Thoracolumbarspine trauma is a major source of morbidity, occurring in approximately 7% of all patients who have sustained blunt trauma.1,2While many injuries may be managed nonoperatively, effectively identifying and treating unstable thoracolumbar injuries is an essential element of modern spine surgical practice. Over the past 40 years, several grading scales have been developed to stratify the severity of thoracolumbar fractures, including the McAfee classification, the AO Spine Thoracolumbar Classification System, and the Thoracolumbar Injury Classification and Severity Score (TLICS).3–5These systems are compared inTable 1. While these classifications help stratify injury severity and distinguish operative from nonoperative injuries, the optimal approach to treating surgical injuries remains an ongoing source of controversy.
A comparison of AO Spine, TLICS, and McAfee grading systems for thoracolumbar trauma
| McAfee | TLICS | AO Spine |
|---|---|---|
| Burst w/o definite PLC injury | 2–4 + N | A3–4 + N |
| Burst w/ PLC injury | 5 + N | A3–4 + B1–2 + N |
| Distraction injury | 7 + N | B1–3 + N |
| Translation injury | 6 + N | C + N |
PLC = posterior ligamentous complex.
“N” denotes that there is a separate score for neurological status.
Open surgical arthrodesis, with or without spinal decompression, has historically been considered the gold standard for treating unstable thoracolumbar injuries. However, such approaches are associated with significant pain and potential morbidity, including infection rates as high as 10% and overall complication rates as high as 80%.6,7These concerns are particularly relevant in polytrauma patients who may be medically compromised and more vulnerable to postoperative complications.8To lessen the morbidity of surgical stabilization, spine surgeons have increasingly pursued less-invasive options of treating thoracolumbar injuries.9Yet the extent to which minimally invasive surgery (MIS) approaches can safely replace traditional open techniques has been a source of ongoing debate.
Previous reviews relying on early surgical experience concluded that the indications for purely minimally invasive approaches to thoracolumbar trauma were limited.9,10For example, a 2014 review by Dhall and colleagues indicated that only patients with burst fractures and diffuse idiopathic skeletal hyperostosis (DISH) or ankylosing spondylitis (AS) should be managed with percutaneous fixation without fusion.9However, increased experience and supporting research have expanded these indications. Most notably, the 2019 Congress of Neurological Surgeons (CNS) guidelines review found that there was no benefit of open surgery or surgical arthrodesis compared with percutaneous fixation alone for the treatment of thoracolumbar burst fractures.17,18This recommendation was based on a preponderance of studies showing comparable clinical and radiographic outcomes between approaches, with minimally invasive fixation alone associated with shorter operative time, decreased blood loss, decreased postoperative pain, and potentially earlier return to work.11–15Additionally, even among cases in which open fusion was associated with improved radiographic outcome compared with percutaneous fixation, clinical outcomes were similar.15
While the updated CNS guidelines marked a major advance in the use of MIS techniques, detail regarding the scope of appropriate MIS indications remained limited. Recognizing the expanding evidence base and evolving practice patterns, the objectives of this study were to 1) identify the range of current practice patterns for thoracolumbar trauma and 2) integrate expert opinion and literature review to develop an updated treatment algorithm.
开云体育世界杯赔率
Clinical Case Questionnaire
To identify variations in expert treatment recommendations, we developed a questionnaire that included 10 thoracolumbar trauma cases. The questionnaire included clinical history and imaging findings for 10 patients (Appendix) and was designed to include a range of clinical and radiographic findings. For each case, respondents chose among the following response options: management with brace only; MIS percutaneous instrumentation only; MIS percutaneous instrumentation with MIS arthrodesis; MIS percutaneous instrumentation, mini-open decompression, and MIS posterior arthrodesis; anterolateral corpectomy with posterior MIS percutaneous instrumentation; open reduction and arthrodesis; open reduction, decompression, and arthrodesis; or “other” recommendations. Although posterior approaches for MIS arthrodesis vary, we generally perform this technique by inserting a guide tube down each stab incision, decorticating the facet joint, and placing allograft prior to pedicle screw placement (AppendixandE-Fig. 1). When necessary, we use a similar tubular approach to perform posterior MIS decompressions.
Algorithm Development
We used a stepwise approach that incorporated a modified Delphi technique to develop the updated treatment algorithm.16First, we conducted a narrative literature review using both Google Scholar and PubMed. To develop the 2019 guideline for the management of thoracolumbar spine trauma, the CNS conducted a systematic review of the evidence supporting different surgical approaches, including the role of MIS techniques.17,18Our review included those findings, along with more recent publications examining the role of different MIS approaches in the treatment of thoracolumbar trauma.
Next, a semistructured questionnaire was sent to a core group of four experienced spine trauma surgeons to solicit feedback related to different considerations in managing thoracolumbar trauma. Respondents provided open-ended responses. Based on this feedback and literature review, an initial management algorithm was developed. Next, the survey described above was sent to a group of 12 experienced orthopedic/neurospine trauma surgeons, including two who had participated in the initial algorithm development. The two senior authors did not participate in the survey. Based on responses to the clinical cases and expert feedback, the algorithm was then refined. Using a modified Delphi approach,16the algorithm was then iteratively updated based on feedback from the full group of 14 spine trauma experts until relative consensus on the final algorithm had been reached. Finally, we identified three illustrative cases to highlight the range of operative trauma stratified by the updated MIS algorithm.
Statistical Analysis
Responses to the clinical case survey were summarized using descriptive statistics. In addition, the overall agreement in responses to each case was quantified using the Fleiss kappa statistic.19Using conventional standards, kappa of 0.81–1.0 is considered almost perfect agreement, 0.61–0.80 indicates substantial agreement, 0.41–0.60 indicates moderate agreement, 0.21–0.40 indicates fair agreement, and 0.01–0.20 indicates slight agreement.20的比例recommendat被治疗ions that were concordant with the final MIS algorithm was also summarized and reported along with the 95% confidence interval. Recognizing differing interpretations of imaging severity, for patients with burst fractures, we considered recommendations as concordant with the algorithm whether based on the assumption that the posterior ligamentous complex was significantly disrupted or not. Statistical analyses were conducted using R version 4.0.1.21The study procedures were reviewed by the senior author’s institutional review board and were determined not to constitute human subject research.
Results
Case-Based Questionnaire
Eleven of 12 attending spine trauma experts contacted responded to the case-based questionnaire; 8 (73%) of the 11 respondents were neurosurgeons, and 3 (27%) were orthopedic surgeons. Nine respondents (82%) had been practicing as an attending for more than 10 years, 1 (9%) had been practicing 5–10 years, and 1 (9%) less than 5 years.
A summary of respondent recommendations to the clinical case survey is shown inTable 2. Four patients had neurological deficits, including 2 with American Spinal Injury Association (ASIA) grade D injuries, 1 with an ASIA grade B injury, and 1 with an ASIA grade A injury. All respondents recommended some form of decompression for the ASIA grade D injuries, and 82%–91% recommended decompression for the ASIA grade A and B injuries. Among the patients with neurological deficits, the proportion of respondents recommending open surgery ranged from 100% for a patient with a fracture-dislocation (case 9) to 55% for a patient with a kyphotic burst fracture and anterior epidural hematoma (case 1).
总结反应临床病例10 the survey
| Case No. | Treatment Recommendation | |||||||
|---|---|---|---|---|---|---|---|---|
| 撑 | Perc Only | MIS Posterior Fusion | MIS Posterior Decompression + Fusion | MIS Anterolat Corpectomy | Open Fusion | Open Decompression + Fusion | Other | |
| 1* | 0 (0) | 0 (0) | 0 (0) | 1 (9) | 4 (36) | 0 (0) | 6 (55) | 0 (0) |
| 2 | 4 (36) | 5 (45) | 2 (18) | 0 (0) | 0 (0) | 0 (0) | 0 (0) | 0 (0) |
| 3 | 6 (55) | 4 (36) | 0 (0) | 0 (0) | 0 (0) | 0 (0) | 1 (9) | 0 (0) |
| 4 | 2 (18) | 4 (36) | 0 (0) | 0 (0) | 0 (0) | 3 (27) | 2 (18) | 0 (0) |
| 5* | 0 (0) | 0 (0) | 0 (0) | 0 (0) | 0 (0) | 1 (9) | 10 (91) | 0 (0) |
| 6 | 3 (27) | 5 (45) | 1 (9) | 0 (0) | 0 (0) | 1 (9) | 1 (9) | 0 (0) |
| 7* | 0 (0) | 0 (0) | 0 (0) | 2 (18) | 0 (0) | 0 (0) | 8 (73) | 1 (9) |
| 8 | 5 (45) | 3 (27) | 0 (0) | 1 (9) | 0 (0) | 1 (9) | 0 (0) | 1 (9) |
| 9* | 0 (0) | 0 (0) | 0 (0) | 0 (0) | 0 (0) | 2 (18) | 9 (82) | 0 (0) |
| 10 | 6 (55) | 1 (9) | 0 (0) | 0 (0) | 0 (0) | 2 (18) | 2 (18) | 0 (0) |
Perc = posterior percutaneous instrumentation.
Values are presented as the number of surgeons (%).
Cases involving patients who presented with a neurological deficit.
Among the neurologically intact patients, the proportion of respondents recommending nonoperative treatment ranged from 18% for an L1 burst fracture with posterior element fractures and kyphosis (case 4) to 55% for patients with lumbar burst fractures and normal alignment (cases 3 and 10). Among neurologically intact patients, no surgeons recommended anterolateral corpectomy, and the proportion recommending decompression ranged from 0% to 18% by case. Among respondents who recommended surgery for the neurologically intact patients, percutaneous instrumentation only (range 20%–80% by case) was generally more common than MIS (range 0%–29%) or open (range 0%–80%) arthrodesis.
Among the 11 survey respondents, the overall Fleiss kappa statistic was 0.23, traditionally considered at the lower end of fair interrater agreement.
MIS Treatment Algorithm
Based on the results of the clinical case questionnaire, literature review, and the modified Delphi process, an updated treatment algorithm was developed. The algorithm presents an overall treatment guide (Fig. 1层云),还有更具体的建议fied by the modified AO and TLICS grading scales (Figs. 2and3). As shown inFig. 1, most thoracolumbar injuries can be treated using an MIS approach, with the exception of fraction/dislocation injuries, injuries with severe distraction or deformity, and surgeries in patients with previous instrumentation. In general, patients with neurological deficits require decompression, typically with a mini-open posterior decompression, or in cases of vertebral body compromise, an anterolateral corpectomy. Among neurologically intact patients with operative AO Spine subtype A3–A4 (TLICS 4) injuries, most can be treated with MIS percutaneous instrumentation without arthrodesis. However, patients with significant vertebral body compromise may require anterolateral corpectomy. Among patients with AO Spine type B injuries (TLICS > 4), those with B1 (bony Chance) fractures, AS, or DISH can typically be treated with percutaneous instrumentation without arthrodesis. Other patients generally require MIS posterior arthrodesis, or potentially anterolateral corpectomy in cases of significant vertebral body compromise.
Overall management algorithm for incorporating MIS techniques to treat thoracolumbar blunt trauma based on the patient’s presenting AO Spine type and TLICS.
Recommendations for using MIS techniques to treat patients with AO Spine subtype A3/A4 (TLICS 4) injuries.
Recommendations for using MIS techniques to treat patients with AO type B (TLICS > 4) injuries. *Open surgery remains an option at surgeon discretion.
Comparing the responses to the case questionnaire with the algorithm recommendations, the survey recommendations were consistent with the MIS algorithm in 91 of 110 instances (83%; 95% CI 74%–89%). The most common points of disagreement involved respondents recommending decompression in neurologically intact patients (n = 7), nonoperative treatment for a DISH patient with an AO Spine subtype B3 injury (n = 4, case 2), or not recommending decompression for ASIA grade A or B injuries (n = 3).
Illustrative Cases
Illustrative Case 1
A 22-year-old woman presented with low-back pain that started while wrestling. She was neurologically intact. A CT scan demonstrated an L1 burst fracture with approximately 50% loss of high, moderate bony retropulsion, and mild focal kyphosis (Fig. 4A). MRI demonstrated injury to the anterior and posterior longitudinal ligaments, but the posterior ligamentous complex was intact. The patient’s TLICS score was 4. Given the focal kyphosis and degree of vertebral body compromise, the patient was offered surgical stabilization. She underwent T11–L3 percutaneous instrumentation and fracture reduction without arthrodesis (Fig. 4B). The patient remained neurologically intact and was discharged home on postoperative day 4. Final follow-up imaging 21 months postoperatively showed stable radiographic findings.
Illustrative case 1. Preoperative CT and MR images (A) and postoperative anteroposterior and lateral view radiographs (B) obtained in a patient with an L1 burst fracture and a TLICS score of 4.
Illustrative Case 2
A 25-year-old man presented as a restrained driver in a motor vehicle collision. He had full strength but complained of left leg numbness and paresthesias and had persistent inability to void. He also had a left clavicle fracture. A lumbar spine CT scan showed an L4 burst fracture with 60% loss of height and moderate narrowing of the spinal canal (Fig. 5A). MRI subsequently showed a ventral epidural hematoma from L3 to S1 causing severe stenosis at L3–4, along with damage to the anterior and posterior longitudinal ligaments and ligamentum flavum. His TLCIS score was 8. Given the combined neurological deficit and vertebral body compromise, the patient underwent an urgent anterior L4 corpectomy and L3–5 anterior interbody fusion through a limited anterior exposure, followed by percutaneous posterior instrumentation and fusion from L3 to L5 (Fig. 5B). The patient was discharged to rehabilitation therapy on postoperative day 6. At follow-up 7 months after surgery, he had stable radiographic findings and was neurologically normal, other than mild persistent lower-extremity sensory changes.
Illustrative case 2. Preoperative CT and MR images (A) and postoperative anteroposterior and lateral view radiographs (B)获得一个L4爆裂骨折患者associated with an incomplete cauda equina injury and damage to the ligamentum flavum, giving a TLICS score of 8.
Illustrative Case 3
A 31-year-old man presented with an ASIA grade A spinal cord injury after a motorcycle collision. CT and MRI showed a severe fracture-dislocation at L3–4, with leftward displacement of L3 on L4 with transection of the spinal canal (Fig. 6A). The TLICS score was 9. The patient had other injuries, including multiple rib fractures and bilateral pneumothoraxes, and several extremity fractures. Given the severity of his fracture-dislocation, the patient underwent open L1–5 decompression and instrumented fusion with de-rotation and fracture reduction (Fig. 6B). The patient was discharged on postoperative day 12. At last follow-up, the patient had mildly increased sensory function but remained dependent on a wheelchair for mobility.
Illustrative case 3. Preoperative CT and MR images (A) and postoperative anteroposterior and lateral view radiographs (B) obtained in a patient with a severe fracture-dislocation at L3–4 associated with an ASIA grade A injury, giving a TLICS score of 9.
Discussion
Along with the overall growth in spine MIS,22,23the past decade has seen substantial expansion in the use of MIS techniques to treat thoracolumbar injuries. With this increased experience, more surgeons have demonstrated comparable—if not potentially superior—outcomes using MIS compared with traditional open techniques for a range of indications. In light of these developments, we surveyed spine trauma experts on their current practice patterns. We then combined expert opinion and an updated literature review to describe indications for and limitations of MIS approaches for thoracolumbar trauma.
As demonstrated by the results of our case-based questionnaire, there was substantial heterogeneity in management recommendations among attending spine surgeons experienced in treating thoracolumbar trauma. This diversity in recommendations extended to the choice of operative versus nonoperative management, open versus MIS approaches, and fusion versus instrumentation only. For instance, in case 2 involving a distraction injury through the disc space in a patient with DISH, recommendations ranged from external brace (36%) to MIS posterior arthrodesis (18%). This range of expert recommendations is an important finding and one that highlights the challenge of providing a framework that incorporates this diversity of views. Consequently, we developed an updated MIS algorithm that reflected overall consensus agreement and the published literature, while recognizing that both differing practice styles and interpretations of injury severity will influence how this algorithm is implemented.
Consistent with the 2014 treatment algorithm published by Dhall and colleagues,9the consensus recommendation was to consider percutaneous fixation without arthrodesis for most injuries (AO Spine type A/B) in patients with AS or DISH. This recommendation was based on both the high complication rate associated with open approaches—higher than 80% in some series24,25—and consistent literature describing the success of percutaneous stabilization in this population.24,26–29While this recommendation has been unchanged since 2014, the updated algorithm presented herein also expands the proposed use of percutaneous instrumentation without fusion.
As established in the 2019 CNS guidelines, the addition of arthrodesis to percutaneous instrumentation for burst fractures does not appear to improve clinical or radiographic outcomes and has been associated with increased blood loss and operative time.18Furthermore, the guideline provided a grade B recommendation that percutaneous techniques showed outcomes that were equivalent to those of traditional open approaches. Indications for percutaneous instrumentation continue to grow,30and a 2017 systematic review by Chu and colleagues noted the effectiveness of percutaneous stabilization without arthrodesis in 19 patients with osseous and 25 patients with ligamentous distraction injuries.31Nonetheless, given concerns related to poor healing of the posterior ligamentous complex,32we believe further evidence is required to justify broad use of percutaneous instrumentation alone for patients with significant ligamentous disruption. Consequently, our current algorithm advises routine use of percutaneous stabilization without arthrodesis only for patients with a TLICS score of 4 (AO Spine subtype A3/A4), or those with DISH, AS, or bony Chance fractures.
While additional studies may be needed to broaden indications for percutaneous instrumentation without arthrodesis, our algorithm does expand the role of MIS posterior arthrodesis. Across a variety of indications, spine surgeons have developed greater comfort employing MIS techniques involving mini-open arthrodesis.33–35Corresponding to this increased experience, several studies have shown comparable outcomes using MIS compared with open techniques for a broader range of thoracolumbar injuries, including flexion-distraction injuries.36–38Consequently, we recommend incorporating MIS posterior instrumentation and arthrodesis for most flexion-distraction injuries (AO type B, TLICS > 4), in the absence of a contraindication such as previous instrumentation. This recommendation contrasts with the 2014 algorithm, where MIS fusion approaches for patients with TLICS > 4 were restricted to anterior or lateral corpectomy.9In the current algorithm, we reserve anterior/lateral corpectomy for patients with neurological deficits and severe vertebral body compromise.
The use of MIS techniques for patients with neurological deficits represents a final update offered by the current algorithm. In the 2014 version, anterior/lateral corpectomy was the only technique recommended to decompress the thecal sac and neural elements. However, large cohorts have not shown convincing evidence of improved neurological outcome with anterior/lateral corpectomy compared with posterior approaches.39Additionally, even minimally invasive anterior/lateral corpectomies are generally associated with increased complication risk compared with posterior-only laminectomy.40–44Furthermore, there is increasing experience using posterior MIS decompression approaches for a variety of degenerative pathologies, along with specific evidence supporting these techniques in patients with thoracolumbar trauma and neurological deficits.41Consequently, we recommend reserving anterior/lateral corpectomy for patients with substantial vertebral body compromise.
Despite the tremendous growth in minimally invasive approaches to thoracolumbar trauma, open approaches remain essential in some circumstances, such as the patient in case 3 with a significant fracture-dislocation. Additionally, further research is needed to clarify several important questions. For example, while many authors advocate removing hardware from percutaneous instrumentation after approximately 12 months,41,45others only advise removing hardware if patients are symptomatic.37Whether and when hardware should be removed remains an open debate.18While we currently recommend arthrodesis whenever decompression of thoracolumbar fractures is performed, further studies should explore whether percutaneous stabilization alone may be adequate in some circumstances. Finally, given the reliance on small single-center series in both the open and MIS literature, rigorous trials and large-scale data sets will be needed to address these and other key questions.
Conclusions
The surgical management of thoracolumbar trauma continues to evolve as MIS technology and techniques expand. Despite substantial heterogeneity in clinical practice patterns among spine trauma experts, the updated algorithm presented incorporates consensus views that were consistent with most treatment recommendations. Most notably, we define and expand proposed uses of percutaneous instrumentation alone, as well as MIS posterior arthrodesis and decompression. We intend to evaluate this framework prospectively and provide continued updates as research in this field expands.
Acknowledgments
Dr. Greenberg was supported by grants from the Agency for Healthcare Research and Quality (1F32HS027075-01A1), the Thrasher Research Fund (#15024), and a Young Investigator Research Grant Award from AO Spine North America. This study received no specific dedicated funding.
Disclosures
Dr. Dailey has research funding from K2M; is a consultant for Medtronic, K2M, and Zimmer-Biomet; and receives honoraria from AO Spine. Dr. Dhall is a consultant for DePuy Spine; patent holder with Greater Circle Technologies; and receives honoraria from DePuy Synthes and Globus. Dr. Hoh reports receiving a stipend as a member ofThe Spine Journaleditorial board; serves on the board ofJournal of Neurosurgery: Spine;是中枢神经系统的一名军官,在executiv吗e committee of AANS/CNS Joint Section of Disorders of the Spine and Peripheral Nerves. Dr. Kanter reports receiving royalties from NuVasive and Zimmer Biomet. Dr. Gelb receives payment for lectures and for development of educational presentations from AO Spine NA; receives royalties from DePuy Synthes Spine; and has stock in Advanced Spinal Intellectual Property, Inc. Dr. Klineberg reports being a consultant for DePuy Synthes, Stryker, and Medicrea/Medtronic; receiving honoraria from AO Spine; being on the speakers bureau of AO Spine, and receiving a fellowship grant from AO Spine. Dr. Lee has received funding from DePuy Synthes, Stryker Spine, and Globus Medical as a paid consultant. Dr. Mummaneni reports being a consultant for Stryker Spine, DePuy Synthes, and Globus; having direct stock ownership in Spinicity/ISD; receiving royalties from DePuy Synthes, Thieme Publishers, and Springer Publishers; and receiving support of non–study-related clinical or research effort from AO Spine, NREF, NIH and ISSG. Dr. Park reports being a consultant for Globus and NuVasive; receiving royalties from Globus; and receiving support of non–study-related clinical or research effort from DePuy, ISSG, SI-BONE, and Cerapedics. Dr. Sansur reports being a consultant for NuVasive and Stryker; receiving royalties from Stryker; and having ownership in Maryland Development Corp. Dr. Than reports being a consultant to Bioventus, DePuy Synthes, and Integrity Implants; and receiving honoraria from LifeNet Health and Globus. Dr. Yoon reports ownership in MedCyclops and Kinesiometrics; and is a consultant for Johnson & Johnson, Biderman Motech, and Ethicon. Dr. Wang reports being a consultant for DePuy Synthes Spine, Medtronic, Stryker, Globus, and Spineology; being a patent holder with DePuy Synthes Spine; and having direct stock ownership in ISD, Kinesiometrics, and Medical Device Partners. Dr. Ray reports stock/equity in Acera Surgical; consulting support from DePuy/Synthes, Globus, and NuVasive; and royalties from Acera Surgical.
Author Contributions
Conception and design: Greenberg, Burks, Dibble, Dhall, Gelb, Sansur, Wang, Ray. Acquisition of data: Greenberg, Dailey, Dhall, Hoh, Gelb, Klineberg, Lee, Mummaneni, Park, Than, Yoon. Analysis and interpretation of data: all authors. Drafting the article: Greenberg. Critically revising the article: all authors. Reviewed submitted version of manuscript: all authors. Approved the final version of the manuscript on behalf of all authors: Greenberg. Statistical analysis: Greenberg. Administrative/technical/material support:. Study supervision: Wang, Ray.
Supplemental Information
Online-Only Content
Supplemental material is available with the online version of the article.
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