What is the treatment for a severe compression wedge fracture of C12 (twelfth cervical vertebra)?

Treatment of Severe Compression Wedge Fracture of T12

Critical Clarification

There is no C12 vertebra in human anatomy—the cervical spine has only 7 vertebrae (C1-C7). This question likely refers to T12 (the 12th thoracic vertebra) or possibly L2, which are common sites for compression fractures. I will address treatment for severe compression fractures at the thoracolumbar junction (T12-L2), as this is the most clinically relevant interpretation.

Initial Management Approach

For severe compression wedge fractures at T12 without neurological deficits or spinal instability, initial conservative management with analgesics, bracing, and early mobilization is the first-line approach, but patients with severe pain, neurological compromise, or spinal instability require immediate surgical consultation. 1

Immediate Assessment Requirements

• Rule out neurological deficits immediately through comprehensive neurological examination, as any deficits mandate urgent surgical referral 1, 2
• Assess for spinal instability including retropulsion, significant kyphotic deformity (>15% kyphosis), or vertebral body height loss >20% 1
• Obtain MRI without contrast (or CT if MRI contraindicated) to characterize fracture acuity, assess for cord compression, and rule out pathologic causes 2, 3
• Screen for "red flags" including malignancy, infection, or trauma mechanisms suggesting instability 1, 2

Treatment Algorithm Based on Clinical Presentation

Immediate Surgical Referral (Orthopedic Surgery or Neurosurgery)

Refer immediately if ANY of the following are present:

• Neurological deficits including motor weakness, sensory changes, or bowel/bladder dysfunction 1, 2
• Spinal instability with retropulsion or significant posterior column involvement 1
• Severe progressive kyphotic deformity (>15% kyphosis or >20% vertebral body height loss) 1, 2
• Spinal cord compression on imaging 4

Conservative Management (First 3 Months)

Initiate if no neurological deficits or instability:

Pain Management

• Calcitonin for the first 4 weeks provides clinically important pain reduction in acute compression fractures 2
• NSAIDs as first-line analgesics with carefully monitored narcotic medications for breakthrough pain only 5
• Minimize narcotic use due to complications including constipation, deconditioning, and dependency risk 1

Immobilization and Bracing

• Thoracolumbosacral orthosis (TLSO) or Jewett brace to provide stability and reduce pain during initial healing 5, 6
• Limit bed rest to less than 2 weeks to avoid complications including bone mass loss, muscle atrophy, and deconditioning 5, 7
• Early mobilization as soon as pain allows to prevent complications of prolonged immobility 1, 5

Physical Therapy

• Initiate physical therapy within 2-8 weeks focusing on core strengthening, proper body mechanics, and gradual return to activities 5, 8
• Progressive rehabilitation program to restore function and prevent deconditioning 5, 6

Osteoporosis Management

• Vitamin D supplementation and calcium intake for fracture prevention 5, 7
• Consider bisphosphonates or other antiresorptive agents to prevent future fractures 1, 7

Interventional Radiology Referral (Vertebral Augmentation)

Consider referral for vertebroplasty or kyphoplasty if:

• Severe pain persists after 3 months of conservative management despite appropriate analgesics and rehabilitation 1, 2
• Worsening symptoms or spinal deformity with pulmonary dysfunction 1
• Patient cannot tolerate prolonged conservative therapy due to complications of immobility or narcotic use 1

Key evidence supporting vertebral augmentation:

• Vertebroplasty provides rapid, marked improvement in pain and function compared to continued medical treatment in patients who have failed conservative therapy 1
• Benefits persist through 1 year after intervention with improvements in pain intensity, vertebral height, sagittal alignment, and quality of life 1
• Kyphoplasty is approximately 2.5 times more expensive than vertebroplasty with similar clinical outcomes, though it may restore vertebral height better 1
• Timing is flexible—patients with fractures >12 weeks have equivalent benefit to those with acute fractures <12 weeks 1

Follow-Up Protocol

• Reassess at 4-6 weeks to evaluate response to initial treatment 2
• If symptoms persist beyond 8 weeks, consider additional imaging to rule out fracture progression or new fractures 2
• Monitor for adjacent level fractures, especially in patients with underlying osteoporosis 5
• Patient education regarding proper body mechanics and reporting any sudden increase in pain suggesting new fracture 5

Common Pitfalls to Avoid

• Do not delay surgical referral if neurological deficits are present—this is a surgical emergency requiring immediate evaluation 1, 2
• Do not prolong bed rest beyond 2 weeks—this increases risk of complications including DVT, pneumonia, muscle atrophy, and bone loss 1, 5
• Do not deny vertebral augmentation to patients with persistent severe pain after 3 months of conservative therapy, as this increases risk of adverse outcomes from prolonged immobility and narcotic use 1
• Do not assume osteoporosis—always rule out pathologic fractures from malignancy or infection, especially if there are red flags 1, 2
• Do not overlook spinal instability—severe compression with >20% height loss or significant kyphosis may require surgical stabilization even without neurological deficits 1, 2