Should a patient with a chronic T12 (thoracic 12) vertebral burst fracture and moderate central spinal canal stenosis with right neural foramen narrowing be referred to orthopedic surgery or neurosurgery?

From the Guidelines

For a patient with a chronic T12 burst fracture and moderate narrowing of the central spinal canal with right foramen narrowing, referral to either orthopedic spine surgery or neurosurgery is appropriate, with the decision based on local expertise and the surgeon's experience with thoracic spine trauma. The management of such a condition involves considerations of both bony structural issues and neural compression elements. According to 1, surgical consultation is usually appropriate for patients with pathologic fractures and neurologic effects, which may be the case in a chronic T12 burst fracture with canal and foraminal narrowing.

Key Considerations

• The presence of moderate narrowing of the central spinal canal and right foramen narrowing suggests potential neural compression, which may require surgical decompression and stabilization if the patient is experiencing neurological symptoms, pain, or instability, as suggested by 1 and 1.
• The chronic nature of the fracture and the involvement of both bony and neural elements indicate the need for a specialist with significant experience in thoracic spine trauma, regardless of their primary specialty background.
• Local expertise and availability should guide the decision between orthopedic spine surgery and neurosurgery, with consideration for collaboration in complex spine cases.
• The most recent and highest quality studies, such as those published in the Journal of the American College of Radiology 1, emphasize the importance of surgical consultation for patients with neurologic deficits, spinal deformity, or spinal instability, supporting the referral to either specialty.

From the Research

Decision Making for Referral

To determine whether a patient with a chronic T12 burst fracture and moderate narrowing of the central spinal canal with right foramen narrowing should be referred to orthopedic surgery or neurosurgery, several factors must be considered:

• The severity of the injury and its impact on neurological status
• The degree of spinal canal narrowing and its potential for spontaneous remodeling
• The presence of neurological deficits and the potential for recovery

Considerations for Referral

Based on the available evidence:

• The study by 2 suggests that neurological damage in burst fractures occurs at the time of injury and may not be due to impingement from bone fragments in the canal afterwards, questioning the need for surgical intervention solely to remove these fragments.
• The research by 3 indicates that neurologic recovery does not correlate with the treatment method or amount of canal decompression but rather with the initial fracture pattern, suggesting that prognosis for neurologic recovery can be made based on initial roentgenograms.
• 4 found significant spontaneous remodeling of the spinal canal following initial surgical reduction, with bony narrowing of the spinal canal recognizable in only 2.4% of patients two years post-operation, which may influence the decision for surgical intervention.
• 5 emphasizes that the selection of operative versus nonoperative treatment should be based on clinical and radiological criteria, with recumbency favored in patients who are intact and have less severe deformity, and surgical intervention indicated in patients with partial neurological deficit or severe instability.
• The study by 6 highlights that the severity of injury, as measured by scores like the New Injury Severity Score (NISS), has a strong association with neurological damage in thoracolumbar burst fractures, which could guide the decision for referral.

Key Factors for Decision Making

When deciding between orthopedic surgery and neurosurgery for a patient with a chronic T12 burst fracture:

• Assess the severity of the injury and its impact on neurological status.
• Evaluate the degree of spinal canal narrowing and consider the potential for spontaneous remodeling.
• Consider the presence of neurological deficits and the potential for recovery based on the initial fracture pattern and severity of injury.
• Use clinical and radiological criteria to guide the decision for operative versus nonoperative treatment.