T12 Burst Fracture Management
Primary Decision Point: Assess Neurological Status
The treatment of T12 burst fractures hinges entirely on neurological status—if the patient is neurologically intact, both surgical and nonoperative management are acceptable options with equivalent outcomes; if neurological deficits are present, surgical intervention is indicated. 1, 2
For Neurologically Intact Patients
Either nonoperative management or surgery can be chosen based on fracture characteristics and clinical judgment, as there is conflicting evidence regarding superiority of either approach. 1, 3
Indicators Favoring Nonoperative Management:
- Intact posterior column (ligamentous structures) 1, 3, 4
- Less than 50% anterior column compression 5
- Less than 50% canal compromise 5
- No rotational malalignment 5
- Kyphotic angulation less than 15 degrees 5
Indicators Favoring Surgical Intervention:
- Significant vertebral collapse 1
- Severe kyphotic angulation (>15 degrees) 1, 5
- Greater than 50% canal compromise 1, 5
- Greater than 50% anterior column compression 5
- Progressive deformity on serial imaging 2, 3
For Patients with Neurological Deficits
Surgical intervention is the standard approach to decompress neural elements, restore alignment, and stabilize the spine. 2, 6
Nonoperative Management Protocol
For stable fractures in neurologically intact patients, external bracing is optional—both bracing and no bracing produce equivalent pain relief, disability improvement, and radiographic outcomes. 1, 7
- The decision to use a TLSO brace is at physician discretion (Grade B recommendation) 1, 7
- Schedule outpatient spine surgery follow-up within 1-2 weeks 2, 3
- Obtain serial imaging to monitor for progressive deformity 2, 3
Critical Warning Signs Requiring Immediate Return:
Surgical Management Algorithm
Step 1: Surgical Approach Selection
Use a posterior approach with pedicle screw instrumentation—this is the most commonly employed technique with equivalent clinical and neurological outcomes to anterior or combined approaches. 1, 2
- Anterior, posterior, or combined approaches all produce equivalent clinical and neurological outcomes (Grade B recommendation) 1, 2
- Posterior approach offers surgeon familiarity and lower complication rates 2
Step 2: Instrumentation Technique
Choose either open or percutaneous pedicle screw fixation—both achieve equivalent clinical outcomes (Grade B recommendation). 1, 2
- Percutaneous instrumentation reduces blood loss and operative time 2
- Open technique may be preferred for complex fracture patterns requiring direct visualization 2
Step 3: Critical Decision—DO NOT ADD FUSION
Perform instrumentation WITHOUT fusion—adding arthrodesis does not improve clinical or radiological outcomes and only increases operative time and blood loss (Grade A recommendation). 1, 2
- Fusion provides no benefit for clinical outcomes 1, 2
- Fusion provides no benefit for radiological outcomes 1, 2
- Fusion increases operative time and blood loss 1, 2
Step 4: Postoperative Management
Encourage early mobilization with instrumentation alone 2
Use CT with multiplanar reconstructions to assess healing 2
Common Pitfalls to Avoid
- Assuming all burst fractures require surgery—neurologically intact patients with stable fractures can be managed nonoperatively with excellent outcomes 1, 3
- Routinely adding fusion to instrumentation—this is unnecessary and increases morbidity without improving outcomes 1, 2
- Failing to assess posterior column integrity—the posterior column, not the middle column, is the key determinant of stability 1, 4
- Inadequate patient education about warning signs—patients must understand when to return immediately 3
- Insufficient follow-up imaging—serial radiographs are essential to detect delayed instability 2, 3
Special Considerations for T12 Specifically
T12 fractures at the thoracolumbar junction warrant particular attention as they may be complicated by intractable low back pain and instability, especially with >50% anterior compression or >50% canal narrowing. 5