Decision making in thoracolumbar fractures.

The management of thoracolumbar fractures continues to evolve. Strong agreements exist in certain aspects of care but significant controversy remains in many other areas. This paper reviews our current diagnostic and therapeutic approach to treating these injuries as of the spring of 2005. Evaluation Initial assessment of a patient should include the history of an injury from as accurate a source as possible, a thorough physical examination, and an accurate assessment of the patient’s neurological status and spinal stability to identify all the associated major injuries that have occurred. Needs proper wording. Clearly , assessment of neurological status and spinal stability is independent of identification of ‘associated injuries’. Treatment priorities include resuscitation of patient, and treatment of life-threatening injuries before mechanical restoration of the injured osteoligamentous column and preservation or restoration of neurological function. Every spine surgeon has to answer three fundamental questions when facing a thoracolumbar fracture: First, how to treat a patient (non-operative or operative)? Second, how many segments should one instrument and fuse (short versus long segment operation)? Third, which approach should be used (anterior, posterior or both)? The three fundamental questions are 1. whether to operate, 2. When to operate (emer gent, next day, or later), and 3. How to operate (anterior or posterior or combined approach. The answers to the above questions begin with a complete evaluation. Patient Comprehensive assessment of the patient must be performed. The medical issues that have occurred in the past must be identified. Medically unfit, obese, demented or noncompliant patients have to be identified. Their pre-injury personality characteristics influence treatment choices and the successful use of short segment surgical reconstruction. Medical problems that determine the patient’s suitability for surgical reconstruction must be identified and assessed. Short segment reconstructive options—the most sophisticated reconstruction now available—are more appropriate for physically fit, intelligent, healthy patients who can understand the need for compliance with post-operative recommendations until their fracture heals. Non-compliant patients, patients with past psychological disturbances, drug abusers and alcoholics are especially vulnerable to surgical failures. The inability to co-operate with post-operative bracing makes long segment instrumentation and fusion the best reconstructive option for people who cannot be trusted to understand the importance of post-operative bracing. Clinical assessment Spine fractures usually result from blunt injuries, which can cause other long bones fractures too. A high index of suspicion must be maintained with palpation of all joints and bones during examination. F ull neurological e xamination (sensation, motor , anal tone, [Mention about signs of sacral sparing in complete paraplegia] etc) should be done and documented repeatedly to look for and pick up neurological deficits and deterioration. The patient’s spine must be palpated using log roll to look for tenderness, swelling, haematoma, gibbus or step off. These can indicate the existence of fracture translation. [The purpose for palpation of the spine after log roll is to look for evidence of posterior column injuiry, like wide gap between the spinous process, hematoma, ecchymoses etc] A seat belt bruise, facial fractures, pelvic hematoma and calcaneus fractures can suggest the possible existence of major organ injuries that should be addressed by the trauma and general surgeon first. Resuscitation