Surgical decision-making framework for the

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.

Decompression

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.

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