Thoracic and lumbar spine fractureMANAGEMENT

TRAUMA PRESENTATIONS · 12 SECTIONS

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599 items

☷ Legend

01Approach to the Critical Patient/attcp58

Immediate priorities

›High risk states

›Airway compromise

›Ventilatory failure

›Hemorrhagic shock

›Neurogenic shock

›Spine motion restriction

›Neutral alignment

›Log roll as a unit

›Minimize transfers

›Resuscitation triggers

›SBP < 90 mmHg

›MAP < 65 mmHg

›Lactate elevation

›Active hemorrhage concern

›Neurogenic shock pattern

›Hypotension with relative bradycardia

›Warm extremities

›Vasopressor requirement after hemorrhage excluded

›Time critical consultations

›Spine surgery for suspected unstable fracture

›Trauma surgery for polytrauma

›Neurosurgery for cord compression concern

›Analgesia and sedation safety

›Hemodynamic monitoring for opioid administration

›Avoid oversedation masking neurologic change

›Early imaging strategy

›CT trauma pan scan workflow alignment

›CT thoracic and lumbar spine reconstructions from chest abdomen pelvis CT when available

›Dedicated CT spine for persistent high suspicion

Neurologic risk stratification

›High risk neurologic scenarios

›New weakness

›New sensory loss

›Saddle anesthesia

›Bowel dysfunction

›Urinary retention

›Acute cord compression concern

›Progressive deficit

›Severe midline tenderness with neuro symptoms

›Suspicion for epidural hematoma

›Cauda equina concern

›Bilateral radicular symptoms

›Reduced perianal sensation

›Reduced anal tone

›PVR elevation

Monitoring and targets

›Hemodynamic targets

›Avoid hypotension

›SBP >= 90 mmHg as minimum trauma threshold

›MAP >= 65 mmHg as minimum perfusion threshold

›If acute spinal cord injury

›MAP 85 to 90 mmHg target

›Duration 7 days when feasible

›ICU level monitoring for vasopressors

›Temperature

›Normothermia

›Fever evaluation for occult infection when non traumatic etiologies possible

›Glucose

›Avoid severe hyperglycemia

›Avoid hypoglycemia mimicking neurologic deficit

02History/hx65

Mechanism and timeline

›Injury narrative

›Time of injury

›High energy mechanism

›MVC

›Fall from height

›Crush

›Sports collision

›Low energy mechanism

›Ground level fall

›Minor twist

›Spine load characteristics

›Axial load

›Flexion

›Extension

›Rotation

›Distraction

›Immediate symptoms

›Midline thoracic pain

›Midline lumbar pain

›Radicular pain

›Paresthesias

›Weakness

›Evolution of symptoms

›Progressive pain

›Progressive neurologic deficit

›Delayed neurologic symptoms

Red flags and risk factors

›Neurologic red flags

›Limb weakness

›Gait instability

›Numbness level on trunk

›Saddle anesthesia

›Bowel dysfunction

›Urinary retention

›Bone fragility risk

›Osteoporosis

›Chronic glucocorticoid use

›Prior vertebral fracture

›Malignancy history

›Ankylosed spine risk

›Ankylosing spondylitis

›Diffuse idiopathic skeletal hyperostosis

›Prior spinal fusion

›Anticoagulation and bleeding risk

›Warfarin

›DOAC

›Antiplatelet therapy

›Coagulopathy history

›Infection and neoplasm clues

›Fever

›Weight loss

›Night pain

›IV drug use

›Recent bacteremia

Functional and baseline context

›Baseline function

›Independent ambulation

›Assist device use

›Baseline neuropathy

›Post injury function

›Ability to stand

›Ability to ambulate

›Pain limiting respiration

›Prior spine disease

›Prior compression fracture

›Prior surgery

›Known stenosis

03Physical Exam/exam49

Primary survey focused exam

›Respiratory mechanics

›Work of breathing

›Splinting from thoracic pain

›Chest wall injury signs

›Hemodynamics

›Shock index

›Skin temperature

›Bradycardia with hypotension pattern

›Spine inspection and palpation

›Midline tenderness thoracic

›Midline tenderness lumbar

›Step off deformity

›Ecchymosis

›Seatbelt sign

Neurologic exam

›Motor

›Hip flexion

›Knee extension

›Ankle dorsiflexion

›Great toe extension

›Ankle plantarflexion

›Sensory

›Dermatomal light touch

›Pinprick when needed

›Truncal sensory level

›Reflexes and tone

›Patellar reflex

›Achilles reflex

›Clonus

›Babinski

›Sacral function

›Perianal sensation

›Anal sphincter tone

›Bulbocavernosus reflex when feasible

›Autonomic findings

›Priapism

›Bradycardia with hypotension

›Temperature dysregulation

Associated injuries screen

›Abdomen and pelvis

›Pelvic instability

›Abdominal tenderness

›Hematuria signs

›Extremities

›Long bone deformity

›Peripheral pulses

›Compartment signs

›Skin and back

›Open fracture wound

›Penetrating trauma track

›Pressure injury risk on board

04Differential Diagnosis/ddx31

Traumatic spine conditions

›Thoracic vertebral fracture (ICD-10 S22.0)

›Compression fracture

›Burst fracture

›Flexion distraction injury

›Fracture dislocation

›Lumbar vertebral fracture (ICD-10 S32.0)

›Compression fracture

›Burst fracture

›Chance fracture

›Fracture dislocation

›Spinal cord injury thoracic level (ICD-10 S24.0)

›Complete injury

›Incomplete injury

›Cauda equina injury (ICD-10 S34.3)

›Traumatic compression

›Epidural hematoma

Non fracture mimics and coexisting diagnoses

›Spinal epidural hematoma (ICD-10 G95.1)

›Anticoagulation associated

›Post traumatic

›Vertebral osteomyelitis or discitis (ICD-10 M46.2)

›Fever

›Elevated inflammatory markers

›Spinal metastasis with pathologic fracture (ICD-10 C79.5)

›Known malignancy

›Night pain

›Aortic injury or dissection with back pain (ICD-10 S25.0 or I71.0)

›High speed deceleration

›Chest trauma findings

›Retroperitoneal hemorrhage

›Anticoagulation

›Pelvic fracture

05Laboratory Tests/lt28

Trauma and bleeding evaluation

›Baseline labs

›Complete blood count for hemorrhage and baseline

›Hemoglobin trend for occult bleeding

›Platelet count for procedure planning

›Electrolytes and renal function for contrast safety

›Creatinine trend

›Potassium abnormalities affecting arrhythmia risk

›Coagulation studies when bleeding risk

›INR for warfarin

›aPTT for heparin effect

›Type and screen for operative or transfusion planning

›Crossmatch when shock or major trauma

›Shock adjuncts

›Venous or arterial blood gas when critically ill

›Lactate mmol/L for perfusion marker

›pH for global shock severity

›Creatine kinase for crush injury or prolonged down time

›Rhabdomyolysis risk stratification

Infection or malignancy concern

›Inflammatory markers when non traumatic etiologies possible

›C reactive protein

›Elevation supporting infection or inflammatory process

›ESR

›Elevation supporting vertebral osteomyelitis

›Blood cultures when febrile or bacteremia concern

›Two sets before antibiotics when feasible

Neurogenic bladder evaluation

›Post void residual when urinary retention concern

›PVR elevation supporting cauda equina physiology

›Foley catheter requirement threshold by local protocol

06Diagnostic Tests/dt101

Scoring Systems

›Thoracolumbar Injury Classification and Severity Score

›Core domains

›Morphology

›Compression pattern points

›Burst pattern points

›Translation rotation points

›Distraction points

›Posterior ligamentous complex integrity

›Intact points

›Suspected or indeterminate points

›Disrupted points

›Neurologic status

›Intact points

›Nerve root injury points

›Cord or conus injury points

›Cauda equina points

›Treatment thresholds

›Score 3 or less

›Non operative pathway typical

›Score 4

›Shared decision based on modifiers

›Score 5 or more

›Operative management often beneficial

›AO Spine thoracolumbar classification

›Morphology groups

›Type A compression failure

›Type B tension band failure

›Type C displacement or translation

›Clinical modifiers

›Neurologic status incorporation

›Patient specific modifiers affecting stability

›Load Sharing Classification

›Burst fracture comminution grading

›Kyphosis correction requirement prediction

›Posterior fixation failure risk stratification

MRI

›Indications

›Neurologic deficit with unclear CT explanation

›Cord compression evaluation

›Cord contusion or hemorrhage evaluation

›Posterior ligamentous complex injury suspicion

›Facet widening on CT

›Interspinous widening

›Epidural hematoma suspicion

›Rapidly progressive deficit

›Anticoagulation

›Pathologic fracture concern

›Malignancy history

›Atypical imaging features

›Contraindications and logistics

›Unstable patient requiring resuscitation

›Ferromagnetic implant considerations

›Prolonged scan time planning for analgesia and monitoring

›Interpretation pearls

›PLC disruption markers

›Interspinous ligament edema

›Supraspinous ligament disruption

›Cord signal change

›T2 hyperintensity for edema

›Hemorrhage signal patterns

›Canal compromise quantification

›Compression degree supporting decompression decisions

›Preferred initial imaging for suspected thoracic lumbar fracture

›High sensitivity for osseous injury

›Rapid acquisition compatible with trauma workflow

›Indications

›High energy mechanism with spinal pain

›Midline tenderness

›Neurologic deficit

›Altered mental status limiting exam reliability

›Distracting injury limiting exam reliability

›Protocol considerations

›Multiplanar reconstructions

›Sagittal and coronal reformats

›Thin slice review

›Whole spine screening in high risk polytrauma

›Non contiguous fractures risk

›Key CT findings affecting stability

›Burst fracture

›Retropulsed fragment

›Canal compromise

›Flexion distraction injury

›Horizontal fracture through posterior elements

›Seatbelt mechanism correlation

›Translation rotation injury

›Facet dislocation

›Vertebral body displacement

›Pitfalls

›Osteoporotic fracture acuity uncertainty

›MRI marrow edema correlation when needed

›Ankylosed spine

›Long lever arm unstable fracture despite subtle CT appearance

Ultrasound (or US)

›Limited role for vertebral fracture diagnosis

›Inadequate sensitivity for posterior element injury

›Not a rule out test

›POCUS adjuncts in trauma

›eFAST for hemoperitoneum

›Positive study altering resuscitation priority

›Cardiac POCUS for tamponade and function

›Shock differential refinement

›Bladder ultrasound for retention

›PVR estimation when catheterization deferred

07Disposition/dispo25

Level of care decisions

›ICU indications

›Acute spinal cord injury with MAP augmentation

›Vasopressor requirement

›Respiratory compromise from high thoracic injury

›Polytrauma with ongoing resuscitation

›Step down or ward admission

›Stable fracture with pain control requirement

›Need for brace fitting and mobilization planning

›Serial neurologic exams

›Transfer criteria

›Need for spine surgery capability not available

›Unstable fracture pattern

›Progressive neurologic deficit

›Epidural hematoma requiring urgent decompression

Discharge criteria for selected cases

›Appropriate only for stable injuries

›Isolated stable compression fracture

›No neurologic deficit

›Ambulation safe

›Pain and function requirements

›Pain controlled on oral regimen

›Mobilization with brace plan when indicated

›Follow up requirements

›Spine clinic or orthopedics follow up timeframe

›Physical therapy plan

›Osteoporosis evaluation when low energy mechanism

08Treatment/t103

Immobilization and supportive care

›Spine protection strategy

›Motion restriction until stability defined

›Collar use not required for isolated thoracolumbar injury unless cervical concern

›Early mobilization once stable plan confirmed

›Analgesia ladder

›Acetaminophen PO 650 mg

›Interval every 6 hours

›Maximum daily dose per local policy

›NSAID when no contraindication

›Ibuprofen PO 400 mg

›Interval every 6 hours

›Avoid in high bleeding risk or renal injury

›Opioid for severe pain

›Hydromorphone IV 0.2 mg

›Titration 0.2 mg every 10 minutes to effect

›Respiratory monitoring

›Morphine IV 2 mg

›Titration 2 mg every 10 minutes to effect

›Avoid in hypotension when possible

›Antiemetic adjunct

›Ondansetron IV 4 mg

›Repeat every 8 hours as needed

›Bowel regimen when opioid use

›Polyethylene glycol PO 17 g

›Daily

›Senna PO 8.6 mg

›Bedtime

›VTE prophylaxis planning

›Mechanical prophylaxis

›Intermittent pneumatic compression

›Early mobilization when safe

›Pharmacologic prophylaxis after hemorrhage risk assessment

›Enoxaparin SC 30 mg

›Interval every 12 hours

›Hold around operative timing per spine service

Neurogenic shock and spinal cord perfusion

›Hemodynamic augmentation in acute spinal cord injury

›MAP 85 to 90 mmHg target

›Duration 7 days when feasible

›Evidence limitations and risk benefit discussion in older cardiac disease

›Vasopressor options

›Norepinephrine infusion initiation

›Start 0.05 mcg/kg/min

›Titration every 2 to 5 minutes

›Goal MAP achieved with lowest dose

›Arrhythmia monitoring

›Phenylephrine infusion for tachyarrhythmia prone patients

›Start 0.5 mcg/kg/min

›Titration every 2 to 5 minutes

›Bradycardia risk monitoring

›Respiratory support in high thoracic injury

›Noninvasive support when appropriate

›Close monitoring for fatigue

›Intubation triggers

›Rising CO2 on blood gas

›Inability to protect airway

›Progressive weakness affecting ventilation

Bracing and mobilization

›TLSO bracing for selected stable fractures

›Compression fracture with pain limiting mobilization

›Brace comfort improving function

›Duration per spine service plan

›Burst fracture treated non operatively

›Brace use based on stability and surgeon preference

›Activity restrictions

›No heavy lifting until cleared

›Avoid flexion rotation loading

›Physical therapy

›Gait training when safe

›Core stabilization progression

Operative and procedural pathways

›Indications for urgent surgery

›Progressive neurologic deficit

›Radiographic cord compression with deficit

›Unstable fracture pattern

›Translation rotation injury

›Distraction injury with PLC disruption

›Open fracture or penetrating injury with instability

›Common surgical strategies

›Posterior instrumentation and fusion

›Stabilization across injury level

›Reduction of deformity

›Decompression procedures

›Laminectomy when posterior compression

›Corpectomy when anterior column compromise

›Minimally invasive options in selected patients

›Percutaneous pedicle screws

›Short segment fixation with augmentation when needed

›Osteoporotic compression fracture interventions

›Vertebroplasty or kyphoplasty selection by spine service

›Persistent severe pain despite conservative management

›Imaging confirming acute fracture edema

Steroids and neuroprotection

›Corticosteroids in acute traumatic spinal cord injury

›High dose methylprednisolone not routine standard of care

›Harm risk

›Infection risk

›GI bleeding risk

›Hyperglycemia risk

›Shared decision pathway only when protocolized and within early window where used as an option

›Temperature and glucose neuroprotection

›Normothermia target

›Fever workup

›Cooling only when indicated by other protocols

›Avoid hypoxia

›SpO2 >= 94 percent target

›Ventilation strategy to avoid hypercapnia

09Special Populations/sp41

Pregnancy

›Maternal resuscitation priorities

›Maternal stabilization first

›Left uterine displacement in late pregnancy

›Imaging considerations

›CT when clinically indicated

›Radiation risk balanced against missed unstable injury

›MRI without gadolinium when feasible for soft tissue questions

›Medication considerations

›NSAID avoidance in third trimester

›Opioid use with fetal monitoring considerations

›Obstetric consultation triggers

›Viable gestation with trauma

›Abdominal pain or bleeding

›Contractions

Geriatric

›High risk features

›Osteoporosis related compression fractures after low energy mechanism

›Anticoagulation increasing epidural hematoma risk

›Baseline stenosis increasing neurologic vulnerability

›Imaging threshold lower

›CT preference for subtle fracture detection

›MRI for acuity and marrow edema confirmation when needed

›Analgesia precautions

›Lower opioid starting doses

›Delirium risk monitoring

›Disposition bias toward admission

›Mobility decline risk

›Falls risk

›Social supports assessment

Pediatrics

›Mechanism patterns

›Sports collision

›MVC with lap belt risk

›Flexion distraction injury suspicion

›Seatbelt sign correlation

›Abdominal injury association

›Imaging strategies

›Radiation minimization

›CT only when indicated

›MRI consideration for ligamentous injury when feasible

›Neurologic exam adaptations

›Age appropriate strength assessment

›Sphincter function history from caregivers

10Background/b50

Epidemiology

›Thoracolumbar junction vulnerability

›T11 to L2 as common injury region

›Transition zone biomechanics increasing fracture risk

›Mechanism distribution

›High energy trauma as common cause in younger patients

›Low energy falls as common cause in older adults with osteoporosis

›Non contiguous fractures risk

›Multilevel injury possible in high energy trauma

›Whole spine screening consideration in polytrauma

Pathophysiology

›Column concepts

›Anterior column

›Vertebral body anterior portion

›Anterior longitudinal ligament

›Middle column

›Posterior vertebral body portion

›Posterior longitudinal ligament

›Posterior column

›Posterior elements

›Posterior ligamentous complex

›Stability determinants

›Posterior ligamentous complex integrity

›Degree of vertebral body comminution

›Translation and rotation indicating gross instability

›Neurologic injury mechanisms

›Canal compromise from retropulsion

›Distraction stretch injury

›Vascular hypoperfusion injury

›Epidural hematoma compression

Therapeutic Considerations

›Non operative principles

›Stable fracture patterns

›Intact PLC

›No significant translation

›Pain control enabling mobilization

›Brace selection individualized

›Operative principles

›Restore stability

›Prevent progression of deformity

›Enable early mobilization

›Decompression when neurologic compromise

›Timing urgency with progressive deficit

›Perfusion strategy in acute spinal cord injury

›MAP augmentation rationale

›Improve spinal cord perfusion pressure

›Reduce secondary injury cascade

›Evidence quality limitations

›Class III evidence basis in older guidelines

›Risk of cardiac ischemia and arrhythmias with vasopressors

›Steroid therapy controversy

›Weak recommendation framework in some guidelines

›Adverse event burden influencing many emergency medicine positions

11Patient Discharge Instructions/pdi27

copy discharge instructions

›Stable thoracic or lumbar fracture after imaging

›Brace use if prescribed

›Wear schedule per spine service

›Skin checks twice daily

›Activity limits

›No heavy lifting

›Avoid bending twisting

›No high risk sports

›Pain control plan

›Acetaminophen dosing schedule

›NSAID plan if safe

›Opioid only if prescribed

›Constipation prevention if opioid

›Hydration

›Laxative regimen

›Follow up

›Spine clinic appointment timeframe

›Repeat imaging plan if ordered

›Return to ED immediately

›New weakness

›New numbness

›Saddle anesthesia

›Urinary retention

›New bowel incontinence

›Fever with worsening back pain

›Uncontrolled pain preventing walking

›New shortness of breath or chest pain after trauma

12References/r21

Clinical guidelines and society statements

›Acute spinal cord injury hemodynamic management

›MAP 85 to 90 mmHg for 7 days recommendation

›Evidence limitations and adverse effect cautions

›Steroids in acute traumatic spinal cord injury

›Emergency medicine and neurosurgical guideline statements on risk benefit

›Position statements discouraging routine high dose methylprednisolone

›AO Spine thoracolumbar injury classification resources

›Morphology framework Type A Type B Type C

›Integration of neurologic status and modifiers

›Thoracolumbar Injury Classification and Severity Score resources

›Scoring domains and operative thresholds

›Shared decision guidance for intermediate scores

Evidence based sources and textbooks

›ATLS spine trauma principles

›Spine motion restriction

›Neurologic exam and reassessment

›Reviews of TLICS and AO Spine classification performance

›Reliability studies

›Treatment threshold discussions

›Trauma spine best practice guidelines

›Imaging strategies

›Perfusion and hypotension avoidance

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed June 16, 2026

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