Treatment of T12 Burst Fractures
For T12 burst fractures requiring surgical intervention, instrumentation without fusion is recommended, as fusion does not improve clinical or radiological outcomes but increases operative time and blood loss. 1
Initial Decision: Operative vs. Nonoperative Management
The first critical decision is whether surgery is indicated at all:
- For neurologically intact patients: The evidence is conflicting regarding surgical versus nonoperative treatment, and the decision should be based on fracture characteristics and clinical judgment 1
- For patients with neurological deficits: Surgical intervention is generally pursued to decompress neural elements, restore alignment, and stabilize the spine 1
Key Fracture Characteristics That Favor Surgery:
- Anterior column compression exceeding 50% 2
- Spinal canal narrowing exceeding 50% 2
- Signs of rotational malalignment 2
- Progressive deformity or instability 3
Common pitfall: Assuming all burst fractures require surgery. Many neurologically intact patients with stable fracture patterns can be managed nonoperatively with bracing and close follow-up. 1, 3
Surgical Approach Selection
When surgery is indicated, multiple approaches are viable:
Posterior Approach (Most Common):
- Instrumentation without fusion is the evidence-based standard (Grade A recommendation) 1
- Short-segment pedicle screw fixation spanning one level above and below the fracture 4
- Decompression can be performed posteriorly if needed for canal compromise 4
Anterior vs. Posterior vs. Combined:
- All three approaches (anterior, posterior, or combined) show equivalent clinical and neurological outcomes (Grade B) 1, 5
- The posterior approach is most commonly used due to surgeon familiarity and lower complication rates 5
- Combined anterior-posterior approaches have higher complication rates and should be avoided unless specifically indicated 5
Surgical Technique: Open vs. Percutaneous
Both open and percutaneous pedicle screw techniques achieve equivalent clinical outcomes (Grade B recommendation) 1:
- Percutaneous instrumentation offers reduced blood loss and operative time 1, 5
- Open techniques may provide better deformity correction in select cases 5
- The choice can be based on surgeon experience and patient factors 1
Why Fusion Should Be Omitted
The Grade A evidence is clear on this point 1:
- Fusion does not improve clinical outcomes 1, 5
- Fusion does not improve radiological outcomes 1, 5
- Fusion increases operative time 1, 5
- Fusion increases blood loss 1, 5
- Fusion adds donor site morbidity 5
This represents a paradigm shift from traditional teaching that advocated for routine fusion with instrumentation.
Nonoperative Management Protocol
For stable fractures in neurologically intact patients 1, 3:
- External bracing (decision at physician discretion) 3
- Close outpatient follow-up within 1-2 weeks 3
- Serial imaging to monitor for progressive deformity 3
Warning Signs Requiring Immediate Evaluation:
Special Considerations for T12 Level
T12 represents the thoracolumbar junction, which has unique biomechanical properties:
- The transition from the rigid thoracic spine to the mobile lumbar spine creates increased stress 2
- L1 fractures (adjacent level) show higher complication rates than T12 in some studies 2
- Posterior element integrity is particularly important for stability assessment at this level 3
Postoperative Management
- Early mobilization is encouraged with instrumentation alone 1
- Consideration for hardware removal may be appropriate in instrumentation-without-fusion cases, though timing and necessity remain unclear 5
- CT with multiplanar reconstructions is the preferred imaging modality for assessing healing 5
Critical pitfall: Failing to provide adequate patient education about warning signs and the importance of close follow-up, particularly in nonoperatively managed cases. 3