What is the recommended treatment approach for thoracolumbar spine issues?

Treatment Approach for Thoracolumbar Spine Issues

For thoracolumbar spine trauma, treatment should be guided by injury classification, radiological findings, and neurological status, with surgical intervention determined by specific fracture patterns and stability assessment rather than universal application.

Evaluation and Classification

• Thoracolumbar spine trauma requires comprehensive radiological evaluation using a combination of plain radiographs, CT scans, and MRI to properly classify injuries and determine treatment 1
• MRI is particularly valuable in assessing posterior ligamentous complex integrity, which can influence management decisions in up to 25% of thoracolumbar fracture cases 1
• Two classification systems have demonstrated good reliability for thoracolumbar injuries: the Thoracolumbar Injury Classification and Severity Score (TLICS/TLISS) and the AO Spine Thoracolumbar Spine Injury Classification System 1
• The Load Sharing Classification (LSC) helps guide treatment of burst fractures by assessing comminution, fragment apposition, and kyphotic deformity correction 1

Treatment Decision Algorithm

Neurologically Intact Patients with Burst Fractures

• For neurologically intact patients with thoracolumbar burst fractures, there is conflicting evidence regarding surgical versus nonoperative treatment 1
• The decision to pursue surgical intervention should be at the discretion of the treating physician based on fracture characteristics and stability assessment 1
• If using external bracing for nonoperative management, this decision should be individualized as there is insufficient evidence to standardize this approach 1

Surgical Approach Selection

• For patients requiring surgery for thoracolumbar burst fractures, anterior, posterior, or combined approaches can be utilized as the selection does not significantly impact clinical or neurological outcomes (Grade B recommendation) 1
• When using a posterior approach for thoracolumbar fractures, the addition of arthrodesis to instrumented stabilization has not been shown to impact clinical outcomes and adds to increased blood loss and operative time (Grade A recommendation) 1
• Both open and percutaneous pedicle screw techniques can be considered for stabilization of thoracolumbar burst fractures as they provide equivalent clinical outcomes (Grade B recommendation) 1

Special Considerations

• For patients with thoracolumbar spinal cord injury, clinicians may consider maintaining mean arterial blood pressures >85 mm Hg to potentially improve neurological outcomes, though evidence specifically for thoracolumbar injuries is limited 1
• When methylprednisolone administration is considered for thoracolumbar fractures with spinal cord injury, the complication profile should be carefully evaluated against potential benefits 1
• For complex multi-level spinal trauma, a staged surgical approach may be necessary, with specific procedures tailored to the injury pattern at each level 2

Radiological Assessment

• CT scanning of the chest, abdomen, and pelvis (CT/CAP) has demonstrated superior accuracy (99%) compared to plain radiographs (87%) for detecting thoracolumbar fractures 3, 4
• MRI may not significantly affect intervention decisions in blunt trauma patients with CT findings of stable thoracolumbar injuries without neurological deficits, though it can increase hospital length of stay 5
• The Congress of Neurological Surgeons provides a Grade B recommendation that radiological findings can predict the need for surgical intervention, particularly when MRI is used to assess posterior ligamentous complex integrity 1

Clinical Pitfalls and Caveats

• There is insufficient evidence that radiographic findings alone can predict clinical outcomes in thoracolumbar fractures 1
• Classification systems like TLICS/TLISS still show variation in treatment recommendations among physicians and require further validation for burst fractures with TLICS scores of 2-4 1
• The thoracolumbar junction (T10-L2) represents a biomechanical transition zone between the rigid thoracic spine and mobile lumbar spine, making it particularly vulnerable to injury and requiring careful assessment 6
• No single classification system has been definitively proven to guide treatment and affect outcomes, highlighting the importance of individualized assessment 1