An updated management algorithm for incorporating minimally invasive techniques to treat thoracolumbar trauma

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  • 1 Department of Neurological Surgery, Washington University in St. Louis, St. Louis, Missouri;
  • | 2 Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida;
  • | 3 Department of Neurosurgery, University of Utah, Salt Lake City, Utah;
  • | 4 Department of Neurological Surgery, University of California, San Francisco, California;
  • | 5 Department of Neurosurgery, University of Florida, Gainesville, Florida;
  • | 6 Departments of Orthopedic Surgery and
  • | 7 Neurosurgery, University of Maryland Medical Center, Baltimore, Maryland;
  • | 8 Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania;
  • | 9 Department of Orthopedic Surgery, University of California, Davis, Sacramento, California;
  • | 10 Department of Orthopedic Surgery, University of Chicago, Chicago, Illinois;
  • | 11 Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan;
  • | 12 Department of Neurosurgery, Duke University, Durham, North Carolina; and
  • | 13 Department of Neurosurgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
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OBJECTIVE

Minimally invasive surgery (MIS) techniques can effectively stabilize and decompress many thoracolumbar injuries with decreased morbidity and tissue destruction compared with open approaches. Nonetheless, there is limited direction regarding the breadth and limitations of MIS techniques for thoracolumbar injuries. Consequently, 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.

METHODS

A survey describing 10 clinical cases with a range of thoracolumbar injuries was sent to 12 surgeons with expertise in spine trauma. The survey results were summarized using descriptive statistics, along with the Fleiss kappa statistic of interrater agreement. To develop an updated treatment algorithm, the authors used a modified Delphi technique that incorporated a literature review, the survey results, and iterative feedback from a group of 14 spine trauma experts. The final algorithm represented the consensus opinion of that expert group.

RESULTS

Eleven of 12 surgeons contacted completed the case survey, including 8 (73%) neurosurgeons and 3 (27%) orthopedic surgeons. For the 4 cases involving patients with neurological deficits, nearly all respondents recommended decompression and fusion, and the proportion recommending open surgery ranged from 55% to 100% by case. Recommendations for the remaining cases were heterogeneous. Among the neurologically intact patients, MIS techniques were typically recommended more often than open techniques. The overall interrater agreement in recommendations was 0.23, indicating fair agreement. Considering both literature review and expert opinion, the updated algorithm indicated that MIS techniques could be used to treat most thoracolumbar injuries. Among neurologically intact patients, percutaneous instrumentation without arthrodesis was recommended for those with AO Spine Thoracolumbar Classification System subtype A3/A4 (Thoracolumbar Injury Classification and Severity Score [TLICS] 4) injuries, but MIS posterior arthrodesis was recommended for most patients with AO Spine subtype B2/B3 (TLICS > 4) injuries. Depending on vertebral body integrity, anterolateral corpectomy or mini-open decompression could be used for patients with neurological deficits.

CONCLUSIONS

Spine trauma experts endorsed a range of strategies for treating thoracolumbar injuries but felt that MIS techniques were an option for most patients. The updated treatment algorithm may provide a foundation for surgeons interested in safe approaches for using MIS techniques to treat thoracolumbar trauma.

ABBREVIATIONS

AS = ankylosing spondylitis; ASIA = American Spinal Injury Association; CNS = Congress of Neurological Surgeons; DISH = diffuse idiopathic skeletal hyperostosis; MIS = minimally invasive surgery; TLICS = Thoracolumbar Injury Classification and Severity Score.

Supplementary Materials

    • Appendix (PDF 12,411 KB)

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