Evaluation and treatment of patients
with Thoracolumbar Spine Trauma
Roughly 7% of all blunt trauma patients experience traumatic injuries in the thoracic and lumbar spine, commonly referred to as ‘thoracolumbar.’ These injuries make up 50% to 90% of the 160,000 traumatic spinal fractures that occur in North America each year.
The extended care required for patients who have sustained persistent disability as a result of thoracolumbar trauma imposes a substantial strain on the healthcare resources of society. The term “thoracolumbar” encompasses three separate regions of the spine:
- the inflexible thoracic spine (T1-10)
- the transitional thoracolumbar junction (T10-L2)
- the flexible lumbar spine (L3-5)
The care of these patients is still a matter of debate as there is no agreement on several aspects, such as how to classify them, how to evaluate them, how to provide medical care, and the intricacies of surgical intervention.
By utilizing the available evidence base and a strict guideline elaboration methodology, the workgroup consisting of the American Association of Neurological Surgeons (AANS)/Congress of Neurological Surgeons (CNS) Section on Disorders of the Spine and Peripheral Nerves and the Section on Neurotrauma and Critical Care has developed a clinical practice guideline for the treatment of patients with thoracolumbar trauma.
Classification of Injury
To enhance the communication between treating physicians and achieve a better understanding of traumatic thoracolumbar injuries, it is recommended to employ a classification system that utilizes clinical data that is readily available, such as computed tomography scans with or without magnetic resonance imaging.
The Thoracolumbar Injury Classification and Severity Scale or the AO Spine Thoracolumbar Spine Injury Classification System are examples of such classification schemes that convey injury morphology.
Providers may consider using magnetic resonance imaging to evaluate the integrity of the posterior ligamentous complex when making decisions about surgery since it has been demonstrated that magnetic resonance imaging can impact the management of as many as 25% of patients with thoracolumbar fractures.
Several neurological assessment scales, such as the Sunnybrook Cord Injury Scale, Frankel Scale for Spinal Cord Injury, and Functional Independence Measure, have exhibited internal reliability and validity in treating patients with thoracic and lumbar fractures.
The initial American Spinal Injury Association Impairment Scale grade, sacral sensation, ankle spasticity, urethral and rectal sphincter function, and AbH motor function are potential predictors of neurological function and outcomes in patients with thoracic and lumbar fractures.
After reviewing previously published literature, the task force has determined that the potential complications of methylprednisolone should be thoroughly evaluated before deciding to administer it.
In an effort to enhance neurological outcomes, clinicians may opt to maintain mean arterial blood pressures above 85 mm Hg.
Prophylaxis and Treatment of Thromboembolic Events
To minimize the risk of venous thromboembolism events in patients with thoracic and lumbar fractures, the use of thromboprophylaxis is recommended.
Whether or not to use an external brace for nonoperative management of neurologically intact patients with thoracic and lumbar burst fractures is up to the treating physician, as both approaches result in comparable improvement in outcomes. Additionally, bracing does not lead to higher rates of adverse events in comparison to not bracing.
Operative vs Nonoperative Treatment
The evidence regarding the effectiveness of surgical intervention in improving clinical outcomes for neurologically intact patients with thoracolumbar burst fracture is inconclusive. Therefore, it is recommended that the treating provider use their discretion to decide whether surgical intervention is necessary for the presenting thoracic or lumbar burst fracture in neurologically intact patients.
Timing of Surgical Intervention
To reduce length of stay and complications, early surgery may be an option for patients with thoracic and lumbar fractures. However, the definition of “early” surgery varies inconsistently in the available literature, ranging from less than 8 hours to less than 72 hours after the injury.
When treating patients with thoracolumbar burst fractures surgically, physicians have the option to use an anterior, posterior, or combined approach as there is no apparent impact on clinical or neurological outcomes associated with the selection of approach.
There is conflicting evidence regarding the comparison among approaches in the surgical treatment of patients with thoracolumbar fractures, thus physicians may opt to use an anterior, posterior, or combined approach to achieve radiological outcomes.
When it comes to surgical treatment of patients with thoracolumbar fractures, there is conflicting evidence regarding which approach (anterior, posterior, or combined) is associated with fewer complications. Therefore, physicians may choose any of these approaches.
Novel Surgical Strategies
It is recommended that surgeons should be mindful that adding arthrodesis to instrumented stabilization in the surgical management of thoracolumbar burst fractures has not been demonstrated to affect clinical or radiological outcomes.
Furthermore, this approach may lead to greater blood loss and a longer duration of surgery. Equivalent clinical outcomes have been suggested by the evidence, and thus the use of both open and percutaneous pedicle screws for stabilization may be considered in the treatment of thoracolumbar burst fractures.
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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.
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