I think if the  spine fracture heals with the conservative treatment it is better to treat it conservatively till the maturity of the foetus, but the seveirity fracture is much more and it is involving the nerve elements then we have to think the operative option.one should think the health of mother and baby both its ideal,if seveirity of diseaes is comprmising mothers health then give priority should be weighed.

It depends on fracture type and neurological status. We have dealed with a similar condition; a Garden type IV collum femoris fracture in a 3rd trimester pregnant lady. Our patient underwent an urgent open surgery on a fracture table in supine position w/o fluoroscopic guidance. Unfortunately the fracture did not heal. The patient underwent a valgisation osteotomy in post-partum 3rd month. The fracture healed 3 months after the osteotomy.

We published 2 consecutive cases with thoracolumbar distraction fractures in advanced pregnancy in 2000. As no neurologic deficit was present we preferred conservative treatment. After happy delivery we found segemental instability in both cases which required surgical treatment with compressive posterior instrumentation.

See below: 

Thoracolumbar distraction fractures in advanced pregnancy: a contribution of two case reports.

Tanchev P. et al

Department of Spine Surgery, Gorna Bania University, Orthopaedic Hospital, Sofia, Bulgaria. European Spine Journal (Impact Factor: 2.47). 05/2000; 9(2):167-70. DOI: 10.1007/s005860050229

Source: PubMed

I have  experience about  vertebrae fractures due to low bone quality with  some endocrinal changes after the delivery. The same mechanism may play important role in third trimester. Intractable pain is the most charecteristic finding. MR is the less hazardous examination  in this triemester and best diagnostic tool. If  it is diagnosed fracture, mostly superior end plate fracture, small amount of bone cement injection help to keep vertebral heighed. Bedrest is also very important to prevent loading of spine in daily life. After the delivery, endocrinal disturbances are getting better slow by slow. In this stage treatment of osteoporosis should be necessary.

I had 2 cases where a surgical decision was taken with posterior fixation. But neither one of us, family and myself, new she was pregnant. Nothing happened with the child.

If this situation comes to me, with a known pregnancy, I would try to evaluate and classify the fracture on MRI. For stable fractures I would be conservative. Grossly unstable fractures where the SC might be at risk, must be surgically approached.

Dr. Ozer, the discussion tackles the problematics of traumatic spinal fractures and not pathological ones like those in osteoporosis. Anyway, I find your idea of vertebrplasty in advanced pregnancy interesting. On the other hand I think the rate of thromboembolic complications would be a serious issue ?

Dr. Vialle, your cases might have been in early pregnancy where diagnosis of pregnancy was missed. Here there are other problems concerning organogenesis and eventual malformations of the embryon. Probably there are many similar cases. 

Otherwise, I agree entirely with your considerations in paragraph 2.

I would recommend conservative treatment unless surgery is unavoidable because of the type of fracture (namely if clinically relevant neurological compression exists). In fact, I would recommend the same approach in any (otherwise healthy) woman in this (fertile) age range, irrespective of whether she is pregnant or not.

Based on the best available evidence I am aware of, it is difficult for me to see a place for vertebroplasty in clinical practice (see N Engl J Med. 2009;361:569-79 or N Engl J Med. 2009 Aug 6;361(6):557-68)

:Dear Dr. Kovacs, I agree with you as far as vertebroplasty  in traumatic vertebral fractures is concerned. I believe one should use other methods to ensure good healing through natural bone regeneration especially in young people. Probably vertebroplasty and kyphoplasty could be used in cases with pathologic fractures of the spine - osteoporosis, metastases, etc.

Dear Mr. Panayot Tanchev , 

It depends wether the fracture is stable or not. If it's not stable it needs immediate stabilization irrespective of pregnancy status.  If it's a stable fracture it can be initially managed conservatively till delivery followed by through evaluation for instability and decide further course of action following delivery. 

Dear Dr. Maila,

My observations are that the thoracolumbar fractures in advanced pregnancy are usually of distraction type (seat belt fractures) and usually affect the disco-ligamentous structures.This is explained with the role of the gravid uterus (foetus) which transforms the bending force into distraction / extension to the posterior structures.

As you  know this type of fractures are unstable only in direction of flexion. So in supine position (slight extension) they are stable. On the other hand the injured soft-tissue has a poor tendency to healing. Furthermore, often no neurologic deficit is present. 

My tactics in similar cases is stabilization to be postponed for the time after delivery which usually takes about 2-3 months of bed rest. I think it is a safer protocol. On the contrary, if incomplete palsy is present the surgical decompression and stabilization should be undertaken on emergency basis.