Evaluation and treatment of patients
with Thoracolumbar Spine Trauma
If lumbar spine pain becomes so severe that it disrupts daily life or is accompanied by swelling, tenderness, or redness, it’s important to seek medical attention.
At Complete Orthopedics, our expert lumbar spine specialists are adept at treating lumbar spine pain through both surgical and non-surgical means. We examine symptoms, diagnose the condition, and recommend suitable treatments, including surgery if necessary.
Serving New York City and Long Island, we partner with six hospitals to offer cutting-edge lumbar spine surgery and comprehensive orthopedic care. You can schedule a consultation with our orthopedic surgeons online or by phone.
Learn about the common causes of lumbar spine pain and the treatment options available, including when surgery might be the best choice.
Overview
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.
Radiological Evaluation
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.
Neurological Assessment
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.
Pharmacological Treatment
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.
Hemodynamic Management
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.
Nonoperative Care
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.
Surgical Approaches
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.
Conclusion
Managing thoracolumbar spine trauma involves a multifaceted approach, with careful consideration of classification, radiological evaluation, neurological assessment, and treatment options. For more detailed information on this topic, explore our comprehensive resources on the evaluation and treatment of patients with thoracolumbar spine trauma.
Do you have more questions?
What is the thoracolumbar spine?
The thoracolumbar spine refers to the lower part of the thoracic spine (middle back) and the upper part of the lumbar spine (lower back), specifically encompassing the vertebrae from T10 to L2.
What are the common causes of thoracolumbar spine injuries?
These injuries are commonly caused by trauma such as car accidents, falls from height, sports injuries, and violent incidents.
What is the primary goal of surgery for thoracolumbar spine injuries?
The main goal is to stabilize the spine, relieve pressure on the spinal cord and nerves, and restore normal spinal alignment to prevent further neurological damage and promote recovery.
How do surgeons decide whether or not to operate?
Surgeons consider factors such as the severity of the injury, neurologic status of the patient, the integrity of the posterior ligaments, and the overall health and fitness of the patient for surgery.
What is decompression in the context of spinal surgery?
Decompression involves removing or relieving pressure on the spinal cord or nerves that may be caused by bone fragments, swelling, or displaced discs.
When is an anterior approach preferred for thoracolumbar injuries?
An anterior approach is preferred for cases of anterior neural compression, when the posterior ligaments are intact, and for direct decompression of the spinal canal and restoration of spinal stability.
What are the risks associated with the anterior approach?
Risks include damage to major blood vessels, complications related to prior abdominal surgery, severe pulmonary disease, and challenges posed by morbid obesity.
When is a posterior approach used?
A posterior approach is used when there is distraction or translation without neural compression, for isolated nerve root deficits with intact posterior ligaments, and in cases of complete neurologic injury with disrupted posterior ligaments.
What are the advantages of a posterior approach?
Advantages include familiarity for the surgeon, avoidance of major visceral and vascular structures, and feasibility for re-exploration and additional procedures if necessary.
What is ligamentotaxis and how does it work in posterior decompression?
Ligamentotaxis is the process of using tension on the ligaments to indirectly reduce and decompress the spinal canal, often achieved through pedicle screw instrumentation.
What are the potential complications of spinal surgery?
Complications can include infection, bleeding, nerve damage, instrumentation failure, and issues related to anesthesia and general surgery risks.
How do surgeons assess the neurologic status of a patient?
Assessment includes clinical examination, imaging studies (like MRI or CT scans), and sometimes electrophysiological testing to evaluate the extent of neurologic injury.
What is the role of imaging in planning surgery for thoracolumbar injuries?
Imaging helps to identify the exact location and extent of the injury, the condition of the spinal cord and nerves, and the integrity of the posterior ligaments, which are critical for surgical planning.
Why is there a lack of universally accepted guidelines for these surgeries?
The variability in injury patterns, patient conditions, and the evolving nature of surgical techniques contribute to the challenge of developing universally accepted guidelines.
What is the Spine Trauma Study Group (STSG) and what is their role?
The STSG is a group of spine trauma experts who provide consensus opinions on the management of spine injuries, helping to guide decision-making in the absence of definitive studies.
How does the morphology of the injury affect surgical decisions?
The shape and structure of the injury (e.g., burst fractures, compression fractures) determine the stability of the spine and the need for decompression and stabilization, influencing the surgical approach.
What are the benefits of using a combined anterior and posterior approach?
This approach allows for thorough decompression, stabilization, and reconstruction of the spine, providing the best chance for recovery in complex cases.
Can all thoracolumbar spine injuries be treated with surgery?
Not all injuries require surgery. Some can be managed conservatively with bracing and physical therapy, especially if they are stable and without significant neurologic impairment.
What is the typical recovery process after thoracolumbar spine surgery?
Recovery involves a combination of physical rehabilitation, pain management, and regular follow-up visits to monitor healing and spinal stability.
Why is expert consensus important in the absence of definitive studies?
Expert consensus provides guidance based on collective experience and knowledge, helping surgeons make informed decisions in the face of uncertain or limited evidence.
How do posterior ligament disruptions affect the choice of surgical approach?
Disruptions of the posterior ligaments often necessitate a posterior approach or a combined approach to ensure spinal stability and effective decompression.
What future research is needed in the field of thoracolumbar spine injury management?
Multicenter randomized prospective clinical trials are needed to compare different treatment approaches and establish evidence-based guidelines.
How does a patient’s overall health impact surgical decision-making?
A patient’s general health, including the presence of comorbid conditions like heart or lung disease, obesity, and previous surgeries, can affect the risks and feasibility of different surgical approaches.
What can patients do to improve their outcomes after thoracolumbar spine surgery?
Patients should follow their surgeon’s post-operative instructions, participate in rehabilitation programs, maintain a healthy lifestyle, and attend all follow-up appointments to monitor their progress.
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.
