What is the initial treatment approach for a T12 compression fracture?

Treatment for T12 Compression Fracture

For neurologically intact patients with a T12 compression fracture, initiate conservative medical management for the first 3 months, reserving percutaneous vertebral augmentation (vertebroplasty or kyphoplasty) for those with persistent severe pain, spinal deformity, or pulmonary dysfunction after this period. 1

Initial Assessment

Before starting treatment, determine the underlying etiology and fracture stability:

• Obtain MRI of the thoracic spine without contrast to identify bone marrow edema indicating acute injury and to differentiate osteoporotic from pathologic fractures 1
• Perform complete neurological examination immediately to identify any deficits that would mandate urgent surgical intervention rather than conservative care 1
• Assess for "red flags" including known malignancy, neurological symptoms, or signs of spinal instability 1
• If malignancy is suspected, obtain MRI of the complete spine with and without contrast 1

Conservative Medical Management (First-Line for 3 Months)

Pain Control:

• Use analgesics including NSAIDs as first-line agents 1
• Limit narcotic use to avoid complications of sedation, falls, and decreased physical conditioning 1
• Consider calcitonin 200 IU (nasal or suppository) for 4 weeks if presenting acutely, which provides clinically important pain reduction 2

Activity Modification:

• Avoid prolonged bed rest, which leads to deconditioning, bone loss, and increased mortality risk 1, 2
• Encourage limited activity within pain tolerance to prevent complications of immobility 1
• Bracing may improve comfort but should not promote prolonged immobilization 3

Osteoporosis Treatment:

• Initiate bisphosphonates (such as ibandronate) or other bone-protective agents to prevent additional symptomatic fractures 2

Indications for Vertebral Augmentation

Consider percutaneous vertebral augmentation (vertebroplasty or kyphoplasty) if:

• Persistent severe pain after 3 weeks to 3 months of conservative management 1
• Development of spinal deformity or pulmonary dysfunction 1
• Severe pain requiring parenteral narcotics or hospitalization 4
• Edema present on MRI indicating acute fracture with ongoing pain 1

The evidence strongly supports vertebral augmentation over continued conservative therapy when medical management fails, as it provides immediate and substantial improvement in pain and mobility, preventing complications associated with prolonged immobility 1. While long-term outcomes may be similar between groups, the early mobilization benefit of vertebral augmentation reduces morbidity and mortality risks associated with bed rest and narcotic use 1.

Surgical Consultation (Urgent)

Immediate surgical referral is mandatory for:

• Any neurological deficits—initiate corticosteroid therapy immediately and perform surgery as soon as possible to prevent further deterioration 1
• Frank spinal instability based on anatomic and clinical factors 1
• Spinal cord compression, particularly from osseous compression, where surgery is more likely to allow neurological recovery than radiation alone 1

Special Considerations for Pathologic Fractures

If the T12 fracture is due to malignancy:

• Asymptomatic pathologic fractures: Radiation oncology consultation or medical management 1
• Severe and worsening pain: Multidisciplinary approach with interventional radiology, surgery, and radiation oncology; percutaneous thermal ablation or vertebral augmentation is appropriate 1
• Neurological involvement: Surgical and radiation oncology consultation 1

Critical Pitfalls to Avoid

• Do not prolong bed rest beyond what is absolutely necessary, as this dramatically increases risk of deconditioning, bone loss, thromboembolism, and mortality 1, 2
• Do not overuse narcotics, which cause sedation, increase fall risk, and worsen physical conditioning 1, 2
• Do not miss unstable fractures by performing inadequate neurological examination—complete assessment is essential 4, 2
• Do not deny vertebral augmentation to appropriate candidates after conservative therapy fails, as this increases adverse outcomes associated with immobility 1