. Most 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). The majority of these fractures (75% to 90%) occur without spinal cord injury (Leahy). Major trauma is the most common cause of thoracic fractures, including motor vehicle accidents, falls, sports injuries, and violence. Minor trauma can also cause a thoracic spine fracture in individuals who have a condition associated with loss of bone mass (e.g., osteoporosis).

Four major types of thoracic spine injury are described, based on the mechanism of injury: compression, burst, flexion-distraction, and fracture-dislocation. Compression fractures (also termed 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, respectively, to be compressed. Compression fractures are common because of the natural curve in the thoracic spine. 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 and may result in losses of motor, sensory, and reflex functions (neurologic deficit). 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). Compression and burst fractures are most often caused by a fall from a height onto the buttocks or feet, respectively, but can also occur as a result of significant direct trauma.

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 seat belt is worn high and without a shoulder harness.

Fracture-dislocations, in which vertebral fractures are found in combination with displacement (dislocation) of adjacent vertebrae, are caused by high-energy trauma. Fracture-dislocations are unstable and can cause complete neurologic deficit (paraplegia) in 90% of individuals injured above T10 and in 60% of individuals injured below the T10 vertebral level (Goodrich, "Spinal Dislocations").

Minor trauma can cause a thoracic spine fracture in individuals with osteoporosis or a loss of bone mass. Most vertebral compression fractures are related to osteoporosis, with up to 50% occurring without an accompanying trauma.

Incidence and Prevalence: Thoracic compression fractures are the most common injury of the thoracic spine. In the US, the occurrence of spinal fractures in serious motor vehicle accidents is 5% to 6%, with the thoraco-lumbar junction (T12, L1, and L2) most commonly affected. The US incidence of vertebral fractures from osteoporosis requiring hospitalization in individuals older than 65 years of age is 150,000 per year (Lane). Many thoracic spine fractures in developing nations in Asia are associated with spinal tuberculosis (Pott's disease) (Nadalo).

Source: Medical Disability Advisor



Causation and Known Risk Factors

Individuals at greatest risk for fractures of the thoracic spine are those involved in motor vehicle accidents (45%), falls (20%), sports injuries (15%), and acts of violence, including gunshot wounds (15%) (Leahy). About 80% of vertebral fractures occur in males, who are injured 4 times more frequently than females. Traumatic injury is most common in individuals between 30 and 39 years of age (Nadalo). Among women over 65 years of age, however, 20% will have one or more vertebral fractures, usually in the thoracic region (Lane). Postmenopausal women with osteoporosis are at increased risk of vertebral fracture. Risk is increased generally in athletes, individuals whose work or recreation places them at risk of falling from a height, and those with osteoporosis or other chronic disease that may be associated with bone loss (e.g., metastatic bone lesion, tuberculosis, osteoarthritis).

Source: Medical Disability Advisor



Diagnosis

History: Recent trauma may be reported. The individual may report tenderness over the area of the fracture and paralysis or numbness and tingling of the legs. Movement of the back causes pain. The individual should be specifically questioned as to previous spine 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 physician may determine neurologic status by testing reflexes and evaluating response to touch and range of motion of extremities. The unconscious or intoxicated individual is difficult to assess in terms of pain and motor sensory function. The physician will assess for the presence of other injuries, including possible head injury and fractures of the extremities.

Tests: Plain x-rays (anteroposterior and lateral views) will be taken initially, with CT scans and MRI to follow for more detailed assessment of fracture and soft tissue injury. MRI permits visualization of the spinal cord and surrounding soft tissue, including ligaments, discs, and epidural space. Bone densitometry may be ordered to evaluate the presence and extent of osteoporosis. A biopsy and histologic exam may be done if malignancy is suspected.

Source: Medical Disability Advisor



Treatment

Treatment goals include preventing deformity, instability, and neurologic deficit. Nonsurgical treatment is used to treat most stable fractures in the absence of neurologic deficit, including most compression fractures and some burst fractures. It begins with pain management and treatment of concomitant injuries. 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. If the fracture has been caused by osteoporosis, treatment may include medications to enhance bone deposition.

Compression fractures of the thoracic spine that remain painful after nonsurgical treatment (i.e., bracing, bed rest, and medication) may be managed with vertebroplasty or kyphoplasty, which are minimally invasive procedures that correct deformity associated with vertebral fractures and help relieve back pain in 90% of individuals (Lane). In vertebroplasty, bone cement is injected into the collapsed vertebral body to strengthen the spinal bones and prevent further fracture and deformity. In kyphoplasty, which is performed in individuals whose fracture is a result of osteoporosis, the height and shape of the vertebrae are restored by inserting a balloon, and bone cement is then injected into the cavity created by the balloon in order to stabilize the fracture. These procedures are performed with visual guidance provided by fluoroscopic imaging.

The indications for surgery for thoracic spine fracture include excessive deformity, the presence of other injuries, and the presence of or threat of neurologic deficit. 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, 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 by using metal plates, rods, wires, and/or screws to stabilize the spine. In fracture-dislocations, the dislocation will first be reduced. An approach from the front (anterior) may be required to remove (corpectomy) and replace a vertebral body with a bone graft or instrumentation. Following surgery, bracing may be used as for nonsurgical treatment. Corticosteroids may help relieve pain and swelling in the individual with temporary swelling near the spinal cord. Analgesics may be prescribed as needed.

Video-assisted thoracoscopic surgery (VATS) is a minimally invasive procedure being performed for correcting spinal deformity in thoracic spine fractures that may require anterior bone grafting and stabilization. The benefits of the procedure are not yet clearly demonstrated in the literature, but research continues since risks and complications associated with open surgery can be avoided by using this method (Leahy).

Source: Medical Disability Advisor



Prognosis

With either surgical or nonsurgical treatment, deformity can often be corrected in most thoracic spine fractures without spinal cord injury. Bone healing may be complete within 6 to 12 weeks. The more severe the final deformity, the more likely that persisting pain, or late-onset pain, will be a problem. Individuals with compression fractures are at a higher risk for additional compression fractures.

Source: Medical Disability Advisor



Rehabilitation

Rehabilitation guidelines for a fracture of the thoracic spine will be based on fracture type and management (operative, nonoperative) (Bucholz). The stability of the fracture must be ascertained prior to proceeding with rehabilitation.

If the spinal cord is intact, the rehabilitation protocol depends on the stability of the fracture. A brace may be used to stabilize the trunk and to limit pain (Bucholz). Because the primary goal of rehabilitation is to restore function in activities of daily living, the emphasis of the initial phase of therapy is independence while minimizing pain through the use of modalities such as heat and cold (Bucholz). Physical therapy will also include deep-breathing exercises to promote full chest expansion and to avoid pulmonary complications. Individuals are instructed in ambulation, transfers, and brace donning/doffing. If the cause of the fracture is related to another disease that compromises bone strength, the integrity of the spine must be assessed prior to continuing rehabilitation.

Once the fracture is healed, trunk conditioning exercises may be indicated. They may include trunk stabilization, stretching, and strengthening exercises. General aerobic exercises may be added to improve overall body strength and conditioning. Bone healing may occur within 6 to 12 weeks. Once healing has occurred, the individual may resume full activities of daily living. However, because bone strength and the ability of the bone to sustain a heavy load may take up to several years to return (Chapman), the therapist should inform the individual not to overload the fracture site until the bone has regained its full strength. The resumption of occupational tasks, heavy work, and sports should be based on the recommendations of the treating physician. Proper body mechanics and safer working postures should be taught as part of the comprehensive program.

In addition to undergoing supervised rehabilitation, the individual should be instructed in a home exercise program to be practiced daily and continued independently after the completion of rehabilitation.

FREQUENCY OF REHABILITATION VISITS
Nonsurgical
SpecialistFracture, Thoracic Spine (Without Spinal Cord Injury)
Physical TherapistUp to 12 visits within 6 weeks
Surgical
SpecialistFracture, Thoracic Spine (Without Spinal Cord Injury)
Physical TherapistUp to 12 visits within 6 weeks
Note on Nonsurgical Guidelines: Rehabilitation may not begin until tissue healing, about 6 to 8 weeks after the fracture.
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 complete deficit, or paraplegia), hunchback (kyphosis), disc herniations, and bone healing with faulty alignment (malunion). Individuals with flexion-distraction fractures also may have associated intra-abdominal injuries in up to 50% of cases (Goodrich, "Chance Fracture"). Complications of surgical treatment may include allergic reaction to anesthesia, deep vein thrombosis, pulmonary embolism, urinary tract infection, surgical wound infection, and dural tears occurring during the procedure.

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, working with the arms held overhead (spine extension), and climbing long flights of stairs may be temporarily restricted. Heavy lifting, carrying moderate to heavy loads, and performing overhead work may be permanently restricted.

Adjusting worktable height and chair height and using footrests may benefit individuals with back problems. The individual may require frequent breaks. Temporarily working reduced hours may be necessary.

Depending on the job duties, the individual may require a permanent reassignment of duties, 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?
  • Was the mechanism of injury determined?
  • Did individual present with findings consistent with a thoracic spine fracture?
  • Was the diagnosis confirmed on x-ray?
  • Were CT scans performed to examine fracture in more detail?
  • Was MRI done to determine if soft tissue injury was present?
  • Does individual have a history of other spinal injury, osteoporosis, or other chronic illness?

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 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?
  • What was the expected outcome?
  • Does individual have any pre-existing conditions (e.g., osteoporosis, cancer, osteoarthritis, or other chronic illness) 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

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

Chapman, Michael W. Chapman's Orthopaedic Surgery. 3rd ed. Philadelphia: Lippincott, Williams & Wilkins, 2001.

Goodrich, Jacob. "Chance Fracture." eMedicine. Ed. James F. Kellam. 10 Jun. 2008. Medscape. 10 Nov. 2008 <http://emedicine.com/orthoped/topic41.htm>.

Goodrich, Jacob. "Spinal Dislocations." eMedicine. Eds. James F. Kellam, et al. 28 Aug. 2008. Medscape. 10 Nov. 2008 <http://emedicine.com/orthoped/topic441.htm>.

Lane, Joseph M., et al. "Minimally Invasive Options for the Treatment of Osteoporotic Vertebral Compression Fractures." Orthopedic Clinics of North America 33 2 (2002): 431-438. MD Consult. Elsevier, Inc. 10 Nov. 2008 <http://home.mdconsult.com/das/journal/view/42916202-2/N/12602213?sid=288992070&source=MI>.

Leahy, Michael, and Mark Rahm. "Thoracic Spine Fractures and Dislocations." eMedicine. Eds. Lee H. Riley, et al. 12 Dec. 2007. Medscape. 26 Jan. 2009 <emedicine.com/orthoped/topic567.htm>.

Nadalo, Lennard A., and James A. Moody. "Thoracic Spine, Trauma." eMedicine. Eds. Michael A. Bruno, et al. 23 Mar. 2009. Medscape. 11 Nov. 2008 <http://emedicine.com/radio/topic816.htm>.

Source: Medical Disability Advisor






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