Thoracic Spine Fractures and Dislocations Guidelines

Updated: Apr 07, 2022
  • Author: Brian J Page, MD; Chief Editor: Murali Poduval, MBBS, MS, DNB  more...
  • Print
Guidelines

AANS/CNS Guidelines on Thoracic and Lumbar Spine Fractures

In 2018, the following guidelines for the treatment of thoracic and lumbar spine fractures were developed by the American Association of Neurological Surgeons (AANS)/Congress of Neurological Surgeons (CNS) Section on Disorders of the Spine and Peripheral Nerves and the Section on Neurotrauma and Critical Care workgroup. [23, 24, 25, 26, 27]

Nonoperative care

Whether to use an external brace is determined at the discretion of the treating physician. [23]  Nonoperative management of neurologically intact patients with thoracic and lumbar burst fractures, either with or without an external brace, produces equivalent improvement in outcomes. Bracing is not associated with increased adverse events.

Operative vs nonoperative treatment

The evidence for or against surgical intervention to improve clinical outcomes in patients with thoracolumbar burst fractures who are neurologically intact is conflicting. [24]  Accordingly, it is recommended that it be left to the discretion of the treating physician to determine whether the presenting thoracic or lumbar burst fracture in a neurologically intact patient warrants surgical intervention.

The evidence is not sufficient to allow recommendation either for or against surgical intervention for nonburst thoracic or lumbar fractures. It is recommended that the decision to pursue surgical treatment for these fractures be left to the discretion of the treating physician.

Timing of surgical intervention

The evidence regarding the effect of timing of surgical intervention on neurologic outcomes in patients with thoracic and lumbar fractures is insufficient and conflicting. [25]

Early surgery is suggested for consideration as an option in patients with thoracic and lumbar fractures to reduce length of stay and complications. Early surgery has not been consistently defined in the literature, ranging from less than 8 hours to less than 72 hours after injury.

Surgical approaches

For surgical treatment of patients with thoracolumbar burst fractures, physicians may follow an anterior, posterior, or combined approach; the surgical approach taken does not appear to have an impact on clinical or neurologic outcomes. [26]

With regard to radiologic outcomes after surgical treatment of thoracolumbar fractures, physicians may follow an anterior, posterior, or combined approach; evidence from comparison of these approaches is conflicting.

With regard to complications after surgical treatment of these fractures, physicians may follow an anterior, posterior, or combined approach; evidence from comparison of these approaches is conflicting.

Novel surgical strategies

In the surgical treatment of patients with thoracolumbar burst fractures, surgeons should understand that the addition of arthrodesis to instrumented stabilization has not been shown to impact clinical or radiologic outcomes and that it adds to increased blood loss and operating time. [27]

Stabilization using both open and percutaneous pedicle screws may be considered in the treatment of thoracolumbar burst fractures; the evidence suggests that clinical outcomes are equivalent.

Next:

ACS Trauma Quality Programs Guidelines on Spine Injury

In March 2022, the American College of Surgeons (ACS) published best practices guidelines on spine injury [28] ; these guidelines were also reviewed and recommended by the American College of Rehabilitation Medicine (ACRM).

Recommended initial measures included the following:

  • Spinal motion restriction (SMR) can be achieved with a backboard, scoop stretcher, vacuum splint, ambulance cot, or other similar devices. When indicated, it should be applied to the entire spine.
  • The cervical collar can be discontinued without additional radiographic imaging in an awake, asymptomatic adult trauma patient with (1) a normal neurologic exam, (2) no high-risk injury mechanism, (3) free range of cervical motion, and (4) no neck tenderness. Collar removal is recommended for an adult blunt trauma patient with no neurologic symptoms and a negative helical cervical computed tomography (CT) scan. A negative helical cervical CT scan suffices for collar removal in an adult blunt trauma patient who is obtunded or unevaluable.
  • Plain radiographs of the cervical and thoracolumbar spine are not recommended in the initial screening of spinal trauma; noncontrast multidetector CT (MDCT) is the initial imaging modality of choice. Magnetic resonance imaging (MRI) is the only modality for evaluating the internal structure of the spinal cord.

Recommendations for injury management included the following:

  • Occipital condyle fractures without neural compression or craniocervical misalignment can be managed with a rigid or semirigid cervical orthosis. Treatment of cervical fractures is individualized according to fracture type and patient factors (eg, age). Stable thoracolumbar fractures without neurologic deficits can be treated with adequate pain control and early ambulation without a brace.
  • The vast majority of penetrating spinal cord injuries (SCIs) result in complete (American Spinal Injury Association [ASIA] A) injuries. Few gunshot SCIs require surgical stabilization. Steroids are not recommended.

Recommendations for care of patients with SCIs included the following:

  • Hypotension must be avoided. The use of mean arterial pressure (MAP) goals of 85-90 mm Hg for 7 days must be weighed against data limitations and associated risks. An agent with both alpha- and beta-adrenergic activity is recommended.
  • The use of methylprednisolone within 8 hours following SCI cannot be definitively recommended. No other potential therapeutic agents have demonstrated efficacy.
  • Chemoprophylaxis for venous thromboembolism (VTE) should be initiated as early as medically possible (typically ≤72 hr), with duration determined on an individualized basis. Surveillance duplex ultrasonography (US) is not recommended in asymptomatic patients but may be considered in high-risk patients who cannot have chemoprophylaxis during the acute period.
  • Treatment of persistent bradycardia or intermittent severe bradycardia may include a beta2-adrenergic agonist, chronotropic agents, or phosphodiesterase inhibitors.
  • Early tracheostomy is recommended to aid in mechanical ventilation in high SCI. Stimulation of the diaphragm should be considered. Open or percutaneous tracheostomy can be performed early after anterior cervical spinal stabilization without increasing the risk of infection or other wound complications.
  • Pain management is a priority in acute SCI and should be delivered via a multimodal approach.
  • Symptoms associated with SCI, such as acute autonomic dysreflexia, spasticity, and skin breakdown, should be adequately addressed.
  • A bowel management program should be initiated for all acute SCI patients. Bladder management should be individualized.
  • Physical and occupational therapy should be initiated within 1 week after injury for acute SCI patients who are determined to be medically ready.
Previous
Next:

AOSpine Guidelines for Spinal Cord Injuries

In 2017, AOSpine (a part of AO [Arbeitsgemeinschaft für Osteosynthesefragen]) published a series of systematic review articles in the Global Spine Journal aimed at providing evidence-based guidelines for the management of spinal cord injuries (SCIs). These articles addressed several controversial topics, including optimal surgical timing, the use of corticosteroids, the type and timing of anticoagulation prophylaxis, the role of magnetic resonance imaging (MRI), and the type and timing of rehabilitation. [29]

Optimal timing of surgical decompression

The guidelines recommended that early surgery (defined as ≤ 24 hr after injury) be considered for adult patients with traumatic central cord syndrome and other adult acute SCI patients. [30] The level of evidence for these recommendations was low. Patients who underwent early decompression were more likely to demonstrate a clinically significant improvement in neurologic status (≥ 2 grade improvement on the American Spinal Injury Association [ASIA] Impairment Scale [AIS]) than those decompressed later (> 24 hr after injury); however, this relation was not statistically significant.

Corticosteroid use

The guidelines recommended against the use of high-dose methylprednisolone sodium succinate in adult patients who present more than 8 hours after an acute SCI; however, they recommended offering a 24-hour infusion of high-dose methylprednisolone sodium succinate to patients presenting within 8 hours after the injury. [31] A small long-term neurologic benefit was found with the use of steroids in early treatment. The level of evidence was moderate for both of these recommendations. Additionally, the guidelines recommended against offering a 48-hour infusion of high-dose methylprednisolone sodium succinate, but no literature was cited to support this recommendation.

Anticoagulation prophylaxis

The guidelines recommended routinely offering chemical anticoagulation for thromboprophylaxis to reduce the risk of thromboembolic events in the acute period after SCI treated with or without surgery; either subcutaneous low-molecular-weight heparin (LMWH) or fixed or low-dose unfractionated heparin (UFH) was suggested, but dose-adjusted heparin was not recommended, because of the potential for increased bleeding. [32] Such chemical thromboprophylaxis should be initiated within 72 hours post injury.

These recommendations were given a grade of low evidence. [32] Of the studies used in the systematic review, none were able to reach statistical significance for the use of chemical thromboprophylaxis to reduce the likelihood of deep vein thrombosis (DVT), pulmonary embolism (PE), mortality, or increased risk of bleeding; however, the authors concluded that chemical thromboprophylactic therapy is superior to no prophylactic treatment for DVT.

Magnetic resonance imaging

The guidelines recommended performing MRI in adult patients with acute SCIs before surgical intervention when possible to aid in clinical decision-making. [33] They also recommended that MRI be performed before or after surgery to improve prediction of the neurologic prognosis. The level of evidence for both of these recommendations was low.

Rehabilitation

The guidelines recommended that rehabilitation be offered to patients with acute SCI upon medical stabilization and subject to patients' tolerance of rehabilitation protocols. [34] No specific studies were cited to support this recommendation, but low-level evidence was available to support several other recommendations. The guidelines recommended offering body weight–supported treadmill training if the resources and expertise are available, as well as electrical therapy to improve hand and upper-extremity function. Offering additional training in unsupported sitting beyond what is currently incorporated in standard rehabilitation programs was not recommended.

Previous