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Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.

Thoracolumbar fracture patterns

Musculoskeletal medicine and orthopaedics · UK scope · Sources checked 27 Aug 2026 · Clinical review pending

RapidFull
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Unstable fracture with neurological compromise

Burst, distraction, translation and ankylosed-spine fractures can compress cord, conus or cauda equina and may deteriorate with shock, transfers or uncoordinated movement.

Action: Maintain the safest spinal alignment, run ABCDE, document motor, sensory and sacral function, treat haemorrhage, obtain urgent complete CT and MRI when neurology is attributable to spinal injury, and involve spinal surgery immediately for deficit, canal compromise or mechanical instability.

Synopsis

Recognise stable and unstable thoracolumbar injury patterns, examine cord and cauda equina function, select CT and MRI stepwise, and protect alignment while specialist operative or non-operative care is agreed.

  • Use mechanism and full-spine examination: a single painful level does not exclude non-contiguous fracture, particularly with high energy or an ankylosed spine.
  • Document leg myotomes, dermatomes, reflexes and sacral sensation, deep anal pressure and voluntary contraction when cord, conus or cauda equina injury is possible.
  • Compression wedge affects mainly anterior body; burst includes posterior-wall failure and retropulsion; flexion-distraction fails the posterior tension band; translation or rotation is highly unstable.
  • CT with multiplanar reformats is the preferred acute test in adults when thoracolumbar imaging is indicated and defines bone, alignment and canal fragments.
  • MRI follows CT urgently for neurological abnormality attributable to spinal injury and helps define cord, conus, cauda equina, disc, epidural and posterior-ligament damage.
  • Maintain the patient's pre-injury alignment in ankylosing disease; forcing a kyphotic spine flat can displace an unstable extension fracture.
  • Stable compression patterns without neurology may receive analgesia and early specialist-guided mobilisation, while instability, deformity, canal compromise or deficit often requires surgical stabilisation or decompression.
  • Search for abdominal injury with Chance-type lap-belt fractures and for osteoporosis or malignancy after low-energy or pathological patterns.

    • Key red flags

    New leg weakness, sensory level, saddle anaesthesia, urinary retention, reduced anal tone or bilateral radicular pain indicates cord, conus or cauda equina compromise requiring emergency MRI and spinal review.

    High-energy flexion-distraction, translation or axial-load mechanism, palpable step, widened interspinous gap or CT posterior-ligament concern suggests unstable multi-column injury.

    Ankylosing spondylitis, DISH, osteoporosis, long-term steroids or cancer creates unstable or pathological fracture risk after minor force and warrants a low threshold for whole-spine CT.

    Investigation priorities

    01
    Preferred CT thoracolumbar spineFirst stepPreferred

    Define acute bone morphology, alignment and canal compromise.

    Management branches

    ImmediateProtect, examine and image

    Thoracolumbar pain, high-risk mechanism or neurological symptoms follow trauma.

    1. Run ABCDE, control haemorrhage and maintain the safest alignment using coordinated transfer, especially in ankylosing disease.
    2. Examine the whole spine and document motor, sensory and sacral function, bladder symptoms and abdominal signs.
    3. Obtain complete CT with multiplanar reformats and urgent MRI when neurology is attributable to cord, conus or cauda equina injury.
    4. Discuss instability, deficit, deformity and associated abdominal injury promptly with spinal and trauma specialists.
    DefinitiveChoose stable or unstable pathway

    Imaging and repeated examination define morphology, neurology and posterior-ligament concern.

    1. For a stable compression pattern without deficit, provide analgesia and specialist-guided early mobilisation, with an orthosis only when it serves a defined purpose.
    2. For distraction, translation, unstable burst, progressive deformity or ankylosed-spine fracture, maintain protection and plan operative stabilisation.
    3. Use decompression when clinically relevant neural compression and deficit warrant it, coordinated with fixation and overall trauma physiology.
    4. Treat abdominal, chest, pelvic and pathological-bone causes in parallel rather than viewing the vertebra in isolation.

    Key medicines

    Paracetamol as baseline fracture analgesiaGive 1 g orally four times daily at intervals of at least 4 hours, maximum 4 g in 24 hours; reduce the maximum for body weight below 50 kg, frailty, malnutrition, chronic alcohol excess or liver impairment.Check all combination products and hepatic risk, and do not let pain suppression substitute for repeat neurological examination or investigation of worsening deformity.
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    Sources and review status4 sources · checked 27 Aug 2026 · clinical review pending+
    Sources

    Sources and review status

    National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.

    • NICE NG41 Spinal injury: assessment and initial management
    • BOASt assessment of the spine in the trauma patient
    • BOASt the management of traumatic spinal cord injury
    • Paracetamol 500 mg tablets Summary of Product Characteristics

    Editorial contact: Doctor’s Passport editorial team. Source-check date is separate from clinical approval. Report a content problem · Content changes

    Authoring stateRapid draftClinical stateAwaiting reviewJurisdictionUnited Kingdom