What is the medically indicated treatment for a patient with multiple thoracic spine fractures and diffuse thoracic pain after a rollover motor vehicle collision?

Treatment of Multiple Thoracic Spine Fractures After High-Energy Trauma

This 37-year-old male with multiple thoracic spine fractures from a rollover motor vehicle collision requires immediate CT imaging of the entire thoracolumbar spine, comprehensive neurological assessment, pain management with IV opioids, thromboprophylaxis, and surgical consultation—with the decision between operative and nonoperative management based on fracture stability, neurological status, and posterior ligamentous complex integrity. 1, 2

Immediate Diagnostic Workup

Imaging Requirements

• CT scan of the entire thoracolumbar spine is mandatory, as it has 94-100% sensitivity for identifying thoracolumbar fractures compared to only 49-62% for plain radiographs of the thoracic spine 1
• Screen the entire spine, as approximately 20% of spine injuries have a second associated spinal injury at a noncontiguous level 1
• This patient meets high-risk criteria requiring imaging: high-energy mechanism (rollover MVC), midline thoracolumbar tenderness, and likely distracting injuries (multiple fractures, abrasions) 1
• MRI without contrast should be obtained to assess posterior ligamentous complex integrity, which is critical for determining stability and surgical candidacy 2, 3

Neurological Assessment

• Perform thorough neurological examination documenting motor strength, sensory levels, and reflexes in all extremities 1, 2
• The presence or absence of neurological deficit fundamentally changes management—neurologically intact patients have different treatment pathways than those with deficits 1, 2
• Assess for cauda equina symptoms if lower lumbar segments are involved 2

Pain Management

Opioid Analgesia

• Initiate IV morphine sulfate at 0.1-0.2 mg/kg every 4 hours as needed, administered slowly to avoid chest wall rigidity 4
• Have naloxone and resuscitative equipment immediately available 4
• Monitor for respiratory depression, especially given the minor head injury 4

Thromboprophylaxis

VTE Prevention

• Initiate thromboprophylaxis immediately, as acute spinal cord injury and thoracolumbar fractures carry high VTE risk with incidence ranging from 4-100% without prophylaxis 1
• While specific evidence for isolated thoracolumbar fractures is insufficient, the consensus based on pooled spinal cord injury populations strongly recommends thromboprophylaxis 1
• Combined pharmacologic and mechanical prophylaxis may provide benefit over mechanical prophylaxis alone 1

Treatment Decision Algorithm

For Neurologically Intact Patients

The decision between surgical and nonoperative management depends on fracture stability characteristics:

Indicators Favoring Nonoperative Management:

• Intact posterior ligamentous complex on MRI 2, 3
• No significant retropulsion into the spinal canal 2
• Minimal kyphotic deformity 2
• Stable fracture pattern (compression fractures without posterior element involvement) 1, 2

If nonoperative management is chosen:

• Provide external thoracolumbar orthosis (TLSO brace) for stabilization—though evidence shows bracing decisions are at physician discretion 1, 2
• Schedule spine surgery follow-up within 1-2 weeks 2
• Educate on warning signs requiring immediate return: new neurological symptoms, severe uncontrolled pain, inability to mobilize safely 2

Indicators Favoring Surgical Management:

• Disruption of posterior ligamentous complex 2, 3
• Significant spinal canal compromise with retropulsion 2
• Progressive kyphotic deformity 2
• Multiple contiguous unstable fractures 5
• Fracture-dislocation patterns 6

For Patients with Neurological Deficits

• Immediate surgical consultation is mandatory 1, 2
• Consider maintaining mean arterial pressure >85 mmHg to potentially improve neurological outcomes 1
• Do not administer methylprednisolone—the complication profile outweighs uncertain benefits, and there is insufficient evidence to recommend its use 1

Surgical Approach Considerations (If Surgery Indicated)

Approach Selection

• Posterior, anterior, or combined approaches all yield equivalent clinical and neurological outcomes for thoracolumbar burst fractures 1
• Posterior approach offers greater surgeon familiarity and ability to perform decompression and stabilization through single incision 7

Instrumentation Strategy

• Omit arthrodesis from instrumented fixation when possible—fusion does not improve clinical or radiological outcomes and increases operative time and blood loss 1, 7
• For mid- and upper thoracic fractures with high instability, consider long-segment stabilization, particularly if concomitant sternal fractures are present 5

Critical Pitfalls to Avoid

• Do not rely on plain radiographs alone—they miss 38-51% of thoracic spine fractures 1
• Do not assume all burst fractures require surgery—evidence shows conflicting data for neurologically intact patients, making this a clinical judgment call 1, 2
• Do not delay surgical consultation if any neurological deficit develops, as this fundamentally changes management urgency 2, 7
• Do not overlook associated thoracic cage injuries (rib fractures, sternal fractures, pneumothorax)—these are common with thoracic spine fractures and affect stability 5
• Do not fail to image the entire spine—20% will have noncontiguous injuries 1
• Do not administer methylprednisolone given insufficient evidence and significant complication risks 1

Follow-up Protocol

• Repeat imaging to monitor for progressive vertebral collapse, increasing kyphotic deformity, or delayed instability 2, 7
• Close outpatient follow-up within 1-2 weeks with spine surgery 2
• Monitor for delayed complications including chronic pain (occurs in 20-40% despite treatment) 7