Surgical decision-making framework for the

Management of Thoracolumbar Injuries

Clinicians base their management decisions for clinical problems on a combination of evidence-based standards, personal experience, and the guidance provided by their mentors. Regrettably, there is a lack of widely accepted evidence-based guidelines for surgeons to follow when determining the most effective surgical treatments for thoracolumbar spine injuries.

In the case of a patient with a thoracolumbar spine injury, the surgeon is faced with the decision of whether or not to perform an operation as part of the treatment plan. In the event that an operation is deemed necessary, the surgeon must then determine if a decompression procedure should also be performed along with stabilization.

Additionally, our surgeons at Complete Orthopedics will make a decision regarding the most suitable approach for optimal achievement of the surgical objective, whether it be anterior, posterior, or a combination of both. When there is a lack of reliable scientific data to inform decision-making, expert consensus opinions are valuable.

The surgical management of thoracolumbar injuries can be guided by factors such as the morphology of the injury, neurologic status, and the integrity of the posterior ligaments. Typically, when neurologic deficits are incomplete and a posterior alignment fails to adequately alleviate the neurologic compromise, anterior decompression is considered as a suitable alternative.

In the majority of cases where there is a disruption of the posterior ligaments, a posterior approach is generally required. If both of these circumstances are present simultaneously, a combined 360 approach is warranted. While other characteristics of the fracture pattern may impact the approach selection, such instances are uncommon in comparison to the more typical presentations.

There is ongoing debate regarding the ideal surgical approach for the treatment of acute thoracolumbar spine injuries. The most reliable evidence of treatment superiority can be obtained by conducting multicenter randomized prospective clinical trials with a sufficiently large patient population to enable a direct comparison of outcomes between different treatment options.

When definitive studies are lacking to inform surgical decision-making, expert consensus opinions may hold some value. A group of experts in the area of spine trauma formed the STSG (Spine Trauma Study Group), which determined that the morphology of the injury, the patient’s neurologic status, and the integrity of the posterior ligaments were the most significant factors in determining the appropriate surgical treatment.

The guidelines outlined in this management scheme could assist surgeons in adopting a more objective approach to decision-making for thoracolumbar trauma and may also aid in promoting additional clinical research in this area.


When patients with an incomplete or undetermined neurologic status experience injuries to the thoracic or lumbar spine, a more aggressive treatment approach is generally recommended, which may involve a decompression procedure in order to optimize their chances for a complete recovery. Since the majority of thoracolumbar fractures result in anterior neural compression, decompression is typically most effectively achieved through an anterior approach.

Posterior decompression can be performed directly through the transpedicular or lateral extracavitary approaches. Although these techniques can achieve sufficient anterior decompression, they are complex and not typically considered routine procedures.

Indications for direct posterior decompression may include comminuted posterior elements resulting in symptomatic posterior neural compression, the evacuation of a posterior epidural hematoma, repairing dural tears associated with burst and lamina fractures, or when an anterior decompression is contraindicated. Pedicle screw instrumentation can indirectly decompress the anterior spinal canal via ligamentotaxis from a posterior approach.

Anterior Approach

Direct decompression of the spinal canal, restoration of anterior column stability, and re-establishment of normal sagittal contour can be achieved by the anterior approach in thoracolumbar spine injuries.

Anterior approaches are recommended in cases of complete neurologic injury with intact posterior ligaments as well as incomplete neurologic injury with intact posterior ligaments. Using an anterior approach in thoracolumbar spine injuries enables the surgeon to re-establish the spinal alignment by inserting structural support, such as allo/autograft or prefabricated prosthetic replacements, in the anterior region.

Moreover, by utilizing a stand-alone anterior approach, the need for fusion in multiple motion segments can be reduced to only one above and below the fractured vertebra. Opting for an anterior approach not only reduces the risk of iatrogenic damage to the posterior paraspinal muscles but also lowers the incidence of complications related to instrumentation and wound.

Injuries in the high thoracic or lower lumbar (L3-L5) spine are among the exceptions to the above indications. In such situations, the anterior approach may pose technical challenges due to the presence of major vessels, making instrumentation impractical.

The stabilization approach is preferred by many surgeons. A different approach involves first performing an anterior decompression, followed by posterior instrumentation for stabilization. The greater cross-sectional area of the spinal canal and absence of the spinal cord in the lumbar spine make a posterior approach more feasible and less risky for the neural elements than in the thoracic spine or thoracolumbar junction.

The following are factors that make an anterior approach less advisable:

  • severe pulmonary disease
  • severe chest or abdominal injuries
  • morbid obesity
  • prior abdominal surgery where anterior exposure can be difficult

Posterior Approach

The spine surgeon is familiar with the posterior approach in treating thoracolumbar spine fractures, which avoids important visceral and vascular structures and enables safe surgical re-exploration.

A posterior approach is appropriate in cases where there is distraction or translation morphology without neural compression or when neural compression can be relieved by reduction, isolated nerve root deficit with intact posterior ligaments, intact neurologic status with disrupted posterior ligaments, complete neurologic injury with intact posterior ligaments, or complete neurologic injury with disrupted posterior ligaments.

If significant comminution results in the loss of anterior vertebral body support, circumferential fusion may be necessary as a standalone posterior approach may lead to late kyphosis and instrumentation failure.

Combined Anterior and Posterior Approach

Circumferential procedures that involve both anterior and posterior approaches are recommended in cases of incomplete neurologic injury and disrupted posterior ligaments, and distraction or translation injuries where a secondary anterior decompression or stabilization is needed after initial posterior stabilization. An anterior approach enables effective decompression and reconstruction of the vertebral column.

Although the anterior approach allows for effective decompression and reconstruction of the vertebral column, it may not be sufficient in resisting additional flexion forces in cases where the posterior ligaments have been compromised. Therefore, it is crucial to have an additional posterior approach to reconstruct the tension band.

A combined anterior and posterior approach may be required in certain situations such as significant osteoporosis, which necessitates internal fixation both anteriorly and posteriorly, or in cases of low lumbar or high thoracic injury where anterior instrumentation is unsafe due to anatomic limitations.

You have arrived at the appropriate location if you want to learn more about Surgical Decision-Making Framework For The Management Of Thoracolumbar Injuries!

Call Us Now!

Based on 107 reviews
Dr. Nakul Karkare is awesome! And patriotic! Thank you, Dr. Karkare for displaying the American Flag in your waiting room, honoring and mourning our military personnel, this Memorial Day, who died while serving in the United States Armed Forces.
00:52 30 May 23
Excellent and skilled orthopedic practice specializing in joint replacements. Dr Karkare was trained at the Hospital for Special Surgery and has excellent results, as do his associates!! Would gladly refer family members to the practice!!
00:24 30 May 23
I had such a wonderful experience with Complete Orthopedics in Stony Brook. Not only did Dr. Kuo fix my broken wrist with such kindness and care, but the office staff, including Billing, Reception and the X-Ray Technician, was always so helpful, going out of their way to ensure that each patient felt welcome, answering any questions with a smile, and ensuring any issues with insurance/billing were handled with the utmost professionalism. I highly recommend their practice!
Victoria DeMatteo
19:49 10 May 23
I'm very happy St. Catherine's sent me to this office for treatment after I broke my collar bone! Unfortunately the break was too severe to repair on its own and I had to have it rebuilt a week after the injury. Dr. Vaksha did a great job fixing it. I'm three months out, and I have full use of the arm and shoulder. The whole office staff is very professional, accommodating, and welcoming. I hope to not need orthopedic services again, but Dr. Vaksha will be my number one choice if I or anyone in family suffers such am injury.
Tina Rivera
20:42 08 May 23
No one likes going to the doctor. But these people make it painless. I go for knees, hips and shoulders. At almost 70 Complete Orthopedics keeps my active life style running smoothly. Whether chasing my Grandson and even surfing again, I highly recommend them!!
Thomas Slavin
15:02 02 Mar 23
Dr. Kuo knowledgeable and competent surgeon- very good experience and more importantly great result.
Joseph McCoy
21:23 25 Feb 23
Dr Vaksha was so kind and helpful. He took extra time with us and explained things so thoroughly. Highly recommend. Office very clean.
Susan Bosinius
20:20 19 Feb 23
Dr Vaksha, is a great doctor very professional knows what he talking about. Treat patient with upmost respect. Thank You
Troy Spencer
16:46 19 Jan 23
Dr. Karkare is an amazing doctor, very caring and attentive, the girl at the front desk is very kind and helpful. .elizabeth .thank you so much .
blanca ventura
21:32 26 Oct 22
Been going to this place before my accident and after I had my knee surgery. So happy how I been treated and how well I am getting. Thank you all and specially Dr. VAKSHA for everything and getting back on track.
Ita Opico
19:01 25 Oct 22
Love this place From the minute I called I was treated kindly. When I arrived The Dr saw me right away he was compassionate and ordered the appropriate tests for me. I came back in for my follow up and had the same great experience.
Christine Rostock
21:28 23 May 22
Dr Vaksha and Dr karkare are 2 of the best orthopedic doctors around my wife Susan had a very serious broken ankle in March of 2019 she didn't think she was going to walk again Dr vaksha did an excellent surgery on her ankle he said it was his toughest he ever did he put a lot of hardware in her ankle and told her she would be alright she made remarkable recovery thanks to his surgery as of now she regained 100 percent use of her ankle she would highly recommend him to anyone. My own experience with Dr karkare has been wonderful he takes his time with you listens to what you have to say and prescribes various treatments and is very caring I would highly recommend him to anyone I would give both doctors a 10 plus rating we are very happy with them the best.
Harry Jones
23:31 19 May 22
Complete orthopedics is a wonderful place to go when you hurt or injured a great staff and wonderful doctors very knowledgeable and helpful I would recommend this place to all of my family and friends that is in me of orthopedic care I give them 10 thumbs up
Wayne Pemberton
17:39 18 May 22
The staff is very professional and helpful. Dr. Vaksha is excellent. He takes time to listen and offer suggestions to help you get better. I’m very thankful and happy to be a patient here at Complete Orthopedics.
Phoenix Rising
19:54 16 May 22
Dr.Karkare is the best. He listens to everything and explains everything I recommend him to everyone. I am so happy he is my doctor.
Myrna James
00:48 13 May 22
Dr.Kuo is amazing very attentive,caring,and passionate and staff is awsome too.Thank you for everything Dr.kuo.
Erick Murillo
23:17 12 May 22
I was in a car accident November 1 I was referred to Dr. Vaksha For shoulder surgery . I he was amazing he made me feel very comfortable and explained everything that was going to happen from surgery all the way through my physical therapy highly recommend Dr. Vaksha
Yolanda Ojeda
19:37 09 May 22
My appointment with Dr. Vaksha was amazing. Dr. Vaksha was very thorough and kind. I would refer this office to anyone who needs a great orthopedic doctor.
John Senechal
19:54 05 May 22
Scheduling my appointment was quick and easy. The staff was super friendly and down to earth. I was seen on time. The appropriate test, “x-rays” were taken before the conversation with doctor, something I really liked, test for analysis and conversation was done upfront. Dr. V had a great personality and was no BS, straight forward diagnosis and a play on next steps. I am happy I found them and would refer them to friends and family.
00:46 03 May 22
I have seen Dr. Kuo two times already and he's awesome along with his staff. Very friendly office and I'm glad to be a patient here.
Camaris A
20:01 28 Apr 22
Amazing team!! Very caring, profesional, and friendly!! Dr. Kevin Kuo, you are the best, very passionate, caring, and helping thank you for getting me better and being so kind to me! Elizabeth you the best thank you for you help always and you big smile and positive actitud❤️🙏🏼
breidy valerio
19:01 22 Apr 22
The staff is truly exceptional, they make you feel comfortable and welcomed. The doctors are amazing,always professional, compassionate and great listeners.
Elizabeth Collado
03:25 09 Apr 22
What a great place! The place is clean and organized.The staff is wonderful. Setting up physical therapy is right there as well.I'm so glad I found this place.
Donna Anne
22:45 05 Apr 22
This was my 1st time breaking something in my 27 years on this planet. I was recommended here by a friend Dr. Vashka helped me from day 1 and still continues to check in on me and my healing ankle. Would highly recommend
tyron davis
16:06 01 Apr 22
Brand new office, same great doctors! Rooms are clean, plenty of parking, physical therapy attached, Dr. Karkare and his staff are awesome. Thank you!
Emily B
02:49 24 Mar 22
Dr.VAksha is the best, I love the way he treats me as his patient, he is caring,understanding and very attentive to my needs
Mirna Caballero
14:53 03 Mar 22
Great staff. Dr. Vaksha is awesome and takes the time to listen to his patients. He is very compassionate. I would highly recommend this office.
Bebe Doyle
01:24 23 Feb 22
After suffering from a severe ankle injury Dr. V was able to help me heal and return back to work completely to a job where I stand for 12 hours a day. The office is very clean and I appreciated the reminders of my appointments via phone call and through text. The patient portal made it easy for me to access all my documents including work notes. The office staff is wonderful and Rebecca was able to schedule me with a busy schedule and awesome at answering all of my questions including referring me to a great physical therapy office. I highly recommend this office to anyone who’s looking for knowledgeable and kind orthopedic office.
Elizabeth Birchwell
21:31 28 Jan 21
The staff here are great, I was seen at the time of my appointment and was well taken care of!
Shaun Berry
18:14 07 Jan 21
They are an excellent practice. The front and back office people are amazing and so helpful. Rebecca is such a kind and understanding person. I had an issue with paperwork and she cleared it right up. Dr. Karkare is very knowledgeable, helpful, and caring.
Matt S.
19:31 18 Nov 20
Rebecca K. - What a true burst of sunshine. Very friendly and definitely an asset to the practice!
Laura Aston
18:17 17 Nov 20
Great experience, the Doctor is nice but the staff is incredible. I worked with Linda, who was profession and assisted me beyond what any person has done at other practices. Complete Ortho should be complimented for having such a person on their staff.I highly recommend this place!!!
Joe Allen
17:26 17 Nov 20
Linda and Becca they are so good ever time I come they are very nice I would tell everyone I no to come to this office..
Barbara Victor
16:45 17 Nov 20
I was rear ended in an auto accident , Dr Vashka was recommended by a friend of mine .I was experiencing Back , neck , and shoulder pain . After a thorough examination and given exercises to do at home , I am feeling much better , and I ended up avoiding surgery . The staff at Complete Ortho is extremely attentive and show great care when making an appointment and are very friendly and i never waited more than 5 minutes for my appointment . So I would strongly recommend Complete Orthopedics for any aches and pains that one might be experiencing.....
Bill Becht
04:44 17 Nov 20
It was the afternoon of Friday Sept. 24. We were in Pt. Jefferson and my wife, Mary Ann, broke her hip. We went to Mather Hospital and it was determined that she would have to have an operation to have it repaired. This would be her third time under the knife in the past year. It just so happened that we were very fortunate enough to have Dr. Karkare, who was on standby, perform the surgery. He put in a rod and two screws in her hip. She spent a few days in the hospital and then went to Gurwin rehabilitee for another few weeks.It has now been almost six weeks and we both worked the election the other day. If it wasn’t for Dr. Karkare’s expertise she never would have been able to work. She is able to walk with a walker and is doing physical therapy three times a week.We can not thank the doctor enough for the compassion and dedication that he puts into his work. It allows Mary Ann do the things that she likes to do, even on a limited basis for a while. I know that with her will, perseverance and the great work that the surgeon performed she will be back on her feet in no time.Sincerely:John V. PlumpEast Northport, NY 11731
Jack Harris
14:36 06 Nov 20
In the year of 2018 I was referred to Dr. Karkare because I was experiencing severe knee joint pain. After exhausting physical therapy and trying to labor through the pain, I had to make a quality of life decision. Total knee replacement was the only viable option. Dr. Karkare made my decision easy as he walked me through the whole process from surgery to recovery.On 12/13/19 ( Friday the 13th) I enter Lenox Hill Hospital in great hands. From the time I entered Dr. Karkare’s office for the first time until now, his staff has been amazing. Andrea the medical coordinator walked me through all the paper work and necessary preparations for the surgery. Courtesy and kind would be an understatement. Dr. Karkare went over and beyond from the wellness checks and phone calls all to assure me that I was important to him. This was the right decision no pain and no limp. Complete Orthopedics should be your choice!
Kenneth Randolph
22:18 25 Sep 20
Dr. Vadshka has a great bedside manner. He really takes his time and explains treatment options.
T Lee
12:33 09 Sep 20
I suffered with pain in both knees for years. My orthopedic doctor kept recommending knee replacement . I fought it for years, as I was just afraid. When I had no choice and could barely walk , it was recommended I see Dr. Karkare. We set up a consultation and my wife and I left his office feeling totally confident and comfortable with moving ahead with the surgery. He explained everything to us, and the office staff set everything up for us and made the process easy. So about one month after our initial meeting I had the first knee done. I was up walking mere hours after the surgery, and on the workout machines the next morning. I went home two days after the surgery, and yes walked my daughter down the aisle at her wedding only one week after the surgery without even a cane! Three months later I had the other knee done and went home the very next day. Dr. Karkare put my fears to rest . I would highly recommend him. His expertise gave me my life back. Thank you Dr. Karkare.SincerelyVito Congro
Ethel Congo
23:58 12 Aug 20
Dr Rhodin really cares for his patients. When I see him he makes sure to review my progress in detail.
Micki Cahill
15:03 08 Feb 20
My mom had a total hip replacement by dr karkare. He is the BEST orthopedic doctor.Her incision is almost invisable.She is going back for her other hip next week. The office staff is the best, love Andrea.You wont find a better doctor.
Ryan Brigandi
21:06 13 Jul 18
There is no better Orthopedic doctor you will find. Broke my ankle three places on a Saturday. Called Dr. Karkare. He had is team ready at the hospital and operated on me within 6 hours after my injury. Now After 3 months of great care by him and his staff, I am walking to normalcy.
Spacecom Tel
04:13 23 Mar 18

I am Vedant Vaksha, Fellowship trained Spine, Sports and Arthroscopic Surgeon at Complete Orthopedics. I take care of patients with ailments of the neck, back, shoulder, knee, elbow and ankle. I personally approve this content and have written most of it myself.

Please take a look at my profile page and don't hesitate to come in and talk.