Approach

The goals of spine trauma care include protection against further injury during evaluation and management; identification of spine injury and documentation of the clinical findings; optimization of conditions for maximal neurologic recovery; maintenance and restoration of spinal alignment; minimization of loss of spinal mobility; obtaining a stable and healed spinal column; and facilitation of rehabilitation.[72]

[Figure caption and citation for the preceding image starts]: Management of thoracolumbar fracturesCreated by Dr B. Nurboja; used with permission [Citation ends].com.bmj.content.model.Caption@52d2f8f7

At the scene: potential vertebral column injuries

All trauma patients should be evaluated based on the principles of Advanced Trauma Life Support®, independent of whether a spinal cord fracture or spinal cord injury is suspected or confirmed.[11] Initial evaluation at the scene includes airway maintenance with spinal motion restriction (SMR), assessment of breathing and ventilation, assessment of circulation with hemorrhage control, and assessment of disability with appropriate exposure of the patient to inspect for any obvious site of major injury.[11][45] Use a hypotensive resuscitation strategy to maintain a target mean arterial blood pressure of 50-65 mmHg if there is ongoing bleeding.[48][49] To improve perfusion, mean arterial pressure should be maintained at 85-90 mmHg for the first 7 days after acute spinal cord injury.[73] In the acute phase following spinal cord injury, intravenous morphine is first line for pain relief. Intravenous ketamine is a second-line agent; intranasal ketamine can be used if there is a delay in getting intravenous access.[46]

According to the American College of Surgeons, significant findings during assessment for thoracic or lumbosacral spine injury that necessitate in-line SMR include:[11]

  • Acutely altered level of consciousness (e.g., GCS <15, evidence of intoxication)

  • Midline neck or back pain and/or tenderness

  • Focal neurologic signs and/or symptoms (e.g., numbness or motor weakness)

  • Anatomic deformity of the spine

  • Distracting circumstances or injury (e.g., long bone fracture, degloving, or crush injuries, large burns, emotional distress, communication barrier, etc.) or any similar injury that impairs the patient’s ability to contribute to a reliable exam.

When SMR is indicated in adults, it should be applied to the entire spine due to the risk of noncontiguous injuries. A critical component of SMR is the application of an appropriately sized cervical collar.[11] The head, neck, and torso should be kept in alignment by placing the patient on a long backboard, a scoop stretcher, a vacuum mattress, or an ambulance cot.[11][47] A rigid backboard should be used for transport only and every effort should be made to remove the board as soon as possible to minimize the risk of pressure ulcers and unnecessary discomfort.[11]

For examining, repositioning, or transferring patients with suspected spinal cord injuries, the American College of Surgeons has made the following recommendations on logrolling (turning patients while ensuring spinal column does not flex) adult patients:[45]

  • Logroll of patients is essential to prevent further damage to the spinal cord. The patient's entire body should be maintained in a neutral alignment, which requires four people:

    • One person to maintain spinal motion restriction

    • Second person for the torso (pelvis and hip)

    • Third person for the pelvis and legs

    • Fourth person to direct the procedure and move the board.

Patients may have one of two types of hypotension. Each requires prompt recognition and treatment.

Hypotension with tachycardia

  • Usually not due to the spine injury, and other causes should be sought (e.g., hemorrhage, dehydration).

  • Should be managed with fluid or blood replacement, taking care not to cause fluid overload and pulmonary edema.

Hypotension with bradycardia or normal heart rate

  • This is neurogenic shock resulting from injury to the spinal cord’s autonomic pathways.[11]

  • Should be managed with fluid/blood replacement, taking care not to cause fluid overload and pulmonary edema; if hypotension persists, vasopressors should be started.[11][45] 

  • The use of vasopressors should preferably be confined to the intensive care setting, where there are facilities for invasive hemodynamic monitoring.[45] An agent with both alpha- and beta-adrenergic activity is recommended treat both hypotension and bradycardia associated with sympathetic denervation.[11] Consult a specialist for guidance on choice and dose of vasopressor.

Type of injury

Isolated anterior column injuries

  • Stable thoracolumbar fractures in patients without neurologic deficits can be safely managed nonoperatively.[11]​ Prolonged bed rest is not indicated for these patients and a best practice involves adequate pain control and early ambulation without a brace.[11][74]​

  • Vertebroplasty or kyphoplasty may be an option in patients with intractable pain, or anterior wedging of vertebral body with an intact posterior cortex of vertebral body (this is to avoid cement leakage into spinal canal).[75]​ However, some studies have questioned the efficacy of vertebral augmentation on outcomes of pain, physical function, and quality of life.[76][77]​​​ Guidelines vary on whether to perform these procedures. See Osteoporotic versus non-osteoporotic fractures.

  • Patients may also require surgery in the presence of instability:[78]

    • A single compression fracture with: loss of >50% of vertebral height, with angulation (particularly if the anterior part of the wedge comes to a point); kyphotic angulation >40° (or 25%) at 1 segment; or residual spinal canal ≤50% normal

    • Three or more contiguous compression fractures

    • Neurologic deficit

    • Disrupted posterior column, or more than minimal middle column failure

    • Progressive kyphosis (risk of progressive kyphosis is increased when loss of height of anterior vertebral body is >75%; risk is higher for lumbar compression fractures than thoracic ones).[75]

Posterior column injuries

  • These are not acutely unstable unless accompanied by failure of the middle column. However, it is important to bear in mind that chronic instability may develop with kyphotic deformity (especially in children).[75]

Fracture dislocations

  • Surgical decompression and stabilization is necessary if there is compression with >50% loss of vertebral height, with angulation; kyphotic angulation >40° (or 25%); neurologic deficit; and/or a desire to shorten length of time of bedrest.

Burst fractures

  • Surgical treatments are required if there is partial neurologic deficit; angular deformity ≥20%; residual canal diameter ≤50% of normal; and/or anterior vertebral body height ≤50% of the posterior height.[78]

Osteoporotic versus non-osteoporotic fractures

Non-osteoporotic fractures

  • Conservative management is indicated in patients with non-osteoporotic fractures if there are no indications for surgical intervention. In those with surgical indications, surgery should be performed unless contraindicated. Surgery is contraindicated in patients with burns or skin loss over the region of the approach; hemodynamic instability; active sepsis; and/or severe medical comorbidities.

Osteoporotic fractures

  • These are usually clinically treatable and preventable. A multidisciplinary approach should be used to manage symptoms caused by a vertebral fracture. The pharmacologic agents used reduce the risk of further fracture within 6 to 12 months by 50% to 80%.[79][80]​ Early treatment of vertebral fractures is essential; 19% of women with osteoporosis and a recent vertebral fracture will sustain a new vertebral fracture within the next 12 months.[40] It is particularly important to identify individuals with vertebral fractures who are osteopenic rather than osteoporotic, and who may otherwise not be considered for pharmacologic treatment.[81]

  • Vertebroplasty and kyphoplasty are techniques that offer a minimally invasive approach. The main aims of treatment are bone stabilization, prevention of kyphosis, and reduction of pain duration (by stabilizing bony fragments). Balloon kyphoplasty and percutaneous vertebroplasty have both been reported in several studies as safe and effective surgical procedures for treating osteoporotic vertebral compression fractures with improvements in pain relief and respiratory function.[82][83][84][85][86]​​ However, some studies have questioned the efficacy of vertebral augmentation on outcomes of pain, physical function, and quality of life.​​​​[76][77]​​ Serious complications reported with these procedures include cement leakage, pulmonary embolism, osteomyelitis, and epidural cement leak.[43]

  • Guidelines vary on whether to perform these procedures.

    • The UK guidelines from the Royal Osteoporosis Society, published in 2022, recommend to consider referral for vertebroplasty or kyphoplasty for hospitalized patients in whom pain is unremitting after 48 hours and severely compromising activities of daily living and mobility in spite of initiation of therapy and acute pain management, and where there is evidence of vertebral body edema on magnetic resonance imaging.[87]

    • The American College of Radiology (ACR) recommends in its 2022 guidance to consider percutaneous vertebroplasty or percutaneous balloon kyphoplasty for pain relief and increased mobility.[88] This recommendation is based on a 2014 US multisociety task force of spine interventionalists reporting that percutaneous vertebroplasty and percutaneous balloon kyphoplasty could be considered generally interchangeable techniques for these indications.[88][89]

    • A 2019 US multisociety task force reconvened and concluded that routine use of vertebral augmentation is not supported by current evidence. For patients with acutely painful vertebral fractures, the data reviewed by the panel in 2019 demonstrated that percutaneous vertebroplasty provides no demonstrable clinically significant benefit over placebo. There was insufficient evidence to recommend kyphoplasty over nonsurgical management.[77]​ These findings are not reflected in the ACR guidance.

  • If there are no neurologic deficits, conservative treatment should be attempted first.

  • Absolute contraindications to percutaneous treatment include septicemia, active osteomyelitis of the target vertebra, infection along the intended trajectory of access, and uncorrectable coagulopathy.[90]​ See Osteoporotic spinal compression fractures.

Conservative (nonsurgical) treatment

The American College of Surgeons recommends that stable thoracolumbar fractures in patients without neurologic deficits can be safely managed nonoperatively.[11] Prolonged bed rest is not indicated for these patients and a best practice involves adequate pain control and early ambulation without a brace.[11][74] 

As well as the absence of neurologic deficit, other indications for conservative treatment include:[91][92][93]

  • Resolving neurologic deficit; or deficit that does not correlate to demonstrable compression, deformity, or instability

  • Acceptable alignment (initial or after postural reduction)

  • Compression fracture <50% of vertebral body height

  • Angulation <20°

Options include:

  • Analgesia and bed rest, giving consideration to the risks of pressure sores, thromboembolism (using thromboembolic deterrent stockings or heparin), respiratory problems, and constipation.[10]

  • Catheterization for bladder problems (suprapubic catheterization for chronic bladder problems).

  • Laxatives to prevent constipation.

  • Appropriate nourishment to optimize fracture and wound healing.

  • Bracing can be prescribed for patient comfort, if desired.[50][94] Braces are often used in thoracolumbar fractures. However, limited high-quality evidence demonstrates that early mobilization without an orthosis can lead to similar pain relief, quality of life, and functional outcome for up to 5-10 years, when compared with the use of a thoracolumbar orthosis.[11][95][96][97][98][99]

    • If an orthosis is applied, it should be noted that external devices tend to become loose over time, and will need adjustments by the clinician.[100]

    • Upper thoracic fractures: need to include the cervical spine (Sternal Occipital Mandibular Immobilizer [SOMI] brace).

    • Thoracolumbar junction: need to include sacrum.

  • Early rehabilitation and physical therapy to prevent respiratory problems (atelectasis) and thromboembolism.[10]

  • In practice, for patients with an osteoporotic fracture, bed rest is typically recommended for 7 days.

Surgical treatment

Surgical intervention is advised if there is:[50][56]​​[100]​​

  • Soft tissue disruption that will not heal with competent ligamentous integrity

  • Significant vertebral body damage

  • Documented neurologic deterioration

  • Kyphotic angulation

  • Spinal canal compromise

  • Increasing pain

  • Increasing malalignment.

The aims of surgery include alignment restoration, deformity correction, neural structure decompression, and achievement of a stable spinal column.

  • Surgical decompression is indicated if there is radiologic evidence of compression and worsening of neurologic deficit.[10][100]​​

  • Surgical stabilization (with rods and screws) is indicated if there is thoracolumbar/lumbar spine dislocation or traumatic spondylolisthesis; or if conservative management has failed or it is not considered a viable option (e.g., patients with dementia).[100]

  • Long segmental instrumentation should be used at the upper and middle thoracic spine (above T10). At the thoracolumbar junction and the lumbar spine short segmental stabilization is mostly sufficient, with better clinical outcomes.[10][101][102][103]​​

Posterior/posterolateral approaches

  • Patients are placed in the prone position with arms abducted to ≤90°, elbows flexed to ≤90°. Midline incision exposes the injured level, after which stabilization and decompression are performed.

Anterior/anterolateral approach

  • Usually performed as a second procedure if partial neurologic deficit persists in patients with failed decompression by posterior stabilization.[104][105]

  • Performed on patients with canal compromise >30% by an anterior fragment (laminectomy will have no effect on decreasing contact load in such cases).[106]

  • Patients are placed in the lateral decubitus position on a flexed table to spread the ribs. Thoracotomy is performed on the intercostal space at the level of the injury. Segmental vessels are then traced and ligated. The rib can be resected and used as a graft. Rongeurs are used to remove the bony fragments of the vertebral bodies while trying to preserve the anterior cortex, which helps to reduce the injury to the large vessels. Once the fractured vertebral body is removed, then an interbody arthrodesis with a strut is performed.

Combined approaches[100]

  • Both anterior and posterior approaches can be performed during the same operation or as a staged procedure.

  • Usually performed for severely compromised spines.

Posterior instrumentation systems are based on bony attachments (hooks and screws) and longitudinal members (rods and plates).[100] Anterior instrumentation systems are based on plates, rods, hybrids, and interbody devices. Complications of instrumentation systems include: CSF leak, deep postoperative infection, transient neurapraxia, and permanent nerve root injury.

There is evidence to suggest that the use of transpedicular intracorporeal bone grafting (TBG) in the instrumental fixation of unstable thoracolumbar fractures may decrease the failure rate.[107] TBG involves the insertion of cancellous bone grafts into the fracture site after the restoration of anatomic alignment using instrumental fixation. Interestingly, one meta-analysis showed no difference between short-segment instrumentation versus long-segment instrumentation as operative treatments for traumatic thoracolumbar spine fractures without neurologic deficit.[108]

Spinal fusion or “spondylodesis” is defined as a permanent fusion of a motion segment. This can be done through either an anterior or a posterior approach.[10]​ Meta-analysis comparing fusion with nonfusion for surgically treated thoracolumbar fractures found that fusion was not necessary when thoracolumbar burst fracture was treated by posterior pedicle screw fixation.[109] No significant difference was identified between the two groups regarding radiologic outcome, functional outcome, neurologic improvement, and implant failure rate. Furthermore, nonfusion was associated with significantly reduced operative time and blood loss. Other meta-analyses have confirmed thoracolumbar fractures that have been operated with nonfusion short-segment instrumentation have less bleeding, shorter surgical time, and fewer bone graft donor site complications.[110][111][112]​​

There is controversy surrounding the specific timing of decompression in patients with thoracolumbar spine fractures and spinal cord injury and whether it has any impact on outcome.[50] Several studies have shown surgical decompression within 24 hours of acute traumatic thoracic and thoracolumbar spinal cord injury is associated with improved neurologic outcomes, as measured by an improvement in motor scores, light touch scores, and pinprick scores, and better American Spinal Injury Association Impairment Scale grades at 1 year after surgery.[10][113][114]​ The Congress of Neurological Surgeons (CNS) and the American Association of Neurological Surgeons (AANS) suggest that “early” surgery be considered as an option in patients with thoracic and lumbar fractures to reduce length of stay and complications. The CNS/AANS note that available literature has defined “early” surgery inconsistently, ranging from <8 hours to <72 hours after injury.[50]​ AOSpine 2017 guidelines concluded that early decompression (≤24 hours after injury) for adult patients presenting with spinal cord injury irrespective of level should be offered, although the quality of evidence for the recommendation was low.[115]

Anterior versus posterior approaches

One meta-analysis found no difference in terms of neurologic recovery, return to work, complications, and Cobb angle between anterior and posterior approaches for the surgical management of thoracolumbar burst fracture.[116] The anterior approach was associated with longer operative time, greater blood loss, and higher cost than the posterior approach. The CNS and ANS identified four randomized clinical trials that did not show any differences in clinical results, including pain and neurologic recovery, between anterior and posterior approaches.[50] Only one level II RCT showed improved clinical outcomes in the posterior-only treatment group compared with the combined group, but the authors recommended against the posterior-only approach because of a high incidence of poor radiologic results.[50][117][118][119][120] The CNS and AAN concluded that anterior, posterior, or combined anterior-posterior approaches are all reasonable treatment options for the surgical management of patients with thoracolumbar fractures, as there was no definitive difference in outcomes or risk of complications when comparing these surgical approaches.[50]

Surgery for thoracolumbar fracture dislocation

Thoracolumbar fracture dislocations are considered unstable, and involve severe injury to the vertebrae and ligaments that stabilize the spine. The optimal treatment for such injuries remains controversial and includes a range of operations, from combined posterior-anterior (P-A) fusion to transforaminal thoracic interbody fusion (TTIF). One randomized controlled trial found that both treatments were similar with respect to the fusion rate, extent of decompression, loss of correction, rate of instrumentation failure, American Spinal Injury Association score, visual analog scale score, and Oswestry Disability Index. However, blood loss, operating time, and rate of perioperative complications were greater in the P-A group than in the TTIF group.[118]

Computer and robotic navigation techniques

Computer-assisted navigation techniques have been used in spine surgery since 1995.[121] Three-dimensional computer-assisted navigation placement of pedicle screws can increase accuracy and reduce surgical time, and can be performed safely and effectively at all levels of the thoracic spine, particularly the upper thoracic spine.[122] Studies have also shown decreased intraoperative radiation exposure and improved safety of minimally invasive spinal surgery with computer-assisted navigation techniques compared with free-hand techniques and fluoroscopy.[123][124][125][126][127][128][129]

Orthopedic robotic surgery combined with computer navigation is also used in some centers to treat thoracic and vertebral fractures.[130]

Analgesia

The most common analgesia used for musculoskeletal pain includes nonsteroidal anti-inflammatory drugs (NSAIDs), acetaminophen, and opioid analgesics, depending on the severity of pain. NSAIDs should be used with caution in older people because of increased susceptibility to adverse effects such as gastrointestinal bleeding and cardiovascular events.[131][132]​​ The UK guidelines recommend to consider acetaminophen ahead of oral NSAIDs, cyclo-oxygenase-2 inhibitors, or opioids.​[87]​ Opioids are recommended only for very short-term use with acute fractures. If used chronically, opioids lose potency, induce dependence, raise risk for addiction, and lead to falls and central sensitization.[43]

Deep vein thrombosis (DVT) prophylaxis

Appropriate DVT prophylaxis is recommended to prevent DVT and pulmonary embolism (PE).[10][50]​​​ Compression stockings and anticoagulation should be commenced within 72 hours of the initial injury.[11] The ACS recommends initiating mechanical prophylaxis (e.g., sequential or pneumatic compression devices and compression stockings) immediately after the injury, if possible, especially for patients with bleeding risk or other contraindications for chemoprophylaxis.[11] There is insufficient evidence to recommend a specific regimen of venous thromboembolism (VTE) prophylaxis to prevent PE (or VTE-associated morbidity and mortality) in patients with thoracic and lumbar fractures.[11][50] The duration of chemoprophylaxis should be determined on an individual patient basis, taking into account injury severity, mobility status, bleeding risk, and other comorbidities. Chemoprophylaxis should never be continued for longer than 3 months.[11]

Pressure ulcers

There is an extremely high risk of developing pressure ulcers after a spinal cord injury due to the following factors:

  • A lack of sensation, leaving patients unaware of the development of a pressure ulcer

  • A lack of muscle activity below the level of injury

  • Impaired circulation, which reduces the transfer of oxygen to the skin.

A pressure ulcer may delay the patient's treatment by weeks, and leave a scar that may be permanently vulnerable. Patients should be regularly turned in a safe manner to reduce pressure on any one side; skin should be regularly assessed for signs of pressure ulcers. It is usually sufficient to turn the patient 30º side-to-side with appropriate pillow support. Heels should be kept clear of the bed and supported with pillows. Pressure-relieving devices such as dynamic mattresses should not be used if the spinal column is unstable, and are usually ineffective in preventing pressure sores in patients with spinal cord injury. Pressure ulcers in children are often caused by pressure from equipment such as braces and splints, as well as lost or forgotten toys in the bed or on the chair cushion. Patients must never be allowed to sit or lie on a pressure ulcer.[133]

Bladder distension

The bladder can become flaccid during spinal shock, leading to overdistension, which can cause permanent damage. All patients will require a urethral catheter, which should initially be set to free drainage.[133]

Autonomic dysreflexia

Autonomic dysreflexia is a potentially dangerous condition that can occur in patients with a spinal cord injury affecting T6 or higher, leading to uncontrolled hypertension, which can further lead to seizures, retinal hemorrhage, brain hemorrhage, pulmonary edema, myocardial infarction, or renal impairment. The pathophysiologic mechanism involves a stimulus below the level of the lesion that activates the sympathetic nervous system. The activated sympathetic system cannot be neuromodulated appropriately by the central nervous system, owing to a lack of spinal cord continuity as descending inhibitory signals cannot travel beyond the level of injury. Lesions below T6 generally allow enough descending inhibitory parasympathetic control to modulate the activated sympathetic tone.[134]

Treatment involves management of the underlying cause of the stimuli, and the use of antihypertensive medication as per local guidelines.

Controversy over corticosteroid use

Intravenous methylprednisolone has previously been recommended for acute spinal cord injury.[10][135][136][137][138][139]​ However, its use is controversial due to severe adverse effects (e.g., decreased wound healing, infections, increased mortality), and problems with the methodology of studies concerning its use.[138] The American College of Surgeons states that the use of methylprednisolone within 8 hours following spinal cord injury cannot be definitively recommended.[11] The Congress of Neurological Surgeons (CNS) and the American Association of Neurological Surgeons (AANS) conclude that there is insufficient evidence to make a recommendation on the use of methylprednisolone; the task force states that, in light of previously published data and guidelines, the complication profile should be carefully considered when deciding on the administration of methylprednisolone.[50] The UK National Institute for Health and Care Excellence (NICE) advises against the use of methylprednisolone for the treatment of acute traumatic spinal cord injury.[46] Although the drug is not approved by the Food and Drug Administration for this application, some clinical guidelines support its use in restricted circumstances (e.g., if initiated within 8 hours of acute spinal trauma).[10][50][139][140]​ If used, the duration of methylprednisolone infusion should be 24-hours as there is an increased risk of adverse events such as pneumonia and sepsis with 48-hour infusion.[139]

Use of this content is subject to our disclaimer