What is the treatment for an L1-L2 transverse process fracture?

Management of L1-L2 Transverse Process Fractures

Isolated transverse process fractures at L1-L2 are structurally and neurologically stable injuries that require conservative management only—no surgical consultation is needed. 1

Initial Assessment and Imaging

Obtain CT imaging to confirm the diagnosis and exclude associated injuries. The key diagnostic priorities are:

• Rule out other spinal injuries: Transverse process fractures frequently occur with other vertebral injuries (compression fractures, facet dislocations, or ligamentous disruption), which would change management entirely 1
• Exclude intra-abdominal injuries: Approximately 30-35% of patients with transverse process fractures have associated abdominal or pelvic injuries that require separate treatment 1
• Confirm neurologic integrity: All patients with isolated transverse process fractures are neurologically intact; any deficit suggests a different or additional injury 1
• MRI is indicated only if: You suspect ligamentous injury, spinal cord compression, or cannot explain neurologic findings with CT alone 2, 3

Conservative Treatment Protocol

Begin immediate conservative management with NSAIDs, muscle relaxants, flexible lumbar support, and early mobilization. 4

The evidence-based treatment approach includes:

• Pain control: NSAIDs and muscle relaxants reduce pain from an average of 8.8/10 to 5.2/10 on visual analog scale 4
• Flexible lumbar corset: Provides comfort and support without causing deconditioning 4
• Early mobilization: Avoid bed rest; maintain activity to prevent muscle deconditioning 5, 4
• Expected timeline: Most patients improve significantly within 1-2 weeks with this protocol 4

When Conservative Treatment Fails

If severe pain persists beyond 1 week despite appropriate conservative management, consider CT-guided fracture site injection with local anesthetic and corticosteroid. 6

This intervention is appropriate when:

• Pain remains severe (>7/10) after 1 week of NSAIDs, muscle relaxants, and activity modification 6
• The patient cannot return to work or daily activities due to pain 6
• You have confirmed the fracture location precisely on CT—missing additional fracture levels will result in treatment failure 6

The procedure involves:

• CT-guided injection of local anesthetic and corticosteroid directly into the fracture site 6
• Immediate pain relief in 75% of patients (3 of 4 in the reported series) 6
• Rapid return to activities: Most successful patients resume normal activities within days 6

Critical Pitfalls to Avoid

Never perform spinal manipulation on acute transverse process fractures—this can worsen pain and delay healing. 7

Additional management errors include:

• Requesting spine surgery consultation for isolated transverse process fractures: These injuries never require surgical stabilization or bracing 1
• Missing additional fracture levels: Always examine the entire spine on CT; multiple-level transverse process fractures are common and each symptomatic level may require treatment 6, 7
• Overlooking associated injuries: Systematically search for other vertebral fractures and abdominal injuries, which occur in approximately one-third of cases 1
• Returning athletes to contact sports prematurely: Restrict contact activities for 4 weeks minimum to allow healing 7
• Treating based on plain radiographs alone: Plain films have insufficient sensitivity and frequently miss these fractures 2, 7

When to Refer for Surgical Evaluation

Surgical referral is indicated only if associated injuries are present, NOT for the transverse process fracture itself. 1

Refer immediately if:

• Neurologic deficits are present: This indicates spinal cord or nerve root injury from a different mechanism 3, 1
• Other unstable spinal injuries exist: Compression fractures, burst fractures, or ligamentous disruption require surgical assessment 3, 1
• Translation or dislocation is visible: This represents a completely different injury pattern requiring immediate stabilization 8

Mechanism and Prognosis

These fractures result from direct posterior trauma (falls backward or blows to the back) and represent low-energy "coronal injuries of the spine." 4

Understanding the injury pattern helps with management:

• CT and MRI show deformation and edema of the fascia and paraspinal muscles around the fracture 4
• The injury is mechanically stable because the anterior and middle columns of the spine remain intact 1
• Prognosis is excellent with appropriate conservative treatment; all patients return to full activities 4, 1
• No long-term complications occur with conservative management 1