How should I treat a patient with a suspected T12 vertebral fracture?

Treatment of Suspected T12 Vertebral Fracture

For a suspected T12 fracture, immediately obtain CT imaging of the thoracolumbar spine to confirm the diagnosis, then stratify management based on fracture etiology (traumatic vs. osteoporotic vs. pathologic), presence of neurological deficits, and spinal stability. 1

Initial Diagnostic Workup

Imaging Protocol

• CT thoracolumbar spine without contrast is the gold standard for diagnosing T12 fractures, with 94-100% sensitivity compared to only 67-82% for plain radiographs 1
• If the patient has already undergone chest/abdomen/pelvis CT for trauma evaluation, obtain sagittal and coronal spine reformats from existing data rather than repeating the scan—this approach has 94-99% sensitivity and is radiation-sparing 1
• MRI thoracolumbar spine without contrast is mandatory if any of the following are present: 1, 2
  • Suspected or confirmed neurological deficits (motor weakness, sensory changes, bowel/bladder dysfunction)
  • Clinical concern for spinal cord compression
  • Need to differentiate acute from chronic fracture (use STIR or fat-saturated T2 sequences to detect bone marrow edema)
  • Suspected pathologic fracture or malignancy

Critical Clinical Assessment

• Perform comprehensive baseline neurological examination documenting lower-extremity motor strength (graded 0-5), sensory testing in all dermatomes, deep tendon reflexes, and gait assessment 2
• The T12 level is at the thoracolumbar junction where mechanical stress is highest, making it particularly vulnerable to both fracture and neurological complications 2
• Screen for "red flags" including: known malignancy, constitutional symptoms (fever, weight loss), age >50 years with new-onset pain, history of trauma, or progressive neurological symptoms 1

Management Algorithm by Clinical Scenario

Variant 1: Traumatic Fracture Without Neurological Deficit

• Most patients (85%) with vertebral fractures have no neurological deficits and can be managed conservatively 2
• Initial treatment includes: 3
  • Short-term bed rest (minimize duration to prevent deconditioning)
  • Multimodal pain management with local and systemic analgesia
  • Bracing for comfort and spinal support during mobilization
  • Early physical therapy consultation for spinal stretching exercises
• However, severe spinal injury without neurological deficit requires vigilant monitoring—patients can suffer unintended neurological injury from further dislocation during routine care 4
• Internal fixation and surgical stabilization are recommended if CT demonstrates fracture-dislocation, significant canal compromise, or mechanical instability, even in the absence of current neurological deficits 4, 5

Variant 2: Osteoporotic Compression Fracture

• Medical management is usually appropriate for the first 3 months in patients with osteoporotic compression fractures without "red flags" 1
• Initial conservative treatment includes: 3
  • Pain control with acetaminophen or NSAIDs (if not contraindicated)
  • Bracing for comfort during acute phase
  • Physical therapy with spinal stretching exercises
  • Gradual return to ordinary activities within pain limits
• Percutaneous vertebral augmentation (vertebroplasty/kyphoplasty) is usually appropriate if the patient develops: 1
  • Persistent severe pain despite 3 months of conservative management
  • Progressive spinal deformity
  • Pulmonary dysfunction from kyphotic deformity
  • MRI-confirmed bone marrow edema indicating acute fracture
• Critical osteoporosis management must be initiated immediately: 6
  • Assess for very high fracture risk (age >74, multiple prior fractures, T-score ≤-3.0, high FRAX scores)
  • For very high-risk patients: start anabolic therapy (teriparatide 20 mcg subcutaneous daily for 18-24 months or romosozumab), followed by mandatory transition to bisphosphonate or denosumab 6
  • For high-risk patients not meeting very high-risk criteria: start oral bisphosphonate (alendronate 70 mg weekly) immediately—do not delay, as secondary fracture risk is highest in the first year and bisphosphonates require 9-12 months before fracture benefit becomes evident 6
  • All patients require calcium 1000-1200 mg daily, vitamin D 800-1000 IU daily (target 25(OH)D ≥30 ng/mL), fall prevention strategies, and weight-bearing exercise 6

Variant 3: Pathologic Fracture (Known or Suspected Malignancy)

• MRI of the complete spine without and with IV contrast is usually appropriate to assess for additional metastatic lesions and epidural extension 1
• Multidisciplinary consultation is mandatory involving interventional radiology, surgery, and radiation oncology 1
• Management stratification: 1
  • Asymptomatic pathologic fracture: radiation oncology consultation or medical management
  • Severe and worsening pain: percutaneous thermal ablation or vertebral augmentation
  • Spinal deformity or pulmonary dysfunction: percutaneous vertebral augmentation with multidisciplinary coordination
  • Any neurological effects: immediate surgical consultation and radiation oncology consultation

Variant 4: Fracture With Neurological Deficits

• Any neurological deficit is an absolute indication for immediate surgical evaluation 1, 2
• Progressive neurological deficits occur in approximately 4-6% of vertebral fracture patients (paraparesis/paraplegia in 4.1%, gait disturbances in 6.8%) 2
• Radiculopathy exceeding expected local vertebral pain is a relative contraindication to vertebral augmentation alone and warrants surgical consultation 2
• Compression of the spinal cord at T12-L1 can produce lower-extremity weakness, sensory alterations, and radicular pain requiring decompression 2
• Significant spinal canal stenosis or retropulsed bone fragments mandate surgical assessment for decompression and stabilization 2

Common Pitfalls to Avoid

• Do not rely on plain radiographs alone—they miss 33-51% of thoracolumbar fractures 1
• Do not delay osteoporosis treatment in patients with compression fractures—the highest risk for subsequent fracture is in the first year, and bisphosphonates take 9-12 months to provide fracture protection 6
• Do not assume absence of neurological deficit means stability—fracture-dislocations can cause delayed neurological injury during routine care or mobilization 4
• Do not perform vertebral augmentation in patients with radiculopathy or neurological deficits without surgical consultation first 2
• Do not forget to image the entire spine—approximately 20% of spine injuries have a second noncontiguous spinal injury 1