What is the appropriate management for a T12 compression fracture with retropulsion?

Management of T12 Compression Fracture with Retropulsion

Surgical consultation is the standard of care for T12 compression fractures with retropulsion due to the risk of neurologic compromise and spinal instability. 1

Assessment and Classification

When evaluating a T12 compression fracture with retropulsion, consider:

• Neurological status: Presence of deficits requires immediate intervention
• Degree of canal compromise: Retropulsed fragments typically arise from the superior aspect of the vertebral body 2
• Spinal stability: Assess using the Spinal Instability Neoplastic Score (SINS) if pathologic fracture is suspected

Management Algorithm

1. For Patients WITH Neurological Deficits:

• Immediate surgical consultation for decompression and stabilization 1
• Administer corticosteroid therapy while awaiting surgery to prevent further neurological deterioration
• Surgical decompression followed by stabilization improves neurological status from non-ambulatory to ambulatory 1
• Post-operative radiation therapy may be considered if pathologic fracture

2. For Patients WITHOUT Neurological Deficits:

A. With significant retropulsion and spinal instability:

• Surgical consultation for potential decompression and stabilization 1
• Options include:
  • Open kyphoplasty after decompression laminectomy 3
  • Percutaneous pedicle screw stabilization plus balloon kyphoplasty 4

B. With minimal retropulsion and stable fracture:

• Consider conservative management if:
  • Kyphosis angle <35°
  • No pedicle or facet joint fractures/dislocations 5
• Monitor for neurological changes and progression of deformity

Evidence Considerations

• Open kyphoplasty allows direct visualization of the spinal canal and can be performed safely in vertebral compression fractures with retropulsed bone 3
• Percutaneous stabilization plus balloon kyphoplasty has shown good long-term outcomes with significant improvement in vertebral kyphosis (19° to 7.7°) and local kyphosis (12.3° to 4.4°) 4
• Even in three-column thoracolumbar junction burst fractures without neurologic deficit, nonsurgical management has shown acceptable outcomes in carefully selected patients 5

Pitfalls to Avoid

1. Overlooking subtle neurological deficits that may warrant surgical intervention
2. Failing to recognize that retropulsed fragments may have:
   • Vertical fractures within the fragment
   • Rotation of 90° ± 60°
   • Migration 3-8 mm cranially or caudally 2
3. Assuming all compression fractures with retropulsion require surgery when some stable fractures without neurological deficits may be managed conservatively
4. Delaying surgical consultation in patients with neurological compromise, as early intervention leads to better outcomes

Follow-up Recommendations

• Regular neurological assessments
• Serial imaging to monitor fracture healing and potential progression of retropulsion
• Pain management as needed
• Osteoporosis evaluation and treatment if applicable

Remember that retropulsed fragments in osteoporotic patients can cause neurologic symptoms even without a history of trauma, and these fragments may be subtle on conventional radiographs 6.