What is the treatment for a healthy adult with a T12 (thoracic 12) burst fracture and no significant medical history?

Treatment of T12 Burst Fractures in Healthy Adults

Initial Management Decision

For a neurologically intact healthy adult with a T12 burst fracture, nonoperative management with early mobilization (with or without bracing) is an appropriate first-line approach, as high-quality evidence demonstrates equivalent outcomes to surgery. 1

The critical first step is determining neurological status:

• Neurologically intact patients: Both surgical and nonoperative management produce equivalent clinical outcomes, making this a physician discretion decision based on fracture characteristics 1, 2
• Any neurological deficit present: Surgical intervention is indicated for decompression, alignment restoration, and stabilization 2

Nonoperative Management Protocol

For stable fractures in neurologically intact patients, the evidence strongly supports conservative treatment:

• External bracing is optional - Level I randomized controlled trial evidence shows no difference in pain, disability, or radiographic outcomes between braced versus non-braced patients at 6 months 1
• Grade B recommendation: Management with or without external brace produces equivalent improvement in outcomes 1, 3
• The decision to use a TLSO brace is entirely at the treating physician's discretion, as bracing adds no clinical benefit but is not associated with increased adverse events 1

Key contraindications to nonoperative management that mandate surgical evaluation include: 2, 3

• Significant vertebral collapse, angulation, or canal compromise
• Any neurological deficit
• TLICS score >4 suggesting instability
• Evidence of shear, rotation, or translational injury components

Nonoperative Protocol Details

• Early mobilization with close outpatient follow-up within 1-2 weeks 2
• Serial imaging to monitor for progressive deformity 2
• If bracing is chosen for patient comfort, limit duration to 8 weeks maximum to prevent trunk muscle atrophy and weakness 4

Surgical Management (When Indicated)

If surgery is pursued based on fracture instability characteristics or patient factors:

Surgical Technique - Evidence-Based Approach

Instrumentation WITHOUT fusion is the Grade A evidence-based standard for T12 burst fractures requiring surgery. 1, 2

• Fusion should be omitted - Grade A evidence shows fusion does not improve clinical or radiological outcomes but increases operative time and blood loss 1, 2
• Two high-quality randomized clinical trials (Level I) and three prospective studies (Level II) demonstrate no difference between fusion and nonfusion groups 1

Surgical Approach Selection

• Posterior approach is most commonly used due to surgeon familiarity and lower complication rates 2
• Anterior, posterior, or combined approaches produce equivalent clinical and neurological outcomes (Grade B recommendation) 1
• The posterior approach offers surgical intervention with decreased perioperative risk and reduced morbidity 5

Open vs. Percutaneous Technique

Both open and percutaneous pedicle screw fixation achieve equivalent clinical outcomes (Grade B recommendation). 1, 2

• Percutaneous instrumentation offers reduced blood loss and shorter operative time 1, 2
• Open fixation may provide slightly better initial deformity correction, but long-term clinical outcomes are equivalent 1

Postoperative Management

• Early mobilization is encouraged with instrumentation alone 2
• CT with multiplanar reconstructions is preferred for assessing healing 2
• Implant removal may be needed in some cases, representing an additional surgical burden unique to the operative approach 6

Common Pitfalls to Avoid

• Do not assume bracing is mandatory - high-quality evidence supports early mobilization without orthosis as equally effective 1, 3
• Do not routinely add fusion to instrumentation - this increases morbidity without improving outcomes 1
• Do not continue rigid bracing beyond 8 weeks - this causes trunk muscle atrophy and functional decline 4
• Do not order TLSO for patients with neurological deficits - these require immediate surgical evaluation 3

Cost Considerations

Surgery is over four times more costly than nonoperative treatment, with additional costs from potential complications and subsequent implant removal procedures 6