What is the treatment for an acute T12 (thoracic 12) fracture?

Treatment for Acute T12 Fracture

The treatment of acute T12 fractures should follow a structured approach based on fracture characteristics, neurological status, and patient factors, with surgical intervention recommended for unstable fractures or those with neurological deficits, while stable fractures without neurological compromise can be managed conservatively with bracing and pain control.

Initial Assessment and Classification

• Neurological evaluation: Use the American Spinal Injury Association (ASIA) Impairment Scale to assess and document neurological status 1
• Imaging studies: CT scan is recommended to evaluate:
  • Fracture pattern and displacement
  • Canal compromise
  • Involvement of adjacent structures
  • Presence of additional fractures 1

Treatment Algorithm

Conservative Management (for stable fractures without neurological deficit)

1. External bracing:

   • While evidence is insufficient to definitively recommend for or against bracing, it remains at the discretion of the treating physician 1
   • Typically involves a thoracolumbosacral orthosis (TLSO) for 8-12 weeks

2. Pain management:

   • First-line: Regular administration of intravenous acetaminophen (1 gram every 6 hours) 2
   • Second-line: Consider NSAIDs with caution, especially in elderly patients 2
   • For moderate to severe pain: Opioids at lowest effective dose for shortest possible duration (hydromorphone preferred over morphine) 2
   • Regional anesthesia options for refractory pain:
     • Thoracic epidural
     • Paravertebral blocks
     • Erector spinae plane blocks
     • Serratus anterior plane blocks 2

3. Thromboprophylaxis:

   • LMWH or UFH should be administered as soon as possible in high and moderate-risk patients, adjusted for renal function and weight 1

4. Monitoring:

   • Regular assessment of pain control
   • Neurological status monitoring
   • Follow-up imaging to assess fracture healing

Surgical Management

Surgical intervention is indicated for:

1. Unstable fractures (significant displacement, canal compromise)
2. Neurological deficit
3. Progressive deformity
4. Failure of conservative management

Surgical approach options:

• Posterior approach: Most common, using pedicle screws and rods
• Anterior approach: For significant anterior column disruption
• Combined approach: For complex fractures

According to the Congress of Neurological Surgeons guidelines, physicians may utilize an anterior, posterior, or combined approach as the selection does not appear to significantly impact clinical or neurological outcomes (Grade B recommendation) 1.

For patients with osteoporotic T12 fractures, vertebroplasty or kyphoplasty may be considered, particularly for pain relief and some correction of kyphosis 3.

Special Considerations

Neurological Status

• Entry ASIA Impairment Scale grade is a strong predictor of neurological outcomes 1
• Patients with lumbar or conus injuries typically have better neurological recovery than those with thoracic injuries 1
• Ankle spasticity is highly predictive of neurogenic bladder dysfunction in patients with thoracolumbar fractures and spinal cord injury 1

Elderly Patients

• Higher risk of complications and mortality
• Consider early mobilization and multidisciplinary approach
• Osteoporotic fractures may benefit from vertebroplasty/kyphoplasty 3
• Early surgical stabilization (≤48 hours) is associated with decreased ICU length of stay and overall hospital stay in appropriate candidates 2

Pharmacological Treatment for Associated Spinal Cord Injury

• There is insufficient evidence to recommend methylprednisolone for thoracolumbar spinal cord injury
• The complication profile should be carefully considered when deciding on the administration of methylprednisolone 1

Follow-up Care

• Initial follow-up within 1-2 weeks of discharge
• All patients should have follow-up in clinic within 2-3 weeks after hospital discharge
• Evaluate pain control, respiratory function, functional status, and need for additional imaging 2
• Progressive rehabilitation program to improve functional outcomes

Prognosis

The prognosis for neurological recovery in T12 fractures depends on:

• Initial fracture pattern
• Degree of canal compromise
• Timing of intervention
• Patient factors (age, comorbidities)

Patients with fractures showing >15 degrees kyphosis typically have better neurological recovery (>90%) regardless of treatment method, while those with less kyphosis but significant canal compromise have poorer recovery (<50%) 4.