Surgical decision making for unstable thoracolumbar spine injuries: results of a consensus panel review by the Spine Trauma Study Group.
OBJECTIVE
The optimal surgical approach and treatment of unstable thoracolumbar spine injuries are poorly defined owing to a lack of widely accepted level I clinical literature. This lack of evidence-based standards has led to varied practice patterns based on individual surgeon preferences. The purpose of this study was to survey the leaders in the field of spine trauma to define the major characteristics of thoracolumbar injuries that influence their surgical decision making. In the absence of good scientific data, expert consensus opinions may provide surgeons with a practical framework to guide therapy and to conduct future research.


METHODS
A panel of 22 leading spinal surgeons from 20 level I trauma centers in seven countries met to discuss the indications for surgical approach selection in unstable thoracolumbar injuries. Injuries were presented to the surgeons in a case scenario survey format. Preferred surgical approaches to the clinical scenarios were tabulated and comments weighed.


RESULTS
All members of the panel agreed that three independent characteristics of thoracolumbar injuries carry primary importance in surgical decision making: the injury morphology, the neurologic status of the patient, and the integrity of the posterior ligaments. Six clinical scenarios based on the neurologic status of the patient (intact, incomplete, or complete) and on the status of the posterior ligamentous complex (intact or disrupted) were created, and consensus treatment approaches were described. Additional circumstances capable of altering the treatments were acknowledged.


CONCLUSIONS
Decision making for the surgical treatment of thoracolumbar injuries is largely dependent on three patient characteristics: injury morphology, neurologic status, and posterior ligament integrity. A logical and practical decision-making process based on these characteristics may guide treatment even for the most complicated fracture patterns.
Vaccaro
Alexander R
AR
Department of Orthopaedic Surgery, Thomas Jefferson University, Philadelphia, PA, USA. alexvaccaro3@aol.com
Lim
Moe R
MR
Hurlbert
R John
RJ
Lehman
Ronald A
RA
Harrop
James
J
Fisher
D Charles
DC
Dvorak
Marcel
M
Anderson
D Greg
DG
Zeiller
Steven C
SC
Lee
Joon Y
JY
Fehlings
Michael G
MG
Oner
F C
FC
D000465:Algorithms; D002420:Cauda Equina / Q000293:injuries; D019091:Critical Pathways; D003657:Decision Making; D006801:Humans; D008023:Ligaments, Articular / Q000293:injuries; D008159:Lumbar Vertebrae / Q000293:injuries*; D011859:Radiography; D016103:Spinal Fractures / Q000628:therapy; D013124:Spinal Injuries / Q000000981:diagnostic imaging / Q000601:surgery*; D013904:Thoracic Vertebrae / Q000293:injuries*