Treatment of Fractures of the Thoracolumbar Spine: Recommendations of the Spine Section of the German Society for Orthopaedics and Trauma (DGOU)

Abstract

Study Design:Abstract consensus paper with systematic literature review.Objective:The aim of this study was to establish recommendations for treatment of thoracolumbar spine fractures based on systematic review of current literature and consensus of several spine surgery experts.Methods:The project was initiated in September 2008 and published in Germany in 2011. It was redone in 2017 based on systematic literature review, including new AOSpine classification. Members of the expert group were recruited from all over Germany working in hospitals of all levels of care. In total, the consensus process included 9 meetings and 20 hours of video conferences.Results:As regards existing studies with highest level of evidence, a clear recommendation regarding treatment (operative vs conservative) or regarding type of surgery (posterior vs anterior vs combined anterior-posterior) cannot be given. Treatment has to be indicated individually based on clinical presentation, general condition of the patient, and radiological parameters. The following specific parameters have to be regarded and are proposed as morphological modifiers in addition to AOSpine classification: sagittal and coronal alignment of spine, degree of vertebral body destruction, stenosis of spinal canal, and intervertebral disc lesion. Meanwhile, the recommendations are used as standard algorithm in many German spine clinics and trauma centers.Conclusion:Clinical presentation and general condition of the patient are basic requirements for decision making. Additionally, treatment recommendations offer the physician a standardized, reproducible, and in Germany commonly accepted algorithm based on AOSpine classification and 4 morphological modifiers.

Traumatic Fractures of the Thoracic Spine

“…Conventional X-ray in two projections is recommended for isolated injuries of the ThSp, as for the thoracolumbar junction and LSp [1]. This is obtained while standing, provided the patient can be moved safely.…”

“…If the patient has been transported lying down due to pain, X-ray examinations are also initially performed with the patient recumbent. A CT scan will be required on recognising a fracture or if interpretation is restricted [1]. With an appropriate history and clinical presentation and given the commonly associated injuries to the ribcage, the whole of the thorax should be depicted on the CT scan [9].…”

“…The majority of publications on fracture management of non-cervical vertebral body fractures deal with the entire thoracolumbar spine, with fractures of the thoracolumbar junction predominating [1]. In contrast, there are significantly fewer studies focusing exclusively on the thoracic spine (ThSp).…”

Klassifikation und Therapieempfehlungen von Verletzungen der Brust- und Lendenwirbelsäule

“…Entscheidend ist, dass konservativ behandelte A1-Frakturen engmaschig klinisch und radiologisch nachkontrolliert werden sollten. Die erste Röntgenkontrolle im Stand muss hierbei bereits spätestens nach einer Woche erfolgen, um eine zunehmende Kyphosierung auszuschließen [40,41].…”

Konservative Behandlung von Wirbelfrakturen in BWS und LWS – was geht wie?

“…Um diese Entscheidungslücke zu schließen, definiert die Leitlinie der DGOU zur Behandlung von thorakolumbalen Wirbelsäulenverletzungen weitere morphologische Kriterien, die in den Entscheidungsprozess mit einfließen [1] (s. Infobox). der ursprünglichen Konfiguration abweichen [7,8]. Hierzu ist eine Röntgenaufnahme unter Belastung, also im Stehen oder Sitzen, essenziell, um die Fehlstellung zu registrieren (▶ Abb.…”