What is the initial treatment for an adult patient with a lumbar lateral transverse process fracture?

Initial Treatment of Lumbar Lateral Transverse Process Fracture

For isolated lumbar transverse process fractures without neurological deficits or associated spinal injuries, initiate immediate pain management with NSAIDs and muscle relaxants, apply a flexible support corset, and begin early mobilization—spine precautions and prolonged immobilization are unnecessary and potentially harmful. 1, 2

Immediate Diagnostic Confirmation

• CT imaging is mandatory to exclude associated vertebral body fractures, which occur in approximately 11-17% of cases and are frequently missed on plain radiographs 2, 3
• If the initial trauma CT scan shows only isolated transverse process fractures with no weight-bearing column involvement, no further spine imaging or specialist consultation is required 2
• Evaluate for associated visceral injuries (kidney, liver, spleen) given the mechanism of injury, as these fractures typically result from high-energy blunt trauma 1, 2

Pain Management Protocol

• NSAIDs combined with muscle relaxants form the foundation of treatment 1
• Flexible support corset provides symptomatic relief and facilitates early mobilization 1
• For refractory pain persisting beyond 1 week of conservative management, CT-guided fracture site injection with local anesthetic and corticosteroid can provide rapid symptom resolution and accelerate return to function 4
• Expected pain reduction: from 8.8/10 to 5.2/10 on visual analog scale within days of initiating treatment 1

Mobilization Strategy

• Discontinue log-roll precautions immediately once CT confirms isolated transverse process fracture without other spinal injuries 2
• Begin physical therapy and mobilization within 24-48 hours of injury—prolonged immobilization (average 29 hours in historical practice) wastes resources and delays recovery 2
• Return to non-contact activities typically occurs within 2-4 weeks depending on pain tolerance 5, 1
• Avoid contact sports for 4 weeks minimum to allow fracture healing 5

Critical Exclusion Criteria Requiring Different Management

• Neurological deficits: Immediate neurosurgical consultation required 6, 7
• Associated vertebral body fractures: Follow burst fracture or compression fracture protocols depending on injury pattern 8
• Multiple contiguous transverse process fractures with severe instability: Consider spine surgery consultation 3
• Spinal cord compression or canal compromise: Urgent surgical evaluation 7

Common Pitfalls to Avoid

• Do not delay mobilization waiting for spine consultation when CT confirms isolated injury—this prolongs hospital stay and increases complications without benefit 2
• Do not rely on plain radiographs alone—they miss 11% of significant associated spinal injuries that are visible on CT 3
• Do not perform spinal manipulation until fracture is excluded radiographically, as this can worsen injury 5
• Do not overlook multiple-level fractures—carefully review entire lumbar spine on CT, as patients average 2.3 fractures per injury 1, 2
• Re-examine imaging if pain persists after appropriate local injection, as additional fracture levels may have been missed initially 4

Expected Clinical Course

• Natural history: Gradual pain improvement over 2-12 weeks with conservative management 9
• Mechanism: These injuries result from backward falls or direct blows to the back (98% of cases), representing "coronal injury of the spine" 1
• Prognosis: Excellent with appropriate early mobilization and pain control—no cases of missed significant injury when adequate CT screening performed 2