Thoracic Spine Fractures: Neurosurgeon vs Orthopedic Surgeon
Consult a neurosurgeon for thoracic spine fractures, particularly when neurological symptoms are present or suspected, as the Congress of Neurological Surgeons has established comprehensive evidence-based guidelines specifically for thoracolumbar trauma management. 1
Primary Recommendation
Both neurosurgeons and orthopedic spine surgeons can manage thoracic spine fractures, but neurosurgeons should be the primary consultants when any neurological involvement exists or cannot be definitively ruled out. 1 The correspondence author for the CNS thoracolumbar guidelines notably holds dual appointments in both Neurological Surgery and Orthopedic Surgery, highlighting that spine fellowship-trained surgeons from either specialty possess the requisite expertise. 1
Decision Algorithm Based on Clinical Presentation
Immediate Neurosurgical Consultation Required:
- Any documented neurological deficit (motor weakness, sensory changes, bowel/bladder dysfunction) 1, 2
- ASIA Impairment Scale grade indicating incomplete or complete spinal cord injury 1
- Loss of sacral sensation, abnormal sphincter function, or ankle spasticity (these predict neurogenic bladder and poor outcomes) 1, 2
- Abductor hallucis motor dysfunction (specific predictor of neurological recovery in thoracolumbar fractures) 2
- Fracture-dislocations or grossly unstable fractures requiring urgent reduction and fixation 3, 4
Either Specialty Acceptable (Spine-Trained):
- Neurologically intact patients with stable fracture patterns that may be managed conservatively 5, 6
- Burst fractures without neurological deficit where treatment approach (operative vs. nonoperative) remains at physician discretion 1
Critical Assessment Components
The consulting surgeon must perform a comprehensive neurological examination including:
- ASIA Impairment Scale grading (strongest predictor of functional outcomes) 1, 2
- Motor strength testing in all major lower extremity muscle groups using 0-5 grading 2
- Specific assessment of abductor hallucis function 1, 2
- Sacral examination: perianal sensation, rectal tone, voluntary anal sphincter contraction 1, 2
- Ankle spasticity evaluation (highly predictive of neurogenic bladder) 1, 2
Imaging and Stability Assessment
MRI should be obtained when neurological symptoms exist or when assessing posterior ligamentous complex integrity influences surgical decision-making (affects management in up to 25% of cases). 1, 6 The consulting surgeon must evaluate for:
- Canal compromise with neurological deficit 6
- Three-column involvement 6
- Progressive neurological deficit 6
- Significant kyphosis 6
Timing Considerations
Urgent/emergent surgical consultation is warranted for patients with neurological deficits to facilitate early reduction and fixation, as this offers the potential for neurological recovery and prevents secondary injury. 4 Even patients with complete paraplegia may show statistically significant improvement with surgical intervention compared to conservative management. 3
Common Pitfalls to Avoid
- Do not assume neurologically intact status without formal ASIA examination 1, 2
- Do not overlook subtle findings like isolated ankle spasticity or sphincter dysfunction, which have major prognostic implications 1, 2
- Do not delay consultation for fracture-dislocations, even without obvious deficits, as these represent grossly unstable injuries 3
Practical Reality
In institutions with spine fellowship-trained orthopedic surgeons experienced in thoracolumbar trauma, either specialty can provide appropriate care for stable fractures without neurological involvement. 5 However, the presence or suspicion of spinal cord injury mandates neurosurgical expertise given the specialized knowledge required for managing neurological complications and optimizing recovery potential. 1, 2, 4