What is the recommended treatment approach for a patient with a T9 compression fracture, inferior plate and spine process fracture, T12 superior plate fracture, and L4 superior and inferior implant fractures?

Management of Multiple Thoracolumbar Vertebral Fractures

For a patient with multiple thoracolumbar compression and endplate fractures (T9, T12, L4), immediate surgical consultation is warranted to evaluate for spinal instability and neurologic compromise, followed by a multidisciplinary approach involving interventional radiology and pain management based on the presence or absence of neurologic deficits. 1

Initial Assessment Priority

Neurologic examination is the critical first step that determines the entire treatment pathway:

• If neurologic deficits are present (weakness, sensory loss, bowel/bladder dysfunction): Immediate surgical consultation is mandatory 1, 2
• If no neurologic deficits: Proceed with imaging and conservative management algorithm 1

The presence of multiple fractures at non-contiguous levels (T9, T12, L4) raises concern for either high-energy trauma or underlying pathologic process requiring further evaluation 1.

Imaging Protocol

MRI of the complete spine without and with IV contrast is the appropriate next step to:

• Differentiate acute from chronic fractures (edema pattern on MRI) 1, 3
• Assess for spinal cord compression or epidural hematoma 2
• Rule out pathologic fractures from malignancy (multiple non-contiguous fractures warrant this concern) 1
• Evaluate ligamentous integrity and spinal stability 2

CT imaging has already been performed (implied by the detailed fracture description), but MRI provides superior soft tissue and neural element assessment 2.

Treatment Algorithm Based on Clinical Presentation

Scenario 1: No Neurologic Deficits + Osteoporotic Fractures

Medical management for 3 months is the initial approach 1, 4:

• Pain control: Calcitonin for the first 4 weeks provides clinically important pain reduction 4
• Mobilization: Avoid prolonged bed rest which worsens bone loss and increases complications including deep venous thrombosis 5, 2
• Bracing: May be considered for comfort and to limit flexion, though evidence is mixed 3
• Physical therapy: Focus on core strengthening, posture, and maintaining mobility 5

Reassess at 4-6 weeks and again at 3 months 4:

• If pain persists beyond 3 months despite conservative management: Refer to interventional radiology for percutaneous vertebral augmentation 1, 4
• If spinal deformity or progressive kyphosis develops: Surgical consultation 1, 4

Scenario 2: Neurologic Deficits Present

Immediate surgical consultation is non-negotiable 1, 2:

• Maintain mean arterial pressure >85-90 mmHg for at least 1 week to prevent secondary spinal cord injury from hypoperfusion 2
• Full spinal precautions until spine surgeon evaluates stability 2
• Surgery indications include: partial or progressive neurologic deficit, spinal instability preventing mobilization, or spinal cord compression 2

Scenario 3: Severe and Worsening Pain Despite Initial Management

Multidisciplinary approach with interventional radiology, surgery, and potentially radiation oncology (if pathologic) 1:

• Percutaneous vertebral augmentation (vertebroplasty or kyphoplasty) provides rapid pain relief and structural reinforcement 1
  • Vertebroplasty has demonstrated superiority over continued medical management when conservative therapy fails 1
  • The hallmark response is sudden improvement in pain and function, not gradual improvement seen with natural healing 1
• Percutaneous thermal ablation may be combined with vertebral augmentation if pathologic fracture from malignancy 1

Scenario 4: Pathologic Fractures from Malignancy

If imaging suggests malignancy (lytic lesions, soft tissue mass, epidural extension):

• Image-guided biopsy of the spine is appropriate when imaging findings are ambiguous 1
• Radiation oncology consultation for external beam radiation therapy or stereotactic body radiation therapy 1
• Surgical consultation if there is spinal cord compression, instability, or retropulsed bone fragments 1
• Percutaneous vertebral augmentation with or without thermal ablation for pain control 1

Critical Pitfalls to Avoid

Do not assume osteoporotic etiology without ruling out malignancy when multiple non-contiguous fractures are present 1. The pattern described (T9, T12, L4) is atypical for simple osteoporotic fractures and warrants contrast-enhanced MRI.

Do not delay surgical consultation if any "red flags" are present 1:

• Progressive neurologic deficits
• Bowel/bladder dysfunction
• Saddle anesthesia
• Severe unrelenting pain despite adequate analgesia

Do not prolong conservative management beyond 3 months if pain persists, as this increases complications from immobility including venous thromboembolism, pneumonia, pressure ulcers, and muscle deconditioning 1, 5.

Implement DVT prophylaxis immediately with low-molecular-weight heparin (superior to unfractionated heparin) or consider IVC filter if patient is bedbound 2.

Vertebroplasty vs Kyphoplasty Decision

When percutaneous vertebral augmentation is indicated:

• Both procedures provide substantial pain relief in the majority of patients who fail conservative therapy 1
• Kyphoplasty costs approximately 2.5 times more than vertebroplasty due to additional equipment and anesthesia requirements 1
• No head-to-head studies demonstrate superiority of one technique over the other 1
• Choice may depend on degree of compression deformity and age of fracture, though benefits in specific subgroups remain undefined 1

Prognosis and Follow-up

Neurologic recovery is a multi-year process with most recovery occurring in the first year, necessitating aggressive rehabilitation 2. Patients should be graded using the American Spinal Injury Association classification if neurologic deficits are present, with the first prognostic score at 72 hours post-injury 2.