Thoracic and lumbar spine fractureMANAGEMENT

SPINE · 12 SECTIONS

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531 items

☷ Legend

01Approach to the Critical Patient/attcp43

Immediate priorities

›Thoracolumbar trauma triage

›Airway and ventilation threats

›High cervical involvement concern triggers parallel cervical pathway

›Neurogenic shock concern with hypotension and bradycardia

›Hemodynamic instability pathway

›Hemorrhage sources

›Massive transfusion activation triggers

›Spine motion restriction

›Hard board avoidance after initial transfer

›Logroll only with team control

›Early neurologic risk stratification

›Progressive weakness

›Saddle anesthesia

›Urinary retention

›Immediate consultation triggers

›Spine surgery for neurologic deficit

›Trauma surgery for high energy mechanism with abdominal signs

Red flags and escalation

›Time critical spine threats

›Cauda equina syndrome concern

›Severe back pain with bilateral radicular symptoms

›New bladder dysfunction

›Conus medullaris syndrome concern

›Early bladder dysfunction

›Mixed upper and lower motor neuron signs

›Epidural hematoma concern

›Anticoagulation or coagulopathy

›Rapid neurologic decline

›Unstable fracture patterns

›Burst fracture with posterior wall involvement

›Chance fracture with posterior ligament complex concern

Initial actions and monitoring

›Monitoring and targets

›Serial neurologic exams

›Motor strength by key myotomes

›Sensation by dermatomes including perineal

›Pain control strategy

›Multimodal analgesia

›Sedation avoidance when serial neuro checks needed

›Bladder management

›Post void residual threshold 300 mL concern

›Foley catheter if retention or spinal cord injury

›Secondary injury prevention

›Normoxia

›Normotension

02History/hx46

Mechanism and risk mapping

›Injury context

›Mechanism

›Low energy fall

›High energy MVC

›Fall from height

›Axial load

›Seatbelt pattern

›Lap belt use

›Abdominal bruising

›Timing

›Time since injury

›Delayed presentation

›Associated injury clues

›Abdominal pain

›Chest pain

›Head injury symptoms

Symptoms and neurologic review

›Spine symptom profile

›Back pain features

›Midline tenderness

›Pain with movement

›Radicular symptoms

›Dermatomal leg pain

›Paresthesia

›Motor symptoms

›Leg weakness

›Gait inability

›Bowel and bladder

›Urinary retention

›Incontinence

›Constipation with overflow

›Sexual function change

›New erectile dysfunction

›Perineal numbness

Patient factors

›Baseline risk modifiers

›Osteoporosis or fragility fracture history

›Prior vertebral compression fracture

›Chronic glucocorticoids

›Malignancy or infection risk

›Known cancer

›IV drug use

›Anticoagulation and bleeding risk

›DOAC use

›Warfarin use

›Prior spine surgery

›Hardware

›Fusion level

03Physical Exam/exam51

Vital signs and instability cues

›Physiologic risk stratification

›Hypotension and bradycardia pattern

›Neurogenic shock consideration

›High thoracic injury consideration

›Hypotension and tachycardia pattern

›Hemorrhage source search

›Concomitant trauma evaluation

›Tachypnea or hypoventilation

›High thoracic cord involvement consideration

›Chest injury coexisting consideration

Spine and soft tissue exam

›Local findings and skin risk

›Midline tenderness localization

›Step off or deformity

›Paraspinal spasm

›Ecchymosis patterns

›Seatbelt sign

›Flank bruising

›Open wound over spine

›Palpation pain out of proportion

Neurologic exam and localization

›Structured neurologic assessment

›Mental status baseline

›Cranial nerves if multisystem trauma

›Motor strength by key myotomes

›Hip flexion

›Knee extension

›Ankle dorsiflexion

›Great toe extension

›Ankle plantarflexion

›Sensory exam

›Light touch in dermatomes

›Pinprick if needed for level

›Reflexes and long tract signs

›Patellar reflex

›Achilles reflex

›Babinski response

›Clonus

›Rectal and perineal assessment when indicated

›Perianal sensation

›Voluntary anal contraction

›Bulbocavernosus reflex when feasible

›Gait if safe and no instability concern

PITFALLS

›Common misses

›Normal initial motor exam with evolving epidural hematoma

›Anticoagulant use increases risk

›Repeat neuro checks after analgesia

›Transverse process fracture as marker of high energy trauma

›Retroperitoneal injury association

›Renal injury association

›Chance fracture with minimal back tenderness

›Abdominal injury coexisting

›Posterior ligament complex injury occult

04Differential Diagnosis/ddx29

Traumatic spine conditions

›Thoracolumbar injury differential

›Compression fracture thoracic or lumbar ICD-10 S22.0 S32.0

›Osteoporotic wedge morphology

›Intact posterior elements

›Burst fracture thoracic or lumbar ICD-10 S22.0 S32.0

›Posterior wall retropulsion

›Canal compromise concern

›Chance fracture flexion distraction ICD-10 S22.0 S32.0

›Horizontal fracture through vertebral body or posterior elements

›Seatbelt mechanism association

›Transverse process fracture ICD-10 S22.0 S32.0

›Stable pattern typical

›High energy marker

›Spondylolysis spondylolisthesis ICD-10 M43.0 M43.1

›Pars defect

›Slip grading

Neurologic emergencies and mimics

›Red flag neurologic differentials

›Cauda equina syndrome ICD-10 G83.4

›Saddle anesthesia

›Urinary retention

›Conus medullaris syndrome SNOMED 399116008

›Early bladder dysfunction

›Mixed UMN and LMN signs

›Spinal epidural hematoma ICD-10 G95.1

›Anticoagulation exposure

›Acute progression

›Spinal epidural abscess ICD-10 G06.1

›Fever or bacteremia

›Severe back pain with neurologic change

05Laboratory Tests/lt21

Trauma and operative pathway labs

›Baseline studies when indicated

›Complete blood count for bleeding concern

›Hemoglobin trend in polytrauma

›Leukocytosis nonspecific

›Electrolytes and creatinine for contrast planning

›eGFR support for CT with contrast

›Rhabdomyolysis concern adjunct

›Coagulation studies for anticoagulation or planned procedure

›INR for warfarin

›Anti Xa level if local protocol for DOAC assessment

Targeted labs by scenario

›Infection or malignancy concern

›C reactive protein for epidural abscess screen

›Elevated supports inflammatory process

›Normal does not exclude early infection

›Blood cultures if febrile or septic

›Antibiotics timing after cultures when feasible

›Source control planning

›Rhabdomyolysis or crush concern

›Creatine kinase for prolonged immobilization

›Rising trend supports muscle injury

›Renal injury monitoring linkage

06Diagnostic Tests/dt71

Scoring Systems

›Thoracolumbar classification and decision tools

›TLICS thoracolumbar injury classification and severity score

›Injury morphology points

›Compression 1

›Burst 2

›Translation rotation 3

›Distraction 4

›Posterior ligament complex status points

›Intact 0

›Suspected 2

›Disrupted 3

›Neurologic status points

›Intact 0

›Nerve root injury 2

›Complete cord injury 2

›Incomplete cord injury 3

›Cauda equina 3

›Treatment implication thresholds

›Score 3 or less nonoperative typical

›Score 4 individualized

›Score 5 or more operative typical

›AO Spine thoracolumbar classification

›Type A compression

›Type B tension band injury

›Type C translation injury

›Meyerding grading for spondylolisthesis

›Grade I 0 to 25 percent slip

›Grade II 26 to 50 percent slip

›Grade III 51 to 75 percent slip

›Grade IV 76 to 100 percent slip

Radiographs

›Plain film pathways

›Thoracic and lumbar series when low risk and stable

›AP and lateral

›Focused level imaging by tenderness

›Alignment assessment

›Vertebral height loss percent

›Kyphosis angle estimation

›Indirect instability clues

›Widened interspinous distance

›Subluxation

›Spondylolysis evaluation

›Lateral view slip assessment

›Oblique pars view if protocol supports

MRI

›MRI indications

›Neurologic deficit with uncertain CT findings

›Cord compression

›Nerve root compression

›Posterior ligament complex evaluation

›TLICS scoring support

›Occult distraction injury

›Epidural hematoma evaluation

›Rapid neurologic progression

›Anticoagulation exposure

›Spondylolysis stress injury

›Bone marrow edema in pars

›Early detection before cortical break

›CT thoracolumbar spine

›High sensitivity fracture detection

›Burst fracture posterior wall definition

›Chance fracture bony components definition

›Indications

›High energy mechanism

›Midline tenderness with concerning exam

›Abnormal radiographs

›Distracting injury

›Canal compromise features

›Retropulsed fragment size

›Percent canal narrowing

›Adjacent injury mapping

›Transverse process fracture correlation with abdominal injury

›Rib fracture correlation with thoracic spine injury

07Disposition/dispo28

Admission and transfer criteria

›Disposition decision set

›Emergent spine consultation

›Any neurologic deficit

›Progressive symptoms

›Admission criteria

›Unstable fracture pattern

›Uncontrolled pain

›Inability to mobilize

›Polytrauma

›Transfer criteria

›Need for operative stabilization without local capability

›Suspected epidural hematoma with deficit

›Observation criteria

›Stable compression fracture with analgesia needs

›Frail patient fall risk

Discharge criteria and follow up

›Safe discharge framework

›Stable pattern on imaging

›Compression fracture without posterior element injury

›Isolated transverse process fracture with negative abdominal evaluation

›Normal neurologic exam

›No saddle anesthesia

›No urinary retention

›Mobility and function

›Ambulation with assistive device if needed

›Home support adequate

›Follow up timing

›Spine or orthopedics within 1 to 2 weeks for bracing plan

›Primary care for osteoporosis workup when fragility fracture

08Treatment/t119

Immediate life-saving interventions

›Immediate stabilization set

›Airway compromise pathway if needed

›Rapid sequence intubation when indicated

›Cervical precautions maintained

›Hemorrhagic shock resuscitation if present

›Balanced blood products

›Pelvic and long bone source control when applicable

›Neurologic emergency escalation

›Emergent MRI when deficit and compressive concern

›Emergent spine surgery consult for cauda equina concern

Immobilization and Splinting

›Spine immobilization and bracing

›Motion restriction principles

›Neutral alignment

›Avoid flexion and rotation

›Brace selection

›TLSO for stable compression fractures per specialist plan

›Jewett brace option for anterior wedge patterns per specialist plan

›Mobilization strategy

›Early mobilization when stable and pain controlled

›Bed rest avoidance when possible

›Reassessment after positioning

›Repeat neuro exam after logroll

›Pain trend after brace placement

Reduction

›Reduction considerations

›Thoracolumbar fractures rarely reduced in ED

›Specialist directed reduction only

›Avoid traction maneuvers

›Indirect stabilization

›Positioning for comfort without deformity creation

›Brace fitting by trained staff

›Post intervention checks

›Neuro exam after any move

›Pain escalation triggers repeat imaging

Open fracture medications and timing

›Open spine injury pathway when applicable

›Penetrating trauma or open wound over spine

›Broad spectrum antibiotics per trauma protocol

›Tetanus prophylaxis per immunization status

›CSF leak concern

›Neurosurgery consultation

›Meningitis risk monitoring

DVT prophylaxis when relevant

›Venous thromboembolism prevention

›High risk groups

›Spinal cord injury

›Prolonged immobilization

›Pharmacologic prophylaxis per trauma protocol

›Low molecular weight heparin typical choice

›Timing coordinated with spine surgery

›Mechanical prophylaxis

›Intermittent pneumatic compression

›Early mobilization when safe

Pain control and adjuncts

›Analgesia framework

›Nonopioid first line when possible

›Acetaminophen oral 1000 mg every 6 hours maximum 4000 mg per day

›NSAID use individualized

›Opioid for severe acute pain

›Hydromorphone IV titration pathway

›Initial dose 0.2 mg IV

›Repeat dose every 5 to 10 minutes to analgesia

›Hold for sedation or hypoventilation

›Typical total dose range 0.5 to 2 mg in ED

›Continuous monitoring when repeated dosing

›Naloxone availability

›Neuropathic pain adjunct when radicular

›Gabapentin oral 300 mg nightly

›Titration per outpatient plan

›Muscle spasm adjunct when appropriate

›Cyclobenzaprine oral 5 mg at bedtime

›Sedation risk counseling

Fracture pattern specific management

›Compression fractures

›Typical stability

›Anterior column involvement

›Posterior elements intact on CT

›Nonoperative typical pathway

›Analgesia and mobilization

›TLSO consideration per specialist

›Osteoporosis secondary prevention

›Calcium and vitamin D review

›Bone density referral

›Burst fractures

›Instability and neurologic risk assessment

›Retropulsion and canal compromise on CT

›Posterior ligament complex status on MRI when uncertain

›Operative consideration triggers

›Neurologic deficit

›Progressive kyphosis

›High TLICS score

›Nonoperative criteria typical

›Neuro intact

›Minimal canal compromise and stable alignment per specialist

›Chance fracture flexion distraction

›High suspicion features

›Seatbelt sign

›Horizontal split pattern on imaging

›Associated injury evaluation

›Abdominal CT when indicated

›Bowel injury vigilance

›Management typical

›Spine surgery consultation

›Operative fixation common with ligamentous injury

›Transverse process fractures

›Stability typical

›No spinal canal involvement typical

›Pain driven limitation

›Associated injury screening

›Hematuria evaluation when flank trauma

›Abdominal injury evaluation when high energy

›Treatment typical

›Analgesia

›Early mobilization

›Spondylolysis and spondylolisthesis

›Acute pars stress injury pathway

›Activity modification

›Physical therapy focus on core stabilization

›Slip progression risk

›High grade slip specialist follow up

›Neurologic symptoms escalation

›Imaging follow up

›MRI for early pars stress changes

›CT for pars cortical definition when needed

09Special Populations/sp30

Pregnancy

›Pregnancy considerations

›Imaging strategy

›MRI preferred for neurologic deficit when available

›CT when maternal benefit outweighs fetal risk

›Analgesia selection

›Acetaminophen preferred

›NSAID avoidance in later pregnancy per obstetric guidance

›Fetal assessment

›Obstetrics involvement for viable gestation

›Rh status evaluation if trauma with bleeding concern

Geriatric

›Older adult considerations

›Fragility compression fracture pathway

›Osteoporosis evaluation referral

›Fall risk assessment

›Delirium and sedation risk

›Opioid minimization

›Avoid benzodiazepines when possible

›Disposition threshold

›Lower threshold for admission

›Rehab planning early

Pediatrics

›Pediatric considerations

›Spondylolysis common in adolescent athletes

›Extension related pain pattern

›MRI for early stress injury

›Chance fracture mechanism risk

›Lap belt injury pattern

›Abdominal injury screening

›Growth and remodeling

›Specialist guided bracing decisions

›Return to sport clearance process

10Background/b54

Epidemiology

›Population patterns

›Compression fractures

›Osteoporosis association common

›Low energy mechanism common

›Burst and Chance fractures

›High energy trauma association common

›MVC and fall from height association common

›Transverse process fractures

›High energy marker

›Associated abdominal injury risk

›Spondylolysis and spondylolisthesis

›Adolescent athlete prevalence higher

›L5 level predominance

Pathophysiology

›Injury mechanics

›Compression fracture

›Axial load with flexion

›Anterior wedge collapse

›Burst fracture

›Axial load

›Posterior wall failure with retropulsion

›Chance fracture

›Flexion distraction around lap belt fulcrum

›Posterior ligament complex injury common

›Transverse process fracture

›Avulsion by psoas or paraspinals

›Rotational or lateral bending force

›Spondylolysis

›Repetitive extension stress to pars

›Stress reaction to fracture continuum

›Spondylolisthesis

›Pars defect with anterior translation

›Slip progression with growth and load

Therapeutic Considerations

›Stability concepts

›Three column model utility

›Anterior column

›Middle column

›Posterior column

›Posterior ligament complex importance

›Instability marker

›MRI role

›TLICS guided decision making

›Lower scores favor nonoperative

›Higher scores favor operative

›Neurologic outcome priorities

›Secondary injury prevention

›Avoid hypotension

›Avoid hypoxia

›Time sensitivity for compressive lesions

›Early decompression improves outcomes in selected cases

›Rapid progression warrants emergent imaging

›Evidence and guideline language

›CT as primary imaging in high risk blunt trauma

›Class I recommendation in many trauma protocols for high energy with tenderness

›Plain radiographs limited sensitivity

11Patient Discharge Instructions/pdi22

Copy discharge instructions

›Discharge instructions set

›Activity and mobility

›Avoid bending lifting twisting

›Walking as tolerated if cleared

›Brace care if prescribed

›Wear schedule per spine team

›Skin checks for pressure injury

›Pain control plan

›Acetaminophen schedule

›Opioid only for breakthrough pain

›Ice and heat guidance

›Ice first 48 hours if helpful

›Heat for muscle spasm after 48 hours if helpful

›Return to ED now

›New or worsening leg weakness

›New numbness in groin or buttocks

›New urinary retention or incontinence

›Fever with severe back pain

›Uncontrolled pain despite medications

›Follow up

›Spine or orthopedics appointment timing provided

›Family doctor for bone health workup when fragility fracture

12References/r17

Clinical guidelines and evidence sources

›Trauma and spine references

›ATLS principles for spine trauma evaluation

›Spine motion restriction in suspected injury

›Secondary survey focus on neurologic deficits

›TLICS classification original and validation literature

›Morphology PLC neurology decision framework

›Nonoperative versus operative thresholds

›AO Spine thoracolumbar classification references

›Type A B C framework

›Management implication mapping

›Emergency medicine and imaging references

›Trauma imaging protocols for thoracolumbar injury

›CT preferred in high energy mechanism with tenderness

›MRI for neurologic deficit or PLC assessment

›Evidence level notation

›ACEP Level C consensus for spine consultation in neurologic deficit

›Class I expert consensus for emergent decompression in cauda equina concern

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed March 6, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.