What is the appropriate follow-up for a patient with a left transverse process fracture of L2 (lumbar vertebra 2) after emergency department (ED) evaluation?

Management of Isolated Transverse Process Fracture of L2

Outpatient orthopedic follow-up is not necessary for an isolated transverse process fracture of L2. 1, 2

Key Management Principles

Conservative management without spine service consultation is the appropriate standard of care for isolated transverse process fractures. 1 These fractures are structurally and neurologically stable injuries that do not require surgical intervention, bracing, or specialized spine service management. 1, 2

Immediate ED Management

• Confirm the fracture is truly isolated by reviewing the CT scan to exclude other vertebral column injuries, particularly fractures of the weight-bearing columns (vertebral bodies, pedicles, or facets). 2
• Screen for associated abdominal injuries, as these occur frequently with transverse process fractures (approximately 32% of cases in one series). 1
• Verify neurologic integrity through examination, though isolated transverse process fractures are not associated with neurologic deficits. 1

Outpatient Treatment Protocol

The patient can be discharged with:

• Nonsteroidal anti-inflammatory drugs (NSAIDs) for pain control 3
• Muscle relaxants as needed 3
• Flexible support corset for comfort during mobilization 3
• Early mobilization rather than prolonged immobilization, which leads to stiffness and poorer outcomes 3, 2

Pain typically improves from 8.8/10 to 5.2/10 on visual analog scale within days to weeks with this conservative protocol. 3

Follow-Up Arrangements

• Primary care physician follow-up is sufficient for symptom management 1, 2
• Physical therapy referral for early mobilization and pain management is more appropriate than spine service consultation 2
• Return to normal activities can typically occur within 4 weeks, though this depends on pain levels and functional recovery 4

Critical Pitfalls to Avoid

Do not prolong log-roll precautions or delay mobilization once adequate CT imaging has excluded other spinal injuries. 2 One study found patients spent an average of 29 hours on unnecessary log-roll precautions awaiting spine consultations that yielded no additional findings or interventions. 2

Do not order routine spine service consultation for isolated transverse process fractures, as this wastes resources and delays appropriate care. 1, 2 In a series of 47 patients with isolated transverse process fractures, zero required surgery or bracing, compared to 22 of 37 patients with associated spinal injuries who needed intervention. 1

Do not miss associated injuries. When transverse process fractures are identified, maintain vigilance for:

• Other spinal column fractures (17% have associated significant vertebral fractures) 2
• Abdominal organ injuries (occur in approximately 32% of cases) 1

Evidence Quality Note

The strongest evidence comes from two retrospective trauma center studies demonstrating that isolated transverse process fractures require no spine service intervention and can be managed conservatively with early mobilization. 1, 2 The ACR Appropriateness Criteria guidelines provided focus on stress fractures and imaging protocols but do not specifically address traumatic transverse process fracture management, making the trauma literature the most relevant evidence base for this clinical scenario.