spine trauma New guidelines, surgical Vs conservative Management.....

1. Spine Trauma - What are the
Current Controversies?
Arif Ali

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. • 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. • 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. 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. 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. 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. 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. • 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. • 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. 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. • 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. • 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. • 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. • 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. 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. • 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. • 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. • 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. 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. • 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. 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. • 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. • 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. Conclusion