Indications for Nonsurgical Treatment of Thoracolumbar Spine Fractures: WFNS Spine Committee Recommendations

Thoracolumbar spine is the most injured spinal region in blunt trauma. Literature on the indications for nonoperative treatment of thoracolumbar fractures is conflicting. The purpose of this systematic review is to clarify the indications for nonsurgical treatment of thoracolumbar fractures. We conducted a systematic literature search between 2010 to 2020 on PubMed/MEDLINE, and Cochrane Central. Up-to-date literature on the indications for nonoperative treatment of thoracolumbar fractures was reviewed to reach an agreement in a consensus meeting of WFNS (World Federation of Neurosurgical Societies) Spine Committee. The statements were voted and reached a positive or negative consensus using the Delphi method. For all of the questions discussed, the literature search yielded 1,264 studies, from which 54 articles were selected for full-text review. Nine studies (4 trials, and 5 retrospective) evaluating 759 participants with thoracolumbar fractures who underwent nonoperative/surgery were included. Although, compression type and stable burst fractures can be managed conservatively, if there is major vertebral body damage, kyphotic angulation, neurological deficit, spinal canal compromise, surgery may be indicated. AO type B, C fractures are preferably treated surgically. Future research is necessary to tackle the relative paucity of evidence pertaining to patients with thoracolumbar fractures.

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Surgical Techniques for Thoracolumbar Spine Fractures: WFNS Spine Committee Recommendations

Neurospine ◽

10.14245/ns.2142206.253 ◽

2021 ◽

Vol 18 (4) ◽

pp. 667-680

Author(s):

Salman Sharif ◽

Yousuf Shaikh ◽

Onur Yaman ◽

Mehmet Zileli

Keyword(s):

Thoracolumbar Spine ◽

Surgical Techniques ◽

Early Mobilization ◽

Skin Lesions ◽

Pulmonary Complications ◽

Consensus Meeting ◽

Thoracolumbar Fracture ◽

World Federation ◽

Thoracolumbar Fractures ◽

Thoracolumbar Spine Fractures

To formulate the specific guidelines for the recommendation of thoracolumbar fracture regarding surgical techniques and nonfusion surgery. WFNS (World Federation of Neurosurgical Societies) Spine Committee organized 2 consensus meeting. For nonfusion surgery and thoracolumbar fracture, a systematic literature search in PubMed and Google Scholar database was done from 2010 to 2020. The search was further refined by excluding the articles which were duplicate, not in English or were based on animal or cadaveric subjects. After thorough shortlisting, only 50 articles were selected for full review in this consensus meeting. To generate a consensus, the levels of agreement or disagreement on each item were voted independently in a blind fashion through a Likert-type scale from 1 to 5. The consensus was achieved when the sum for disagreement or agreement was ≥ 66%. Each consensus point was clearly defined with evidence strength, recommendation grade, and consensus level provided. A magnitude of prospective papers were analyzed to formulate consensus on various surgical techniques that can be employed to address different types of thoracolumbar fractures. Surgical treatment of thoracolumbar fractures can be a better option over the nonoperative approach, especially for those who cannot tolerate months in an orthosis or cast, such as those with multiple extremity injuries, skin lesions, obesity, and so forth. It generally allows early mobilization, less hospital stay, reduced pulmonary complications, and better correction of sagittal balance. Current available literature fails to demonstrate any statistically significant benefit of fusion surgery over nonfusion in thoracolumbar fractures.

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Does Tranexamic Acid Reduce Perioperative Bleeding in Short Segment Pedicle Screw Fixation in Thoracolumbar Spine Fractures?

Journal of Nepal Medical Association ◽

10.31729/jnma.2785 ◽

2015 ◽

Vol 53 (199) ◽

pp. 169-173 ◽

Cited By ~ 3

Author(s):

Rabindra Lal Pradhan ◽

Bimal Kumar Pandey

Keyword(s):

Tranexamic Acid ◽

Pedicle Screw ◽

Screw Fixation ◽

Thoracolumbar Spine ◽

Pedicle Screw Fixation ◽

Control Group ◽

Thoracolumbar Fractures ◽

Short Segment ◽

Perioperative Bleeding ◽

Thoracolumbar Spine Fractures

Introduction: Blood loss with spinal surgery is common potential cause of morbidity and often requires blood transfusion. Tranexamic acid (TXA), is effective in reducing bleeding in patients undergoing knee arthroplasty. TXA used in spine surgery studies have included different cases leading to inconsistence of surgical procedures. Purpose of this prospective observational study was to examine effect of TXA decreasing bleeding in short segment pedicle screw fixation for thoracolumbar fractures. Methods: 38 patients' undergoing short segment pedicle screw for thoracolumbar fractures were enrolled in study from July to August 2013. There were 28 male and 10 female patients, with an average age of 36.5 years. Patients received 10 mg/kg of TXA or a control 30 minutes intravenously before skin incision and 3 hours post-operative and oral medication for three days. Intraoperative bleeding was estimated by weighing surgical sponges, blood collected by suction container and by subtracting all irrigation fluid. Postoperative bleeding was measured from volume in vacuum drainage bag. Results: Twenty (20) patients were in control group and eighteen(18) to TXA group. There were no statistical differences between groups in terms of age, gender, co-morbidities, and operating time, preoperative Hemoglobin, PT and INR. Intra-operative bleeding in TXA group was significant than in control group. Post-operative drainage and Hemoglobin in first 48 h was reduced compared with placebo in TXA group. Need for post-operative transfusion was nil in TXA group. Conclusions: Administration of TXA before surgery significantly reduces perioperative bleeding in patients undergoing short segment pedicle screw fixation for thoracolumbar spine fractures. Keywords: bleeding; spinal surgery; tranexamic acid.

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Treatment of Traumatic Thoracolumbar Spine Fractures: A Multicenter Prospective Randomized Study of Operative Versus Nonsurgical Treatment

Spine ◽

10.1097/01.brs.0000247804.91869.1e ◽

2006 ◽

Vol 31 (25) ◽

pp. 2881-2890 ◽

Cited By ~ 176

Author(s):

Jan Siebenga ◽

Vincent J. M. Leferink ◽

Michiel J. M. Segers ◽

Matthijs J. Elzinga ◽

Fred C. Bakker ◽

...

Keyword(s):

Randomized Study ◽

Thoracolumbar Spine ◽

Nonsurgical Treatment ◽

Prospective Randomized Study ◽

Spine Fractures ◽

Thoracolumbar Spine Fractures

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Bracing for thoracolumbar fractures

Neurosurgical FOCUS ◽

10.3171/2014.4.focus1477 ◽

2014 ◽

Vol 37 (1) ◽

pp. E3 ◽

Cited By ~ 25

Author(s):

Victor Chang ◽

Langston T. Holly

Keyword(s):

Vertebral Fractures ◽

Thoracolumbar Spine ◽

The Elderly ◽

Nonoperative Treatment ◽

Neurological Deficits ◽

Thoracolumbar Fractures ◽

High Quality ◽

High Quality Evidence ◽

Osteoporotic Vertebral Fractures ◽

Quality Evidence

Traumatic fractures of the thoracolumbar spine are relatively common occurrences that can be a source of pain and disability. Similarly, osteoporotic vertebral fractures are also frequent events and represent a significant health issue specific to the elderly. Neurologically intact patients with traumatic thoracolumbar fractures can commonly be treated nonoperatively with bracing. Nonoperative treatment is not suitable for patients with neurological deficits or highly unstable fractures. The role of operative versus nonoperative treatment of burst fractures is controversial, with high-quality evidence supporting both options. Osteoporotic vertebral fractures can be managed with bracing or vertebral augmentation in most cases. There is, however, a lack of high-quality evidence comparing operative versus nonoperative fractures in this population. Bracing is a low-risk, cost-effective method to treat certain thoracolumbar fractures and offers efficacy equivalent to that of surgical management in many cases. The evidence for bracing of osteoporotic-type fractures is less clear, and further investigation will be necessary to delineate its optimal role.

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Classification and Radiological Diagnosis of Thoracolumbar Spine Fractures: WFNS Spine Committee Recommendations

Neurospine ◽

10.14245/ns.2142650.325 ◽

2021 ◽

Vol 18 (4) ◽

pp. 656-666

Author(s):

Abdul Hafid Bajamal ◽

Khrisna Rangga Permana ◽

Muhammad Faris ◽

Mehmet Zileli ◽

Nikolay A. Peev

Keyword(s):

Literature Review ◽

Text Analysis ◽

Thoracolumbar Spine ◽

Radiological Diagnosis ◽

Management Decision ◽

World Federation ◽

Spine Fractures ◽

Radiologic Diagnosis ◽

Management Decision Making ◽

Thoracolumbar Spine Fractures

The aim of this review to determine recommendations for classification and radiological diagnosis of thoracolumbar spine fractures. Recommendation was made through a literature review of the last 10 years. The statements created by the authors were discussed and voted on during 2 consensus meetings organized by the WFNS (World Federation Neurosurgical Societies) Spine Committee. The literature review was yielded 256 abstracts, of which 32 were chosen for full-text analysis. Thirteen papers evaluated the reliability of a classification system by our expert members and were also chosen in this guideline analysis. This literature review-based recommendation provides the classification and radiologic diagnosis in thoracolumbar spine fractures that can elucidate the management decision-making in clinical practice.

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Timing of surgery in thoracolumbar trauma: is early intervention safe?

Neurosurgical FOCUS ◽

10.3171/2014.5.focus1473 ◽

2014 ◽

Vol 37 (1) ◽

pp. E7 ◽

Cited By ~ 19

Author(s):

Christopher Paul O'Boynick ◽

Mark F. Kurd ◽

Bruce V. Darden ◽

Alexander R. Vaccaro ◽

Michael G. Fehlings

Keyword(s):

Spinal Cord ◽

Posterior Instrumentation ◽

Thoracolumbar Spine ◽

Spine Fractures ◽

Thoracolumbar Fractures ◽

Surgical Timing ◽

Cord Injury ◽

Thoracolumbar Spine Fractures ◽

Support Cost ◽

Early Fixation

The understanding of the optimal surgical timing for stabilization in thoracolumbar fractures is severely limited. Thoracolumbar spine fractures can be devastating injuries and are often associated with significant morbidity and mortality. The role of early surgical stabilization (within 48–72 hours of injury) as a vehicle to improve outcomes in these patients has generated significant interest. Goals of early stabilization include improved neurological recovery, faster pulmonary recovery, improved pain control, and decreased health care costs. Opponents cite the potential for increased bleeding, hypotension, and the risk of further cord injury as a few factors that weigh against early stabilization. The concept of spinal cord injury and its relationship to surgical timing remains in question. However, when neurological outcomes are eliminated from the equation, certain measures have shown positive influences from prompt surgical fixation. Early fixation of thoracolumbar spine fractures can significantly decrease the duration of hospital stay and the number of days in the intensive care unit. Additionally, prompt stabilization can reduce rates of pulmonary complications. This includes decreased rates of pneumonia and fewer days on ventilator support. Cost analysis revealed as much as $80,000 in savings per patient with early stabilization. All of these benefits come without an increase in morbidity or evidence of increased mortality. In addition, there is no evidence that early stabilization has any ill effect on the injured or uninjured spinal cord. Based on the existing data, early fixation of thoracolumbar fractures has been linked with positive outcomes without clear evidence of negative impacts on the patient's neurological status, associated morbidities, or mortality. These procedures can be viewed as “damage control” and may consist of simple posterior instrumentation or open reductions with internal fixation as indicated. Based on the current literature it is advisable to proceed with early surgical stabilization of thoracolumbar fractures in a well-resuscitated patient, unless extenuating medical conditions would prevent it.

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Incidence and Epidemiology of Thoracolumbar Spine Fractures: WFNS Spine Committee Recommendations

Neurospine ◽

10.14245/ns.2142418.209 ◽

2021 ◽

Vol 18 (4) ◽

pp. 704-712

Author(s):

Mehmet Zileli ◽

Salman Sharif ◽

Maurizio Fornari

Keyword(s):

Elderly Population ◽

Motor Vehicle ◽

Thoracolumbar Spine ◽

Osteoporotic Fractures ◽

Developed Countries ◽

Incidence Rates ◽

World Federation ◽

Spine Fractures ◽

Low Velocity ◽

Thoracolumbar Spine Fractures

This review aims to search the epidemiology and incidence rates of thoracolumbar spine fractures. A systematic review of the literature of the last 10 years gave 586 results with “incidence,” and 387 results with “epidemiology,” of which 39 papers were analyzed. The review results were discussed and voted in 2 consensus meetings of the WFNS (World Federation of Neurosurgical Societies) Spine Committee. Out of 39 studies, 15 studies have focused on thoracolumbar trauma, remaining 24 studies have looked at all spine trauma. Most were retrospective in nature; few were prospective and multicenter. Some studies have focused on specific injuries. The annual incidence of TL fractures is about 30/100,000 inhabitants including osteoporotic fractures. There is a trend to increase the fractures in elderly population especially in developed countries, while an increase of motor vehicle accidents in developing countries. The mortality rate among male elderly patients is relatively high. The incidence of thoracolumbar spine fractures is increasing because of low-velocity falls in the elderly population. The main reasons are falls and traffic accidents. Learning the regional differences and some special forms of trauma such as extreme sports, war, and gunshot injuries will help the prevention of the thoracolumbar spine fractures.

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Treatment Options for Thoracolumbar Spine Fractures

Bosnian Journal of Basic Medical Sciences ◽

10.17305/bjbms.2005.3279 ◽

2005 ◽

Vol 5 (2) ◽

pp. 20-26 ◽

Cited By ~ 1

Author(s):

Eldin E. Karaiković ◽

Hector O. Pacheco

Keyword(s):

Nonoperative Management ◽

Treatment Options ◽

Thoracolumbar Spine ◽

Educational Background ◽

Spine Fractures ◽

Thoracolumbar Fractures ◽

Short Segment ◽

Risks And Benefits ◽

Thoracolumbar Spine Fractures ◽

Surgical Option

A decision for operative versus nonoperative management of thoracolumbar fractures should NEVER be based solely on one factor. Only after a thorough physical, neurological, and spinal examination, and an assessment of a patient’s prior activity, social and educational background and patient’s expectations, one should review the patient’s radiographs and CT scans to determine risks and benefits of operative versus nonoperative care. Both treatment options are discussed in this paper. As a surgical option our preference is short-segment instrumentation and fusion. Careful and appropriate patient selection and an excellent operative technique insure the minimum complications.

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Assessment of the Accuracy of the AO Spine-TL Classification for Thoracolumbar Spine Fractures Using the AO Surgery Reference Mobile App

Global Spine Journal ◽

10.1177/2192568220901694 ◽

2020 ◽

pp. 219256822090169

Author(s):

Allan Hiroshi de Araujo Ono ◽

Verônica Yulin Prieto Chang ◽

Erico Myung Rodenbeck ◽

Alex Oliveira de Araujo ◽

Rafael Garcia de Oliveira ◽

...

Keyword(s):

Thoracolumbar Spine ◽

Fracture Morphology ◽

Neurological Status ◽

Mobile App ◽

Spine Fractures ◽

Thoracolumbar Fractures ◽

Kappa Index ◽

Thoracolumbar Spine Fractures ◽

Fractures Of The Spine ◽

Classification Agreement

Study Design: Cohort study. Objectives: This study aimed to evaluate the accuracy of the AO Surgery Reference mobile app in the diagnosis of thoracolumbar fractures of the spine according to the AO TL classification, and to discuss the usefulness of this app in the teaching and training of the resident physicians in orthopedics and traumatology area. Methods: The 24 residents of Orthopedic and Traumatology program assessed 20 cases of thoracolumbar fractures selected from the hospital database on 2 different occasions, with a 30-day interval, and they classified these cases with and without using the AO Surgery Reference app. A group of spine experts previously established the gold standard and the answers were statistically compared, with the inter- and intraobserver reliability evaluated by the kappa index. Results: The use of the AO Surgery Reference app increased the classification success rate of the fracture morphology (from 53.4% to 72.5%), of the comorbidity modifier (from 61.4% to 77.9%) and of the neurological status modifier (from 55.1% to 72.9%). In addition, the mobile app raised the classification agreement and accuracy. The kappa index increased from 0.30 to 0.53 regarding the morphological classification of fractures. Conclusions: The residents improved their ability to recognize and classify thoracolumbar spine fractures, which reinforces the importance of this tool in medical education and clinical practice.

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Kyphosis After Thoracolumbar Spine Fractures: WFNS Spine Committee Recommendations

Neurospine ◽

10.14245/ns.2142340.170 ◽

2021 ◽

Vol 18 (4) ◽

pp. 681-692

Author(s):

Onur Yaman ◽

Mehmet Zileli ◽

Salim Şentürk ◽

Kemal Paksoy ◽

Salman Sharif

Keyword(s):

English Language ◽

Case Reports ◽

Thoracolumbar Spine ◽

Case Series ◽

Osteoporotic Fractures ◽

World Federation ◽

Posterior Surgery ◽

Posttraumatic Kyphosis ◽

Time Treatment ◽

Thoracolumbar Spine Fractures

Thoracolumbar fractures change the biomechanics of the spine. Load distribution causes kyphosis by the time. Treatment of posttraumatic kyphosis is still controversial. We reviewed the literature between 2010 and 2020 using a search with keywords “thoracolumbar fracture and kyphosis.” We removed osteoporotic fractures, ankylosing spondylitis fractures, non-English language papers, case reports, and low-quality case series. Up-to-date information on posttraumatic kyphosis management was reviewed to reach an agreement in a consensus meeting of the World Federation of Neurosurgical Societies (WFNS) Spine Committee. The first meeting was conducted in Peshawar in December 2019 with WFNS Spine Committee members’ presence and participation. The second meeting was a virtual meeting via the internet on June 12, 2020. We utilized the Delphi method to administer the questionnaire to preserve a high degree of validity. We summarized 42 papers on posttraumatic kyphosis. Surgical treatment of thoracolumbar kyphosis due to unstable burst fractures can be done via a posterior only approach. Less blood loss and reduced surgery time are the main advantages of posterior surgery. Kyphosis angle for surgical decision and fusion levels are controversial. However, global sagittal balance should be taken into consideration for the segment that has to be included. Adding an intermediate screw at the fractured level strengthens the construct.

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