Abstract
Study design
Review of illustrative cases of a new algorithm to help in the treatment decision of thoracolumbar spine trauma.
Objectives
To illustrate the use of the new algorithm for managing thoracic and lumbar spine trauma.
Settings
Recently, a new algorithm for helping in the decision of the best treatment modality for thoracolumbar spine trauma (TLST) was published. The algorithm considers injury morphology, neurological status, clinical status (pain and disability), and also multimodal radiological evaluation (MMRE) in the decision for non-operative versus operative treatment for TLST. Injuries were classified in three groups: (1) stable injuries, (2) potentially unstable injuries/ delayed instability, or (3) clearly unstable injuries.
Methods
Cases examples of the algorithm application were presented and discussed.
Results
Stable injuries (minor fractures without instability) are non-surgically treated; potentially unstable injuries or associated with delayed instability may be initially managed non-surgically and operative treatment is an option, especially in the setting of important pain, deformity or a new neurological deficit. Clearly unstable injuries are treated surgically as soon as possible to avoid neurological worsening, severe pain, and/ or progressive spinal deformity.
Conclusions
Clinical examples of TLST were presented, discussed and classified as stable, potentially unstable and clearly unstable injuries. Further studies addressing the reliability and safety of this algorithm are necessary.
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Introduction
Treatment of thoracolumbar spine trauma (TLST) is mainly based on non-operative versus surgical management. This decision is based on many factors, such as injury morphology, neurological, and clinical status and also information obtained with radiological images such as CT scans, MRI, and standing plain radiographs when necessary [1, 2].
Recently, we published a theoretic algorithm grouping injuries in three scenarios, according to the instability definition proposed by Abbasi Fard et al. [3, 4] Injuries were grouped in stable, without risk of neurological deterioration or deformity, treated non-operatively; potentially unstable injuries, who require close radiological and clinical follow-up due to a potential risk of progressive spinal deformity, neurological deterioration and/ or clinical symptoms—surgery may be recommended in this group—and, finally, clearly unstable injuries, who require early surgical treatment due to a higher risk of spinal deformity, severe pain and/ or neurological deterioration [4]. The diagnosis of potentially unstable injuries may also be important to identify patients who may have benefits of additional radiological assessment, such as dynamic radiological exams and MRI, as well as to identify characteristics that may be associated with late surgical treatment.
In this paper, we presented illustrative cases examples to illustrate the clinical application of our proposal algorithm.
Methods
Cases of TLST were retrospectively reviewed from a trauma database (IRB approved—CAAE: 06425012.9.0000.5404). Cases were then classified according to their morphology using the new AOSpine Classifications system, neurological status and clinical status by the authors (Fig. 1—flow Chart of our treatment algorithm) [5]. The new AOSpine classification was recently proposed by Vaccaro et al. for a better morphological categorization, classifying injuries in three main types: type A—compression injuries (compression and burst fractures), type B—distraction injuries and type C translation injuries (with displacement and dislocation).
The rational of the treatment option was discussed.
Results
1) Stable injuries—include stable and minor fractures, without neurological deficits and without risk of spinal deformity—characteristics of this group are presented in Table 1.
An illustrative case (Fig. 2) is presented.
2) Potentially unstable injuries—characteristics of this group are presented in Table 2. This group includes borderline injuries whose morphological characteristics are associated with a higher risk of failure of non-operative management.
Illustrative cases (Figs. 3 and 4) are presented.
3) Clearly unstable injuries—characteristics of this group are presented in Table 3. These injuries may lead to severe pain, spinal deformity, or neurological worsening when surgical treatment is not performed.
Discussion
In this paper, we presented a few cases of TLST, with and without neurological deficits, considering our recently proposed treatment algorithm for acute traumatic injuries [4]. The idea is that, considering not only CT scan and fracture morphology, but also other image modalities, such as standing plain radiographs and MRI, we can improve the way we treat TLST based on additional information, such as ligamentous status and load effect into the vertebrae. On the other hand, although many fracture patterns are quite similar, such as a burst fracture in the thoracolumbar junction, the details of each case are unique, such as pain perception, neurological deficits (radicular, incomplete, and complete) and fracture characteristics (such as degree of canal compromise, vertebral body comminution, posterior elements fractures, among others).
Historically, many studies addressed radiological characteristics of spinal fractures in an attempt to decide the best treatment modality. Some of these characteristics include the degree of canal compression, local kyphosis (>20–30°), and vertebral body comminution (such as the load sharing classification system) [6–10]. Interesting, normal thresholds for surgical versus non-operative management are difficult to be defined. As an example, normal wedging of a vertebral body (the ratio between the anterior and posterior vertebral height) in asymptomatic adults has been suggested to be up to 10°, although some authors reported up to 25° as a normal wedge limit [11,12,13,14,15]. This variation of what is considered normal may result in potentially different outcomes and interpretation of a compression fracture in an adult patient, especially in the setting of degenerative spine disease. By this reason, we think that a large group of spinal injuries, with “borderline” morphological characteristics, may be better grouped as “potentially unstable” injuries, which are at higher risk of failure non-operative management. For security, this group did not include patients with spinal dislocation, where ligamentous injury was clearly evident and surgical treatment is recommended, even in patients without neurological deficits [15, 16].
Radcliff et al. evaluated prospectively 46 patients with traumatic burst fractures from T10-L2. The objective of the study was to assess if the degree of canal compromise (CC) and neurological deficits correlate with posterior ligamentous injury (PLC) and neurological deficits [17]. Loss of vertebral body height (LOVBH), vertebral translation, local kyphosis (LK), and CC were evaluated, as well as ligamentous and neurological injury. Ligamentous injury was assessed based on the PLC on MRI signal of the supraspinous ligament, ligament flavum and interspinous ligament. Ten patients had kyphosis >20° and one patient had >30°. Nine patients had >50% of LOVBH. Vertebral body translation >3.5 mm was documented in 34 patients and 50% of the patients had CC >50%. PLC injury was detected in 16 cases. Segment translation >3.5 mm strongly correlates with ligamentous injury (p = 0.029) and ASIA motor score (p = 0.009). PLC injury and neurological status did not correlate with LOVBH >50%, vertebral body kyphosis >20°, caudal or cephalad interspinous widening >7 mm or CC >50%. They concluded that the LOVBH and LK did not correlate with PLC injury in burst fractures at the thoracolumbar junction. On the other hand, segment translation correlates with the integrity of the PLC. A potential explanation of this is that severe bone destruction may expect to have less ligamentous injury because the injury impact was more evident on the bone than in the soft tissues. However, the role of PLC injury in the outcome of TL burst was not evaluated.
These individual radiological characteristics should also be considered together with the complex trauma scenario and in the presence of other comorbidities. A patient with a potentially unstable injury but who will be lying down for some weeks, for instance, due to a severe traumatic injury, may be considered for non-operative treatment, whereas the same fracture in a young and healthy adult may require surgical fixation. Conversely, early surgery may be given to the poly-trauma patient if bracing is not possible secondary to other injuries.
To maintain long-term spinal stability and also neurological preservation is the main treatment goal in patients without neurological deficits, whereas in patients with neurological impairment, early decompression and spinal stabilization are the main objectives [1, 2].
Stable injuries are generally associated with good clinical outcomes, once they generally heal well [1, 2]. On the other hand, injuries that may develop spinal deformity or chronic pain are more complex, once the role of surgical intervention is uncertain. Finally, unstable injuries may result in spine deformity due to loss of the ability to sustain the body weight under physiological loads. On the same context, a spine trauma may be considered “unstable” from a neurological point of view in the setting of neurological deficits and persistent neural tissue compression. In this situation, surgical treatment may be recommended [2].
The potential advantage of our algorithm is to classify some injuries as potentially unstable, which may benefit from additional radiological evaluation with MRI and dynamic or standing/load plain radiographs for further information, as well as considering some clinical data, such as mechanical and persistent pain, before treatment decision. Patients with potentially unstable injuries may also be selected for future clinical trials to evaluate the role of surgical versus non-operative treatment in their long-term outcome.
Conclusions
The rational of treatment of TLST was explained based on multiple factors, such as radiological characteristics, patients’ symptoms, and neurological status. The best treatment option is discussed with some case examples. Prospective clinical studies are necessary to evaluate the best treatment modality for some specific fracture patterns, mostly those included in our group of potentially unstable injuries.
References
Vaccaro AR, Zeiller SC, Hulbert RJ, Anderson Pa, Harris M, Hedlund R, et al. The thoracolumbar injury severity score: a proposed treatment algorithm. J Spinal Disord Tech. 2005;18:209–15.
Joaquim AF, Patel AA. Thoracolumbar spine trauma: evaluation and surgical decision making. J Craniovert Jun Spine. 2013;4:3–9.
Abbasi Fard S, Skoch J, Avila MJ, Patel AS, Sattarov KV, Walter CM, Baaj AA. Instability in thoracolumbar trauma: is a new definition warranted? Clin Spine Surg. 2017;30:E1046–1049.
Joaquim AF, Patel AA, Schroeder GD, Vaccaro AR. A simplified treatment algorithm for treating thoracic and lumbar spine trauma. J Spinal Cord Med. 2018;7:1–11.
Vaccaro AR, Oner C, Kepler CK, Dvorak M, Schnake K, Bellabarba C, et al. AOSpine Spinal Cord Injury & Trauma Knowledge Forum. AOSpine thoracolumbar spine injury classification system: fracture description, neurological status, and key modifiers. Spine. 2013;38:2028–37.
Munting E. Surgical treatment of post-traumatic kyphosis in the thoracolumbar spine: indications and technical aspects. Eur Spine J. 2010;19:69–73.
McCormack T, Karaikovic E, Gaines RW. The load sharing classification of spine fractures. Spine. 1994;19:1741–4.
Cantor JB, Lebwohl NH, Garvey T, Eismont FJ. Non-operative management of stable thoracolumbar burst fractures with early ambulation and bracing. Spine. 1993;18:971–6.
McAfee PC, Bohlman HH, Yuan HA. The value of computed tomography in thoracolumbar fractures: An analysis of one hundred consecutive cases and a new classification. J Bone Jt Surg Am. 1985;67:89–104.
Gaca AM, Barnhart HX, Bisset GS 3rd. Evaluation of wedging of lower thoracic and upper lumbar vertebral bodies in the pediatric population. AJR Am J Roentgenol. 2010;194:516–20.
Genant HK, Wu CY, van Kuijk C, Nevitt MC. Vertebral fracture assessment using a semiquantitative technique. J Bone Miner Res. 1993;8:1137–48.
Szulc P, Munoz F, Marchand F, Delmas PD. Semiquantitative evaluation of prevalent vertebral deformities in men and their relationship with osteoporosis: the MINOS Study. Osteoporos Int. 2001;12:302–10.
McKiernan FE. The broadening spectrum of osteoporotic vertebral fracture. Skelet Radiol. 2009;38:303–8.
Matsumoto M, Okada E, Kaneko Y, Ichihara D, Watanabe K, Chiba K, Toyama Y, Fujiwara H, Momoshima S, Nishiwaki Y, Hashimoto T, Takahata T. Wedging of vertebral bodies at the thoracolumbar junction in asymptomatic healthy subjects on magnetic resonance imaging. Surg Radiol Anat. 2011;33:223–28.
Haiyun Y, Rui G, Shucai D, Zhanhua J, Xiaolin Z, Xin L, et al. Three-column reconstruction through single posterior approach for the treatment of unstable thoracolumbar fracture. Spine. 2010;35:E295–302.
Wang XB, Yang M, Li J, Xiong GZ, Lu C, Lu GH. Thoracolumbar fracture dislocations treated by posterior reduction interbody fusion and segmental instrumentation. Indian J Orthop. 2014;48:568–73.
Radcliff K, Su BW, Kepler CK, Rubin T, Shimer AL, Rihn JA, Harrop JA, Albert TJ, Vaccaro AR. Correlation of posterior ligamentous complex injury and neurological injury to loss of vertebral body height, kyphosis, and canal compromise. Spine. 2012;37:1142–50.
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Joaquim, A.F., Patel, A.A., Schroeder, G.D. et al. Clinical application and cases examples of a new treatment algorithm for treating thoracic and lumbar spine trauma. Spinal Cord Ser Cases 4, 56 (2018). https://doi.org/10.1038/s41394-018-0093-4
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DOI: https://doi.org/10.1038/s41394-018-0093-4
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