Approach to a Patient with Low Back Pain and Multiple Thoracolumbar Vertebral Fractures

1. Initial Resuscitation — ATLS Framework

• Secure airway and breathing first
• Address hemodynamic instability — distinguish neurogenic shock (hypotension + paradoxical bradycardia, absent sympathetic response) from hypovolemic shock (hypotension + compensatory tachycardia). Both may coexist; most polytrauma patients have at least a hypovolemic component
• Full spinal precautions from first contact: rigid backboard + cervical collar until spinal injury is definitively ruled out. Remove the backboard promptly after imaging to prevent decubitus ulcers (especially critical in neurologically impaired patients)

2. History

• Mechanism: motor vehicle collision (most common, 36.7%), fall from height (31.7%), or low-energy fall in elderly/osteoporotic patient
• Bimodal age distribution: young males (<30 yrs, high-energy) vs. elderly with poor bone quality (low-energy)
• Onset, radiation, and character of pain
• Neurologic symptoms: leg weakness, numbness, saddle anesthesia, bowel/bladder dysfunction, priapism
• Comorbidities: osteoporosis, ankylosing spondylitis, malignancy, prior spinal surgery

3. Physical Examination

General Examination

• Log-roll technique (one person stabilizing cervical spine + two stabilizing torso and lower extremities, moved as one unit)
• Inspect for soft tissue injuries, step-off deformity, ecchymosis
• Palpate the entire spine for tenderness, gaps, or malalignment

Neurological Examination

• Complete motor + sensory examination in dermatomal distribution (pinprick and light touch)
• Assess perianal sensation — this may be the only sign of sacral sparing (incomplete injury), a critical positive prognostic finding
• Bulbocavernosus reflex: absent reflex suggests the patient is in spinal shock (any assessment of completeness is unreliable until spinal shock resolves)
• Hyperreflexia/hyporeflexia to differentiate cord vs. nerve root injury (note: hyperreflexia is typically absent in the acute phase even with upper motor neuron injury)
• Priapism — ominous sign of complete sensory and motor deficit

ASIA Impairment Scale (AIS) — Classify Severity

Syndrome Recognition

4. Associated Injuries

• Thoracic spine fractures associated with: rib cage (47%), lumbar spine (26%), cervical spine (25%), lungs (35%), intracranial (24%)
• Lumbar spine fractures associated with: rib cage (38%), thoracic spine (22%), pelvic ring (20%), lungs (26%), intracranial (19%)
• Overall mortality strongly correlated with injury severity score

• Cardiovascular: orthostatic hypotension, autonomic dysreflexia
• Pulmonary: respiratory failure, pulmonary edema
• Urologic: neurogenic bladder, UTI, renal failure
• GI: neurogenic bowel dysfunction
• Musculoskeletal: spasticity, heterotopic ossification, disuse osteoporosis

5. Imaging

CT Scan — First-line

• High-resolution CT with 3D reconstruction is the primary imaging modality (plain X-ray no longer recommended as first-line)
• Usually reconstructed from CT chest-abdomen-pelvis (simultaneous screening for visceral injuries)
• Delayed/missed diagnosis in 5–24% of patients without appropriate imaging — can cause devastating neurologic deficits in unstable injuries

• Sagittal and coronal spinal alignment
• Rotation or translation
• Denis three-column integrity (anterior, middle, posterior)
• Vertebral body height loss (measure as ratio vs. intact adjacent level)
• Widened interpedicular distance → burst fracture
• Increased interspinous distance → posterior tension band injury
• Posterior cortex involvement → burst fracture (vs. simple compression fracture)

Plain Radiographs (adjunct)

• AP + lateral views
• Upright films help guide management decisions
• Useful for assessing regional kyphosis angle

MRI — Mandatory with Neurological Deficit

• Evaluate for cord compression, cord signal change, disc herniation, posterior ligamentous complex (PLC) injury
• Assess dural integrity (traumatic durotomy)
• Supine MRI may underestimate deformity (upright positioning often worsens kyphosis)

6. Fracture Classification

AOSpine Thoracolumbar Classification (current standard)

• N0: Intact
• N1: Transient deficit
• N2: Radiculopathy
• N3: Incomplete SCI
• N4: Complete SCI
• ND: Unable to determine

• M1: Posterior ligamentous complex injury
• M2: Metabolic bone disease (osteoporosis, ankylosing spondylitis)

Denis Classification (historical reference)

• Three columns: anterior (ALL + anterior 2/3 vertebral body), middle (posterior 1/3 + PLL), posterior (pedicles, facets, spinous process, supraspinous ligament)
• Failure of two or more columns = unstable fracture

7. Management

Non-operative

• Neurologically intact patients with stable fractures (no significant column disruption)
• Elderly/osteoporotic patients with limited deformity
• Compression fractures without significant kyphosis (<30°) or height loss (<50%)

Operative Indications

• Progressive neurological deficit
• Incomplete SCI (urgent decompression, especially within 24 hours)
• Complete SCI (may benefit from early decompression)
• Unstable fractures (Type B/C AOSpine; two- or three-column failure)
• Kyphosis >25–30° or >50% vertebral height loss
• Significant spinal canal compromise with deficit
• Failure of conservative management

Surgical Principles

• Posterior approach: open or minimally invasive pedicle screw fixation ± laminectomy for decompression
• Anterior approach: corpectomy + interbody fusion (for significant anterior column deficiency — but risk of subsidence in osteoporotic bone)
• Combined anterior-posterior: for highly comminuted burst fractures, three-column injuries, or when anterior column support is inadequate for posterior fixation alone
• In osteoporotic patients, stand-alone anterior procedures carry high risk of cage subsidence and kyphosis progression — supplemental posterior fixation strongly recommended

Important: In ankylosing spondylitis or DISH, fractures behave like long-bone fractures — highly unstable, prone to neurological deterioration; low threshold for surgical stabilization. A 2026 meta-analysis (PMID 40921017) found minimally invasive surgery has advantages over open surgery for thoracolumbar fractures in ankylosing spinal disease.

8. Post-acute Management

• Methylprednisolone for SCI: evidence remains controversial; not universally recommended in current guidelines
• DVT prophylaxis: mechanical compression + LMWH (begin 24–72 hrs post-injury or post-op)
• Bladder management: intermittent catheterization preferred over indwelling catheter
• Bowel program: establish early to prevent ileus and obstruction
• Pressure ulcer prevention: frequent turning, pressure mattress
• Rehabilitation: multidisciplinary — physiotherapy, occupational therapy, pain management, psychological support
• Osteoporosis treatment if underlying metabolic bone disease (bisphosphonates, teriparatide)

Summary Algorithm

Multiple TL Fractures + Low Back Pain
           ↓
ATLS → Resuscitation → Spinal precautions
           ↓
History + Neurological exam → ASIA grade
           ↓
CT (primary) + MRI (if neuro deficit)
           ↓
AOSpine classification (A/B/C + N modifier)
           ↓
Stable, intact neurology? → Conservative (brace + physio)
Unstable OR neuro deficit? → Surgical (decompress + stabilize)
           ↓
Post-op: DVT, bladder, pressure care, rehabilitation