Lumbar Spine Fractures and Dislocations Guidelines

Updated: Oct 06, 2020
  • Author: Federico C Vinas, MD; Chief Editor: Jeffrey A Goldstein, MD  more...
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Guidelines

AANS/CNS Guidelines on Lumbar and Thoracic Spine Fractures

In 2018, the following guidelines for the treatment of lumbar and thoracic spine fractures were developed by the American Association of Neurological Surgeons (AANS)/Congress of Neurological Surgeons (CNS) Section on Disorders of the Spine and Peripheral Nerves and the Section on Neurotrauma and Critical Care workgroup. [29, 30, 31, 32, 33]

Nonoperative care

Whether to use an external brace is determined at the discretion of the treating physician. [29] Nonoperative management of neurologically intact patients with thoracic and lumbar burst fractures, either with or without an external brace, produces equivalent improvement in outcomes. Bracing is not associated with increased adverse events.

Operative vs nonoperative treatment

The evidence for or against surgical intervention to improve clinical outcomes in patients with thoracolumbar burst fractures who are neurologically intact is conflicting. [30] Accordingly, it is recommended that it be left to the discretion of the treating physician to determine whether the presenting thoracic or lumbar burst fracture in a neurologically intact patient warrants surgical intervention.

The evidence is not sufficient to allow recommendation either for or against surgical intervention for nonburst thoracic or lumbar fractures. It is recommended that the decision to pursue surgical treatment for these fractures be left to the discretion of the treating physician.

Timing of surgical intervention

The evidence regarding the effect of timing of surgical intervention on neurologic outcomes in patients with thoracic and lumbar fractures is insufficient and conflicting. [31]

Early surgery is suggested for consideration as an option in patients with thoracic and lumbar fractures to reduce length of stay and complications. Early surgery has not been consistently defined in the literature, ranging from less than 8 hours to less than 72 hours after injury.

Surgical approaches

For surgical treatment of patients with thoracolumbar burst fractures, physicians may follow an anterior, posterior, or combined approach; the surgical approach taken does not appear to have an impact on clinical or neurologic outcomes. [32]

With regard to radiologic outcomes after surgical treatment of thoracolumbar fractures, physicians may follow an anterior, posterior, or combined approach; evidence from comparison of these approaches is conflicting.

With regard to complications after surgical treatment of these fractures, physicians may follow an anterior, posterior, or combined approach; evidence from comparison of these approaches is conflicting.

Novel surgical strategies

In the surgical treatment of patients with thoracolumbar burst fractures, surgeons should understand that the addition of arthrodesis to instrumented stabilization has not been shown to impact clinical or radiologic outcomes and that it adds to increased blood loss and operating time. [33]

Stabilization using both open and percutaneous pedicle screws may be considered in the treatment of thoracolumbar burst fractures; the evidence suggests that clinical outcomes are equivalent.