Evaluation And Treatment Of Patients With Thoracolumbar Spine Trauma
Publication Date: January 1, 2019
Last Updated: March 14, 2022
RECOMMENDATIONS
Classification of Injury
A classification scheme that uses readily available clinical data (eg, computed tomography scans with or without magnetic resonance imaging) to convey injury morphology, such as Thoracolumbar Injury Classification and Severity Scale or the AO Spine Thoracolumbar Spine Injury Classification System, should be used to improve characterization of traumatic thoracolumbar injuries and communication among treating physicians. (B)
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There is insufficient evidence to recommend a universal classification system or severity score that will readily guide treatment of all injury types and thereby affect outcomes. (I)
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Radiological Evaluation
Because magnetic resonance imaging has been shown to influence the management of up to 25% of patients with thoracolumbar fractures, providers may use magnetic resonance imaging to assess posterior ligamentous complex integrity, when determining the need for surgery. (B)
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Due to a paucity of published studies, there is insufficient evidence that radiographic findings can be used as predictors of clinical outcomes in thoracolumbar fractures. (I)
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Neurological Assessment
Numerous neurological assessment scales (Functional Independence Measure, Sunnybrook Cord Injury Scale, and Frankel Scale for Spinal Cord Injury) have demonstrated internal reliability and validity in the management of patients with thoracic and lumbar fractures. Unfortunately, other contemporaneous measurement scales (ie, American Spinal Cord Injury Association Impairment Scale) have not been specifically studied in patients with thoracic and lumbar fractures. (C)
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Entry American Spinal Injury Association Impairment Scale grade, sacral sensation, ankle spasticity, urethral and rectal sphincter function, and AbH motor function can be used to predict neurological function and outcome in patients with thoracic and lumbar fractures. (B)
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Pharmacological Treatment
There is insufficient evidence to make a recommendation; however, the task force concluded, in light of previously published data and guidelines, the complication profile should be carefully considered when deciding on the administration of methylprednisolone. (I)
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Hemodynamic Management
There is insufficient evidence to recommend for or against the use of active maintenance of arterial blood pressure after thoracolumbar spinal cord injury. (I)
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However, in light of published data from pooled (cervical and thoracolumbar) spinal cord injury patient populations, clinicians may choose to maintain mean arterial blood pressures >85 mm Hg in an attempt to improve neurological outcomes. (CR)
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Prophylaxis and Treatment of Thromboembolic Events
There is insufficient evidence to recommend for or against routine screening for deep venous thrombosis in preventing pulmonary embolism (or venous thromboembolism-associated morbidity and mortality) in patients with thoracic and lumbar fractures. (I)
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There is insufficient evidence to recommend a specific regimen of venous thromboembolism prophylaxis to prevent pulmonary embolism (or venous thromboembolism-associated morbidity and mortality) in patients with thoracic and lumbar fractures. (I)
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There is insufficient evidence to recommend for or against a specific treatment regimen for documented venous thromboembolism that would provide fewer complications than other treatments in patients with thoracic and lumbar fractures. (I)
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Based on published data from pooled (cervical and thoracolumbar) spinal cord injury populations, the use of thromboprophylaxis is recommended to reduce the risk of venous thromboembolism events in patients with thoracic and lumbar fractures. (CR)
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Nonoperative Care
The decision to use an external brace is at the discretion of the treating physician, as the nonoperative management of neurologically intact patients with thoracic and lumbar burst fractures either with or without an external brace produces equivalent improvement in outcomes. Bracing is not associated with increased adverse events compared to not bracing. (B)
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Operative vs Nonoperative Treatment
There is conflicting evidence to recommend for or against the use of surgical intervention to improve clinical outcomes in patients with thoracolumbar burst fracture who are neurologically intact. Therefore, it is recommended that the discretion of the treating provider be used to determine if the presenting thoracic or lumbar burst fracture in the neurologically intact patient warrants surgical intervention. (I)
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There is insufficient evidence to recommend for or against the use of surgical intervention for nonburst thoracic or lumbar fractures. It is recommended that the decision to pursue surgery for such fractures be at the discretion of the treating physician. (I)
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Timing of Surgical Intervention
There is insufficient and conflicting evidence regarding the effect of timing of surgical intervention on neurological outcomes in patients with thoracic and lumbar fractures. (I)
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It is suggested that “early” surgery be considered as an option in patients with thoracic and lumbar fractures to reduce length of stay and complications. The available literature has defined “early” surgery inconsistently, ranging from <8 h to <72 h after injury. (B)
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Surgical Approaches
In the surgical treatment of patients with thoracolumbar burst fractures, physicians may utilize an anterior, posterior, or a combined approach as the selection of approach does not appear to impact clinical or neurological outcomes. (B)
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With regard to radiological outcomes in the surgical treatment of patients with thoracolumbar fractures, physicians may utilize an anterior, posterior, or combined approach because there is conflicting evidence in the comparison among approaches. (I)
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With regard to complications in the surgical treatment of patients with thoracolumbar fractures, physicians may utilize an anterior, posterior, or combined approach because there is conflicting evidence in the comparison among approaches. (I)
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Novel Surgical Strategies
It is recommended that in the surgical treatment of patients with thoracolumbar burst fractures, surgeons should understand that the addition of arthrodesis to instrumented stabilization has not been shown to impact clinical or radiological outcomes, and adds to increased blood loss and operative time. (A)
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Stabilization using both open and percutaneous pedicle screws may be considered in the treatment of thoracolumbar burst fractures as the evidence suggests equivalent clinical outcomes. (B)
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Recommendation Grading
Overview
Title
Evaluation And Treatment Of Patients With Thoracolumbar Spine Trauma
Authoring Organization
Congress of Neurological Surgeons
Publication Month/Year
January 1, 2019
Last Updated Month/Year
June 8, 2023
Supplemental Implementation Tools
Document Type
Guideline
External Publication Status
Published
Country of Publication
US
Document Objectives
To determine, through evidence-based guidelines review: (1) whether the use of MRI to identify ligamentous integrity predicted the need for surgical intervention; and (2) if there are any radiological findings that can assist in predicting clinical outcomes.
Target Patient Population
Patients With Thoracolumbar Spine Trauma
Inclusion Criteria
Adolescent, Adult, Older adult
Health Care Settings
Ambulatory, Emergency care, Hospital, Operating and recovery room, Outpatient
Intended Users
Nurse, nurse practitioner, physician, physician assistant
Scope
Assessment and screening, Management
Diseases/Conditions (MeSH)
D013131 - Spine, D008159 - Lumbar Vertebrae, D013906 - Thoracoscopy, D020196 - Trauma, Nervous System
Keywords
orthopedic surgery, trauma, thoracolumbar fracture
Source Citation
Neurosurgery, Volume 84, Issue 1, January 2019, Pages E28–E31