Treatment of T12 Compression Fracture with Height Loss and Retropulsion
For T12 compression fracture with height loss and retropulsion inferiorly, surgical consultation is strongly recommended as the primary treatment due to the spinal deformity and potential for neurological compromise.
Initial Assessment and Decision Making
When evaluating a T12 compression fracture with height loss and retropulsion, several key factors must be considered:
- Presence of neurological deficits
- Degree of spinal deformity
- Stability of the fracture
- Extent of retropulsion into the spinal canal
The presence of retropulsion is a critical factor that significantly influences treatment decisions, as it indicates posterior cortical compromise and potential risk for neurological complications.
Treatment Algorithm
1. Surgical Intervention
Surgical consultation should be the first step for patients with T12 compression fractures showing:
- Retropulsion of bone fragments into the spinal canal
- Significant height loss causing spinal deformity
- Risk of neurological compromise
According to the ACR Appropriateness Criteria, "Surgical intervention is reserved for patients with neurologic deficits, spinal deformity (eg, junctional kyphosis, retropulsion), or spinal instability" 1. The presence of retropulsion specifically warrants surgical evaluation as it represents a high-risk feature.
Surgical Options:
- Decompression laminectomy with open kyphoplasty: This approach allows direct visualization of the spinal canal and safe reduction of the fractured vertebral body while protecting neural elements 2.
- Posterior stabilization: May be necessary if there is significant instability.
2. Vertebral Augmentation Considerations
Standard percutaneous vertebroplasty or kyphoplasty is not routinely recommended for vertebral fractures with posterior cortical compromise/retropulsion 2. However, modified approaches may be considered:
- Open kyphoplasty after decompression: Can be performed safely in selected cases with retropulsed bone fragments 2.
- Vertebral augmentation under direct visualization: Allows for safer cement placement when posterior cortex is compromised.
3. Conservative Management
If the patient is not a surgical candidate or has minimal retropulsion without neurological symptoms, conservative management may include:
- Medical therapy: Pain management with analgesics
- Bracing: For external stabilization
- Osteoporosis treatment: To prevent future fractures
However, conservative management alone is generally insufficient for cases with significant retropulsion due to the risk of progressive deformity and neurological compromise.
Complications and Considerations
Risks of Vertebral Augmentation in Retropulsion Cases
When vertebral augmentation is performed in cases with posterior cortical compromise:
- Cement leakage: Higher risk of cement extravasation into the spinal canal 3
- Neurological injury: Potential for nerve compression from displaced bone fragments or cement
- Pulmonary embolism: Cement can enter the venous system and embolize to the lungs 3
Biomechanical Considerations
Restoration of vertebral height is important for biomechanical stability:
- Vertebral augmentation can significantly reduce von Mises stresses at different heights of vertebral compression fractures 4
- However, complete restoration to anatomical height is not always necessary for clinical improvement 4
Follow-up and Monitoring
After treatment, close monitoring is essential for:
- Neurological status
- Pain control
- Progressive deformity
- Adjacent level fractures
Conclusion
The presence of retropulsion with a T12 compression fracture represents a more complex scenario than simple compression fractures. While standard percutaneous vertebroplasty/kyphoplasty is often contraindicated in these cases, surgical decompression with open kyphoplasty offers a viable treatment option that addresses both the fracture and the retropulsed fragments threatening the spinal canal.