title: Is spine consultation needed for all thoracolumbar fractures? Evaluation of a subspecialist-sparing protocol for screening and management of stable fractures.
abstract: BACKGROUND
  The shortage of neurosurgeons is a problem in many US trauma centers. Most thoracolumbar spine fractures are treated conservatively, and at our institution, we found that most patients did not require surgery. We hypothesize that most spine fractures can be treated safely and effectively by the trauma team, without neurosurgical consultation, using a protocol to guide diagnosis and treatment.
  
  
  METHODS
  A treatment protocol was designed, which used radiologic criteria to screen for potentially stable fractures and guide their treatment by the trauma service without obtaining a spine consult. All patients meeting criteria were ambulated 1 day to 2 days after admission, either with or without a thoracolumbar support orthotic, depending on their level of spinal injury. All received a repeat spine computed tomographic (CT) scan after ambulation. Any change in the fractures on CT findings triggered neurosurgical consultation. Patients with no change in their fractures were discharged with outpatient neurosurgery follow-up and imaging.
  
  
  RESULTS
  Sixty-one patients were evaluated prospectively and 45 met inclusion criteria. Of the 45 patients, 39 were managed without the need for neurosurgical consult. Six patients had mild postambulation CT changes, triggering spine consultation, and all six were managed nonoperatively. All unstable fractures, cord injuries, or cases requiring surgery were identified during the initial trauma survey. One hundred fifty-two retrospective cases were then reviewed. Of these 152 patients, 85 met inclusion criteria. Overall, patients with postambulation CT changes were older (median age, 72 vs. 46 years). Of the 85 patients, none of the 9 patients who had postambulation CT changes required surgery. Hundred percent were managed with repeat CT scan and continued bracing. All operative or unstable fractures during the study period would have been effectively screened out by the protocol's radiologic criteria.
  
  
  CONCLUSIONS
  The use of a treatment protocol for stable thoracolumbar fractures seems to be safe and is currently in clinical practice at our institution. Its use could conserve neurosurgical resources without sacrificing patient safety outcomes.
authors.affiliation: Division of Trauma, Department of Surgery, Berkshire Medical Center, Pittsfield, Massachusetts 01201, USA. baldwik@hotmail.com
authors.forename: Keith M
authors.initials: KM
authors.lastname: Baldwin
authors.forename: Gabriel E
authors.initials: GE
authors.lastname: Ryb
authors.forename: Daniel
authors.initials: D
authors.lastname: Miller
authors.forename: Timothy C
authors.initials: TC
authors.lastname: Counihan
authors.forename: Sheldon
authors.initials: S
authors.lastname: Brotman
mesh_terms: D000328:Adult; D000368:Aged; D016009:Chi-Square Distribution; D002985:Clinical Protocols; D005260:Female; D006801:Humans; D008159:Lumbar Vertebrae / Q000000981:diagnostic imaging / Q000293:injuries*; D008297:Male; D008875:Middle Aged; D009493:Neurosurgery; D011446:Prospective Studies; D012017:Referral and Consultation; D012189:Retrospective Studies; D016103:Spinal Fractures / Q000000981:diagnostic imaging* / Q000628:therapy*; D013904:Thoracic Vertebrae / Q000000981:diagnostic imaging / Q000293:injuries*; D014057:Tomography, X-Ray Computed; D014193:Trauma Centers