Summary Statement: Thoracolumbar Spine Trauma

Field: Medicine (Health Sciences)

In general, thoracolumbar spinal trauma classification systems have reflected an understanding of spinal instability as understood at the time of the system's origin. As the understanding of spinal instability and injury mechanisms has evolved, so has the complexity of the various classification systems. While this has resulted in more elaborate and perhaps more complete classification schemes, the usability and reliability of these systems in practical clinical decision-making have been questioned. The consensus among experienced spinal traumatologists is that spinal stability following a thoracolumbar injury appears to be related to injury morphology, the integrity of the posterior ligamentous complex, and the patient's neurologic status. Insights gained from investigating the importance of these variables in clinical decision-making has led to the development of a novel classification system, the Thoracolumbar Injury Classification and Severity Scale. The present paper is an attempt to determine the reliability of this new classification system. When thoracolumbar fractures are associated with mechanical instability, pain, deformity, and or neural injury, segmental instrumentation is a useful and important method of surgical reconstruction, which allows for adequate reconstruction of spinal alignment, stability, and early mobilization. Among the options for spinal internal fixation, short- and long-segment fixation strategies offer differing but distinct advantages over one another. Long-segment internal fixation is intended to stabilize thoracic and high thoracolumbar fractures with minimal immobilization of the caudal lumbar motion segments. Extending internal fixation into the thoracic region allows the surgeon to apply sufficient corrective force to correct sagittal deformity and restore spinal alignment. Short-segment instrumentation limits the number of spinal segments immobilized in order to restore sagittal balance and stabilize the fracture. Short-segment internal fixation depends on pedicle screw anchors to rigidly immobilize spinal segments of the thoracolumbar or lumbar spine, providing excellent sagittal, axial, and torsional stability. Both the surgical and mechanical disturbance to adjacent lumbar motion segments is kept to an absolute minimum. To date, outcomes data comparing anterior, posterior and short versus long internal fixation strategies are limited. Individual patient variables and surgeon experience remain important factors in specific treatment algorithms applied to unstable thoracolumbar injuries. One of the most difficult biomechanical challenges is the stabilization of the lumbosacral and sacropelvic junction. The advent of low profile rigid lumbosacral segmental fixation techniques and iliac fixation bolts has offered a solution to complex lumbo-sacral-pelvic injuries. This has allowed for early, brace-free mobilization and has eliminated the consequences of prolonged recumbency and skeletal traction. Specific indications for surgical intervention for these complex injuries revolve around significantly displaced fracture-dislocations and patients with neurologic injuries. Contemporary surgical management of these injuries allows for early mobilization and appears to provide an environment to allow for neurologic improvement in peripheral nerve and cauda equine injuries. Unfortunately, these procedures are technically demanding and are associated with a high incidence of instrumentation and wound complications. While the effectiveness of open stabilization has been widely demonstrated in thoracolumbar trauma, innovative methods now offer the opportunity to accomplish instrumented stabilization with less soft tissue injury and blood loss. Currently, anterior endoscopic and or posterior percutaneous posterior instrumentation systems are being used for a limited number of spinal trauma patients at several centers around the world. Numerous controversies exist concerning novel techniques such as balloon-assisted endplate reduction combined with cement augmentation as an adjunct to posterior short-segment fixation or as a stand-alone procedure to reinforce the anterior spinal column in the setting of compression and burst-type injuries. Currently, the specific clinical indications for these less invasive techniques in thoracolumbar trauma are still being defined and will likely change as surgeons' interest, skill set, and facility with evolving MIS technologies grows. Overall, the theoretical benefits of applying these techniques in the trauma population is sound; however, insufficient data exist from which to draw firm conclusions as to whether these techniques are associated with superior outcomes compared with conventional techniques. Well-controlled prospective studies will be required to assess the safety, efficacy, and impact of these techniques on at least short-term outcomes (i.e., reduced blood loss, perioperative pain, hospital stay, and reduced operative time) to justify the learning curve and increased cost that is often associated with these less invasive and indirect procedures.