Management of Thoracolumbar Fractures

Initial Assessment and Stability Determination

The American College of Radiology recommends evaluating fracture stability by determining the extent of anterior vertebral body involvement, integrity of posterior elements, presence of retropulsion into the spinal canal, and degree of kyphotic deformity 3, 4
Immediate assessment of neurological status is crucial, as any neurological deficit changes the management algorithm and warrants urgent surgical consultation, according to the American Association of Neurological Surgeons 1, 2

The American College of Radiology suggests initiating medical management for the first 3 months as the primary treatment approach for neurologically intact thoracolumbar fractures, with conflicting evidence for surgical versus nonoperative treatment 1, 2, 5
Medical management includes analgesics and pain control, early mobilization, and external bracing at the discretion of the treating physician, as recommended by the American College of Radiology 4, 5

The American College of Radiology recommends considering surgical intervention if neurological deficits, spinal deformity, pulmonary dysfunction, or failure of medical management occur 4, 5, 6
Surgical approaches may include anterior, posterior, or combined approaches, with no significant impact on clinical or neurological outcomes, according to the American Association of Neurological Surgeons 1, 7, 8

The American College of Radiology recommends obtaining MRI of the thoracic spine without contrast to assess for bone marrow edema, evaluate posterior ligamentous complex integrity, and rule out pathologic fracture 4, 5
Repeat imaging at follow-up is necessary to monitor for progressive vertebral collapse, increasing kyphotic deformity, and delayed instability, as suggested by the American College of Radiology 3, 4

Approximately 40% of conservatively treated patients may have persistent pain at 1 year, and 1 in 5 patients will develop chronic back pain, according to the American College of Radiology 4
Percutaneous vertebral augmentation is usually appropriate for pain relief and functional improvement if pain persists beyond 3 months despite optimal medical management, as recommended by the American College of Radiology 4, 5