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Spine trauma what are the current controversies

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Spine trauma what are the current controversies

  1. 1. Spine Trauma - What are the Current Controversies? Arif Ali
  2. 2. Introduction • Traumatic injuries of the spinal column represent only a minority of all fractures, with a reported incidence of 4%– 23% in various epidemiological studies. Oliver M, Inaba K, Tang A, et al. The changing epidemiology of spinal trauma: a 13-year review from a Level I trauma centre. Injury. 2012;43: 1296–1300. • Management of spine injuries has continued to be a source of considerable contention within the overall field of musculoskeletal traumatology. • Spine surgical techniques have also undergone various refinements in regards to approach options and implant performance
  3. 3. • There are several factors, which set spine trauma apart from other areas of musculoskeletal trauma. • Firstly, the perspectives of spinal cord and cauda equina injury with its threat of irreversible neural tissue damage have a profound effect on patient outcomes and consequently may alter management. • For patients without neurologic injury or multiple concurrent traumas, the decision-making between nonoperative management and surgical care is far from settled. • Especially for injury patterns where progressive deformity or secondary neurologic deterioration is unlikely, the question remains if surgical intervention contributes to an improved quality of life
  4. 4. • In case of surgical approaches and fixation techniques, surgical invasiveness of the approach and implant technology provides another variable that has traditionally not been factored into the decision-making process regarding surgical versus nonsurgical care.
  5. 5. Areas Of Persistent Substantial Controversy Regarding The Management Of Spine Trauma 1. The role and timing of medical and surgical interventions for patients with associated neurologic injury. 2. Type and timing of surgical stabilization for multiply injured patients. 3. The role of nonsurgical versus surgical treatment.
  6. 6. 4. The role of different surgical approaches and techniques 5. Methods of non-operative management 6. Care of elderly patients with concurrent complex disorders
  7. 7. The Role and Timing of Medical and Surgical Interventions in Patients With Neurologic Injury • Spinal cord or cauda equina injury remains a feared consequence of spine trauma. • In clinical reality, however, several large-scale prospectively randomized trials have questioned a beneficial effect of steroids on the outcome of acute traumatic spinal cord injuries. • The traditional premise that early surgical intervention may be detrimental for neurologic recovery has been firmly refuted. Fehlings MG, Vaccaro A, Wilson JR, et al. Early versus delayed decompression for traumatic cervical spinal cord injury: results of the Surgical Timing in Acute Spinal Cord Injury Study (STASCIS). PLoS One. 2012; 7:e32037
  8. 8. Type and Timing of Surgical Stabilization for Multiply Injured Patients • According to a study using the German Trauma Registry, approximately 36% of all polytrauma patients have associated spine injuries. Bliemel C, Lefering R, Buecking B, et al. Early or delayed stabilization in severely injured patients with spinal fractures? Current surgical objectivity according to the Trauma Registry of DGU: treatment of spine injuries in polytrauma patients. J Trauma Acute Care Surg. 2014;76: 366–373. • The question of timing of surgical intervention in treating spine fractures in polytrauma patients remains unresolved to the present date. • Bellabarba et al concluded in their 2010 systematic review that patients with unstable thoracic fractures are preferably treated with early (defined as less than 72 hours) spine surgery. Bellabarba C, Fisher C, Chapman JR, et al. Does early fracture fixation of thoracolumbar spine fractures decrease morbidity or mortality? Spine (Phila Pa 1976). 2010;35:S138–S145.
  9. 9. • In thoracolumbar fractures, Xing et al also concluded that early stabilization reduced the length of stay, intensive care unit stay, ventilator days, morbidity, and hospital expenses when surgery was performed less than 72 hours after the index trauma. Xing D, Chen Y, Ma JX, et al. A methodological systematic review of early versus late stabilization of thoracolumbar spine fractures. Eur Spine J. 2013;22:2157–2166. • Taking early intervention concept further, a prospective study applied the “damage control” principles to spine trauma and showed that such a protocol is a safe and efficient treatment strategy. Stahel PF, VanderHeiden T, Flierl MA, et al. The impact of a standardize “spine damage-control” protoco for unstable thoracic and lumba spine fractures in severely injured patients: a prospective cohort study J Trauma Acute Care Surg. 2013;74:590–596.
  10. 10. • However, 2 recent studies showed that in certain subgroups of multiply injured patients, early surgical intervention may become a “second hit” and push patients over the edge. • At this time, the question if all multiply injured patients with concurrent spine trauma benefit from early intervention or some subgroups should be deferred for medical reasons is not resolved
  11. 11. The Role of Nonsurgical Versus Surgical Treatment • There are 2 spine injuries that continue to be fraught with a wide divergence of recommended treatment. Odontoid fractures of the elderly are the most common cervical spine injuries in that age group and remain a prominent source of disagreement. • The other topic of controversy pertains to the management of AO Spine type A burst (A3 or A4) fractures without associated neurologic or posterior tension band injuries (type B). • This is a common injury variant, especially at the thoracolumbar junction, constituting about 45% of all thoracolumbar fractures
  12. 12. • Surgical management offers the possibility of immediate stability and earlier pain control, which may promote early mobilization, avoidance of burdensome orthotic treatment, and prevention of deformity. • Nonoperative care offers the avoidance of surgical intervention with its associated morbidity and higher costs. • In the last 2 decades, 2 randomized controlled trials were published with conflicting outcomes.
  13. 13. • No significant differences were found between the 2 groups with respect to clinical or radiological outcomes at an average follow-up of 44 months. • In a recent publication, they presented the long-term follow-up results from 16 to 22 years for the same cohort. Seventyeight percent (37/47) of the original randomized 47 patients were included. Wood KB, Buttermann GR, Phukan R, et al. Operative compared with nonoperative treatment of a thoracolumbar burst fracture without neurological deficit: a prospective randomized study with follow-up at sixteen to twenty-two years. J Bone Joint Surg Am. 2015;97:3–9.
  14. 14. • In contrast to the studies by Wood et al, a large prospective multicenter registry study from German and Austrian Trauma Centers has also reported favorable outcomes and far lower complications for surgically treated patients. Reinhold M, Knop C, Beisse R, et al. Operative treatment of 733 patients with acute thoracolumbar spinal injuries: comprehensive results from the second, prospective, Internet-based multicenter study of the Spine Study Group of the German Association of Trauma Surgery. Eur Spine J. 2010; 19:1657–1676 • To complete the confusion on this matter, a prospectively randomized study from Canada questioned the role of bracing in “stable” thoracolumbar burst injuries by finding no differences in outcomes and complications of patients who received nothing but activity restrictions and guidance versus those who received usual and customary orthotics.
  15. 15. • Nonoperative management in itself has remained a poorly defined entity and constitutes another controversy. • In summary, at this time, there are no definitive guidelines regarding operative or nonsurgical management of common spine injuries in the cervical and thoracolumbar spine where there is minimal risk of secondary neurologic deterioration or high propensity for progressive deformity. • An international multicenter parallel cohort study has recently been launched by AOSpine concerning the thoracolumbar burst fractures, which will hopefully provide some substance to the current medical decision-making.
  16. 16. Surgical Approaches and Techniques • The aim of surgery for spinal trauma is to reduce the fracture and stabilize the injured segments and decompress neurologic tissues if necessary. • The question remains if one surgical approach is superior to others in the surgical effectivity, morbidity, or cost-effectiveness • For the management of subaxial cervical spine injuries, both anterior and posterior approaches showed equivocally satisfactory results without meaningful differences relative to the approach used. Gelb DE, Aarabi B, Dhall SS, et al. Treatment of subaxial cervical spinal injuries. Neurosurgery. 2013;72(suppl 2):187– 194.
  17. 17. • Relative to thoracolumbar fractures, there is a wide spread of recommended surgical approaches. • In their 2004 retrospective review, Verlaan et al could not find significant outcomes differences between various surgical approaches. Verlaan JJ, Diekerhof CH, Buskens E, et al. Surgical treatment of traumatic fractures of the thoracic and lumbar spine: a systematic review of the literature on techniques, complications, and outcome. Spine (Phila Pa 1976). 2004;29:803–814. • In general, there is consensus that pedicle screw instrumentation offers superior stable fixation.
  18. 18. • At this moment, there is insufficient evidence due to the difficulty of obtaining high-level evidence from prospective studies of spine trauma. • The correction of sagittal deformity was better maintained in the combined group, but the functional results including pain and return-to-work were superior for patients treated posteriorly only. • The advent of less invasive surgical techniques over the last decade has only added to the treatment debate.
  19. 19. • Theoretically, minimal invasive techniques may reduce perioperative morbidities typically for vulnerable patient populations such as the multiply injured and elderly with fractures of an ankylosing spine.
  20. 20. Methods of Nonoperative Management • Many spinal injury types can be managed without surgical intervention. However, it is not always clear what constitutes a “non-surgical treatment.” • For upper cervical and subaxial cervical spine, halo vest treatment has been shown to provide sufficient stabilization and may be an alternative to surgical stabilization. van Middendorp JJ, Slooff WB, Nellestein WR, et al. Incidence of and risk factors for complications associated with halo-vest immobilization: a prospective, descriptive cohort study of 239 patients. J Bone Joint Surg Am. 2009;91:71–79. • For cervical spine, there is no evidence for the use of various collars in “stable” type injuries, although this is common practice.
  21. 21. • For the thoracolumbar spine, several groups have examined the necessity of a brace after type A burst fractures but did not find any differences in vertebral height loss, kyphotic progression, clinical outcomes, or adverse events between those treated with or without an orthosis. Shamji MF, Roffey DM, Young DK, et al. A pilot evaluation of the role of bracing in stable thoracolumbar burst fractures without neurological deficit. J Spinal Disord Tech. 2014;27:370–375. • In summary, the common practice of using some kind of external support in the form of collars, braces, casts, or various orthoses is not supported by reliable evidence.
  22. 22. Care of Elderly Patients With Concurrent Complex Disorders • As we in general are leading longer and healthier lives, the spinal column of elderly patients commonly undergoes a number of changes, which raise its vulnerability to spine injuries. • The presence of reduced bone stock, concurrent arthritic disorders, dementia and loss of other neurocognitive functions, social deprivation, and serious comorbidities with concordant polypharmacy affect management choices and outcomes profoundly in these patients.
  23. 23. • For many elderly patients with cervical spinal stenosis, a relatively simple blunt impact such as a fall can lead to serious neurologic injury in form of a central cord injury. • These injuries commonly do not feature an unstable fracture or cord impact from an acute disc herniation. • The treatment of osteopenic thoracolumbar fractures remains a source of great debate.
  24. 24. • With the conclusion of 2 multicenter international prospective randomized controlled trials that showed no discernible differences of vertebroplasty to a sham injection treatment, the subject of vertebral augmentation of vertebral compression fractures seemed to be all but closed.
  25. 25. Conclusion

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