THORACOLUMBAR TRAUMA GUIDELINES

Andrew T. Dailey, MD∗

Paul M. Arnold, MD‡
Paul A. Anderson, MD§ Congress of Neurological Surgeons Systematic
John H. Chi, MD, MPH¶
Sanjay S. Dhall, MD
Kurt M. Eichholz, MD#
Review and Evidence-Based Guidelines on the
James S. Harrop, MD∗∗
Daniel J. Hoh, MD‡‡
Sheeraz Qureshi, MD, MBA§§
Evaluation and Treatment of Patients With
Craig H. Rabb, MD¶¶
P. B. Raksin, MD Thoracolumbar Spine Trauma: Classification

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Michael G. Kaiser, MD##
John E. O’Toole, MD, MS∗∗∗

∗
of Injury
Department of Neurosurgery, University of
Utah, Salt Lake City, Utah; ‡ Department of
Neurosurgery, University of Kansas School of
Medicine, Kansas City, Kansas; § Department QUESTION 1: Are there classification systems for fractures of the thoracolumbar spine
of Orthopedics and Rehabilitation, that have been shown to be internally valid and reliable (ie, do these instruments provide
University of Wisconsin, Madison, Wisconsin;
¶
Department of Neurosurgery, Harvard consistent information between different care providers)?
Medical School, Brigham and Women’s
Hospital, Boston, Massachusetts; RECOMMENDATION 1: A classification scheme that uses readily available clinical data (eg,

Department of Neurological Surgery, computed tomography scans with or without magnetic resonance imaging) to convey
University of California, San Francisco, San
Francisco, California; # St. Louis Minimally injury morphology, such as Thoracolumbar Injury Classification and Severity Scale or the
Invasive Spine Center, St. Louis, Missouri;
∗∗
Departments of Neurological Surgery and
AO Spine Thoracolumbar Spine Injury Classification System, should be used to improve
Orthopedic Surgery, Thomas Jefferson characterization of traumatic thoracolumbar injuries and communication among treating
University, Philadelphia, Pennsylvania;
‡‡
Lillian S. Wells Department of Neurological physicians.
Surgery, University of Florida, Gainesville, Strength of Recommendation: Grade B
Florida; §§ Department of Orthopaedic
Surgery, Weill Cornell Medical College, New QUESTION 2: In treating patients with thoracolumbar fractures, does employing a formally
York, New York; ¶¶ Department of
Neurosurgery, University of Utah, Salt Lake tested classification system for treatment decision-making affect clinical outcomes?
City, Utah;  Division of Neurosurgery, John RECOMMENDATION 2: There is insufficient evidence to recommend a universal classifi-
H. Stroger, Jr Hospital of Cook County and
Department of Neurological Surgery, Rush cation system or severity score that will readily guide treatment of all injury types and
University Medical Center, Chicago, Illinois;
##
Department of Neurosurgery, Columbia
thereby affect outcomes.
University, New York, New York;
∗∗∗
Strength of Recommendation: Grade Insufficient
Department of Neurological Surgery,
Rush University Medical Center, Chicago, The full version of the guideline can be reviewed at: https://www.cns.org/guideline-
Illinois
chapters/congress-neurological-surgeons-systematic-review-evidence-based-guidelines/
Sponsored by: Congress of Neurological
chapter_2.
Surgeons and the Section on Disorders of KEY WORDS: Classification, Fracture, Thoracolumbar, Vertebrae
the Spine and Peripheral Nerves in
collaboration with the Section on
Neurosurgery 84:E24–E27, 2019 DOI:10.1093/neuros/nyy372 www.neurosurgery-online.com
Neurotrauma and Critical Care

Endorsed by: The Congress of

Neurological Surgeons (CNS) and the
American Association of Neurological
Surgeons (AANS)
No part of this article has been published
or submitted for publication elsewhere.
Correspondence:
Andrew T. Dailey, MD,
Department of Neurosurgery,
University of Utah,
175 North Medical Drive East,
Salt Lake City, UT 84132.
E-mail: andrew.dailey@hsc.utah.edu
Received, May 30, 2018.
Accepted, July 18, 2018.
Published Online, September 6, 2018.
Copyright 
C 2018 by the
Congress of Neurological Surgeons
Goals and Rationale
Classification systems should enhance
communication between clinicians with varying
degrees of experience about the severity of
an injury or disease process, reliably guide
treatment, and predict the outcome of various
treatment options.1-4 There are at least 12
ABBREVIATIONS: AO, Arbeitsgemeinschaft fur
Osteosynthesenfragen; CNS, Congress of Neuro-
logical Surgeons; CT, computed tomography;
LSC, Load Sharing Classification; PLC, posterior
ligamentous complex; TLICS, Thoracolumbar Injury
Classification Scale; TLISS, Thoracolumbar Injury
Severity Scale
different classification systems that have been
used over the years.5-18 Many classification
systems have been developed for thoracolumbar
trauma, but no single classification system
has been universally accepted. Early attempts
were prone to pattern recognition of fracture
types, and therefore, the interobserver relia-
bility was low. More recent attempts focus
not only on description of the fracture but
have also focused on prognosis and treatment.
These systems have attempted to provide an
injury severity score to help guide the clinician
determine an acceptable treatment plan. In
this guideline, the authors tried to determine
(1) whether there are classification systems for
fractures of the thoracolumbar spine that have

E24 | VOLUME 84 | NUMBER 1 | JANUARY 2019 www.neurosurgery-online.com


been shown to be valid and reliable, and (2) when treating
patients, whether employing a particular classification system
affects clinical outcomes.
METHODS
Details of the systematic literature review are provided in the full
text of this guideline (https://www.cns.org/guideline-chapters/congress-
neurological-surgeons-systematic-review-evidence-based-guidelines/
chapter_2) and in the methodology (https://www.cns.org/guideline-
chapters/congress-neurological-surgeons-systematic-review-evidence-
based-guidelines/chapter_1) article of this guideline series. The guide-
lines task force initiated a systematic review of the literature relevant
to the diagnosis and treatment of patients with thoracolumbar trauma
and a medical librarian implemented the literature search for the period
from January 1, 1946, to March 31, 2015, using the National Library
of Medicine PubMed database and the Cochrane Library. The literature
search yielded 932 abstracts. Task force members reviewed all abstracts
yielded from the literature search and identified the literature for full-text
review and extraction, addressing the clinical questions, in accordance
with the Literature Search Protocol.
RESULTS
The literature search yielded 932 abstracts of which 52 were
selected for full-text review. Twenty articles assessed interobserver
and/or intraobserver reliability of a classification system and were
also selected for review in this guideline.19-38
DISCUSSION
Initial classification systems relied on plain radiographs and
were not tested for reliability. With the advent of computed
tomography (CT), advanced imaging could give a better anatomic
image of a thoracolumbar injury and allow physicians to describe
the injury with fine detail. Denis conceptually divided the spine
into 3 columns with the integrity of the middle column having
the most importance for stability with disruption leading to
potential neurological instability. He described 4 major injury
types with 16 subtypes. Magerl et al14 described the Arbeits-
gemeinschaft fur Osteosynthesenfragen (AO) Comprehensive
Classification system from a retrospective review of 1445 thoracic
and lumbar injuries showing 3 major injury patterns: type A-
axial compression, type B-distraction of anterior and/or posterior
elements, and type C-axial torque leading to anterior and
posterior element disruption with rotation. When consecutive
series of trauma patients are reviewed there is fair to moderate
inter- and intraobserver reliability at the first level of classification,
but the classification is much less reliable at the subtype and subdi-
vision level, making the original AO Classification difficult to use
in day to day practice.
More recently developed systems, including the Thora-
columbar Injury Classification and Severity Scale (TLICS/TLISS)
or the AO Spine Thoracolumbar Spine Injury Classification
System, focus not only on description of the fracture but also
NEUROSURGERY
CLASSIFICATION OF INJURY
focus on prognosis and treatment, and these systems generally
have higher interobserver and intraobserver reliability than prior
classification systems. This was the first classification system to
quantify the neurological status of the patient. If the point total
was 5 or greater, the injury was deemed operable, and those injury
patterns with only 3 points were thought capable of being treated
nonsurgically.
Due to regional differences in the threshold for surgical inter-
vention, and because of the often low reliability of discerning
posterior ligamentous complex (PLC) injury and the wide
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variation in the availability of magnetic resonance imaging to help
determine PLC injury,35-37 the AO Spine Classification Group
was tasked with the development of a morphologically based
classification scheme that also paid attention to the critical deter-
minant of neurological examination.6,17 The resultant AO Spine
Thoracolumbar Injury Classification System is a comprehensive
yet simple scheme that appears on initial evaluation to have
greater reproducibility and reliability than prior schemes. The
wide availability and use of CT for evaluation of trauma patients
is the basis for this scheme and uses the Magerl hierarchy of injury
types with each successive type indicating ascending severity. Type
A injuries are compression injuries with injury of the anterior
elements and preservation of the posterior ligamentous complex.
Type B injuries are failure of the posterior or anterior tension
band in distraction: B1 injuries are transosseous monosegmental
failure of the posterior tension band; B2 are bony and/or
ligamentous failure of the posterior tension band in conjunction
with an A fracture of the vertebral body; and B3 injuries are hyper-
extension injuries through the disc space or bone as commonly
seen in ankylosing spondylitis. There is some confusion because
the first iteration of this new AO Classification System included
these injuries under type C. However, for the purposes of this
guideline, the authors will include them as type B as this is the
classification that has been investigated for internal and external
reliability.
Finally, type C injuries suffer disruption of all elements with
displacement or dislocation of the cranial spinal elements relative
to the caudal elements. There are no subtypes any longer for this
injury pattern. In addition to the morphological classification,
there is also a neurological grading component (N0 = intact,
N1 = transient symptoms, N2 = radiculopathy, N3 = incom-
plete or cauda injury, and N4 = complete), and case-specific
modifiers. Studies both within the original working groups and
by independent researchers showing good to excellent inter- and
intraobserver reliability with this new AO classification.
One classification system, the Load Sharing Classi-
fication (LSC), has helped guide treatment of burst
fractures. Three characteristics were identified on CT: (1)
comminution/involvement, (2) apposition of fragments, and (3)
correction of kyphotic deformity in an attempt to determine if
posterior short-segment instrumentation would fail in the setting
of a burst fracture. Using this classification, a patient’s CT pattern
could be assigned a point total and a patient with a total of 7
to 9 points would be likely to benefit from both posterior and
VOLUME 84 | NUMBER 1 | JANUARY 2019 | E25
DAILEY ET AL
anterior fixation, while fractures with >6 points could be treated
by posterior short-segment fixation alone. The classification has
been used outside the original group with good to excellent
interobserver reliability. In addition, the original working group
treated over 50 consecutive patients using this classification,
without hardware failure, demonstrating the clinical efficacy of
the LSC.
Future Research
These studies show that TLICS/TLISS cannot yet be adapted
to predict management in all thoracolumbar trauma populations
because there is still wide variation in treatment recommenda-
tions for physicians who treat these types of injuries. Further,
prospective studies are necessary to validate the best treatment
options for burst fractures that may be considered stable and
have a TLICS score of 2 to 4. Prospective research is also
lacking to demonstrate that the utilization of any classification
system (compared to not using any system) in making treatment
decisions results in superior clinical outcomes for patients with
thoracolumbar spine injuries.
CONCLUSION
In summary, several classification systems for thoracolumbar
trauma have been proposed over the last 100 yr. Some
systems follow mechanistic descriptions of the fracture patterns,
while others are considered morphological classification systems.
However, all systems had limitations with some being overly
comprehensive or inclusive, and therefore, difficult to learn and
use, while other systems had fewer fracture types and subtypes,
which left gaps that did not allow for descriptions of all fracture
types. In addition, none of the classification systems went through
a rigorous validation process, and therefore were often difficult to
reproduce outside of the original working group that proposed
the system.
In the last 10 yr, 2 classification systems have been proposed,
TLICS and the AO Thoracolumbar Spine Injury Classification
System. These have both undergone studies to measure internal
and external reliability and were found to be inclusive and
descriptive of most thoracolumbar fractures. Hopefully, more
studies using these systems will become available to determine if
these systems can accurately predict fracture treatment through
specific treatment protocols. The authors recommend utilizing
a thoracolumbar trauma classification scheme that uses readily
available clinical data, such as the TLICS/TLISS or the AO Spine
Thoracolumbar Spine Injury Classification System. However,
there is insufficient evidence to recommend a universal classifi-
cation system that can guide treatment and affect outcomes of
these injuries.
Disclosures
These evidence-based clinical practice guidelines were funded exclusively by
the Congress of Neurological Surgeons (CNS) and the Section on Disorders of the
Spine and Peripheral Nerves in collaboration with the Section on Neurotrauma
E26 | VOLUME 84 | NUMBER 1 | JANUARY 2019
and Critical Care, which received no funding from outside commercial sources to
support the development of this document.
Potential Conflicts of Interest:
The task force members were required to report all possible conflicts of interest
(COIs) prior to beginning work on the guideline, using the COI disclosure
form of the AANS/CNS Joint Guidelines Committee, including potential
COIs that are unrelated to the topic of the guideline. The CNS Guidelines
Committee and Guideline Task Force Chairs reviewed the disclosures and either
approved or disapproved the nomination. The CNS Guidelines Committee
and Guideline Task Force Chairs are given latitude to approve nominations
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of Task Force members with possible conflicts and address this by restricting
the writing and reviewing privileges of that person to topics unrelated to
the possible COIs. The conflict of interest findings are provided in detail in
the companion introduction and methods manuscript (https://www.cns.org/
guideline-chapters/congress-neurological-surgeons-systematic-review-evidence-
based-guidelines/chapter_1). The authors have the following potential conflicts
of interest: Dr Anderson: Aesculap-Consultant, SI Bone-Stock shareholder,
Spartec-Stock shareholder, Expanding Orthopedics-Stock shareholder, Titan
Spine-Stock shareholder, RTI-Other, Stryker-Other, Lumbar Spine Research
Society-Board officer position (President). Dr Arnold: Medtronic-Consultant,
Sofamor Danek-Consultant, Spine Wave-Consultant, InVivo-Consultant,
Stryker Spine-Consultant, Evoke Medical-Stock shareholder, Z-Plasty-Stock
shareholder, AO Spine North America-Sponsored or reimbursed travel (for
self only). Dr Chi: DePuy Spine-Consultant, K2M-Consultant. Dr Dailey:
K2M-Grants/Research support/Consultant, Zimmer Biomet-Consultant,
Medtronic-Consultant. Dr Dhall: Globus Medical-Honorarium, Depuy Spine-
Honorarium. Dr Harrop: DePuy Spine-Consultant, Asterias-Other/Scientific
advisor, Tejin-Other/Scientific advisor, Bioventus-Other/Scientific advisor, AO
Spine-Board, trustee, or officer position. Dr O’Toole: Globus Medical-Consultant
fee, RTI Surgical-Consultant, Theracell, Inc.-Stock shareholder.
Disclaimer of Liability
This clinical systematic review and evidence-based guideline was developed
by a multidisciplinary physician volunteer task force and serves as an educational
tool designed to provide an accurate review of the subject matter covered. These
guidelines are disseminated with the understanding that the recommendations
by the authors and consultants who have collaborated in their development are
not meant to replace the individualized care and treatment advice from a patient’s
physician(s). If medical advice or assistance is required, the services of a competent
physician should be sought. The proposals contained in these guidelines may not
be suitable for use in all circumstances. The choice to implement any particular
recommendation contained in these guidelines must be made by a managing
physician in light of the situation in each particular patient and on the basis of
existing resources.
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Acknowledgments
The guidelines task force would like to acknowledge the CNS Guidelines
Committee for their contributions throughout the development of the guideline
and the American Association of Neurological Surgeons/CNS Joint Guidelines
Review Committee for their review, comments, and suggestions throughout peer
review, as well as the contributions of Trish Rehring, MPH, CHES, Senior
Manager of Clinical Practice Guidelines for the CNS, and Mary Bodach, MLIS,
Guidelines Specialist and Medical Librarian for assistance with the literature
searches. Throughout the review process, the reviewers and authors were blinded
from one another. At this time, the guidelines task force would like to acknowledge
the following individual peer reviewers for their contributions: Maya Babu, MD,
MBA, Greg Hawryluk, MD, PhD, Steven Kalkanis, MD, Yi Lu, MD, PhD,
Jeffrey J. Olson, MD, Martina Stippler, MD, Cheerag Upadhyaya, MD, MSc,
and Robert Whitmore, MD.
VOLUME 84 | NUMBER 1 | JANUARY 2019 | E27
 THORACOLUMBAR TRAUMA GUIDELINES

Sheeraz Qureshi, MD, MBA∗

Sanjay S. Dhall, MD‡
Paul A. Anderson, MD§ Congress of Neurological Surgeons Systematic
Paul M. Arnold, MD¶
John H. Chi, MD, MPH||
Andrew T. Dailey, MD#
Review and Evidence-Based Guidelines on the
Kurt M. Eichholz, MD∗∗
James S. Harrop, MD‡‡
Daniel J. Hoh, MD§§
Evaluation and Treatment of Patients With
Craig H. Rabb, MD¶¶
P. B. Raksin, MD||||
Thoracolumbar Spine Trauma: Radiological

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Michael G. Kaiser, MD##
John E. O’Toole, MD, MS∗∗∗ Evaluation
∗
Department of Orthopaedic Surgery, Weill
Cornell Medical College, New York, New
York; ‡ Department of Neurological Surgery, BACKGROUND: Radiological evaluation of traumatic thoracolumbar fractures is used to
University of California, San Francisco, classify the injury and determine the optimal treatment plan. Currently, there remains a
San Francisco, California; § Department of
Orthopedics and Rehabilitation, University lack of consensus regarding appropriate radiological protocol. Most clinicians use a combi-
of Wisconsin, Madison, Wisconsin;
¶
nation of plain radiographs, 3-dimensional computed tomography with reconstructions,
Department of Neurosurgery, University
of Kansas School of Medicine, Kansas City, and magnetic resonance imaging (MRI).
Kansas; || Department of Neurosurgery, OBJECTIVE: To determine, through evidence-based guidelines review: (1) whether the use
Harvard Medical School, Brigham and
Women’s Hospital, Boston, Massachusetts; of MRI to identify ligamentous integrity predicted the need for surgical intervention; and
#
Department of Neurosurgery, University
of Utah, Salt Lake City, Utah; ∗∗ St. Louis
(2) if there are any radiological findings that can assist in predicting clinical outcomes.
Minimally Invasive Spine Center, St. Louis, METHODS: A systematic review of the literature was performed using the National Library
Missouri; ‡‡ Departments of Neurological
Surgery and Orthopedic Surgery, Thomas of Medicine/PubMed database and the Cochrane Library for studies relevant to thora-
Jefferson University, Philadelphia, columbar trauma. Clinical studies specifically addressing the radiological evaluation of
Pennsylvania; §§ Lillian S. Wells Department
of Neurological Surgery, University of thoracolumbar spine trauma were selected for review.
Florida, Gainesville, Florida; ¶¶ Department RESULTS: Two of 2278 studies met inclusion criteria for review. One retrospective review
of Neurosurgery, University of Utah, Salt
Lake City, Utah; |||| Division of Neurosurgery, (Level III) and 1 prospective cohort (Level III) provided evidence that the addition of an
John H. Stroger, Jr Hospital of Cook County MRI scan in acute thoracic and thoracolumbar trauma can predict the need for surgical
and Department of Neurological Surgery,
Rush University Medical Center, Chicago, intervention. There was insufficient evidence that MRI can help predict clinical outcomes
Illinois; ## Department of Neurosurgery,
Columbia University, New York, New York;
in patients with acute traumatic thoracic and thoracolumbar spine injuries.
∗∗∗
Department of Neurological Surgery, CONCLUSION: This evidence-based guideline provides a Grade B recommendation that
Rush University Medical Center, Chicago,
Illinois radiological findings in patients with acute thoracic or thoracolumbar spine trauma can
predict the need for surgical intervention. This evidence-based guideline provides a grade
Sponsored by: Congress of Neurological insufficient recommendation that there is insufficient evidence to determine if radio-
Surgeons and the Section on Disorders of
the Spine and Peripheral Nerves in
graphic findings can assist in predicting clinical outcomes in patients with acute thoracic
collaboration with the Section on and thoracolumbar spine injuries.
Neurotrauma and Critical Care RECOMMENDATIONS:
Endorsed by: The Congress of QUESTION 1: Are there radiographic findings in patients with traumatic thoracolumbar
Neurological Surgeons (CNS) and the fractures that can predict the need for surgical intervention?
American Association of Neurological
Surgeons (AANS)
RECOMMENDATION 1: Because MRI has been shown to influence the management of up
to 25% of patients with thoracolumbar fractures, providers may use MRI to assess posterior
No part of this article has been published
or submitted for publication elsewhere.
ligamentous complex integrity, when determining the need for surgery.
Strength of Recommendation: Grade B
Correspondence: QUESTION 2: Are there radiographic findings in patients with traumatic thoracolumbar
Sheeraz Qureshi, MD, MBA, fractures that can assist in predicting clinical outcomes?
Hospital for Special Surgery,
535 East 70th Street,
RECOMMENDATION 2: Due to a paucity of published studies, there is insufficient evidence
New York, NY 10021. that radiographic findings can be used as predictors of clinical outcomes in thoracolumbar
E-mail: sheerazqureshimd@gmail.com fractures.
Strength of Recommendation: Grade Insufficient
Received, May 30, 2018.
Accepted, July 18, 2018. The full version of the guideline can be reviewed at: https://www.cns.org/guideline-
Published Online, September 6, 2018. chapters/congress-neurological-surgeons-systematic-review-evidence-based-guidelines/
chapter_3.
Copyright 
C 2018 by the

Congress of Neurological Surgeons

E28 | VOLUME 84 | NUMBER 1 | JANUARY 2019 www.neurosurgery-online.com


KEY WORDS: Clinical guidelines, Diagnostic imaging, Magnetic resonance imaging (MRI), Spinal injury, Spine
fracture, Thoracolumbar, Risk assessment
Neurosurgery 84:E28–E31, 2019
Goals and Rationale
This clinical guideline was created to improve the quality
and efficiency of patient care by guiding qualified physicians
through diagnostic and treatment decisions in the evaluation and
treatment of patients with thoracolumbar spine trauma.
The thoracolumbar junction, being uniquely positioned
between the rigid thoracic spine and the flexible lumbar spine,
is subject to significant biomechanical stress, and thus fractures
of this region are the most common injuries of the vertebral
column.1 Fractures of the thoracic and lumbar region constitute a
spectrum of injuries ranging from simple nondisplaced fractures
to complex fracture dislocations.2
While anteroposterior and lateral plain radiographs are used to
evaluate alignment, instability, loss of vertebral body height, and
widening of interpedicular or interspinous distance,3-5 computed
tomography (CT) scans, to characterize fractures and assess spinal
canal compromise, and magnetic resonance imaging (MRI) scans,
to evaluate spinal cord, nerve root, or other soft tissue injury
and the presence of spinal cord edema, epidural hematoma,6 and
noncontiguous spine injuries,7,8 are generally required in these
cases.
Controversy still exists regarding the impact of radiological
findings on treatment decision and patient outcome. The purpose
of this guideline is to assess whether radiological findings can
predict the need for surgical intervention or assist in predicting
patient outcomes.
METHODS
Details of the systematic literature review are provided in the full
text of this guideline (https://www.cns.org/guideline-chapters/congress-
neurological-surgeons-systematic-review-evidence-based-guidelines/
chapter_3) and in the methodology (https://www.cns.org/guideline-
chapters/congress-neurological-surgeons-systematic-review-evidence-
based-guidelines/chapter_1) article of this guideline series. The guide-
lines task force initiated a systematic review of the literature relevant
to the diagnosis and treatment of patients with thoracolumbar trauma.
Through objective evaluation of the evidence and transparency in
ABBREVIATIONS: AANS, American Association of Neurological
Surgeons; AO, Arbeitsgemeinschaft fur Osteosynthesefragen; CNS,
Congress of Neurological Surgeons; COIs, conflicts of interest; CT,
computed tomography; MRI, magnetic resonance imaging; PLC,
posterior ligamentous complex; TLICS, thoracolumbar injury classifi-
cation and severity
NEUROSURGERY
RADIOLOGICAL EVALUATION
DOI:10.1093/neuros/nyy373 www.neurosurgery-online.com
the process of making recommendations, this evidence-based clinical
practice guideline was developed for the diagnosis and treatment of adult
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patients with thoracolumbar injuries. These guidelines are developed
for educational purposes to assist practitioners in their clinical decision-
making processes. Additional information about the methods utilized in
this systematic review is provided in the introduction and methodology
chapter. (https://www.cns.org/guideline-chapters/congress-neurological-
surgeons-systematic-review-evidence-based-guidelines/chapter_1).
RESULTS
Task force members reviewed 2278 abstracts and identified
literature for full text review and extraction. They then identified
the best research evidence to answer targeted clinical questions.
When Level I, II, and/or III literature was available, the task
force did not review Level IV studies. The task force selected
126 articles for full-text review, of which 124 were rejected and
3 were selected for inclusion (Appendix II; https://www.cns.org/
guideline-chapters/congress-neurological-surgeons-systematic-
review-evidence-based-guidelines/chapter_3).
DISCUSSION
Winklhofer et al,9 who evaluated the influence of additional
MRI compared to CT alone on the classification of traumatic
spinal injuries, found that 162 fractures were identified on CT
scan, and 196 on CT and MRI together, and the Arbeitsge-
meinschaft fur Osteosynthesefragen (AO) classification changed
in 31%, and the thoracolumbar injury classification and severity
(TLICS) classification, in 33% of patients after MRI review.
Based on CT and MRI together, the TLICS value changed from
values less than 5 (indication for conservative therapy) to values of
5 or greater (indication for surgical therapy) in 24% of patients.
Because of the heterogeneous patient population, this retro-
spective study was downgraded from Level II to Level III evidence.
Pizones et al10 prospectively studied the usefulness of MRI in
fracture diagnosis and treatment. Acute traumatic thoracolumbar
fractures in 33 patients were classified based on X-ray and CT
using the AO classification. Following an MRI, the fractures were
classified per the TLICS system and reclassified following the AO
system. Forty-one fractures were diagnosed using plain X-rays
and CT scans. Following the MRI, 50 fractures and 9 vertebral
contusions were diagnosed. The addition of MRI modified the
diagnosis in 40% of patients, the classification of fracture pattern
in 24% of fractures, and the therapeutic management in 16% of
VOLUME 84 | NUMBER 1 | JANUARY 2019 | E29
QURESHI ET AL
patients. This study was graded Level III evidence due to small
sample size and lack of consecutive patients.
Both these studies provide Level III evidence that the addition
of an MRI can provide findings that can help predict the need for
surgical intervention.
Future Research
Several gaps exist in the literature regarding the ability of
radiological studies to predict the need for surgery and clinical
outcomes in patients with acute traumatic thoracolumbar spine
injuries. Currently, only 2 studies provide Level III evidence that
MRI scans in patients with acute thoracic and thoracolumbar
spine trauma can impact classification of injury and the decision
to proceed with surgical intervention. Thus, there is a need for
studies that provide a higher level of evidence for each of these
questions.
Furthermore, visualization of complete vs incomplete posterior
ligamentous complex (PLC) rupture and identification of self-
healing PLC ruptures versus those that require surgery is not
possible. Radiological studies that focus on the characteristics of
PLC injuries will be valuable.
With respect to radiological findings assisting in the prediction
of clinical outcomes, there is insufficient evidence that MRI
is useful. Additional research is needed to test the capacity of
MRI scans and other imaging modalities in predicting long-term
outcomes.
CONCLUSION
The existing evidence suggests that MRI in patients with thora-
columbar spinal trauma improves the detection of fractures and
soft tissue compared with CT alone and changes the overall
trauma classification. MRI is a useful tool in the evaluation of
acute thoracolumbar fractures as it allows for better visualization
of the posterior ligamentous complex integrity and of the levels
involved, offering additional information compared to traditional
diagnostic tools.
Disclosures
These evidence-based clinical practice guidelines were funded exclusively by
the Congress of Neurological Surgeons and the Section on Disorders of the Spine
and Peripheral Nerves in collaboration with the Section on Neurotrauma and
Critical Care, which received no funding from outside commercial sources to
support the development of this document.
Potential Conflicts of Interest
The task force members were required to report all possible conflicts of interest
(COIs) prior to beginning work on the guideline, using the COI disclosure
form of the American Association of Neurological Surgeons (AANS)/Congress
of Neurological Surgeons (CNS) Joint Guidelines Committee, including
potential COIs that are unrelated to the topic of the guideline. The CNS
Guidelines Committee and Guideline Task Force Chairs reviewed the disclosures
and either approved or disapproved the nomination. The CNS Guidelines
Committee and Guideline Task Force Chairs are given latitude to approve
E30 | VOLUME 84 | NUMBER 1 | JANUARY 2019
nominations of Task Force members with possible conflicts and address this
by restricting the writing and reviewing privileges of that person to topics
unrelated to the possible COIs. The COI findings are provided in detail in
the companion introduction and methods manuscript (https://www.cns.org/
guideline-chapters/congress-neurological-surgeons-systematic-review-evidence-
based-guidelines/chapter_1). The authors have the following potential conflicts
of interest: Dr Anderson: Aesculap-Consultant, SI Bone-Stock shareholder,
Spartec-Stock shareholder, Expanding Orthopedics-Stock shareholder, Titan
Spine-Stock shareholder, RTI-Other, Stryker-Other, Lumbar Spine Research
Society-Board officer position (President). Dr Arnold: Medtronic-Consultant,
Sofamor Danek-Consultant, Spine Wave-Consultant, InVivo-Consultant,
Downloaded from https://academic.oup.com/neurosurgery/article-abstract/84/1/E28/5091888 by guest on 16 August 2019
Stryker Spine-Consultant, Evoke Medical-Stock shareholder, Z-Plasty-Stock
shareholder, AO Spine North America-Sponsored or reimbursed travel (for
self only). Dr Chi: DePuy Spine-Consultant, K2M-Consultant. Dr Dailey:
K2M-Grants/Research support/Consultant, Zimmer Biomet-Consultant,
Medtronic-Consultant. Dr Dhall: Globus Medical-Honorarium, Depuy Spine-
Honorarium. Dr Harrop: DePuy Spine-Consultant, Asterias-Other/Scientific
advisor, Tejin-Other/Scientific advisor, Bioventus-Other/Scientific advisor, AO
Spine-Board, trustee, or officer position. Dr O’Toole: Globus Medical-Consultant
fee, RTI Surgical-Consultant, Theracell, Inc.-Stock shareholder.
Disclaimer of Liability
This clinical systematic review and evidence-based guideline was developed
by a multidisciplinary physician volunteer task force and serves as an educational
tool designed to provide an accurate review of the subject matter covered. These
guidelines are disseminated with the understanding that the recommendations
by the authors and consultants who have collaborated in their development are
not meant to replace the individualized care and treatment advice from a patient’s
physician(s). If medical advice or assistance is required, the services of a competent
physician should be sought. The proposals contained in these guidelines may not
be suitable for use in all circumstances. The choice to implement any particular
recommendation contained in these guidelines must be made by a managing
physician in light of the situation in each particular patient and on the basis of
existing resources.
REFERENCES
1. el-Khoury GY, Whitten CG. Trauma to the upper thoracic spine: anatomy,
biomechanics, and unique imaging features. Am J Roentgenol. 1993;160(1):95-102.
2. Wood KB, Li W, Lebl DR, Ploumis A. Management of thoracolumbar spine
fractures. Spine J. 2014;14(1):145-164.
3. Keene JS. Radiographic evaluation of thoracolumbar fractures. Clin Orthop Relat
Res. 1984;(189):58-64.
4. Dalinka MK, Kessler H, Weiss M. The radiographic evaluation of spinal trauma.
Emerg Med Clin North Am. 1985;3(3):475-490.
5. Harris JH, Jr. Radiographic evaluation of spinal trauma. Orthop Clin North Am.
1986;17(1):75-86.
6. Tarr RW, Drolshagen LF, Kerner TC, Allen JH, Partain CL, James AE, Jr. MR
imaging of recent spinal trauma. J Comput Assist Tomogr. 1987;11(3):412-417.
7. Korres DS, Boscainos PJ, Papagelopoulos PJ, Psycharis I, Goudelis G,
Nikolopoulos K. Multiple level noncontiguous fractures of the spine. Clin Orthop
Relat Res. 2003;(411):95-102.
8. Henderson RL, Reid DC, Saboe LA. Multiple noncontiguous spine fractures.
Spine. 1991;16(2):128-131.
9. Winklhofer S, Thekkumthala-Sommer M, Schmidt D, et al. Magnetic resonance
imaging frequently changes classification of acute traumatic thoracolumbar spine
injuries. Skeletal Radiol. 2013;42(6):779-786.
10. Pizones J, Izquierdo E, Alvarez P, et al. Impact of magnetic resonance imaging
on decision making for thoracolumbar traumatic fracture diagnosis and treatment.
Eur Spine J. 2011;20(S3):390-396.
www.neurosurgery-online.com
 RADIOLOGICAL EVALUATION

Acknowledgments Medical Librarian for assistance with the literature searches. Throughout the
review process, the reviewers and authors were blinded from one another. At
The guidelines task force would like to acknowledge the CNS Guidelines
this time, the guidelines task force would like to acknowledge the following
Committee for their contributions throughout the development of the guideline
individual peer reviewers for their contributions: Maya Babu, MD, MBA, Greg
and the AANS/CNS Joint Guidelines Review Committee for their review,
Hawryluk, MD, PhD, Steven Kalkanis, MD, Yi Lu, MD, PhD, Jeffrey J.
comments, and suggestions throughout peer review, as well as the contribu-
Olson, MD, Martina Stippler, MD, Cheerag Upadhyaya, MD, MSc, and Robert
tions of Trish Rehring, MPH, CHES, Senior Manager of Clinical Practice
Whitmore, MD.
Guidelines for the CNS, and Mary Bodach, MLIS, Guidelines Specialist and

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NEUROSURGERY VOLUME 84 | NUMBER 1 | JANUARY 2019 | E31

 THORACOLUMBAR TRAUMA GUIDELINES
James S. Harrop, MD∗
John H. Chi, MD, MPH‡
Paul A. Anderson, MD§
Paul M. Arnold, MD¶
Andrew T. Dailey, MD||
Sanjay S. Dhall, MD#
Kurt M. Eichholz, MD∗∗
Daniel J. Hoh, MD‡‡
Congress of Neurological Surgeons Systematic
Sheeraz Qureshi, MD, MBA§§
Craig H. Rabb, MD¶¶
Review and Evidence-Based Guidelines on the
P. B. Raksin, MD||||
Michael G. Kaiser, MD##
John E. O’Toole, MD, MS∗∗∗
Evaluation and Treatment of Patients With
∗ Departments
Thoracolumbar Spine Trauma: Neurological

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of Neurological Surgery
and Orthopedic Surgery, Thomas Jefferson
University, Philadelphia, Pennsylvania;
‡ Department of Neurosurgery, Harvard Medical
Assessment
School, Brigham and Women’s Hospital,
Boston, Massachusetts; § Department of
Orthopedics and Rehabilitation, University of QUESTION 1: Which neurological assessment tools have demonstrated internal reliability
Wisconsin, Madison, Wisconsin; ¶ Department
of Neurosurgery, University of Kansas School of and validity in the management of patients with thoracic and lumbar fractures (ie, do these
Medicine, Kansas City, Kansas; || Department of
Neurosurgery, University of Utah, Salt Lake City,
instruments provide consistent information between different care providers)?
Utah; # Department of Neurological Surgery, RECOMMENDATION 1: Numerous neurologic assessment scales (Functional Indepen-
University of California, San Francisco, San
Francisco, California; ∗∗ St. Louis Minimally dence Measure, Sunnybrook Cord Injury Scale and Frankel Scale for Spinal Cord Injury)
Invasive Spine Center, St. Louis, Missouri;
‡‡ Lillian S. Wells Department of Neurological have demonstrated internal reliability and validity in the management of patients with
Surgery, University of Florida, Gainesville,
Florida; §§ Department of Orthopaedic Surgery,
thoracic and lumbar fractures. Unfortunately, other contemporaneous measurement
Weill Cornell Medical College, New York, New scales (ie, American Spinal Cord Injury Association Impairment Scale) have not been specif-
York; ¶¶ Department of Neurosurgery, University
of Utah, Salt Lake City, Utah; |||| Division of ically studied in patients with thoracic and lumbar fractures.
Neurosurgery, John H. Stroger, Jr Hospital of
Cook County and Department of Neurological
Strength of Recommendation: Grade C
Surgery, Rush University Medical Center, QUESTION 2: Are there any clinical findings (eg, presenting neurological grade/function)
Chicago, Illinois; ## Department of Neurosurgery,
Columbia University, New York, New York; in patients with thoracic and lumbar fractures that can assist in predicting clinical
∗∗∗ Department of Neurological Surgery, Rush
University Medical Center, Chicago, Illinois
outcomes?
RECOMMENDATION 2: Entry American Spinal Injury Association Impairment Scale
Sponsored by: Congress of Neurological grade, sacral sensation, ankle spasticity, urethral and rectal sphincter function, and AbH
Surgeons and the Section on Disorders of
motor function can be used to predict neurological function and outcome in patients
the Spine and Peripheral Nerves in
collaboration with the Section on with thoracic and lumbar fractures (Table I https://www.cns.org/guideline-chapters/
Neurotrauma and Critical Care. congress-neurological-surgeons-systematic-review-evidence-based-guidelines/chapter_
Endorsed by: The Congress of
4_table1).
Neurological Surgeons (CNS) and the Strength of Recommendation: Grade B
American Association of Neurological The full version of the guideline can be reviewed at: https://www.cns.org/guideline-
Surgeons (AANS).
chapters/congress-neurological-surgeons-systematic-review-evidence-based-guidelines/
No part of this article has been published chapter_4.
or submitted for publication elsewhere.
KEY WORDS: Thoracic, Thoracolumbar, Lumbar, Neurologic examination, SCI
Correspondence:
James S. Harrop, MD, Neurosurgery 84:E32–E35, 2019 DOI:10.1093/neuros/nyy370 www.neurosurgery-online.com
Departments of Neurological Surgery
and Orthopedic Surgery,

Division of Spine and Peripheral Nerve
Surgery,
Neurosurgery of Delaware Valley SCI
Center,
Thomas Jefferson University,
909 Walnut Street – Third Floor,
Philadelphia, PA 19107.
E-mail: James.Harrop@jefferson.edu
Received, May 30, 2018.
Accepted, July 16, 2018.
Published Online, September 3, 2018.
Copyright 
C 2018 by the
Congress of Neurological Surgeons
T
raumatic thoracic and lumbar fractures
with or without neurological deficits are
less common injuries that typically have
been included with all traumatic spine fractures
due to their lower prevalence. However, these
injuries have unique features in terms of their
ABBREVIATIONS: AbH, abductor halluces; AIS,
ASIA Impairment Scale; FIM, Functional Indepen-
dence Measure; SCI, spinal cord injury
mechanism of injury, recovery, and neurologic
outcomes due to the presence of both upper and
lower motor injuries. The objective of this study
was to identify neurologic signs and assessment
tools that aid in the evaluation and treatment
of patients with traumatic thoracic and lumbar
fractures.
Variability exists even for these fractures
due to the unique biomechanics based on
fracture location, association with surrounding
anatomical structures, and an individual patient’s
demographics. Overall, patient outcomes are

E32 | VOLUME 84 | NUMBER 1 | JANUARY 2019 www.neurosurgery-online.com


based on numerous factors; however, the patient’s neurologic
status will have a significant impact on their prognosis and
quality of life. Therefore, this clinical practice guideline focuses on
the literature regarding neurologic assessment tools for thoracic
and lumbar fractures and sought to evaluate the literature with
respect to the following question: Which neurological assessment
tools have demonstrated internal reliability and validity in the
management of patients with thoracic and lumbar fractures?
And are there any clinical findings (eg, presenting neurological
grade/function) in patients with thoracic and lumbar fractures
that can assist in predicting clinical outcomes?
METHODS
Details of the systematic literature review are provided in the
full text of this guideline (https://www.cns.org/guideline-chapters/
congress-neurological-surgeons-systematic-review-evidence-based-
guidelines/chapter_4) and in the methodology (https://www.cns.org/
guideline-chapters/congress-neurological-surgeons-systematic-review-
evidence-based-guidelines/chapter_1) article of this guideline series.
The guidelines task force initiated a systematic review of the literature
relevant to the diagnosis and treatment of patients with thoracolumbar
trauma. The National Library of Medicine PubMed database and the
Cochrane Library were searched for the period from January 1, 1946,
to March 31, 2015, using the MeSH subject headings and related
keywords.
RESULTS
A total of 1195 abstracts were identified. Task force members
reviewed all abstracts yielded from the literature search and
identified 79 full-text articles for review. Of these, 66 were rejected
for not meeting inclusion criteria or for being off-topic. Thirteen
articles were selected for inclusion in this systematic review. Three
articles addressed the question of which neurological assessment
tools have demonstrated internal reliability and validity in the
management of patients with thoracic and lumbar fractures, and
10 articles addressed the question of whether there are any clinical
findings in patients with thoracic and lumbar fractures that can
assist in predicting clinical outcomes.
DISCUSSION
Numerous neurological assessment scales (Functional Indepen-
dence Measure [FIM], Sunnybrook Cord Injury Scale, and
Frankel Scale for Spinal Cord Injury (SCI)) have demon-
strated internal reliability and validity in the management of
patients with thoracic and lumbar fractures. However, entry ASIA
Impairment Scale (AIS) grade, sacral sensation, ankle spasticity,
urethral and rectal sphincter function, and abductor hallucis
(AbH) motor function can be used to predict neurological
function and outcome in patients with thoracic and lumbar
fractures.
Davis et al1 performed a prospective review of 43 thoracic and
lumbar patients and evaluated the reliability of the Frankel and
NEUROSURGERY
NEUROLOGICAL ASSESSMENT
Sunnybrook scales. Although the inter-rater reliability was high
with both scales, ranging from 94% to 100%, there was better
agreement in terms of inter-rater reliability with the Frankel scale
over the Sunnybrook scale. Both scales were deemed insensitive
in that significant recovery in a patient’s motor, sensory, bladder,
or walking functions occurred without any change in their scale.
Beck et al2 reviewed 56 traumatic thoracic and lumbar patients
and concluded that a thoracic SCI patient’s disposition could
be based on the level of spine injury and the completeness
of SCI alone using the FIM assessment tool. Barbetta et al3
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reported the FIM was valid and responsive for thoracic and
lumbar fractures, and neurological injuries in a large series of 218
Brazilian individuals with SCI. There are numerous level III and
IV retrospect prognostic studies on thoracic and lumbar fractures
and their association with neurological deficits and assessment
techniques These studies show that patients with more severe
neurological injuries had worse neurological outcomes in terms
of recovery.4-8
Benzel and Larson9 retrospectively reviewed 105 anteriorly
decompressed and fused cases of thoracic and lumbar fractures
and noted that none of the 34 patients with complete motor
and sensory loss had any return of function. McLain7 retro-
spectively reviewed the return to work status at 5-yr follow-
up after injury and used the Frankel grade on 70 thoracic,
thoracolumbar, and lumbar spine fractures that had a variety
of operative treatments. The authors also reported that the
patient’s neurological injury had a greater impact on functional
outcome over any other variable.7 Dobran et al5 further noted
that the neurological examination or admission ASIA grade of
patients undergoing a posterior approach for thoracolumbar
fractures was the strongest predictive factor of neurological
improvement in univariate analysis (P = .0005). These authors
in an additional multivariate analysis reported that preoper-
ative neurological status (P = .0491) and the fracture type
(P = .049) had a positive predictive value on neurological
outcome.
Harrop et al6 retrospectively reviewed 94 spine trauma patients
and categorized them by the level of injury as thoracic (T4-9),
thoracolumbar (T10-T12), and lumbar SCI, and noted that the
lumbar or conus injuries had the greatest neurologic recovery as
graded by the ASIA classification. They attributed the improved
recovery to the higher concentration of lower motor neurons and
the ability of the neurons to develop “root escape.”6 Kingwell
et al10 also illustrated that the anatomic level of injury based
on neurological examination is a better predictor of recovery
than the magnetic resonance imaging fracture location. Schouten
et al8 noted in these 126 cases, patients with neurological injuries
graded by the ASIA classification had worse outcome measures.
In addition to the larger retrospective series on neurological
injury and outcome, several authors have identified clinical
indications and neurological recovery.10-14 Overall, the authors
concluded that in thoracolumbar fracture patients with neuro-
logical deficits, ankle spasticity is highly accurate in predicting
neurogenic bladder dysfunction.12
VOLUME 84 | NUMBER 1 | JANUARY 2019 | E33
HARROP ET AL
Schurch13 prospectively examined 63 patients with thora-
columbar fractures and SCI using the ASIA protocol and urody-
namics. Seven patients recovered from their neuropathic voiding
disorders, and there was a significant correlation between the
reappearance of a voluntary external anal/urethral sphincter
contraction and bladder recovery (P < .0l). In a later report,
Schurch et al14 noted that in thoracolumbar SCI patients,
pinprick sensation in the perineal area is of negative predictive
value. Specifically, the absence of pinprick sensation predicts poor
bladder recovery.
CONCLUSION
There is limited research and literature that focuses specif-
ically on thoracic and lumbar fracture patients. Despite these
limitations, there are numerous neurological assessment scales
(FIM, Sunnybrook, and Frankel) that have demonstrated internal
reliability and validity in the management of patients with
thoracic and lumbar fractures. Unfortunately, other contempo-
raneous measurement scales (ie, ASIA) have not been specif-
ically studied in patients with thoracic and lumbar fractures.
However, entry AIS grade, sacral sensation, ankle spasticity,
urethral and rectal sphincter function, and AbH motor function
can be used to predict neurological function and outcome in these
patients.
Disclosures
These evidence-based clinical practice guidelines were funded exclusively by
the Congress of Neurological Surgeons and the Section on Disorders of the Spine
and Peripheral Nerves in collaboration with the Section on Neurotrauma and
Critical Care, which received no funding from outside commercial sources to
support the development of this document.
Potential Conflicts of Interest
The task force members were required to report all possible conflicts of interest
(COIs) prior to beginning work on the guideline, using the COI disclosure
form of the AANS/CNS Joint Guidelines Committee, including potential
COIs that are unrelated to the topic of the guideline. The CNS Guidelines
Committee and Guideline Task Force Chairs reviewed the disclosures and either
approved or disapproved the nomination. The CNS Guidelines Committee
and Guideline Task Force Chairs are given latitude to approve nominations
of Task Force members with possible conflicts and address this by restricting
the writing and reviewing privileges of that person to topics unrelated to
the possible COIs. The conflict of interest findings are provided in detail in
the companion introduction and methods manuscript (https://www.cns.org/
guideline-chapters/congress-neurological-surgeons-systematic-review-evidence-
based-guidelines/chapter_1). The authors have the following potential conflicts
of interest: Dr Anderson: Aesculap-Consultant, SI Bone-Stock shareholder,
Spartec-Stock shareholder, Expanding Orthopedics-Stock shareholder, Titan
Spine-Stock shareholder, RTI-Other, Stryker-Other, Lumbar Spine Research
Society-Board officer position (President). Dr Arnold: Medtronic-Consultant,
Sofamor Danek-Consultant, Spine Wave-Consultant, InVivo-Consultant,
Stryker Spine-Consultant, Evoke Medical-Stock shareholder, Z-Plasty-Stock
shareholder, AO Spine North America-Sponsored or reimbursed travel (for
self only). Dr Chi: DePuy Spine-Consultant, K2M-Consultant. Dr Dailey:
K2M-Grants/Research support/Consultant, Zimmer Biomet-Consultant,
Medtronic-Consultant. Dr Dhall: Globus Medical-Honorarium, Depuy Spine-
E34 | VOLUME 84 | NUMBER 1 | JANUARY 2019
Honorarium. Dr Harrop: DePuy Spine-Consultant, Asterias-Other/Scientific
advisor, Tejin-Other/Scientific advisor, Bioventus-Other/Scientific advisor, AO
Spine-Board, trustee, or officer position. Dr O’Toole: Globus Medical-Consultant
fee, RTI Surgical-Consultant, Theracell, Inc.-Stock shareholder.
Disclaimer of Liability
This clinical systematic review and evidence-based guideline was developed
by a multidisciplinary physician volunteer task force and serves as an educational
tool designed to provide an accurate review of the subject matter covered. These
guidelines are disseminated with the understanding that the recommendations
by the authors and consultants who have collaborated in their development are
Downloaded from https://academic.oup.com/neurosurgery/article-abstract/84/1/E32/5091879 by guest on 16 August 2019
not meant to replace the individualized care and treatment advice from a patient’s
physician(s). If medical advice or assistance is required, the services of a competent
physician should be sought. The proposals contained in these guidelines may not
be suitable for use in all circumstances. The choice to implement any particular
recommendation contained in these guidelines must be made by a managing
physician in light of the situation in each particular patient and on the basis of
existing resources.
REFERENCES
1. Davis LA, Warren SA, Reid DC, Oberle K, Saboe LA, Grace MG. Incomplete
neural deficits in thoracolumbar and lumbar spine fractures. Arch Phys Med Rehabil.
1993;18:83-89.
2. Beck LA, Harris MR, Basford J. Factors influencing functional outcome
and discharge disposition after thoracic spinal cord injury. SCI Nurs. 1999;16:
127-132.
3. Barbetta DC, Cassemiro LC, Assis MR. The experience of using the scale of
functional independence measure in individuals undergoing spinal cord injury
rehabilitation in Brazil. Spinal Cord. 2014;52:276-281.
4. Benzel EC, Larson SJ. Functional recovery after decompressive operation for
thoracic and lumbar spine fractures. Neurosurgery 1986;19:772-778.
5. Dobran M, Iacoangeli M, Di Somma LG, et al. Neurological outcome in a
series of 58 patients operated for traumatic thoracolumbar spinal cord injuries.
Surg Neurol Int. 2014;5:S329-332.
6. Harrop JS, Naroji S, Maltenfort MG, et al. Neurologic improvement after
thoracic, thoracolumbar, and lumbar spinal cord (conus medullaris) injuries. Spine
2011;36:21-25.
7. McLain RF. Functional outcomes after surgery for spinal fractures: return to work
and activity. Spine. 2004;29:470-477; discussion Z476.
8. Schouten R, Keynan O, Lee RS, et al. Health-related quality-of-life outcomes
after thoracic (T1-T10) fractures. Spine J. 2014;14:1635-1642.
9. Benzel EC, Larson SJ. Recovery of nerve root function after complete quadriplegia
from cervical spine fractures. Neurosurgery. 1986;19:809-812.
10. Kingwell SP, Noonan VK, Fisher CG, et al. Relationship of neural axis level
of injury to motor recovery and health-related quality of life in patients with a
thoracolumbar spinal injury. J Bone Joint Surg Am. 2010;92:1591-1599.
11. Calancie B, Molano MR, Broton JG. Abductor hallucis for monitoring lower-
limb recovery after spinal cord injury in man. Spinal Cord. 2004;42:573-580.
12. Chen SL, Huang YH, Wei TY, Huang KM, Ho SH, Bih LI. Motor and bladder
dysfunctions in patients with vertebral fractures at the thoracolumbar junction. Eur
Spine J. 2012;21:844-849.
13. Schurch B. The predictive value of plantar flexion of the toes in the assessment of
neuropathic voiding disorders in patients with spine lesions at the thoracolumbar
level. Arch Phys Med Rehabil. 1999;80:681-686.
14. Schurch B, Schmid DM, Kaegi K. Value of sensory examination in predicting
bladder function in patients with T12-L1 fractures and spinal cord injury. Arch
Phys Med Rehabil. 2003;84:83-89.
Acknowledgments
The guidelines task force would like to acknowledge the CNS Guidelines
Committee for their contributions throughout the development of the guideline
www.neurosurgery-online.com

and the AANS/CNS Joint Guidelines Review Committee for their review,
comments, and suggestions throughout peer review, as well as the contributions of
Trish Rehring, MPH, CHES, Senior Manager of Clinical Practice Guidelines for
the CNS, and Mary Bodach, MLIS, Guidelines Specialist and Medical Librarian
for assistance with the literature searches. Throughout the review process the
NEUROSURGERY
NEUROLOGICAL ASSESSMENT
reviewers and authors were blinded from one another. At this time, the guidelines
task force would like to acknowledge the following individual peer reviewers for
their contributions: Maya Babu, MD, MBA, Greg Hawryluk, MD, PhD, Steven
Kalkanis, MD, Yi Lu, MD, PhD, Jeffrey J. Olson, MD, Martina Stippler, MD,
Cheerag Upadhyaya, MD, MSc, and Robert Whitmore, MD.
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VOLUME 84 | NUMBER 1 | JANUARY 2019 | E35
 THORACOLUMBAR TRAUMA GUIDELINES

Paul M. Arnold, MD∗

Paul A. Anderson, MD‡
Congress of Neurological Surgeons Systematic
John H. Chi, MD, MPH§
Andrew T. Dailey, MD¶ Review and Evidence-Based Guidelines on the
Sanjay S. Dhall, MD||
Kurt M. Eichholz, MD#
James S. Harrop, MD∗∗
Evaluation and Treatment of Patients With
Daniel J. Hoh, MD‡‡
Sheeraz Qureshi, MD, MBA§§ Thoracolumbar Spine Trauma: Pharmacological

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Craig H. Rabb, MD¶¶
P. B. Raksin, MD||||
Michael G. Kaiser, MD##
Treatment
John E. O’Toole, MD, MS∗∗∗

∗ Department of Neurosurgery, University
of Kansas School of Medicine, Kansas City,
Kansas; ‡ Department of Orthopedics and
Rehabilitation, University of Wisconsin, Madison,
Wisconsin; § Department of Neurosurgery,
Harvard Medical School, Brigham and Women’s
Hospital, Boston, Massachusetts; ¶ Department
of Neurosurgery, University of Utah, Salt
Lake City, Utah; || Department of Neurological
Surgery, University of California, San Francisco,
San Francisco, California; # St. Louis Minimally
Invasive Spine Center, St. Louis, Missouri;
∗∗ Departments of Neurological Surgery
and Orthopedic Surgery, Thomas Jefferson
University, Philadelphia, Pennsylvania; ‡‡ Lillian
S. Wells Department of Neurological Surgery,
University of Florida, Gainesville, Florida;
§§ Department of Orthopaedic Surgery, Weill
Cornell Medical College, New York, New York;
¶¶ Department of Neurosurgery, University
of Utah, Salt Lake City, Utah; |||| Division of
Neurosurgery, John H. Stroger, Jr Hospital of
Cook County and Department of Neurological
Surgery, Rush University Medical Center,
Chicago, Illinois; ## Department of Neurosurgery,
Columbia University, New York, New York;
∗∗∗ Department of Neurological Surgery, Rush
University Medical Center, Chicago, Illinois
Sponsored by: Congress of Neurological
Surgeons and the Section on Disorders of
the Spine and Peripheral Nerves in
collaboration with the Section on
Neurotrauma and Critical Care
Endorsed by: The Congress of
Neurological Surgeons (CNS) and the
American Association of Neurological
Surgeons (AANS)
No part of this article has been published
or submitted for publication elsewhere.
Correspondence:
Paul M. Arnold, MD,
Department of Neurosurgery,
University of Kansas School of Medicine,
3901 Rainbow Blvd, MS 3021,
Kansas City, KS 66160.
E-mail: parnold@kumc.edu
Received, May 30, 2018.
Accepted, July 16, 2018.
Published Online, September 6, 2018.
Copyright 
C 2018 by the
Congress of Neurological Surgeons
QUESTION: Does the administration of a specific pharmacologic agent (eg, methylpred-
nisolone) improve clinical outcomes in patients with thoracic and lumbar fractures and
spinal cord injury?
RECOMMENDATION: There is insufficient evidence to make a recommendation; however,
the task force concluded, in light of previously published data and guidelines, that the
complication profile should be carefully considered when deciding on the administration
of methylprednisolone.
Strength of recommendation: Grade Insufficient
The full version of the guideline can be reviewed at: https://www.cns.org/guideline-
chapters/congress-neurological-surgeons-systematic-review-evidence-based-guidelines/
chapter_5.
KEY WORDS: Thoracic spinal cord injury, lumbar spinal cord injury, thoracolumbar spine trauma
Neurosurgery 84:E36–E38, 2019 DOI:10.1093/neuros/nyy371 www.neurosurgery-online.com
Goals and Rationale have been shown to significantly improve neuro-
There are currently few options available logical outcome following acute SCI, and the use
for the treatment of spinal cord injury (SCI). of methylprednisolone for SCI remains contro-
Surgical management includes decompression versial.
of the injured spinal cord and fixation and
fusion of the spine with prevention of secondary
injury, but surgery does not directly address
the initial insult. Improvements in the medical
METHODS
management of SCI patients now provide the Details of the systematic literature review are
opportunity for a near-normal life span. provided in the full text of this guideline (https://www.
An increased understanding of the patho- cns.org/guideline-chapters/congress-neurological-
physiology of SCI has led to the initiation surgeons-systematic-review-evidence-based-guidelines/
of several recent pharmacologic clinical trials, chapter_5) and in the methodology (https://www.
including National Acute Spinal Cord Injury cns.org/guideline-chapters/congress-neurological-
surgeons-systematic-review-evidence-based-guidelines/
Study (NASCIS) I and II, the Sygen (GM-
chapter_1) article of this guideline series. The guide-
1 ganglioside) trials, riluzole, minocycline, and
lines task force initiated a systematic review of the
others. However, to date, none of these drugs literature relevant to the diagnosis and treatment of
patients with thoracolumbar SCIs. Through objective
evaluation of the evidence and transparency in the
ABBREVIATIONS: AANS, American Association of process of making recommendations, this evidence-
based clinical practice guideline was developed
Neurological Surgeons; CNS, Congress of Neuro-
for the diagnosis and treatment of adult patients
logical Surgeons; MPSS, methylprednisolone
sodium succinate; NASCIS, National Acute Spinal with thoracolumbar injury. These guidelines are
Cord Injury Study; SCI, spinal cord injury developed for educational purposes to assist practi-
tioners in their clinical decision-making processes.

E36 | VOLUME 84 | NUMBER 1 | JANUARY 2019 www.neurosurgery-online.com


Additional information about the methods used in this systematic
review can be found in the introduction and methodology chapter
(https://www.cns.org/guideline-chapters/congress-neurological-
surgeons-systematic-review-evidence-based-guidelines/chapter_1).
RESULTS
The literature search yielded 2614 abstracts. Task force
members reviewed all abstracts yielded from the literature
search and identified the literature for full text review and
extraction, addressing the clinical questions, in accordance with
the Literature Search Protocol (Appendix I; https://www.cns.org/
guideline-chapters/congress-neurological-surgeons-systematic-
review-evidence-based-guidelines/chapter_5). Task force
members identified the best research evidence available to
answer the targeted clinical questions. When Level I, II, or III
literature was available to answer specific questions, the task force
did not review Level IV studies.
The task force selected 167 articles for full text review. Of
these, all studies were rejected for not meeting inclusion criteria
or for being off-topic. No studies were selected for systematic
review (Appendix II; https://www.cns.org/guideline-chapters/
congress-neurological-surgeons-systematic-review-evidence-based-
guidelines/chapter_5).
DISCUSSION
Methylprednisolone Sodium Succinate
Methylprednisolone sodium succinate (MPSS) is by far the
most extensively studied pharmacologic agent used to treat
patients with acute SCI. There have been 3 NASCIS studies
performed between 1980 and 1998. The first study (NASCIS I)
compared low-dose MPSS vs high-dose MPSS, and the short- and
long-term results showed no significant neurological difference
between the 2 groups. There were significantly more complica-
tions in the high-dose group, including a 3-times higher rate of
wound infection.1
The second NASCIS study (NASCIS II) compared a higher
dose MPSS with naloxone and a placebo control.2 The last
NASCIS study (NASCIS III) compared a 24-h continuous
infusion of MPSS vs a 48-h infusion. A third arm of the study
looked at tirilizad mesylate. This trial showed no long-lasting
neurological benefit of MPSS.
One other prospective study looked at the effects of MPSS for
acute SCI. Pointillart et al3 showed no benefit of MPSS. This
study had a small number of patients and methodological flaws,
and thus the value of these data is limited.
The use of MPSS as an adjunct to the management of acute
SCI remains controversial, because of the paucity of functional
neurological benefits, the high rate of complications in the MPSS
group, and the use of post-hoc analysis to determine benefits in
a subsection of the patient population. The American Associ-
ation of Neurological Surgeons (AANS)/CNS Guidelines for the
Management of Acute Cervical Spine and Spinal Cord Injuries
NEUROSURGERY
PHARMACOLOGICAL TREATMENT
(https://academic.oup.com/neurosurgery/article/72/suppl_3/54/
2557454) were specific, noting that the use of MPSS was not
recommended for the treatment of acute SCI.4 The authors went
on to note that the US Food and Drug Administration does not
approve its use for SCI, and that there was no Class I or Class
II medical evidence supporting MPSS for this diagnosis. They
also noted the higher rate of complications, including death,
associated with MPSS.
GM-1 Ganglioside (Sygen)
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There have been 2 prospective randomized clinical trials
that investigated the efficacy of Sygen, a GM-1 ganglioside, in
the treatment of acute SCI. The first study was performed at
a single institution with 37 patients.5 Data showed that the
GM-1 patients had significant neurological recovery compared
to the MPSS-only patients, which was the impetus for a larger
multicenter trial. However, this larger trial failed to show a
significant difference in neurological outcome compared to the
MPSS patients, despite a trend for earlier recovery in the GM-1
patients.6
The calcium-channel blocker nimodipine was evaluated in an
acute SCI trial along with a placebo and MPSS. A fourth arm
of this study included MPSS and nimodipine. There were only
100 patients in the study, and no treatment group showed any
improved neurological function compared to the placebo group.3
Several other agents, including minocycline,7 ProCord,8,9
BA-210/Cethrin,10 recombinant human erythropoietin,11,12
riluzole,13 and granulocyte colony-stimulating factor14 have also
been investigated for use following traumatic SCI. These trials
have been pilot studies, nonrandomized, or too underpowered to
show any current benefit.
FUTURE RESEARCH
Despite intense interest and the completion of several well-
designed prospective randomized clinical trials, no pharmacologic
agent has been shown to improve neurological outcomes in acute
SCI. However, there are several current clinical trials investigating
both pharmacologic and nonpharmacologic agents, and there is
optimism that one of these therapies will be efficacious, offering
hope for the treatment of this devastating injury. One of the
current studies underway includes the In Vivo product, a scaffold
that is placed intradurally in patients with American Spinal Injury
Association thoracic SCI. Early results from this trial were encour-
aging, and data on the first 8 patients were presented at the CNS
2016 meeting in San Diego.15
CONCLUSION
For the past 30 yr, intense research has been focused on
identifying an effective pharmacologic or cell-based treatment for
patients with SCI. There have been significant advances at the
molecular and preclinical levels in our understanding regarding
the pathophysiology of SCI, but these advances have not
VOLUME 84 | NUMBER 1 | JANUARY 2019 | E37
ARNOLD ET AL
translated to an effective treatment paradigm that will improve
neurological outcome. Although several new potential therapies
are currently under investigation, an effective treatment for acute
SCI remains elusive.
Disclosures
These evidence-based clinical practice guidelines were funded exclusively by
the CNS and the Section on Disorders of the Spine and Peripheral Nerves in
collaboration with the Section on Neurotrauma and Critical Care, which received
no funding from outside commercial sources to support the development of this
document.
Potential Conflicts of Interest
The task force members were required to report all possible conflicts of
interest (COIs) prior to beginning work on the guideline, using the COI
disclosure form of the AANS/CNS Joint Guidelines Committee, including
potential COIs that are unrelated to the topic of the guideline. The CNS
Guidelines Committee and Guideline Task Force Chairs reviewed the disclosures
and either approved or disapproved the nomination. The CNS Guidelines
Committee and Guideline Task Force Chairs are given latitude to approve
nominations of Task Force members with possible conflicts and address this
by restricting the writing and reviewing privileges of that person to topics
unrelated to the possible COIs. The conflict of interest findings are provided in
detail in the companion introduction and methods manuscript (https://www.
cns.org/guideline-chapters/congress-neurological-surgeons-systematic-review-
evidence-based-guidelines/chapter_1). The authors have the following potential
conflicts of interest: Dr Anderson: Aesculap-Consultant, SI Bone-Stock share-
holder, Spartec-Stock shareholder, Expanding Orthopedics-Stock shareholder,
Titan Spine-Stock shareholder, RTI-Other, Stryker-Other, Lumbar Spine
Research Society-Board officer position (President). Dr Arnold: Medtronic-
Consultant, Sofamor Danek-Consultant, Spine Wave-Consultant, InVivo-
Consultant, Stryker Spine-Consultant, Evoke Medical-Stock shareholder,
Z-Plasty-Stock shareholder, AO Spine North America-Sponsored or reimbursed
travel (for self only). Dr Chi: DePuy Spine-Consultant, K2M-Consultant. Dr
Dailey: K2M-Grants/Research support/Consultant, Zimmer Biomet-Consultant,
Medtronic-Consultant. Dr Dhall: Globus Medical-Honorarium, Depuy Spine-
Honorarium. Dr Harrop: DePuy Spine-Consultant, Asterias-Other/Scientific
advisor, Tejin-Other/Scientific advisor, Bioventus-Other/Scientific advisor, AO
Spine-Board, trustee, or officer position. Dr O’Toole: Globus Medical-Consultant
fee, RTI Surgical-Consultant, Theracell, Inc-Stock shareholder.
Disclaimer of Liability
This clinical systematic review and evidence-based guideline was developed
by a multidisciplinary physician volunteer task force and serves as an educational
tool designed to provide an accurate review of the subject matter covered. These
guidelines are disseminated with the understanding that the recommendations
by the authors and consultants who have collaborated in their development are
not meant to replace the individualized care and treatment advice from a patient’s
physician(s). If medical advice or assistance is required, the services of a competent
physician should be sought. The proposals contained in these guidelines may not
be suitable for use in all circumstances. The choice to implement any particular
recommendation contained in these guidelines must be made by a managing
physician in light of the situation in each particular patient and on the basis of
existing resources.
E38 | VOLUME 84 | NUMBER 1 | JANUARY 2019
REFERENCES
1. Bracken MB, Collins WF, Freeman DF, et al. Efficacy of methylprednisolone in
acute spinal cord injury. JAMA. 1984;251(1):45-52.
2. Bracken MB, Shepard MJ, Collins WF, et al. A randomized, controlled trial of
methylprednisolone or naloxone in the treatment of acute Spinal-Cord injury. N
Engl J Med. 1990;322(20):1405-1411.
3. Pointillart V, Petitjean ME, Wiart L, et al. Pharmacological therapy of spinal
cord injury during the acute phase. Spinal Cord. 2000;38(2):71-76.
4. Hurlbert RJ, Hadley MN, Walters BC, et al. Pharmacological therapy for acute
spinal cord injury. Neurosurgery. 2013;72(suppl 2):93-105.
5. Geisler FH, Dorsey FC, Coleman WP. Recovery of motor function after
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Spinal-Cord injury – A randomized, Placebo-Controlled trial with GM-1
ganglioside. N Engl J Med. 1991;324(26):1829-1838.
6. Geisler FH, Coleman WP, Grieco G, Poonian D. The sygen multicenter acute
spinal cord injury study. Spine. 2001;26(24 Suppl):S87-S98.
7. Casha S, Zygun D, McGowan MD, Bains I, Yong VW, Hurlbert RJ. Results of
a phase II placebo-controlled randomized trial of minocycline in acute spinal cord
injury. Brain. 2012;135(Pt 4):1224-1236.
8. Assina R, Sankar T, Theodore N, et al. Activated autologous macrophage
implantation in a large-animal model of spinal cord injury. Neurosurg Focus. 2008;
25(5):E3. doi: 10.3171/FOC.2008.25.11.E3.
9. Knoller N, Auerbach G, Fulga V, et al. Clinical experience using incubated autol-
ogous macrophages as a treatment for complete spinal cord injury: phase I study
results. J Neurosurg Spine. 2005;3(3):173-181.
10. Fehlings MG, Theodore N, Harrop J, et al. A phase I/IIa clinical trial of a
recombinant Rho protein antagonist in acute spinal cord injury. J Neurotrauma.
2011;28(5):787-796.
11. Alibai E, Zand F, Rahimi A, Rezaianzadeh A. Erythropoietin plus methyl-
prednisolone or methylprednisolone in the treatment of acute spinal cord injury: a
preliminary report. Acta Med Iran. 2014;52(4):275-279.
12. Costa DD, Beghi E, Carignano P, et al. Tolerability and efficacy of erythro-
poietin (EPO) treatment in traumatic spinal cord injury: a preliminary randomized
comparative trial vs. methylprednisolone (MP). Neurol Sci. 2015;36(9):1567-
1574.
13. Grossman RG, Fehlings MG, Frankowski RF, et al. A prospective, multicenter,
phase I matched-comparison group trial of safety, pharmacokinetics, and prelim-
inary efficacy of riluzole in patients with traumatic spinal cord injury. J Neuro-
trauma. 2014;31(3):239-255.
14. Kamiya K, Koda M, Furuya T, et al. Neuroprotective therapy with granu-
locyte colony-stimulating factor in acute spinal cord injury: a comparison with
high-dose methylprednisolone as a historical control. Eur Spine J. 2015;24(5):
963-967.
15. Layer RT, Ulich TR, Coric D, et al. New Clinical-Pathological classification of
intraspinal injury following traumatic acute complete thoracic spinal cord injury:
Postdurotomy/Myelotomy observations from the INSPIRE trial. Neurosurgery.
2017;64(CN_suppl_1):105-109.
Acknowledgments
The guidelines task force would like to acknowledge the CNS Guidelines
Committee for their contributions throughout the development of the guideline
and the AANS/CNS Joint Guidelines Review Committee for their review,
comments, and suggestions throughout peer review, as well as the contributions of
Trish Rehring, MPH, CHES, Senior Manager of Clinical Practice Guidelines for
the CNS, and Mary Bodach, MLIS, Guidelines Specialist and Medical Librarian
for assistance with the literature searches. Throughout the review process the
reviewers and authors were blinded from one another. At this time, the guidelines
task force would like to acknowledge the following individual peer reviewers for
their contributions: Maya Babu, MD, MBA, Greg Hawryluk, MD, PhD, Steven
Kalkanis, MD, Yi Lu, MD, PhD, Jeffrey J. Olson, MD, Martina Stippler, MD,
Cheerag Upadhyaya, MD, MSc, and Robert Whitmore, MD.
www.neurosurgery-online.com
 THORACOLUMBAR TRAUMA GUIDELINES

P. B. Raksin, MD∗
James S. Harrop, MD‡
Paul A. Anderson, MD§
Paul M. Arnold, MD¶ Congress of Neurological Surgeons Systematic
John H. Chi, MD, MPH||
Andrew T. Dailey, MD#
Sanjay S. Dhall, MD∗∗ Review and Evidence-Based Guidelines on the
Kurt M. Eichholz, MD‡‡
Daniel J. Hoh, MD§§
Sheeraz Qureshi, MD, MBA¶¶
Evaluation and Treatment of Patients With
Craig H. Rabb, MD#
Michael G. Kaiser, MD||||
John E. O’Toole, MD##
Thoracolumbar Spine Trauma: Prophylaxis and

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∗
Division of Neurosurgery, John H. Treatment of Thromboembolic Events
Stroger, Jr Hospital of Cook County and
Department of Neurological Surgery, Rush
University Medical Center, Chicago, Illinois;
‡
Departments of Neurological Surgery QUESTION 1: Does routine screening for deep venous thrombosis prevent pulmonary
and Orthopedic Surgery, Thomas Jefferson
University, Philadelphia, Pennsylvania; embolism (or venous thromboembolism (VTE)-associated morbidity and mortality) in
§
Department of Orthopedics & Rehabilitation,
University of Wisconsin, Madison, Wisconsin;
patients with thoracic and lumbar fractures?
¶
Department of Neurosurgery, University RECOMMENDATION 1: There is insufficient evidence to recommend for or against routine
of Kansas School of Medicine, Kansas City,
Kansas; || Department of Neurosurgery, screening for deep venous thrombosis in preventing pulmonary embolism (or VTE-
Harvard Medical School, Brigham and
Women’s Hospital, Boston, Massachusetts;
associated morbidity and mortality) in patients with thoracic and lumbar fractures.
#
Department of Neurosurgery, University of Strength of Recommendation: Grade Insufficient
Utah, Salt Lake City, Utah; ∗∗ Department of
Neurological Surgery, University of California, QUESTION 2: For patients with thoracic and lumbar fractures, is one regimen of VTE
San Francisco, San Francisco, California; ‡‡ St. prophylaxis superior to others with respect to prevention of pulmonary embolism (or VTE-
Louis Minimally Invasive Spine Center, St.
Louis, Missouri; §§ Lillian S. Wells Department associated morbidity and mortality)?
of Neurological Surgery, University of
Florida, Gainesville, Florida; ¶¶ Department of RECOMMENDATION 2: There is insufficient evidence to recommend a specific regimen
Orthopaedic Surgery, Weill Cornell Medical
College, New York, New York; |||| Department
of VTE prophylaxis to prevent pulmonary embolism (or VTE-associated morbidity and
of Neurosurgery, Columbia University, New mortality) in patients with thoracic and lumbar fractures.
York, New York; ## Department of Neurological
Surgery, Rush University Medical Center, Strength of Recommendation: Grade Insufficient
Chicago, Illinois
QUESTION 3: Is there a specific treatment regimen for documented VTE that provides
Sponsored by: Congress of Neurological
fewer complications than other treatments in patients with thoracic and lumbar fractures?
Surgeons and the Section on Disorders of RECOMMENDATION 3: There is insufficient evidence to recommend for or against a
the Spine and Peripheral Nerves in specific treatment regimen for documented VTE that would provide fewer complications
collaboration with the Section on
Neurotrauma and Critical Care.
than other treatments in patients with thoracic and lumbar fractures.
Strength of Recommendation: Grade Insufficient
Endorsed by: The Congress of
Neurological Surgeons (CNS) and the RECOMMENDATION 4: Based on published data from pooled (cervical and thora-
American Association of Neurological columbar) spinal cord injury populations, the use of thromboprophylaxis is recommended
Surgeons (AANS).
to reduce the risk of VTE events in patients with thoracic and lumbar fractures.
No part of this article has been published Consensus Statement by the Workgroup
or submitted for publication elsewhere.
The full version of the guideline can be reviewed at: https://www.cns.org/guideline-
Correspondence: chapters/congress-neurological-surgeons-systematic-review-evidence-based-guidelines/
P. B. Raksin, MD, chapter_7.
Department of Neurological Surgery,
Rush University Medical Center, KEY WORDS: Deep venous thrombosis, Pulmonary embolism, Spinal cord injury, Thoracolumbar spine fracture,
John H. Stroger, Jr Hospital of Cook Venous thromboembolic event
County,
Division of Neurosurgery, Neurosurgery 84:E39–E42, 2019 DOI:10.1093/neuros/nyy367 www.neurosurgery-online.com
1900 W Polk St,
Admin Bldg, Rm 641,
Chicago, IL 60612.
E-mail: patricia_raksin@rush.edu
Goals and Rationale thromboembolic (VTE) complications of
Acute traumatic spinal cord injury (SCI) is deep venous thrombosis (DVT) and pulmonary
Received, May 30, 2018. associated with an increased risk for venous embolism (PE). When accounting for differences
Accepted, July 12, 2018. in level of injury, diagnostic modality employed,
Published Online, September 1, 2018.
ABBREVIATIONS: CNS, Congress of neurological surgeons; DVT, deep venous thrombosis; EPCC, external
Copyright 
C 2018 by the
pneumatic calf compression; PE, pulmonary embolism; SCI, spinal cord injury; VTE, venous thromboembolism
Congress of Neurological Surgeons

NEUROSURGERY VOLUME 84 | NUMBER 1 | JANUARY 2019 | E39

RAKSIN ET AL

and surveillance strategy, the overall incidence of VTE events
among patients with acute SCI receiving no or suboptimal
prophylaxis has been estimated as 4% to 100%.1-13 Decision-
making regarding thromboprophylaxis for these patients is often
complex. Many of the same factors, such as immobility, associated
long-bone or pelvic fractures, post-traumatic inflammation, and
the need for surgical intervention(s) that contribute to this
vulnerability must also be taken into account when considering
potential benefits and harms (particularly, bleeding) associated
with available therapeutic modalities. Comorbid traumatic brain
search and identified those warranting full text review and extraction,
in accordance with the Literature Search Protocol (Appendix I;
https://www.cns.org/guideline-chapters/congress-neurological-surgeons-
systematic-review-evidence-based-guidelines/chapter_7). Task force
members identified the best research evidence available to answer
the targeted clinical questions. When Level I, II, or III literature was
available to answer specific questions, the task force did not review
level IV studies. The guideline task force used a modified version of the
North American Spine Society’s evidence-based guideline development
methodology for classification of evidence.

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injury or visceral injury may further confound this calculus.
Interestingly, several studies suggest the highest incidence RESULTS
of VTE events occurs among patients with thoracic segment
The literature search yielded 697 PubMed results. A separate
SCI.14-17 Studies also suggest that early initiation of prophy-
Cochrane search produced 49 results which, after prescreening
laxis and continuation for a period of approximately
for non-English and duplicates, yielded 21 additional refer-
3 mo postinjury are effective strategies for the prevention
ences, for a total of 718. After applying inclusion and exclusion
of VTE.10,16,18,19 Numerous published investigations report
criteria, the task force ultimately selected 60 articles for full text
the results of individual or multiple, combined prophylactic
review. Among these selections, 28 were potentially applicable
measures.8,9,11,17,20-32 The regimens are sufficiently heteroge-
to question 2, 6 to question 1, and none to question 3. Of the
neous that few generalities can be advanced. In aggregate, these
60 full-text articles, 59 were rejected for not meeting inclusion
studies suggest that some prophylaxis is better than no prophylaxis
criteria or for being off topic (most for enrolling <80% patients
and that while one pharmacologic agent may not be demonstrably
with thoracolumbar segment injuries or not stratifying results by
superior to another, pharmacologic prophylaxis may be better
involved spine segment). One study—relevant to Question 2—
than mechanical measures alone. Combination therapy may offer
was selected for inclusion in this systematic review.
additional benefit beyond any singular modality. However, these
A single study provides Level II evidence that while EPCC
same studies—while integral to any discussion of the indica-
(external pneumatic calf compression) decreases the incidence
tions for and potential benefits of thromboprophylaxis—share
of DVT, the combination of mechanical and pharmacologic
a lack of specificity that limits their applicability to the current
prophylaxis (aspirin and dipyridamole) results in a greater
investigation. Either “spinal cord injury” is equated with cervical
reduction. Green et al. published a prospective study comparing
segment pathology, injuries are not stratified by segment, or the
mechanical and combined pharmacologic/mechanical regimens
investigators did not enroll a sufficient number of thoracic and
for the prevention of DVT in patients with SCI.33 Twenty-eight
lumbar segment injuries to warrant inclusion for this analysis.
consecutive patients with “lower limb paralysis” were randomized
Here, the authors address considerations specific to the occur-
to receive either EPCC or EPCC in combination with aspirin
rence of VTE events in the setting of thoracic and lumbar spine
(300 mg 2 times daily) and dipyridamole (75 mg 3 times daily)
fractures. Three questions were posed: (1) does routine screening
for the first 30 d postinjury. Overall, DVT was detected in 9/27
for DVT prevent PE in this population; (2) is one regimen of
(33%) patients analyzed (1 was lost to transfer). This was signif-
DVT prophylaxis superior to others with respect to prevention of
icant as compared with the 78% DVT rate observed previously
PE; and, (3) is there a specific treatment regimen for documented
in a cohort of 37 patients who received no prophylaxis. The
VTE that provides fewer complications than other treatments in
use of EPCC lowered the rate to 40%, while the addition of
this population?
aspirin and dipyridamole lowered the rate further to 25%. This
study was downgraded from Level I to Level II in recognition of
METHODS multiple deficiencies: method of randomization not reported, lack
Details of the systematic literature review are provided in the full of blinding, no power analysis, inadequate reporting of baseline
text of this guideline (https://www.cns.org/guideline-chapters/congress- data, no post-treatment assessment, and a discussion referencing
neurological-surgeons-systematic-review-evidence-based-guidelines/ untreated “controls” from a previously published study.
chapter_7) and in the methodology (https://www.cns.org/guideline-
chapters/congress-neurological-surgeons-systematic-review-evidence-
based-guidelines/chapter_1) article of this guideline series. The authors DISCUSSION
collaborated with a medical librarian to search for articles published
from 1946 to March 31, 2015. Two electronic databases—PubMed and Ultimately, only 1 article was identified that met inclusion
Cochrane—were searched, yielding a total of 697 and 21 references, criteria for any of the 3 questions posed. This study provides
respectively. The authors supplemented searches of electronic databases level II evidence applicable to question 2. This now 34-yr-
with manual screening of the bibliographies of all retrieved publications. old publication reports on a pharmacologic regimen that would
Task force members reviewed all abstracts yielded from the literature be considered “historical” in 2016. Still, the suggestion that

E40 | VOLUME 84 | NUMBER 1 | JANUARY 2019 www.neurosurgery-online.com


combined pharmacologic and mechanical prophylaxis might
provide a benefit over mechanical alone is consistent with
available literature for the broader topic of “acute spinal cord
injury.”
The absence of sufficient evidence to permit discrete recommen-
dations should not be construed as an indication to forego screening
or prophylaxis for this acknowledged high-risk group. Rather, this
conclusion merely reflects strict adherence to methodology. The
literature search strategy for this topic was designed to restrict
results to the specific subpopulation of patients with injury to the
thoracic or lumbar segments. Most published studies on the topic
of VTE prophylaxis in the setting of SCI fail either to distinguish
between patients presenting with tetraplegia or paraplegia or to
stratify injury by spine segment. The great majority of poten-
tially relevant articles were excluded for failure to reach 80%
thoracolumbar injury threshold alone. If a wider net is cast to
encompass “acute spinal cord injury” as a general subject term,
there exists ample evidence, predominantly Level III, but with
some Level I and II studies, for the use of DVT prophylaxis.
CONCLUSION
In summary, there is insufficient evidence to provide discrete
recommendations regarding VTE prophylaxis for the specific
population of patients presenting with thoracic and lumbar spine
injuries. However, the consensus of the work group—on the basis
of pooled spinal cord populations—is that thromboprophylaxis is
recommended.
Disclosures
These evidence-based clinical practice guidelines were funded exclusively by
the Congress of Neurological Surgeons and the Section on Disorders of the Spine
and Peripheral Nerves in collaboration with the Section on Neurotrauma and
Critical Care, which received no funding from outside commercial sources to
support the development of this document.
Potential Conflicts of Interest
The task force members were required to report all possible conflicts of interest
(COIs) prior to beginning work on the guideline, using the COI disclosure
form of the American Association of Neurological Surgeons / Congress of
Neurological Surgeons (CNS) Joint Guidelines Committee, including potential
COIs that are unrelated to the topic of the guideline. The CNS Guidelines
Committee and Guideline Task Force Chairs reviewed the disclosures and either
approved or disapproved the nomination. The CNS Guidelines Committee
and Guideline Task Force Chairs are given latitude to approve nominations
of Task Force members with possible conflicts and address this by restricting
the writing and reviewing privileges of that person to topics unrelated to
the possible COIs. The conflict of interest findings are provided in detail in
the companion introduction and methods manuscript (https://www.cns.org/
guideline-chapters/congress-neurological-surgeons-systematic-review-evidence-
based-guidelines/chapter_1). The authors have the following potential conflicts
of interest: Dr Anderson: Aesculap-Consultant, SI Bone-Stock shareholder,
Spartec-Stock shareholder, Expanding Orthopedics-Stock shareholder, Titan
Spine-Stock shareholder, RTI-Other, Stryker-Other, Lumbar Spine Research
Society-Board officer position (President). Dr Arnold: Medtronic-Consultant,
Sofamor Danek-Consultant, Spine Wave-Consultant, InVivo-Consultant,
Stryker Spine-Consultant, Evoke Medical-Stock shareholder, Z-Plasty-Stock
NEUROSURGERY
PROPHYLAXIS AND TREATMENT OF THROMBOEMBOLIC EVENTS
shareholder, AO Spine North America-Sponsored or reimbursed travel (for
self only). Dr Chi: DePuy Spine-Consultant, K2M-Consultant. Dr Dailey:
K2M-Grants/Research support/Consultant, Zimmer Biomet-Consultant,
Medtronic-Consultant. Dr Dhall: Globus Medical-Honorarium, Depuy Spine-
Honorarium. Dr Harrop: DePuy Spine-Consultant, Asterias-Other/Scientific
advisor, Tejin-Other/Scientific advisor, Bioventus-Other/Scientific advisor, AO
Spine-Board, trustee, or officer position. Dr O’Toole: Globus Medical-Consultant
fee, RTI Surgical-Consultant, Theracell, Inc.-Stock shareholder.
Disclaimer of Liability
This clinical systematic review and evidence-based guideline was developed
Downloaded from https://academic.oup.com/neurosurgery/article-abstract/84/1/E39/5091886 by guest on 16 August 2019
by a multidisciplinary physician volunteer task force and serves as an educational
tool designed to provide an accurate review of the subject matter covered. These
guidelines are disseminated with the understanding that the recommendations
by the authors and consultants who have collaborated in their development are
not meant to replace the individualized care and treatment advice from a patient’s
physician(s). If medical advice or assistance is required, the services of a competent
physician should be sought. The proposals contained in these guidelines may not
be suitable for use in all circumstances. The choice to implement any particular
recommendation contained in these guidelines must be made by a managing
physician in light of the situation in each particular patient and on the basis of
existing resources.
REFERENCES
1. Rathore MF, Hanif S, New PW, Butt AW, Aasi MH, Khan SU. The prevalence
of deep vein thrombosis in a cohort of patients with spinal cord injury following
the Pakistan earthquake of October 2005. Spinal Cord. 2008;46(7):523-526.
2. Powell M, Kirshblum S, O’Connor KC. Duplex ultrasound screening for deep
vein thrombosis in spinal cord injured patients at rehabilitation admission. Arch
Phys Med Rehabil. 1999;80(9):1044-1046.
3. Geerts WH, Code KI, Jay RM, Chen E, Szalai JP. A prospective study of venous
thromboembolism after major trauma. N Engl J Med. 1994;331(24):1601-1606.
4. Lamb GC, Tomski MA, Kaufman J, Maiman DJ. Is chronic spinal cord injury
associated with increased risk of venous thromboembolism? J Am Paraplegia Soc.
1993;16(3):153-156.
5. Waring WP, Karunas RS. Acute spinal cord injuries and the incidence of clinically
occurring thromboembolic disease. Paraplegia. 1991;29(1):8-16.
6. Watson N. Venous thrombosis and pulmonary embolism in spinal cord injury.
Paraplegia. 1968;6(3):113-121.
7. Burns GA, Cohn SM, Frumento RJ, Degutis LC, Hammers L. Prospective
ultrasound evaluation of venous thrombosis in high-risk trauma patients. J Trauma.
1993;35(3):405-408.
8. Gunduz S, Ogur E, Mohur H, Somuncu I, Acjksoz E, Ustunsoz B. Deep vein
thrombosis in spinal cord injured patients. Paraplegia. 1993;31(9):606-610.
9. Kulkarni JR, Burt AA, Tromans AT, Constable PD. Prophylactic low dose
heparin anticoagulant therapy in patients with spinal cord injuries: A retrospective
study. Paraplegia. 1992;30(3):169-172.
10. El Masri WS, Silver JR. Prophylactic anticoagulant therapy in patients with spinal
cord injury. Paraplegia. 1981;19(6):334-342.
11. Frisbie JH, Sasahara AA. Low dose heparin prophylaxis for deep venous
thrombosis in acute spinal cord injury patients: A controlled study. Paraplegia.
1981;19(6):343-346.
12. Myllynen P, Kammonen M, Rokkanen P, Bostman O, Lalla M, Laasonen E.
Deep venous thrombosis and pulmonary embolism in patients with acute spinal
cord injury. J Trauma. 1985;25(6):541-543.
13. Merli GJ, Crabbe S, Doyle L, Ditunno JF, Herbision GJ. Mechanical plus
pharmacological prophylaxis for deep vein thrombosis in acute spinal cord injury.
Paraplegia. 1992;30(8):558-562.
14. Rossi EC, Green D, Rosen JS, Spies SM, Jao JS. Sequential changes in factor VIII
and platelets preceding deep vein thrombosis in patients with spinal cord injury.
Br J Haematol. 1980;45(1):143-151.
15. Winemiller MH, Stolp-Smith KA, Silverstein MD, Therneau TM. Prevention of
venous thromboembolism in patients with spinal cord injury: effects of sequential
pneumatic compression and heparin. J Spinal Cord Med. 1999;22(3):182-191.
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RAKSIN ET AL
16. Jones T, Ugalde V, Franks P, Zhou H, White RH. Venous thromboembolism
after spinal cord injury: Incidence, time course, and associated risk factors in 16,240
adults and children. Arch Phys Med Rehabil. 2005;86(12):2240-2247.
17. Worley S, Short C, Pike J, Anderson D, Douglas JA, Thompson K. Dalteparin
vs low-dose unfractionated heparin for prophylaxis against clinically evident venous
thromboembolism in acute traumatic spinal cord injury: a retrospective cohort
study. J Spinal Cord Med. 2008;31(4):379-387.
18. Walsh JJ, Tribe C. Phlebo-thrombosis and pulmonary embolism in paraplegia.
Paraplegia. 1965;3(3):209-213.
19. Ploumis A, Ponnappan RK, Bessey JT, Patel R, Vaccaro AR. Thromboprophy-
laxis in spinal trauma surgery: Consensus among spine trauma surgeons. Spine J.
2009;9(7):530-536.
20. Becker DM, Gonzalez M, Gentili A, Eismont F, Green BA. Prevention of
deep venous thrombosis in patients with acute spinal cord injuries: Use of rotating
treatment tables. Neurosurgery. 1987;20(5):675-677.
21. Katz RT, Green D, Sullivan T, Yarkony G. Functional electric stimulation to
enhance systemic fibrinolytic activity in spinal cord injury patients. Arch Phys Med
Rehabil. 1987;68(7):423-426.
22. Casas ER, Sanchez MP, Arias CR, Masip JP. Prophylaxis of venous throm-
bosis and pulmonary embolism in patients with acute traumatic spinal cord lesions.
Paraplegia. 1977;15(3):209-214.
23. Hachen HJ. Anticoagulant therapy in patients with spinal cord injury. Paraplegia.
1974;12(3):176-187.
24. Green D, Lee MY, Ito VY, et al. Fixed- vs adjusted-dose heparin in the
prophylaxis of thromboembolism in spinal cord injury. JAMA. 1988;260(9):1255-
1258.
25. Slavik RS, Chan E, Gorman SK, et al. Dalteparin versus enoxaparin for venous
thromboembolism prophylaxis in acute spinal cord injury and major orthopedic
trauma patients: ‘DETECT’ trial. J Trauma. 2007;62(5):1075-1081.
26. Chiou-Tan FY, Garza H, Chan KT, et al. Comparison of dalteparin and enoxa-
parin for deep venous thrombosis prophylaxis in patients with spinal cord injury.
Am J Phys Med Rehabil. 2003;82(9):678-685.
27. Thumbikat P, Poonnoose PM, Balasubrahmaniam P, Ravichandran G,
McClelland MR. A comparison of heparin/warfarin and enoxaparin throm-
boprophylaxis in spinal cord injury: the Sheffield experience. Spinal Cord.
2002;40(8):416-420.
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28. Green D, Lee MY, Lim AC, et al. Prevention of thromboembolism
after spinal cord injury using low-molecular-weight heparin. Ann Intern Med.
1990;113(8):571-574.
29. Spinal Cord Injury Thromboprophylaxis Investigators. Prevention of venous
thromboembolism in the acute treatment phase after spinal cord injury: a
randomized, multicenter trial comparing low-dose heparin plus intermittent
pneumatic compression with enoxaparin. The Journal of Trauma: Injury, Infection,
and Critical Care. 2003;54(6):1116-1126.
30. Spinal Cord Injury Thromboprophylaxis Investigators. Prevention of venous
thromboembolism in the rehabilitation phase after spinal cord injury: Prophylaxis
with low-dose heparin or enoxaparin. J Trauma. 2003;54(6):1111-1115.
31. Maxwell RA, Chavarria-Aguilar M, Cockerham WT, et al. Routine prophy-
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lactic vena cava filtration is not indicated after acute spinal cord injury. J Trauma.
2002;52(5):902-906.
32. Merli GJ, Herbison GJ, Ditunno JF, et al. Deep vein thrombosis: Prophylaxis in
acute spinal cord injured patients. Arch Phys Med Rehabil. 1988;69(9):661-664.
33. Green D, Rossi EC, Yao JS, Flinn WR, Spies SM. Deep vein thrombosis in spinal
cord injury: Effect of prophylaxis with calf compression, aspirin, and dipyridamole.
Paraplegia. 1982;20(4):227-234.
Acknowledgments
The guidelines task force would like to acknowledge the CNS Guidelines
Committee for their contributions throughout the development of the guideline
and the AANS/CNS Joint Guidelines Review Committee for their review,
comments, and suggestions throughout peer review, as well as the contributions of
Trish Rehring, MPH, CHES, Senior Manager of Clinical Practice Guidelines for
the CNS, and Mary Bodach, MLIS, Guidelines Specialist and Medical Librarian
for assistance with the literature searches. Throughout the review process the
reviewers and authors were blinded from one another. At this time, the guidelines
task force would like to acknowledge the following individual peer reviewers for
their contributions: Maya Babu, MD, MBA, Greg Hawryluk, MD, PhD, Steven
Kalkanis, MD, Yi Lu, MD, PhD, Jeffrey J. Olson, MD, Martina Stippler, MD,
Cheerag Upadhyaya, MD, MSc, and Robert Whitmore, MD.
www.neurosurgery-online.com
 THORACOLUMBAR TRAUMA GUIDELINES

Sanjay S. Dhall, MD∗

Andrew T. Dailey, MD‡
Paul A. Anderson, MD§ Congress of Neurological Surgeons Systematic
Paul M. Arnold, MD¶
John H. Chi, MD, MPH||
Kurt M. Eichholz, MD#
Review and Evidence-Based Guidelines on the
James S. Harrop, MD∗∗
Daniel J. Hoh, MD‡‡
Sheeraz Qureshi, MD, MBA§§
Evaluation and Treatment of Patients With
Craig H. Rabb, MD‡
P. B. Raksin, MD¶¶ Thoracolumbar Spine Trauma: Hemodynamic

Downloaded from https://academic.oup.com/neurosurgery/article-abstract/84/1/E43/5091881 by guest on 16 August 2019

Michael G. Kaiser, MD||||
John E. O’Toole, MD, MS##
Management
∗
Department of Neurological Surgery,
University of California, San Francisco,
San Francisco, California; ‡ Department of
Neurosurgery, University of Utah, Salt Lake
QUESTION: Does the active maintenance of arterial blood pressure after injury affect
City, Utah; § Department of Orthopedics clinical outcomes in patients with thoracic and lumbar fractures?
and Rehabilitation, University of Wisconsin,
Madison, Wisconsin; ¶ Department of RECOMMENDATIONS: There is insufficient evidence to recommend for or against the use
Neurosurgery, University of Kansas School of of active maintenance of arterial blood pressure after thoracolumbar spinal cord injury.
Medicine, Kansas City, Kansas; || Department
of Neurosurgery, Harvard Medical School, Grade of Recommendation: Grade Insufficient
Brigham and Women’s Hospital, Boston,
Massachusetts; # St. Louis Minimally
However, in light of published data from pooled (cervical and thoracolumbar) spinal
Invasive Spine Center, St. Louis, Missouri;
∗∗
cord injury patient populations, clinicians may choose to maintain mean arterial blood
Departments of Neurological Surgery
and Orthopedic Surgery, Thomas Jefferson pressures >85 mm Hg in an attempt to improve neurological outcomes.
University, Philadelphia, Pennsylvania;
‡‡
Lillian S. Wells Department of Neurological
Consensus Statement by the Workgroup
Surgery, University of Florida, Gainesville, The full version of the guideline can be reviewed at: https://www.cns.org/guideline-
Florida; §§ Department of Orthopaedic
Surgery, Weill Cornell Medical College, New chapters/congress-neurological-surgeons-systematic-review-evidence-based-guidelines/
York, New York; ¶¶ Division of Neurosurgery, chapter_6.
John H. Stroger, Jr Hospital of Cook County
and Department of Neurological Surgery,
Rush University Medical Center, Chicago, KEY WORDS; Hemodynamic management, Mean arterial pressure, Thoracolumbar spinal cord injury
Illinois; |||| Department of Neurosurgery,
Columbia University, New York, New York; Neurosurgery 84:E43–E45, 2019 DOI:10.1093/neuros/nyy368 www.neurosurgery-online.com
##
Department of Neurological Surgery, Rush
University Medical Center, Chicago, Illinois

Sponsored by: Congress of Neurological
Surgeons (CNS) and the Section on
Disorders of the Spine and Peripheral
Nerves in collaboration with the Section
on Neurotrauma and Critical Care.
Endorsed by: The Congress of
Neurological Surgeons (CNS) and the
American Association of Neurological
Surgeons (AANS).
No part of this article has been published
or submitted for publication elsewhere.
Correspondence:
Sanjay S. Dhall, MD,
Department of Neurological Surgery,
University of California, San Francisco,
Spinal Neurotrauma,
San Francisco General Hospital,
505 Parnassus Avenue,
San Francisco, CA 94143-0112.
E-mail: sanjaydhall@gmail.com
Received, May 30, 2018.
Accepted, July 12, 2018.
Published Online, September 6, 2018.
Copyright 
C 2018 by the
Congress of Neurological Surgeons
Goals and Rationale
Thoracolumbar spinal cord injuries (TLSCIs)
have historically had a relatively lower incidence
and thus have been studied less often than
other spinal cord injuries (SCIs). Much of
the management of TLSCI has been extrapo-
lated from cervical SCI studies, including the
management of blood pressure (BP).1,2 The task
force attempted to answer the question: Does
the active maintenance of arterial BP after injury
affect clinical outcomes in patients with thoracic
and lumbar fractures? While the application of
mean arterial blood pressure (MAP) goals to
TLSCI is becoming more frequent in trauma
centers, it is worthy of study as there is some risk
ABBREVIATIONS: AISA, American Spinal Injury
Association Spinal Injury grade; BP, blood pressure;
MAP, mean arterial blood pressure; SCI, spinal cord
injury; TLSCI, thoracolumbar spinal cord injury
of complication, particularly in older and more
frail populations.
METHODS
Details of the systematic literature review are
provided in the full text of this guideline (https://www.
cns.org/guideline-chapters/congress-neurological-
surgeons-systematic-review-evidence-based-guidelines/
chapter_6) and in the methodology (https://www.
cns.org/guideline-chapters/congress-neurological-
surgeons-systematic-review-evidence-based-guidelines/
chapter_1) article of this guideline series. The liter-
ature search yielded 1100 abstracts. Task force
members reviewed all abstracts yielded from the
literature search and identified the literature for full
text review and extraction, addressing the clinical
questions, in accordance with the Literature Search
Protocol (Appendix I; https://www.cns.org/guideline-
chapters/congress-neurological-surgeons-systematic-
review-evidence-based-guidelines/chapter_6). Task
force members identified the best research evidence
available to answer the targeted clinical questions.
When Level I, II, or III literature was available to

NEUROSURGERY VOLUME 84 | NUMBER 1 | JANUARY 2019 | E43

DHALL ET AL
answer specific questions, the task force did not review Level IV
studies.
RESULTS
The task force selected 19 articles for full-text review. Of
these, 18 were rejected for not meeting inclusion criteria or for
being off-topic. The majority of rejected articles did not include
TLSCI or did not provide separate analysis of these injuries. One
manuscript was selected for inclusion in this systematic review
(Appendix II; https://www.cns.org/guideline-chapters/congress-
neurological-surgeons-systematic-review-evidence-based-
guidelines/chapter_6).
DISCUSSION
While there have been numerous articles that have addressed
the use of MAP goals in TLSCI, only 1 study provided a separate
analysis of these patients apart from cervical SCI. Vale et al retro-
spectively studied BP management in acute SCI in both cervical
and thoracolumbar injuries.3 Of the total 77 patients, 29 had
TLSCI. Of the 21 TLSCI patients with American Spinal Injury
Association Spinal Injury (AISA) grade A injuries, 7 improved by
≥1 ASIA grade at 1 yr of follow-up. Two patients improved to
AIS D, 3 to AIS C, and 2 to AIS B. Of the 5 AIS B patients,
all improved by >1 AIS grade at 1 yr of follow-up; 2 improved
to AIS D, 2 to AIS C, and 1 to AIS B. The study also showed
that TLSCI patients with incomplete injuries were more likely to
recover than complete, and 88% of these regained the ability to
walk (Level III evidence).
Hawryluk et al4 retrospectively studied vital sign data every
minute and the relationship of MAP goals and short-term
(discharge) neurological outcome. Of the 100 patients, 24 had
thoracic or TLSCI. The authors found that higher average
MAP values correlated with improved neurological function at
discharge. The authors evaluated a new device that records vital
sign data for SCI. Analysis was performed at 1-min time points.
This study showed that patients above the threshold had greater
recovery. Thoracolumbar trauma patients were broken out in
a group of 24 patients (meets inclusion criteria). There was
no comparison group. This study showed AIS grade improve-
ments. Although the authors concluded that a relationship
existed between degree of improvement and maintenance of
BP, this treatment group was combined with cervical patients
and not evaluated separately for thoracolumbar trauma patients.
Therefore, this study was excluded from the evidentiary table.
Future Research
This guideline highlights the need for higher-quality
prospective observational data, such as would be provided
by a multicenter prospective SCI registry. While randomized
controlled trials may initially sound ideal, it may be difficult
to conduct such a trial in SCI patients given many clinicians’
E44 | VOLUME 84 | NUMBER 1 | JANUARY 2019
possible lack of equipoise regarding MAP goals and the risk of
neurological deterioration.
CONCLUSION
While the use of MAP goals to maintain spinal cord perfusion
after traumatic SCI has become common practice in many high-
volume trauma centers, the scientific data supporting this practice
are mainly derived from cervical SCI studies.1,2 These data have
been used to justify similar management in TLSCI. While such a
Downloaded from https://academic.oup.com/neurosurgery/article-abstract/84/1/E43/5091881 by guest on 16 August 2019
practice appears to be a reasonable option, the medical evidence
specifically for patients with TLSCI is lacking.
Disclosures
These evidence-based clinical practice guidelines were funded exclusively by
the Congress of Neurological Surgeons and the Section on Disorders of the Spine
and Peripheral Nerves in collaboration with the Section on Neurotrauma and
Critical Care, which received no funding from outside commercial sources to
support the development of this document.
Potential Conflicts of Interest
The task force members were required to report all possible conflicts of
interest (COIs) prior to beginning work on the guideline, using the COI
disclosure form of the AANS/CNS Joint Guidelines Committee, including
potential COIs that are unrelated to the topic of the guideline. The CNS
Guidelines Committee and Guideline Task Force Chairs reviewed the disclosures
and either approved or disapproved the nomination. The CNS Guidelines
Committee and Guideline Task Force Chairs are given latitude to approve
nominations of Task Force members with possible conflicts and address this
by restricting the writing and reviewing privileges of that person to topics
unrelated to the possible COIs. The conflict of interest findings are provided
in detail in the companion introduction and methods manuscript (https://
www.cns.org/guideline-chapters/congress-neurological-surgeons-systematic-
review-evidence-based-guidelines/chapter_1). The authors have the following
potential conflicts of interest: Dr Anderson: Aesculap-Consultant, SI Bone-Stock
shareholder, Spartec-Stock shareholder, Expanding Orthopedics-Stock share-
holder, Titan Spine-Stock shareholder, RTI-Other, Stryker-Other, Lumbar Spine
Research Society-Board officer position (President). Dr Arnold: Medtronic-
Consultant, Sofamor Danek-Consultant, Spine Wave-Consultant, InVivo-
Consultant, Stryker Spine-Consultant, Evoke Medical-Stock shareholder,
Z-Plasty-Stock shareholder, AO Spine North America-Sponsored or reimbursed
travel (for self only). Dr Chi: DePuy Spine-Consultant, K2M-Consultant. Dr
Dailey: K2M-Grants/Research support/Consultant, Zimmer Biomet-Consultant,
Medtronic-Consultant. Dr Dhall: Globus Medical-Honorarium, Depuy Spine-
Honorarium. Dr Harrop: DePuy Spine-Consultant, Asterias-Other/Scientific
advisor, Tejin-Other/Scientific advisor, Bioventus-Other/Scientific advisor, AO
Spine-Board, trustee, or officer position. Dr O’Toole: Globus Medical-Consultant
fee, RTI Surgical-Consultant, Theracell, Inc.-Stock shareholder.
Disclaimer of Liability
This clinical systematic review and evidence-based guideline was developed
by a multidisciplinary physician volunteer task force and serves as an educa-
tional tool designed to provide an accurate review of the subject matter
covered. These guidelines are disseminated with the understanding that the
recommendations by the authors and consultants who have collaborated
in their development are not meant to replace the individualized care and
treatment advice from a patient’s physician(s). If medical advice or assis-
tance is required, the services of a competent physician should be sought.
The proposals contained in these guidelines may not be suitable for use in
www.neurosurgery-online.com

all circumstances. The choice to implement any particular recommendation
contained in these guidelines must be made by a managing physician in
light of the situation in each particular patient and on the basis of existing
resources.
REFERENCES
1. Inoue T, Manley GT, Patel N, Whetstone WD. Medical and surgical management
after spinal cord injury: vasopressor usage, early surgerys, and complications. J
Neurotrauma. 2014;31(3):284-291.
2. Readdy WJ, Whetstone WD, Ferguson AR, et al. Complications and outcomes
of vasopressor usage in acute traumatic central cord syndrome. J Neurosurg Spine.
2015;23(5):574-580.
3. Vale FL, Burns J, Jackson AB, Hadley MN. Combined medical and surgical
treatment after acute spinal cord injury: results of a prospective pilot study to assess
the merits of aggressive medical resuscitation and blood pressure management. J
Neurosurg. 1997;87(2):239-246.
NEUROSURGERY
HEMODYNAMIC MANAGEMENT
4. Hawryluk G, Whetstone W, Saigal R, et al. Mean arterial blood pressure correlates
with neurological recovery after human spinal cord injury: analysis of high frequency
physiologic data. J Neurotrauma. 2015;32(24):1958-1967.
Acknowledgments
The guidelines task force would like to acknowledge the CNS Guidelines
Committee for their contributions throughout the development of the guideline
and the AANS/CNS Joint Guidelines Review Committee for their review,
comments, and suggestions throughout peer review, as well as the contributions of
Trish Rehring, MPH, CHES, Senior Manager of Clinical Practice Guidelines for
Downloaded from https://academic.oup.com/neurosurgery/article-abstract/84/1/E43/5091881 by guest on 16 August 2019
the CNS, and Mary Bodach, MLIS, Guidelines Specialist and Medical Librarian
for assistance with the literature searches. Throughout the review process the
reviewers and authors were blinded from one another. At this time, the guidelines
task force would like to acknowledge the following individual peer reviewers for
their contributions: Maya Babu, MD, MBA, Greg Hawryluk, MD, PhD, Steven
Kalkanis, MD, Yi Lu, MD, PhD, Jeffrey J. Olson, MD, Martina Stippler, MD,
Cheerag Upadhyaya, MD, MSc, and Robert Whitmore, MD.
VOLUME 84 | NUMBER 1 | JANUARY 2019 | E45
 THORACOLUMBAR TRAUMA GUIDELINES

Daniel J. Hoh, MD∗

Sheeraz Qureshi, MD, MBA‡
Paul A. Anderson, MD§
Congress of Neurological Surgeons Systematic
Paul M. Arnold, MD¶
John H. Chi, MD, MPH||
Andrew T. Dailey, MD#
Review and Evidence-Based Guidelines on the
Sanjay S. Dhall, MD∗∗
Kurt M. Eichholz, MD‡‡ Evaluation and Treatment of Patients With
James S. Harrop, MD§§
Craig H. Rabb, MD#
P. B. Raksin, MD¶¶
Thoracolumbar Spine Trauma: Nonoperative Care

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Michael G. Kaiser, MD||||
John E. O’Toole, MD, MS##
BACKGROUND: Thoracic and lumbar burst fractures in neurologically intact patients are
∗
Lillian S. Wells Department of Neurological
Surgery, University of Florida, Gainesville, considered to be inherently stable, and responsive to nonsurgical management. There is
Florida; ‡ Department of Orthopaedic a lack of consensus regarding the optimal conservative treatment modality. The question
Surgery, Weill Cornell Medical College, New
York, New York; § Department of Orthopedics remains whether external bracing is necessary vs mobilization without a brace after these
and Rehabilitation, University of Wisconsin,
Madison, Wisconsin; ¶ Department of
injuries.
Neurosurgery, University of Kansas School of OBJECTIVE: To determine if the use of external bracing improves outcomes compared to
Medicine, Kansas City, Kansas; || Department
of Neurosurgery, Harvard Medical no brace for neurologically intact patients with thoracic or lumbar burst fractures.
School, Brigham and Women’s Hospital,
Boston, Massachusetts; # Department of
METHODS: A systematic review of the literature was performed using the National Library
Neurosurgery, University of Utah, Salt Lake of Medicine PubMed database and the Cochrane Library for studies relevant to thora-
City, Utah; ∗∗ Department of Neurological
Surgery, University of California, San columbar trauma. Clinical studies specifically comparing external bracing to no brace for
Francisco, San Francisco, California; ‡‡ St. Louis neurologically intact patients with thoracic or lumbar burst fractures were selected for
Minimally Invasive Spine Center, St. Louis,
Missouri; §§ Departments of Neurological review.
Surgery and Orthopedic Surgery, Thomas
Jefferson University, Philadelphia,
RESULTS: Three studies out of 1137 met inclusion criteria for review. One randomized
Pennsylvania; ¶¶ Division of Neurosurgery, controlled trial (level I) and an additional randomized controlled pilot study (level II)
John H. Stroger, Jr Hospital of Cook County
and Department of Neurological Surgery, provided evidence that both external bracing and no brace equally improve pain and
Rush University Medical Center, Chicago, disability in neurologically intact patients with burst fractures. There was no difference in
Illinois; |||| Department of Neurosurgery,
Columbia University, New York, New York; final clinical and radiographic outcomes between patients treated with an external brace
##
Department of Neurological Surgery, Rush
University Medical Center, Chicago, Illinois
vs no brace. One additional level IV retrospective study demonstrated equivalent clinical
outcomes for external bracing vs no brace.
Sponsored by: Congress of Neurological CONCLUSION: This evidence-based guideline provides a grade B recommendation that
Surgeons and the Section on Disorders of
management either with or without an external brace is an option given equivalent
the Spine and Peripheral Nerves in
collaboration with the Section on improvement in outcomes for neurologically intact patients with thoracic and lumbar
Neurotrauma and Critical Care. burst fractures. The decision to use an external brace is at the discretion of the treating
Endorsed by: The Congress of physician, as bracing is not associated with increased adverse events compared to no
Neurological Surgeons (CNS) and the brace.
American Association of Neurological
RECOMMENDATIONS:
Surgeons (AANS).
QUESTION: Does the use of external bracing improve outcomes in the nonoperative
No part of this article has been published
treatment of neurologically intact patients with thoracic and lumbar burst fractures?
or submitted for publication elsewhere.
RECOMMENDATION: The decision to use an external brace is at the discretion of the
Correspondence: treating physician, as the nonoperative management of neurologically intact patients with
Daniel J. Hoh, MD, thoracic and lumbar burst fractures either with or without an external brace produces
Lillian S. Wells Department
of Neurological Surgery,
equivalent improvement in outcomes. Bracing is not associated with increased adverse
University of Florida, events compared to not bracing.
Box 100265, Strength of Recommendation: Grade B
Gainesville, FL 32610.
E-mail: Daniel.Hoh@neurosurgery.ufl.edu
The full version of the guideline can be reviewed at: https://www.cns.org/guideline-
chapters/congress-neurological-surgeons-systematic-review-evidence-based-guidelines/
Received, May 30, 2018. chapter_8.
Accepted, July 12, 2018.
Published Online, September 6, 2018. KEY WORDS: Bracing, Nonoperative care, Orthosis, Lumbar burst fracture, Thoracic burst fracture

Copyright 
C 2018 by the Neurosurgery 84:E46–E49, 2019 DOI:10.1093/neuros/nyy369 www.neurosurgery-online.com
Congress of Neurological Surgeons

E46 | VOLUME 84 | NUMBER 1 | JANUARY 2019 www.neurosurgery-online.com


Goals and Rationale
Burst fractures are a common injury pattern following trauma
to the thoracic and lumbar spine. They are characterized by axial
compression of the vertebral body without concomitant shear,
rotation, or translational injury.1,2 Burst fractures with significant
vertebral collapse, angulation, canal compromise, or associated
neurological deficit are generally considered to be unstable and
necessitate surgical intervention.3-7 Conversely, burst fractures
without neurological deficit are thought to be relatively stable.8-11
Reports of successful nonoperative treatment of burst fractures in
neurologically intact patients point to the overall stability of this
particular injury pattern.12-17 Current nonoperative treatment
options include external orthosis with a brace vs early
mobilization without orthosis.18-23
The benefit of external bracing compared to no brace in the
nonoperative treatment of patients with neurologically intact
burst fractures with respect to neurologic function, pain, and
disability is a clinically relevant question. The purpose of this
evidence-based guideline is to address the question of whether
external bracing improves outcomes vs no brace in the nonop-
erative treatment of neurologically intact patients with thoracic
or lumbar burst fractures.
METHODS
Details of the systematic literature review are provided in the
full text of this guideline (https://www.cns.org/guideline-chapters/
congress-neurological-surgeons-systematic-review-evidence-based-
guidelines/chapter_8) and in the methodology (https://www.cns.org/
guideline-chapters/congress-neurological-surgeons-systematic-review-
evidence-based-guidelines/chapter_1) article of this guideline series.
The guidelines task force initiated a systematic review of the liter-
ature relevant to the diagnosis and treatment of patients with thora-
columbar trauma. Through objective evaluation of the evidence and
transparency in the process of making recommendations, this evidence-
based clinical practice guideline was developed for the diagnosis and
treatment of adult patients with thoracolumbar injury. These guide-
lines are developed for educational purposes to assist practitioners
in their clinical decision-making processes. Additional information
about the methods used in this systematic review can be found in
the introduction and methodology chapter (https://www.cns.org/
guideline-chapters/congress-neurological-surgeons-systematic-review-
evidence-based-guidelines/chapter_1).
RESULTS
The literature search yielded 1137 abstracts. Task force
members reviewed all abstracts yielded from the literature
search and identified the literature for full-text review and
ABBREVIATIONS: RMDQ, Roland Morris Disability Questionnaire; SF-
36, short form-36 health survey; TLSO, thoracolumbosacral orthosis;
VAS, visual analog scale
NEUROSURGERY
NONOPERATIVE CARE
extraction, addressing the clinical questions, in accordance with
the Literature Search Protocol (Appendix I; https://www.cns.org/
guideline-chapters/congress-neurological-surgeons-systematic-
review-evidence-based-guidelines/chapter_8). Task force
members identified the best research evidence available to
answer the targeted clinical questions. When Level I, II, and/or
III literature was available to answer specific questions, the task
force did not review Level IV studies.
The task force selected 11 full-text articles for review. Of these,
8 were rejected for not meeting inclusion criteria or for being
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off-topic. Three were selected for inclusion in this systematic
review. (Appendix II; https://www.cns.org/guideline-chapters/
congress-neurological-surgeons-systematic-review-evidence-
based-guidelines/chapter_8)
DISCUSSION
Level I Evidence
Bailey et al24 performed a randomized controlled trial from
3 Canadian spine centers to compare functional and quality of
life outcomes in patients at 3 mo after thoracolumbar burst
fracture treated either with or without a thoracolumbosacral
orthosis (TLSO) brace. Significant improvement in Roland
Morris Disability Questionnaire (RMDQ) was observed in both
the brace and no brace cohorts at all-time points up to 6 mo
postinjury, after which improvement leveled off (P < .001). An
overall benefit was found for visual analog scale (VAS) and short
form-36 health survey (SF-36) at most time points compared to
baseline up to 6 mo postinjury in both cohorts. At the primary
endpoint of 3 mo postinjury, there was no significant difference
in RMDQ, VAS, SF-36 patient satisfaction, kyphosis, or length
of stay between cohorts.
Level II Evidence
Shamji et al25 performed a randomized controlled pilot
study at 2 centers to compare nonoperative treatment with or
without a brace for neurologically intact thoracolumbar burst
fractures. Both brace and no brace groups demonstrated signif-
icant improvement in VAS at each time point after injury up
to 6 mo. There was no significant difference in follow-up VAS,
oswestry disability index, and SF-36 scores between treatment
groups. Similarly, there was no significant difference in fractional
anterior vertebral body height loss and sagittal Cobb angle
between cohorts. The only reported difference between cohorts
was a statistically significant shorter length of stay in those treated
without a brace.
Level IV Evidence
Post et al26 performed a retrospective study of functional
outcomes in neurologically intact patients who were treated
conservatively at a single center for thoracolumbar fractures. The
decision to manage either with or without a brace was determined
by the treating physician at initial presentation. The investigators
VOLUME 84 | NUMBER 1 | JANUARY 2019 | E47
HOH ET AL
observed no significant difference in functional outcome between
cohorts on the dynamic lifting test or ergometry exercise test.
Similarly, there was no difference in RMDQ, VAS, or SF-36.
Future Research
Optimal protocols with respect to specific activity restrictions,
physical therapy, and duration of conservative management have
not been standardized. Further studies determining whether the
same equivalence of bracing vs no brace for fractures in the rostral
thoracic and caudal lumbar spine are necessary. Future research
may better elucidate that specific fracture subtypes are better
treated surgically or nonoperatively with bracing or no brace.
Overall cost effectiveness of external bracing vs no brace treatment
should be determined.
CONCLUSION
Two randomized controlled studies provide evidence that
neurologically intact patients with thoracic and lumbar burst
fractures have equivalent improvement in clinical outcome when
treated nonoperatively either with or without a brace. An
additional retrospective comparative study provided lower level
evidence for no difference in outcome between bracing and no
brace. Although outcomes were similar between patients treated
nonoperatively with or without a brace, the decision to use an
external brace is at the discretion of the treating physician, as
bracing is not associated with increased adverse events compared
to no brace.
Disclosures
These evidence-based clinical practice guidelines were funded exclusively by
the Congress of Neurological Surgeons and the Section on Disorders of the Spine
and Peripheral Nerves in collaboration with the Section on Neurotrauma and
Critical Care, which received no funding from outside commercial sources to
support the development of this document.
Potential Conflicts of Interest
The task force members were required to report all possible conflicts of interest
(COIs) prior to beginning work on the guideline, using the COI disclosure
form of the AANS/CNS Joint Guidelines Committee, including potential
COIs that are unrelated to the topic of the guideline. The CNS Guidelines
Committee and Guideline Task Force Chairs reviewed the disclosures and either
approved or disapproved the nomination. The CNS Guidelines Committee
and Guideline Task Force Chairs are given latitude to approve nominations
of Task Force members with possible conflicts and address this by restricting
the writing and reviewing privileges of that person to topics unrelated to
the possible COIs. The conflict of interest findings are provided in detail in
the companion introduction and methods manuscript (https://www.cns.org/
guideline-chapters/congress-neurological-surgeons-systematic-review-evidence-
based-guidelines/chapter_1). The authors have the following potential conflicts
of interest: Dr Anderson: Aesculap-Consultant, SI Bone-Stock shareholder,
Spartec-Stock shareholder, Expanding Orthopedics-Stock shareholder, Titan
Spine-Stock shareholder, RTI-Other, Stryker-Other, Lumbar Spine Research
Society-Board officer position (President). Dr Arnold: Medtronic-Consultant,
Sofamor Danek-Consultant, Spine Wave-Consultant, InVivo-Consultant,
Stryker Spine-Consultant, Evoke Medical-Stock shareholder, Z-Plasty-Stock
shareholder, AO Spine North America-Sponsored or reimbursed travel (for
E48 | VOLUME 84 | NUMBER 1 | JANUARY 2019
self only). Dr Chi: DePuy Spine-Consultant, K2M-Consultant. Dr Dailey:
K2M-Grants/Research support/Consultant, Zimmer Biomet-Consultant,
Medtronic-Consultant. Dr Dhall: Globus Medical-Honorarium, Depuy Spine-
Honorarium. Dr Harrop: DePuy Spine-Consultant, Asterias-Other/Scientific
advisor, Tejin-Other/Scientific advisor, Bioventus-Other/Scientific advisor, AO
Spine-Board, trustee, or officer position. Dr O’Toole: Globus Medical-Consultant
fee, RTI Surgical-Consultant, Theracell, Inc.-Stock shareholder.
Disclaimer of Liability
This clinical systematic review and evidence-based guideline was developed
by a multidisciplinary physician volunteer task force and serves as an educational
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tool designed to provide an accurate review of the subject matter covered. These
guidelines are disseminated with the understanding that the recommendations
by the authors and consultants who have collaborated in their development are
not meant to replace the individualized care and treatment advice from a patient’s
physician(s). If medical advice or assistance is required, the services of a competent
physician should be sought. The proposals contained in these guidelines may not
be suitable for use in all circumstances. The choice to implement any particular
recommendation contained in these guidelines must be made by a managing
physician in light of the situation in each particular patient and on the basis of
existing resources.
REFERENCES
1. Denis F. The three column spine and its significance in the classification of acute
thoracolumbar spinal injuries. Spine. 1983;8(8):817-831.
2. Magerl F, Aebi M, Gertzbein SD, Harms J, Nazarian S. A
comprehensive classification of thoracic and lumbar injuries. Eur Spine J.
1994;3(4):184-201.
3. Dai LY, Wang XY, Jiang LS. Neurologic recovery from thoracolumbar burst
fractures: is it predicted by the amount of initial canal encroachment and kyphotic
deformity? Surg Neurol. 2007;67(3):232-237; discussion 238.
4. Kim NH, Lee HM, Chun IM. Neurologic injury and recovery in patients with
burst fracture of the thoracolumbar spine. Spine. 1999;24(3):290-293; discussion
294.
5. Schnee CL, Ansell LV. Selection criteria and outcome of operative approaches for
thoracolumbar burst fractures with and without neurological deficit. J Neurosurg.
1997;86(1):48-55.
6. Benson DR, Burkus JK, Montesano PX, Sutherland TB, McLain RF. Unstable
thoracolumbar and lumbar burst fractures treated with the AO fixateur interne. J
Spinal Disord. 1992;5(3):335-343.
7. Denis F, Armstrong GW, Searls K, Matta L. Acute thoracolumbar burst fractures
in the absence of neurologic deficit. A comparison between operative and nonop-
erative treatment. Clin Orthop Relat Res. 1984;(189):142-149.
8. James KS, Wenger KH, Schlegel JD, Dunn HK. Biomechanical evaluation of
the stability of thoracolumbar burst fractures. Spine. 1994;19(15):1731-1740.
9. Holdsworth F. Review article fractures, dislocations, and fracture-dislocations of
the spine. J Bone Joint Surg. 1970;52(8):1534-1551.
10. Moller A, Hasserius R, Redlund-Johnell I, Ohlin A, Karlsson MK. Nonoper-
atively treated burst fractures of the thoracic and lumbar spine in adults: a 23- to
41-year follow-up. Spine J. 2007;7(6):701-707.
11. Reid DC, Hu R, Davis LA, Saboe LA. The nonoperative treatment of burst
fractures of the thoracolumbar junction. J Trauma. 1988;28(8):1188-1194.
12. Cantor JB, Lebwohl NH, Garvey T, Eismont FJ. Nonoperative management
of stable thoracolumbar burst fractures with early ambulation and bracing. Spine.
1993;18(8):971-976.
13. Mumford J, Weinstein JN, Spratt KF, Goel VK. Thoracolumbar brst fractures.
Spine. 1993;18(8):955-970.
14. de Klerk LW, Fontijne WP, Stijnen T, Braakman R, Tanghe HL, van Linge
B. Spontaneous remodeling of the spinal canal after conservative management of
thoracolumbar burst fractures. Spine. 1998;23(9):1057-1060.
15. Weinstein JN, Collalto P, Lehmann TR. Thoracolumbar “burst” fractures treated
conservatively: a long-term follow-up. Spine. 1988;13(1):33-38.
16. McEvoy RD, Bradford DS. The management of burst fractures of the thoracic
and lumbar spine. Experience in 53 patients. Spine. 1985;10(7):631-637.
www.neurosurgery-online.com

17. Kinoshita H, Nagata Y, Ueda H, Kishi K. Conservative treatment of burst
fractures of the thoracolumbar and lumbar spine. Paraplegia. 1993;31(1):58-67.
18. Chow GH, Nelson BJ, Gebhard JS, Brugman JL, Brown CW, Donaldson
DH. Functional outcome of thoracolumbar burst fractures managed with hyperex-
tension casting or bracing and early mobilization. Spine. 1996;21(18):2170-2175.
19. Anderson PA. Nonsurgical treatment of patients with thoracolumbar fractures.
Instr Course Lect. 1995;44:57-65.
20. Alanay A, Yazici M, Acaroglu E, Turhan E, Cila A, Surat A. Course of nonsurgical
management of burst fractures with intact posterior ligamentous complex: an MRI
study. Spine. 2004;29(21):2425-2431.
21. Tropiano P, Huang RC, Louis CA, Poitout DG, Louis RP. Functional and
radiographic outcome of thoracolumbar and lumbar burst fractures managed by
closed orthopaedic reduction and casting. Spine. 2003;28(21):2459-2465.
22. Stadhouder A, Buskens E, Vergroesen DA, Fidler MW, de Nies F,
Oner FC. Nonoperative treatment of thoracic and lumbar spine fractures: a
prospective randomized study of different treatment options. J Orthop Trauma.
2009;23(8):588-594.
23. Hitchon PW, Torner JC, Haddad SF, Follett KA. Management
options in thoracolumbar burst fractures. Surg Neurol. 1998;49(6):619-627;
discussion 626-617.
24. Bailey CS, Urquhart JC, Dvorak MF, et al. Orthosis versus no
orthosis for the treatment of thoracolumbar burst fractures without neuro-
logic injury: a multicenter prospective randomized equivalence trial. Spine J.
2014;14(11):2557-2564.
NEUROSURGERY
NONOPERATIVE CARE
25. Shamji MF, Roffey DM, Young DK, Reindl R, Wai EK. A pilot evaluation
of the role of bracing in stable thoracolumbar burst fractures without neurological
deficit. J Spinal Disord Tech. 2014;27(7):370-375.
26. Post RB, Keizer HJ, Leferink VJ, van der Sluis CK. Functional outcome
5 years after non-operative treatment of type A spinal fractures. Eur Spine J.
2006;15(4):472-478.
Acknowledgments
The guidelines task force would like to acknowledge the CNS Guidelines
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Committee for their contributions throughout the development of the guideline
and the AANS/CNS Joint Guidelines Review Committee for their review,
comments, and suggestions throughout peer review, as well as the contributions of
Trish Rehring, MPH, CHES, Senior Manager of Clinical Practice Guidelines for
the CNS, and Mary Bodach, MLIS, Guidelines Specialist and Medical Librarian
for assistance with the literature searches. Throughout the review process the
reviewers and authors were blinded from one another. At this time, the guidelines
task force would like to acknowledge the following individual peer reviewers for
their contributions: Maya Babu, MD, MBA, Greg Hawryluk, MD, PhD, Steven
Kalkanis, MD, Yi Lu, MD, PhD, Jeffrey J. Olson, MD, Martina Stippler, MD,
Cheerag Upadhyaya, MD, MSc, and Robert Whitmore, MD.
VOLUME 84 | NUMBER 1 | JANUARY 2019 | E49
 THORACOLUMBAR TRAUMA GUIDELINES

Craig H. Rabb, MD∗ Congress of Neurological Surgeons Systematic

Daniel J. Hoh, MD‡
Paul A. Anderson, MD§
Paul M. Arnold, MD¶
Review and Evidence-Based Guidelines on the
John H. Chi, MD, MPH||
Andrew T. Dailey, MD# Evaluation and Treatment of Patients with
Sanjay S. Dhall, MD∗∗
Kurt M. Eichholz, MD‡‡
James S. Harrop, MD§§
Thoracolumbar Spine Trauma: Operative Versus

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Sheeraz Qureshi, MD, MBA¶¶
P. B. Raksin, MD|||| Nonoperative Treatment
Michael G. Kaiser, MD##
John E. O’Toole, MD, MS∗∗∗

∗ Department of Neurosurgery, University of

QUESTION 1: Does the surgical treatment of burst fractures of the thoracic and lumbar
Utah, Salt Lake City, Utah; ‡ Lillian S. Wells spine improve clinical outcomes compared to nonoperative treatment?
Department of Neurological Surgery, University
of Florida, Gainesville, Florida; § Department of RECOMMENDATION 1: There is conflicting evidence to recommend for or against the use
Orthopedics and Rehabilitation, University of
Wisconsin, Madison, Wisconsin; ¶ Department
of surgical intervention to improve clinical outcomes in patients with thoracolumbar burst
of Neurosurgery, University of Kansas School of fracture who are neurologically intact. Therefore, it is recommended that the discretion
Medicine, Kansas City, Kansas; || Department of
Neurosurgery, Harvard Medical School, Brigham of the treating provider be used to determine if the presenting thoracic or lumbar burst
and Women’s Hospital, Boston, Massachusetts;
# Department of Neurosurgery, University of
fracture in the neurologically intact patient warrants surgical intervention.
Utah, Salt Lake City, Utah; ∗∗ Department of Strength of Recommendation: Grade Insufficient
Neurological Surgery, University of California,
San Francisco, San Francisco, California; ‡‡ St. QUESTION 2: Does the surgical treatment of nonburst fractures of the thoracic and lumbar
Louis Minimally Invasive Spine Center, St.
Louis, Missouri; §§ Departments of Neurological
spine improve clinical outcomes compared to nonoperative treatment?
Surgery and Orthopedic Surgery, Thomas RECOMMENDATION 2: There is insufficient evidence to recommend for or against the
Jefferson University, Philadelphia, Pennsylvania;
¶¶ Department of Orthopaedic Surgery, Weill use of surgical intervention for nonburst thoracic or lumbar fractures. It is recommended
Cornell Medical College, New York, New York;
|||| Division of Neurosurgery, John H. Stroger, Jr that the decision to pursue surgery for such fractures be at the discretion of the treating
Hospital of Cook County and Department of physician.
Neurological Surgery, Rush University Medical
Center, Chicago, Illinois; ## Department of Strength of Recommendation: Grade Insufficient
Neurosurgery, Columbia University, New York,
New York; ∗∗∗ Department of Neurological
The full version of the guideline can be reviewed at: https://www.cns.org/guideline-
Surgery, Rush University Medical Center, chapters/congress-neurological-surgeons-systematic-review-evidence-based-guidelines/
Chicago, Illinois
chapter_1.
Sponsored by: Congress of Neurological KEY WORDS: Brace, Conservative, Nonoperative, Operative, Thoracolumbar fracture, Stabilization
Surgeons and the Section on Disorders of
the Spine and Peripheral Nerves in
Neurosurgery 84:E50–E52, 2019 DOI:10.1093/neuros/nyy361 www.neurosurgery-online.com
collaboration with the Section on
Neurotrauma and Critical Care

Endorsed by: The Congress of Goals and Rationale The most concerning complication related
Neurological Surgeons (CNS) and the
American Association of Neurological The decision as to whether or not neurologi- to nonoperative treatment of a patient with
Surgeons (AANS) cally intact patients with thoracolumbar fractures thoracolumbar fractures has been neurologic
No part of this article has been published require surgical intervention remains contro- deterioration due to a failure to surgically
or submitted for publication elsewhere. versial. A consensus regarding the treatment of decompress and/or stabilize the injured spine.1
burst fractures, in particular, has been difficult to More recently, physicians electing nonoper-
Correspondence: ative care for neurologically intact patients are
Craig H. Rabb, MD,
obtain. With the advent of modern spinal instru-
Department of Neurosurgery, mentation, the options for surgical intervention recognizing the potential for the progressive
University of Utah, have been refined considerably. The evolution of development of chronic pain and deformity. By
175 North Medical Drive East, imaging techniques, such as magnetic resonance contrast, surgeons should strive to determine
5th Floor, Neurosurgery,
imaging and reformatted computed tomography the best treatment option for each individual
Salt Lake City, UT 84132.
E-mail: craig.rabb@hsc.utah.edu (CT) scans, has led to a better understanding of patient, so as to avoid unnecessary surgery.
these injuries. A comprehensive assessment of the published
Received, May 30, 2018. literature devoted to this subject is critical to
Accepted, July 16, 2018. assist clinicians with decision-making as to
Published Online, September 6, 2018.
which injuries require operative vs nonoperative
ABBREVIATION: RCTs, randomized controlled trials treatment.
Copyright 
C 2018 by the

Congress of Neurological Surgeons

E50 | VOLUME 84 | NUMBER 1 | JANUARY 2019 www.neurosurgery-online.com


METHODS
Details of the systematic literature review are provided in the full
text of this guideline (https://www.cns.org/guideline-chapters/congress-
neurological-surgeons-systematic-review-evidence-based-guidelines/
chapter_9) and in the methodology article (https://www.cns.org/
guideline-chapters/congress-neurological-surgeons-systematic-review-
evidence-based-guidelines/chapter_1) of this guideline series. The
task force members identified search terms/parameters, and a medical
librarian implemented the literature search, consistent with the literature
search protocol, using the National Library of Medicine PubMed
database and the Cochrane Library (which included the Cochrane
Database of Systematic Reviews, the Database of Abstracts of Reviews of
Effect, the Cochrane Central Register of Controlled Trials, the Health
Technology Assessment Database, and the National Health Service
Economic Evaluation Database) for the period from January 1, 1946,
to March 31, 2015, using the search strategies provided in Appendix I
(https://www.cns.org/guideline-chapters/congress-neurological-surgeons-
systematic-review-evidence-based-guidelines/chapter_9).
RESULTS
The literature search yielded 836 abstracts. Task force members
reviewed all abstracts yielded from the literature search and
identified the literature for full-text review and extraction to
address the clinical questions. Task force members identified the
best research evidence available to answer the targeted clinical
questions. When level I, II, or III literature was available to
answer specific questions, the task force did not review level IV
studies. The task force selected 144 articles for full-text review. Of
these, 138 were rejected for not meeting inclusion criteria or for
being off topic. Six were selected for inclusion in the systematic
review (Appendix II; https://www.cns.org/guideline-chapters/
congress-neurological-surgeons-systematic-review-evidence-based-
guidelines/chapter_9).
DISCUSSION
None of the studies met the criteria to be considered level I
evidence. There were 3 class II studies.2-4 Although these studies
were randomized controlled trials (RCTs), various flaws led to
downgrading them to level II evidence. In the study by Shen
et al,2 outcomes were similar at 2 yr when comparing nonop-
erative treatment with short-segment posterior pedicle screw
fixation. Siebenga et al3 also compared operative and nonop-
erative management in patients with AO type A fractures who
were neurologically intact; they concluded that patients with AO
type A3 (burst) fractures fare better with short-segment posterior
fixation. The study by Wood et al,4 although considered an RCT,
fell short of being considered level I evidence.4 No significant
differences were found regarding return to work, pain scores,
or kyphosis. Some comparative studies met inclusion criteria,
but were downgraded to level III. In the retrospective compar-
ative study by Landi et al,5 patients had better satisfaction with
surgery. Another study included patients with A1 and A2 fractures
NEUROSURGERY
OPERATIVE VERSUS NONOPERATIVE TREATMENT
(including nonburst fractures) and concluded that outcomes with
surgery were superior.6 Wood et al4,7 conducted a long-term
follow-up study of patients previously studied in 2003. This
study included a small number of patients who were consecutively
assigned and randomized to operative treatment or nonoperative
treatment, but the method of randomization was not reported.
The study was downgraded to level III but showed an advantage
to nonoperative care over surgery. There were some relevant level
IV studies, which were all excluded.8-11
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Future Research
As this literature review has demonstrated, there is a need for
further research regarding operative vs nonoperative treatment of
patients with burst or nonburst thoracolumbar fractures. With
respect to burst fractures, given the rapid evolution of imaging,
a focus on the posterior ligamentous complex in neurologically
intact patients should be more thoroughly investigated. Hetero-
geneity of thoracolumbar injuries has hindered the interpretation
of the literature with regard to nonburst fractures, as no high-
quality RCTs exist in this area. It may prove to be too challenging
ethically to try to perform such studies. In fact, prospective
registries of patients treated for various nonburst thoracolumbar
fractures may provide the greatest amount of information to guide
treatment decisions.
CONCLUSION
Most surgeons today use surgical intervention for patients with
thoracolumbar fractures who present with neurologic deficits,
owing to assumed instability and the desire to restore alignment,
decompress neural elements, and stabilize the spine to reduce
pain, prevent deformity, and allow for early mobilization. There
is little research available for the neurologically intact patient.
Relatively high-quality studies have been performed for patients
with burst fractures, but these have yielded conflicting conclu-
sions, such that either surgery or nonoperative treatment remain
viable options. Unfortunately, high-quality studies have yet to
be performed to investigate which option results in the best
outcomes for nonburst fractures. As such, it must be left to the
discretion of the treating surgeon as to which treatment option is
best for a given patient.
Disclosures
These evidence-based clinical practice guidelines were funded exclusively by
the Congress of Neurological Surgeons and the Section on Disorders of the Spine
and Peripheral Nerves in collaboration with the Section on Neurotrauma and
Critical Care, which received no funding from outside commercial sources to
support the development of this document.
Potential Conflicts of Interest
The task force members were required to report all possible conflicts of interest
(COIs) prior to beginning work on the guideline, using the COI disclosure form
of the AANS/CNS Joint Guidelines Committee, including potential COIs that
are unrelated to the topic of the guideline. The CNS Guidelines Committee and
Guideline Task Force Chairs reviewed the disclosures and either approved or
VOLUME 84 | NUMBER 1 | JANUARY 2019 | E51
RABB ET AL
disapproved the nomination. The CNS Guidelines Committee and Guideline
Task Force Chairs are given latitude to approve nominations of Task Force
members with possible conflicts and address this by restricting the writing and
reviewing privileges of that person to topics unrelated to the possible COIs.
The conflict of interest findings are provided in detail in the companion intro-
duction and methods manuscript (https://www.cns.org/guideline-chapters/
congress-neurological-surgeons-systematic-review-evidence-
based-guidelines/chapter_1). The authors have the following potential conflicts
of interest: Dr Anderson: Aesculap-Consultant, SI Bone-Stock shareholder,
Spartec-Stock shareholder, Expanding Orthopedics-Stock shareholder, Titan
Spine-Stock shareholder, RTI-Other, Stryker-Other, Lumbar Spine Research
Society-Board officer position (President). Dr Arnold: Medtronic-Consultant,
Sofamor Danek-Consultant, Spine Wave-Consultant, InVivo-Consultant,
Stryker Spine-Consultant, Evoke Medical-Stock shareholder, Z-Plasty-Stock
shareholder, AO Spine North America-Sponsored or reimbursed travel (for
self only). Dr Chi: DePuy Spine-Consultant, K2M-Consultant. Dr Dailey:
K2M-Grants/Research support/Consultant, Zimmer Biomet-Consultant,
Medtronic-Consultant. Dr Dhall: Globus Medical-Honorarium, Depuy Spine-
Honorarium. Dr Harrop: DePuy Spine-Consultant, Asterias-Other/Scientific
advisor, Tejin-Other/Scientific advisor, Bioventus-Other/Scientific advisor, AO
Spine-Board, trustee, or officer position. Dr O’Toole: Globus Medical-Consultant
fee, RTI Surgical-Consultant, Theracell, Inc.-Stock shareholder.
Disclaimer of Liability
This clinical systematic review and evidence-based guideline was developed
by a multidisciplinary physician volunteer task force and serves as an educational
tool designed to provide an accurate review of the subject matter covered. These
guidelines are disseminated with the understanding that the recommendations
by the authors and consultants who have collaborated in their development are
not meant to replace the individualized care and treatment advice from a patient’s
physician(s). If medical advice or assistance is required, the services of a competent
physician should be sought. The proposals contained in these guidelines may not
be suitable for use in all circumstances. The choice to implement any particular
recommendation contained in these guidelines must be made by a managing
physician in light of the situation in each particular patient and on the basis of
existing resources.
REFERENCES
1. Denis F, Armstrong GW, Searls K, Matta L. Acute thoracolumbar burst fractures
in the absence of neurologic deficit. A comparison between operative and nonop-
erative treatment. Clin Orthop Relat Res. 1984;(189):142-149.
2. Shen WJ, Liu TJ, Shen YS. Nonoperative treatment versus posterior fixation
for thoracolumbar junction burst fractures without neurologic deficit. Spine.
2001;26(9):1038-1045.
E52 | VOLUME 84 | NUMBER 1 | JANUARY 2019
3. Siebenga J, Leferink VJ, Segers MJ, et al. Treatment of traumatic thoracolumbar
spine fractures: a multicenter prospective randomized study of operative versus
nonsurgical treatment. Spine. 2006;31(25):2881-2890.
4. Wood K, Buttermann G, Mehbod A, Garvey T, Jhanjee R, Sechriest
V. Operative compared with nonoperative treatment of a thoracolumbar burst
fracture without neurological deficit. A prospective, randomized study. J Bone Joint
Surg Am. 2003;85-A(5):773-781.
5. Landi A, Marotta N, Mancarella C, Meluzio MC, Pietrantonio A, Delfini
R. Percutaneous short fixation vs conservative treatment: comparative analysis
of clinical and radiological outcome for A.3 burst fractures of thoraco-lumbar
junction and lumbar spine. Eur Spine J. 2014;23(S6):671-676.
6. Medici A, Meccariello L, Falzarano G. Non-operative vs percutaneous stabi-
Downloaded from https://academic.oup.com/neurosurgery/article-abstract/84/1/E50/5091880 by guest on 16 August 2019
lization in Magerl’s A1 or A2 thoracolumbar spine fracture in adults: is it
really advantageous for a good alignment of the spine? Preliminary data from a
prospective study. Eur Spine J. 2014;23(S6):677-683.
7. Wood KB, Buttermann GR, Phukan R, et al. Operative compared with nonop-
erative 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. 2014;97(1):3-9.
8. Fang D, Leong JC, Cheung HC. The treatment of thoracolumbar spinal injuries
with paresis by conservative versus surgical methods. Ann Acad Med Singapore.
1982;11(2):203-206.
9. Soreff J, Axdorph G, Bylund P, Odeen I, Olerud S. Treatment of patients with
unstable fractures of the thoracic and lumbar spine: a follow-up study of surgical
and conservative treatment. Acta Orthop Scand. 1982;53(3):369-381.
10. Willen J, Dahllof AG, Nordwall A. Paraplegia in unstable thoracolumbar
injuries. A study of conservative and operative treatment regarding neuro-
logical improvement and rehabilitation. Scand J Rehabil Med Suppl. 1983;9:195-
205.
11. Willen J, Lindahl S, Nordwall A. Unstable thoracolumbar fractures. A compar-
ative clinical study of conservative treatment and Harrington instrumentation.
Spine. 1985;10(2):111-122.
Acknowledgments
The guidelines task force would like to acknowledge the CNS Guidelines
Committee for their contributions throughout the development of the guideline
and the AANS/CNS Joint Guidelines Review Committee for their review,
comments, and suggestions throughout peer review, as well as the contributions of
Trish Rehring, MPH, CHES, Senior Manager of Clinical Practice Guidelines for
the CNS, and Mary Bodach, MLIS, Guidelines Specialist and Medical Librarian
for assistance with the literature searches. Throughout the review process the
reviewers and authors were blinded from one another. At this time, the guidelines
task force would like to acknowledge the following individual peer reviewers for
their contributions: Maya Babu, MD, MBA, Greg Hawryluk, MD, PhD, Steven
Kalkanis, MD, Yi Lu, MD, PhD, Jeffrey J. Olson, MD, Martina Stippler, MD,
Cheerag Upadhyaya, MD, MSc, and Robert Whitmore, MD.
www.neurosurgery-online.com
 THORACOLUMBAR TRAUMA GUIDELINES

Kurt M. Eichholz, MD∗

Craig H. Rabb, MD‡
Paul A. Anderson, MD§
Congress of Neurological Surgeons Systematic
Paul M. Arnold, MD¶
John H. Chi, MD, MPH|| Review and Evidence-Based Guidelines on the
Andrew T. Dailey, MD‡
Sanjay S. Dhall, MD#
James S. Harrop, MD∗∗
Evaluation and Treatment of Patients With
Daniel J. Hoh, MD‡‡
Sheeraz Qureshi, MD, MBA§§
Thoracolumbar Spine Trauma: Timing of Surgical

Downloaded from https://academic.oup.com/neurosurgery/article-abstract/84/1/E53/5091878 by guest on 16 August 2019

P. B. Raksin, MD¶¶
Michael G. Kaiser, MD|||| Intervention
John E. O’Toole, MD, MS##

∗
St. Louis Minimally Invasive Spine Center, QUESTION: Does early surgical intervention improve outcomes for patients with thoracic
St. Louis, Missouri; ‡ Department of
Neurosurgery, University of Utah, Salt Lake and lumbar fractures?
City, Utah; § Department of Orthopedics and RECOMMENDATIONS: There is insufficient and conflicting evidence regarding the effect
Rehabilitation, University of Wisconsin,
Madison, Wisconsin; ¶ Department of
of timing of surgical intervention on neurological outcomes in patients with thoracic and
Neurosurgery, University of Kansas School of lumbar fractures.
Medicine, Kansas City, Kansas; || Department
of Neurosurgery, Harvard Medical School,
Strength of Recommendation: Grade Insufficient
Brigham and Women’s Hospital, Boston, It is suggested that “early” surgery be considered as an option in patients with thoracic
Massachusetts; # Department of Neurological
Surgery, University of California, San
and lumbar fractures to reduce length of stay and complications. The available literature
Francisco, San Francisco, California; has defined “early” surgery inconsistently, ranging from <8 h to <72 h after injury.
∗∗
Departments of Neurological Surgery and
Orthopedic Surgery, Thomas Jefferson Strength of Recommendation: Grade B
University, Philadelphia, Pennsylvania; The full version of the guideline can be reviewed at: https://www.cns.org/guideline-
‡‡
Lillian S. Wells Department of Neurological
Surgery, University of Florida, Gainesville, chapters/congress-neurological-surgeons-systematic-review-evidence-based-guidelines/
Florida; §§ Department of Orthopaedic chapter_10.
Surgery, Weill Cornell Medical College, New
York, New York; ¶¶ Division of Neurosurgery, KEY WORDS: Thoracic and lumbar fractures, Thoracic and lumbar fusion, Timing of surgery, Treatment of thoracic
John H. Stroger, Jr Hospital of Cook County and lumbar fractures
and Department of Neurological Surgery,
Rush University Medical Center, Chicago,
Neurosurgery 84:E53–E55, 2019 DOI:10.1093/neuros/nyy362 www.neurosurgery-online.com
Illinois; |||| Department of Neurosurgery,
Columbia University, New York, New York;
##
Department of Neurological Surgery, Rush

University Medical Center, Chicago, Illinois
Sponsored by: Congress of Neurological
Surgeons and the Section on Disorders of
the Spine and Peripheral Nerves in
collaboration with the Section on
Neurotrauma and Critical Care
Endorsed by: The Congress of
Neurological Surgeons (CNS) and the
American Association of Neurological
Surgeons (AANS)
No part of this article has been published
or submitted for publication elsewhere.
Correspondence:
Kurt M. Eichholz, MD,
St. Louis Minimally Invasive Spine Center,
4590 South Lindbergh Blvd,
St. Louis, MO 63127.
E-mail: kurt@stlmisc.com
Received, May 30, 2018.
Accepted, July 16, 2018.
Published Online, September 6, 2018.
T
reatment methodology for thoracolumbar
fractures has evolved over time. Adverse
consequences of prolonged bed rest and
the evolution of surgical technique have led to
effective operative approaches for stabilization
of thoracolumbar fractures. In many circum-
stances, surgery is now considered the optimal
treatment for patients presenting with unstable
thoracolumbar spine fractures.
However, the timing of surgical intervention
in the setting of thoracolumbar fractures has
been debated over the years, and the relationship
of timing of surgical intervention to clinical
outcome has not been well defined.
The goal of this guideline is to evaluate the
available literature to determine if the timing
of surgical intervention has an effect of the
ABBREVIATIONS: COIs, conflict of interests
clinical outcome for patients suffering thoracic
and lumbar fractures.
METHODS
Details of the systematic literature review are
provided in the full text of this guideline (https://www.
cns.org/guideline-chapters/congress-neurological-
surgeons-systematic-review-evidence-based-guidelines/
chapter_10) and in the methodology (https://www.
cns.org/guideline-chapters/congress-neurological-
surgeons-systematic-review-evidence-based-guidelines/
chapter_1) article of this guideline series. The authors
collaborated with a medical librarian to search articles
published between January 1, 1946, and March
31, 2015, using the National Library of Medicine
PubMed database and the Cochrane Database of
Systemic Reviews, the Database of Abstracts
of Reviews of Effect, the Cochrane Central Register of
Controlled Trials, the Health Technology Assessment
Database, and the NHS Economic Evaluation
Database. See search strategies provided in Appendix I

Copyright 
C 2018 by the

Congress of Neurological Surgeons

NEUROSURGERY VOLUME 84 | NUMBER 1 | JANUARY 2019 | E53

EICHHOLZ ET AL
(https://www.cns.org/guideline-chapters/congress-neurological-
surgeons-systematic-review-evidence-based-guidelines/chapter_10).
A total of 1172 citations were manually reviewed by the task force.
The authors supplemented searches of electronic databases with manual
screening of the bibliographies of all retrieved publications.
RESULTS
Of the 1172 citations, the task force selected 69 articles for full
text review. Of these, 58 articles were rejected for not meeting
inclusion criteria or for being off-topic. Eleven studies were
selected for inclusion in this systemic review. Using these studies,
the task force sought to determine the whether the literature
supported a recommendation regarding the timing of surgical
intervention in patients with thoracolumbar fractures. Please
see the full text articles (Appendix II) for detailed analysis of
each individual article (https://www.cns.org/guideline-chapters/
congress-neurological-surgeons-systematic-review-evidence-
based-guidelines/chapter_10).
DISCUSSION
Timing of Surgery
The literature was highly variable with regards to what the
definition of “early” and “late” surgery was. Two papers defined
early surgery as <8 h after injury,1,2 while 4 papers defined it
as <24 h.3-6 One paper defined it as <48 h,7 and 4 defined it
as <72 h.8-11 Because of the high degree of variability regarding
the time to surgery, there is insufficient evidence to determine
which cut-off would be an appropriate definition of early vs late
surgery.
Neurological Recovery
Six studies evaluated neurological improvement in relation to
timing of surgery.1-3,5-7 One study7 showed no difference in
neurological recovery between early surgery and late surgery at
48 h, while 4 studies showed that early surgery may improve
neurological recovery.1,2,5,6 Two studies3,6 showed that there is
no indication for early surgery in complete spinal cord injury,
and Schlegal et al12 showed that the presence of neurological
deficit increased the risk of morbidity compared to patients who
are neurologically intact, although this study included cervical
patients. Rahimi-Movaghar et al3 also showed that neurological
recovery can occur in both early and late surgery (before and
after 24 h). The inconsistency of the data regarding neurological
outcome in relation to timing of surgery in these 7 studies led to
the recommendation of insufficient evidence regarding the effect
of timing of surgical intervention on neurological outcome.
Length of Stay
Hospital length of stay and intensive care unit stay were
reviewed in several studies, as well as the number of days of
mechanical ventilation. Five studies showed that early surgery
may decrease the hospital length of stay.1,4,8,10,11 However, none
E54 | VOLUME 84 | NUMBER 1 | JANUARY 2019
of the above-mentioned studies compared postoperative length
of stay. Therefore, one can make the assertion that the longer
length of stay in patients undergoing late surgery was directly
related to the time of delay between admission and surgical inter-
vention. In other words, for any given patient, a delay of several
days between admission and surgery would increase that patient’s
hospitalization by that amount of time. The more time that the
patient is recumbent prior to surgery, the greater the patient’s
length of stay, and therefore, increase the risk of complications
related to recumbency.
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Complications
Complications related to recumbency were reviewed in 6
studies.1,4,8–11 These studies also showed a correlation between
longer length of stay and late surgery. Therefore, one would
expect that the increased rate of complications is due to the
prolonged recumbency for patients undergoing late surgery, and
the increased time of recumbency between admission and surgical
intervention for patients undergoing late surgery.
Mortality
There is insufficient evidence to conclude that morbidity is
higher with early surgery compared to late surgery for those with
thoracolumbar fractures. Overall, 2 Level III articles and 7 Level
IV articles were positive for “early surgery”, while 1 Level III
articles and 2 Level IV articles were negative for “early surgery”.
However, the definition of early surgery was inconsistent among
these articles.
Future Research
In reviewing the available medical literature, it is clear that
there is a lack of research that adequately compares the timing
of surgery to neurological outcome. Even the definition of “early”
and “late” surgery varies considerably in the currently available
literature. However, the nature of traumatic injuries does not lend
itself to randomized controlled trials. The fact that many patients
with thoracolumbar fractures also have concurrent multisystem
injuries makes it difficult to parse out confounding factors that
could also have an effect on the relationship between timing of
surgery and neurological outcome. Future trials or the implemen-
tation of prospective registries are needed in order to ascertain
a relationship between the timing of surgical intervention and
neurological outcome for patients with thoracolumbar fractures.
CONCLUSION
The available medical literature is inconsistent in determining a
definitive correlation between timing of surgical intervention and
its effect on neurological outcome. The data suggests that early
surgery reduces the length of hospitalization, and therefore may
reduce the risk of complications related to recumbency. Surgery
may be performed as early after injury as medically feasible in
order to reduce the length of stay and complications related
to recumbency for patients with thoracolumbar fractures. The
www.neurosurgery-online.com

available literature has a highly variable definition of what is
considered “early” surgery, ranging from <8 h to <72 h after
injury.
Disclosures
These evidence-based clinical practice guidelines were funded exclusively by
the Congress of Neurological Surgeons and the Section on Disorders of the Spine
and Peripheral Nerves in collaboration with the Section on Neurotrauma and
Critical Care, which received no funding from outside commercial sources to
support the development of this document.
Potential Conflicts of Interest
The task force members were required to report all possible conflicts of interest
(COIs) prior to beginning work on the guideline, using the COI disclosure
form of the AANS/CNS Joint Guidelines Committee, including potential
COIs that are unrelated to the topic of the guideline. The CNS Guidelines
Committee and Guideline Task Force Chairs reviewed the disclosures and either
approved or disapproved the nomination. The CNS Guidelines Committee
and Guideline Task Force Chairs are given latitude to approve nominations
of Task Force members with possible conflicts and address this by restricting
the writing and reviewing privileges of that person to topics unrelated to
the possible COIs. The conflict of interest findings are provided in detail in
the companion introduction and methods manuscript (https://www.cns.org/
guideline-chapters/congress-neurological-surgeons-systematic-review-evidence-
based-guidelines/chapter_1). The authors have the following potential conflicts
of interest: Dr Anderson: Aesculap-Consultant, SI Bone-Stock shareholder,
Spartec-Stock shareholder, Expanding Orthopedics-Stock shareholder, Titan
Spine-Stock shareholder, RTI-Other, Stryker-Other, Lumbar Spine Research
Society-Board officer position (President). Dr Arnold: Medtronic-Consultant,
Sofamor Danek-Consultant, Spine Wave-Consultant, InVivo-Consultant,
Stryker Spine-Consultant, Evoke Medical-Stock shareholder, Z-Plasty-Stock
shareholder, AO Spine North America-Sponsored or reimbursed travel (for
self only). Dr Chi: DePuy Spine-Consultant, K2M-Consultant. Dr Dailey:
K2M-Grants/Research support/Consultant, Zimmer Biomet-Consultant,
Medtronic-Consultant. Dr Dhall: Globus Medical-Honorarium, Depuy Spine-
Honorarium. Dr Harrop: DePuy Spine-Consultant, Asterias-Other/Scientific
advisor, Tejin-Other/Scientific advisor, Bioventus-Other/Scientific advisor, AO
Spine-Board, trustee, or officer position. Dr O’Toole: Globus Medical-Consultant
fee, RTI Surgical-Consultant, Theracell, Inc.-Stock shareholder.
Disclaimer of Liability
This clinical systematic review and evidence-based guideline was developed
by a multidisciplinary physician volunteer task force and serves as an educational
tool designed to provide an accurate review of the subject matter covered. These
guidelines are disseminated with the understanding that the recommendations
by the authors and consultants who have collaborated in their development are
not meant to replace the individualized care and treatment advice from a patient’s
physician(s). If medical advice or assistance is required, the services of a competent
physician should be sought. The proposals contained in these guidelines may not
be suitable for use in all circumstances. The choice to implement any particular
recommendation contained in these guidelines must be made by a managing
physician in light of the situation in each particular patient and on the basis of
existing resources.
NEUROSURGERY
TIMING OF SURGICAL INTERVENTION
REFERENCES
1. Cengiz SL, Kalkan E, Bayir A, Ilik K, Basefer A. Timing of thoracolomber
spine stabilization in trauma patients; Impact on neurological outcome and clinical
course. A real prospective (rct) randomized controlled study. Arch Orthop Trauma
Surg. 2008;128(9):959-966.
2. Gaebler C, Maier R, Kutscha-Lissberg F, Mrkonjic L, Vecsei V. Results of spinal
cord decompression and thoracolumbar pedicle stabilisation in relation to the time
of operation. Spinal Cord. 1999;37(1):33-39.
3. Rahimi-Movaghar V, Niakan A, Haghnegahdar A, Shahlaee A, Saadat
S, Barzideh E. Early versus late surgical decompression for traumatic
thoracic/thoracolumbar (T1-L1) spinal cord injured patients. Primary results
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of a randomized controlled trial at one year follow-up. Neurosciences (Riyadh).
2014;19(3):183-191.
4. Stahel PF, VanderHeiden T, Flierl MA, et al. The impact of a standardized
“spine damage-control” protocol for unstable thoracic and lumbar spine fractures
in severely injured patients: a prospective cohort study. J Trauma Acute Care Surg.
2013;74(2):590-596.
5. Dvorak MF, Noonan VK, Fallah N, et al. The influence of time from injury to
surgery on motor recovery and length of hospital stay in acute traumatic spinal cord
injury: An observational Canadian cohort study. J Neurotrauma. 2015;32(9):645-
654.
6. Petitjean ME, Mousselard H, Pointillart V, Lassie P, Senegas J, Dabadie P.
Thoracic spinal trauma and associated injuries: should early spinal decompression
be considered? J Trauma. 1995;39(2):368-372.
7. Kerwin AJ, Frykberg ER, Schinco MA, et al. The effect of early surgical treatment
of traumatic spine injuries on patient mortality. J Trauma. 2007;63(6):1308-1313.
8. Boakye M, Arrigo RT, Hayden Gephart MG, Zygourakis CC, Lad S. Retro-
spective, propensity score-matched cohort study examining timing of fracture
fixation for traumatic thoracolumbar fractures. J Neurotrauma. 2012;29(12):2220-
2225.
9. Kerwin AJ, Griffen MM, Tepas JJ, 3rd, Schinco MA, Devin T, Frykberg
ER. Best practice determination of timing of spinal fracture fixation as defined
by analysis of the National Trauma Data Bank. J Trauma. 2008;65(4):824-
831.
10. Park KC, Park YS, Seo WS, Moon JK, Kim BH. Clinical results of early stabi-
lization of spine fractures in polytrauma patients. J Crit Care. 2014;29(4):694.e7-
694.e9.
11. Schinkel C, Frangen TM, Kmetic A, Andress HJ, Muhr G. Timing of thoracic
spine stabilization in trauma patients: impact on clinical course and outcome.
Journal Trauma. 2006;61(1):156-160.
12. Schlegel J, Bayley J, Yuan H, Fredricksen B. Timing of surgical decompression
and fixation of acute spinal fractures. J Orthop Trauma 1996;10(5):323-330.
Acknowledgments
The guidelines task force would like to acknowledge the CNS Guidelines
Committee for their contributions throughout the development of the guideline
and the AANS/CNS Joint Guidelines Review Committee for their review,
comments, and suggestions throughout peer review, as well as the contributions of
Trish Rehring, MPH, CHES, Senior Manager of Clinical Practice Guidelines for
the CNS, and Mary Bodach, MLIS, Guidelines Specialist and Medical Librarian
for assistance with the literature searches. Throughout the review process the
reviewers and authors were blinded from one another. At this time, the guidelines
task force would like to acknowledge the following individual peer reviewers for
their contributions: Maya Babu, MD, MBA, Greg Hawryluk, MD, PhD, Steven
Kalkanis, MD, Yi Lu, MD, PhD, Jeffrey J. Olson, MD, Martina Stippler, MD,
Cheerag Upadhyaya, MD, MSc, and Robert Whitmore, MD.
VOLUME 84 | NUMBER 1 | JANUARY 2019 | E55
 THORACOLUMBAR TRAUMA GUIDELINES

Paul A. Anderson, MD∗

P. B. Raksin, MD‡
Paul M. Arnold, MD§
John H. Chi, MD, MPH¶
Andrew T. Dailey, MD||
Sanjay S. Dhall, MD#
Congress of Neurological Surgeons Systematic
Kurt M. Eichholz, MD∗∗
James S. Harrop, MD‡‡
Daniel J. Hoh, MD§§
Review and Evidence-Based Guidelines on the
Sheeraz Qureshi, MD, MBA¶¶
Craig H. Rabb, MD||
Michael G. Kaiser, MD##
Evaluation and Treatment of Patients with
John E. O’Toole, MD, MS∗∗∗
Thoracolumbar Spine Trauma: Surgical Approaches

Downloaded from https://academic.oup.com/neurosurgery/article-abstract/84/1/E56/5091883 by guest on 16 August 2019

∗
Department of Orthopedics and
Rehabilitation, University of Wisconsin,
‡
Madison, Wisconsin; Division of
Neurosurgery, John H. Stroger, QUESTION: Does the choice of surgical approach (anterior, posterior, or combined
Jr Hospital of Cook County and anterior-posterior) improve clinical outcomes in patients with thoracic and lumbar
Department of Neurological Surgery,
Rush University Medical Center, Chicago, fractures?
Illinois; § Department of Neurosurgery,
University of Kansas School of Medicine, RECOMMENDATIONS: In the surgical treatment of patients with thoracolumbar burst
Kansas City, Kansas; ¶
Department fractures, physicians may use an anterior, posterior, or a combined approach as the
of Neurosurgery, Harvard Medical
School, Brigham and Women’s Hospital, selection of approach does not appear to impact clinical or neurological outcomes.
Boston, Massachusetts; || Department of
Neurosurgery, University of Utah, Salt Lake Strength of Recommendation: Grade B
City, Utah; # Department of Neurological
Surgery, University of California, San With regard to radiologic outcomes in the surgical treatment of patients with thora-
Francisco, San Francisco, California; ∗∗ St. columbar fractures, physicians may utilize an anterior, posterior, or combined approach
Louis Minimally Invasive Spine Center,
St. Louis, Missouri; ‡‡ Departments of because there is conflicting evidence in the comparison among approaches.
Neurological Surgery and Orthopedic
Surgery, Thomas Jefferson University, Strength of Recommendation: Grade Insufficient
Philadelphia, Pennsylvania; §§ Lillian S.
Wells Department of Neurological Surgery, With regard to complications in the surgical treatment of patients with thoracolumbar
University of Florida, Gainesville, Florida;
¶¶
Department of Orthopaedic Surgery,
fractures, physicians may use an anterior, posterior, or combined approach because there
Weill Cornell Medical College, New York, is conflicting evidence in the comparison among approaches.
New York; ## Department of Neurosurgery,
Columbia University, New York, New York;
∗∗∗
Strength of Recommendation: Grade Insufficient
Department of Neurological Surgery,
Rush University Medical Center, Chicago, The full version of the guideline can be reviewed at: https://www.cns.org/guideline-
Illinois
chapters/congress-neurological-surgeons-systematic-review-evidence-based-guidelines/
Sponsored by: Congress of Neurological chapter_11.
Surgeons (CNS) and the Section on
KEY WORDS: Anterior decompression and fusion, Combined anterior and posterior approach, Posterior instru-
Disorders of the Spine and Peripheral
Nerves in collaboration with the Section
mentation, Surgical approach, Surgical treatment, Thoracolumbar fractures
on Neurotrauma and Critical Care
Neurosurgery 84:E56–E58, 2019 DOI:10.1093/neuros/nyy363 www.neurosurgery-online.com
Endorsed by: The Congress of
Neurological Surgeons (CNS) and the
American Association of Neurological Goals and Rationale retropulsed bone fragments in burst fractures
Surgeons (AANS) led to the use of anterior decompression and
The surgical management of thoracolumbar
No part of this article has been published fractures is highly variable. The objectives of fusion, which was eventually combined with
or submitted for publication elsewhere. surgical treatment of thoracolumbar fractures are anterior internal fixation. The transition from
to decompress neural elements when required, hook-rod constructs to pedicle screw fixation
Correspondence: realign the spine, reduce fractures and disloca- reduced the number of levels involved in instru-
Paul A. Anderson, MD,
tions, and provide long-term stability. Histori- mentation and arthrodesis. In addition, the use
Department of Orthopedic Surgery and
Rehabilitation, cally, the surgical management of thoracolumbar of a combined approach has also been described.
University of Wisconsin, fractures involved posterior instrumentation and Modern surgical approaches to the
UWMF Centennial Bldg,
fusion. Recognizing the importance of reducing management of thoracolumbar fractures
1685 Highland Ave, 6th Floor,
Madison, WI 53705-2281.
include anterior decompression and fusion,
E-mail: anderson@ortho.wisc.edu posterior instrumentation with or without
decompression, and combined anterior-
Received, May 30, 2018. posterior approach. However, there is
Accepted, July 16, 2018. ABBREVIATIONS: AANS, American Association of variation in practice and no consensus exists
Published Online, September 6, 2018. Neurological Surgeons; COI, conflict of interest; CNS, with respect to the optimal approach to
Congress of Neurological Surgeons
Copyright 
C 2018 by the surgical treatment of thoracolumbar fractures.
Congress of Neurological Surgeons

E56 | VOLUME 84 | NUMBER 1 | JANUARY 2019 www.neurosurgery-online.com


METHODS
Details of the systematic literature review are provided in the
full text of this guideline (https://www.cns.org/guideline-chapters/
congress-neurological-surgeons-systematic-review-evidence-based-
guidelines/chapter_11) and in the methodology (https://www.cns.org/
guideline-chapters/congress-neurological-surgeons-systematic-review-
evidence-based-guidelines/chapter_1) article of this guideline series.
The Guidelines Task Force initiated a systematic review of the literature
relevant to the diagnosis and treatment of patients with thoracolumbar
trauma. Through objective evaluation of the evidence and transparency
in the process of making recommendations, this evidence-based clinical
practice guideline was developed for the diagnosis and treatment
of adult patients with thoracolumbar injury. These guidelines are
developed for educational purposes to assist practitioners in their clinical
decision-making processes. Additional information about the methods
utilized in this systematic review can be found in the introduction and
methodology chapter (https://www.cns.org/guideline-chapters/congress-
neurological-surgeons-systematic-review-evidence-based-guidelines/
chapter_1).
RESULTS
A total of 1413 abstracts were reviewed from which eleven
studies were identified as either cohort or randomized clinical
trials that compared anterior, posterior, or combined anterior-
posterior approaches. There were 4 randomized controlled trials
that were rated as Level II.1-4 All 6 retrospective cohort studies
were rated as Level III.5-10 One prospective cohort study was rated
a Level III.11
DISCUSSION
Only questions regarding the best approach to surgical
treatment of burst fractures in adults and not for other
fracture types could be evaluated. The outcomes measured
included neurologic recovery and clinical outcome, radiologic
results, and complications related to treatment. The anterior
approach included corpectomy or partial corpectomy and recon-
struction with strut grafting or cage and anterior instrumen-
tation. If additional posterior instrumentation was used, then
the patient was considered to be a combined anterior-posterior
approach. The posterior group used pedicle screws except
in 2 studies where posterior rod-hook instrumentation was
performed. Posterior decompression may have been performed
as needed in this group. Additionally, 2 studies that used
transformational interbody decompression and fusion combined
with posterior pedicle screw instrumentation were included in
the posterior approach group.1,11 Combined anterior-posterior
approach included corpectomy or partial corpectomy and recon-
struction with strut grafting or cage and anterior instrumentation
and additional posterior pedicle screw instrumentation.
NEUROSURGERY
SURGICAL APPROACHES
Comparison of Anterior Versus Posterior Approaches
There were 7 studies that compared clinical and neurologic
outcomes of anterior decompression and fusion to posterior
surgery with or without decompression. No differences in neuro-
logic outcomes or clinical outcomes were noted in any study. Two
studies showed better overall fracture Cobb angle correction at
final follow-up with anterior surgery, while 5 studies reported no
differences in radiologic outcomes between anterior and posterior
approaches. The 2 studies that favored anterior surgery were both
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Level III evidence, while 2 Level II and 3 Level III studies did not
show a difference. One Level II study demonstrated fewer compli-
cations and favored the anterior approach and 1 Level II study
favored the posterior approach. Three Level III studies showed
no differences between approaches.
Comparison of Posterior Versus Anterior-Posterior
Approach
Five studies compared posterior instrumentation with
or without decompression to combined anterior-posterior
approaches. Two studies were Level II randomized controlled
trials, 2 studies were Level III retrospective cohort study, and
1 study was a Level III prospective cohort study. Four studies
(1 Level II and 3 Level III) reported no difference in clinical
outcomes. One Level II study reported better clinical outcomes in
the posterior approach, although, despite lower pain, the authors
recommended against the posterior-only approach because of a
high incidence of poor radiologic results.4 One Level II and 2
Level III studies reported no difference in radiologic outcomes
between groups, while 1 Level II study and 1 Level III favored
the anterior-posterior approach. Complications occurred more
frequently after anterior-posterior fusion compared to posterior
approach in 2 Level II studies, while all 3 Level III studies
reported no difference between groups.
Future Research
Future research is still needed to determine an optimum
surgical approach for thoracolumbar fractures. Although there
were 5 randomized controlled trials, these trials had significant
deficiencies, including lack of power analysis, lack of description
of randomization methods, and absent a priori identification of
primary outcome variables. When developing the research plan,
the use of the CONSORT method and reporting results is recom-
mended. Many of the studies used outdated surgical techniques,
so new studies using modern methods are needed. The results
should be stratified based on neurologic injury and fracture types.
The new methods to classify thoracolumbar fractures need to be
incorporated into study design, and the results should be analyzed
according to the severity of injury based on these schemes.
CONCLUSION
Eleven studies compared outcomes between anterior and
posterior approaches and anterior-posterior and posterior
VOLUME 84 | NUMBER 1 | JANUARY 2019 | E57
ANDERSON ET AL
approaches. There was moderate evidence that no differences
in clinical outcomes based on approach occur. In addition,
conflicting evidence was present indicating that minimal differ-
ences in radiologic or complication risk exist between approaches.
Thus, surgeons may choose any of 3 approaches when deciding
optimal surgical treatment for thoracolumbar burst fractures.
Disclosures
These evidence-based clinical practice guidelines were funded exclusively by
the Congress of Neurological Surgeons and the Section on Disorders of the Spine
and Peripheral Nerves in collaboration with the Section on Neurotrauma and
Critical Care, which received no funding from outside commercial sources to
support the development of this document.
Potential Conflicts of Interest
The task force members were required to report all possible COIs prior
to beginning work on the guideline, using the COI disclosure form of the
(American Association of Neurological Surgeon/ Congress of Neurological
Surgeons) AANS/CNS Joint Guidelines Committee, including potential COIs
that are unrelated to the topic of the guideline. The CNS Guidelines Committee
and Guideline Task Force Chairs reviewed the disclosures and either approved or
disapproved the nomination. The CNS Guidelines Committee and Guideline
Task Force Chairs are given latitude to approve nominations of Task Force
members with possible conflicts and address this by restricting the writing
and reviewing privileges of that person to topics unrelated to the possible
COIs. The conflict of interest findings are provided in detail in the companion
introduction and methods manuscript (https://www.cns.org/guideline-chapters/
congress-neurological-surgeons-systematic-review-evidence-based-guidelines/
chapter_1). The authors have the following potential conflicts of interest (COI):
Dr Anderson: Aesculap-Consultant, SI Bone-Stock shareholder, Spartec-Stock
shareholder, Expanding Orthopedics-Stock shareholder, Titan Spine-Stock
shareholder, RTI-Other, Stryker-Other, Lumbar Spine Research Society-Board
officer position (President). Dr Arnold: Medtronic-Consultant, Sofamor
Danek-Consultant, Spine Wave-Consultant, InVivo-Consultant, Stryker Spine-
Consultant, Evoke Medical-Stock shareholder, Z-Plasty-Stock shareholder, AO
Spine North America-Sponsored or reimbursed travel (for self only). Dr Chi:
DePuy Spine-Consultant, K2M-Consultant. Dr Dailey: K2M-Grants/Research
support/Consultant, Zimmer Biomet-Consultant, Medtronic-Consultant.
Dr Dhall: Globus Medical-Honorarium, Depuy Spine-Honorarium. Dr
Harrop: DePuy Spine-Consultant, Asterias-Other/Scientific advisor, Tejin-
Other/Scientific advisor, Bioventus-Other/Scientific advisor, AO Spine-Board,
trustee, or officer position. Dr O’Toole: Globus Medical-Consultant fee, RTI
Surgical-Consultant, Theracell, Inc.-Stock shareholder.
Disclaimer of Liability
This clinical systematic review and evidence-based guideline was developed
by a multidisciplinary physician volunteer task force and serves as an educational
tool designed to provide an accurate review of the subject matter covered. These
guidelines are disseminated with the understanding that the recommendations
by the authors and consultants who have collaborated in their development are
not meant to replace the individualized care and treatment advice from a patient’s
physician(s). If medical advice or assistance is required, the services of a competent
physician should be sought. The proposals contained in these guidelines may not
E58 | VOLUME 84 | NUMBER 1 | JANUARY 2019
be suitable for use in all circumstances. The choice to implement any particular
recommendation contained in these guidelines must be made by a managing
physician in light of the situation in each particular patient and on the basis of
existing resources.
REFERENCES
1. Hao D, Wang W, Duan K, et al. Two-year follow-up evaluation of surgical
treatment for thoracolumbar fracture-dislocation. Spine. 2014;39(21):E1284-
E1290.
2. Wood K, Buttermann G, Mehbod A, Garvey T, Jhanjee R, Sechriest
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V. Operative compared with nonoperative treatment of a thoracolumbar burst
fracture without neurological deficit. A prospective, randomized study. J Bone Joint
Surg Am. 2003;85A:(5)773-781.
3. Lin B, Chen ZW, Guo ZM, Liu H, Yi ZK. Anterior Approach Versus
Posterior Approach With Subtotal Corpectomy, Decompression, and Recon-
struction of Spine in the Treatment of Thoracolumbar Burst Fractures: A
Prospective Randomized Controlled Study. J Spinal Disord Tech. 2011;25:(6)309-
317.
4. Korovessis P, Baikousis A, Zacharatos S, Petsinis G, Koureas G, Iliopoulos
P. Combined anterior plus posterior stabilization versus posterior short-segment
instrumentation and fusion for mid-lumbar (L2-L4) burst fractures. Spine.
2006;31(8):859-868.
5. Esses SI, Botsford DJ, Kostuik JP. Evaluation of surgical treatment for burst
fractures. Spine. 1990;15(7):667-673.
6. Danisa OA, Shaffrey CI, Jane JA, et al. Surgical approaches for the correction
of unstable thoracolumbar burst fractures: a retrospective analysis of treatment
outcomes. J Neurosurg. 1995;83(6):977-983.
7. Been HD, Bouma GJ. Comparison of two types of surgery for thoraco-lumbar
burst fractures: Combined anterior and posterior stabilisation vs. Acta Neurochir
(Wien). 1999;141(4):349-357.
8. Wu H, Wang CX, Gu CY, et al. Comparison of three different surgical approaches
for treatment of thoracolumbar burst fracture. Chin J Traumatol. 2013;16(1):31-
35.
9. Hitchon PW, Torner J, Eichholz KM, Beeler SN. Comparison of anterolateral
and posterior approaches in the management of thoracolumbar burst fractures.
Neurosurg Spine. 2006;5(2):117-125.
10. Sasso RC, Renkens K, Hanson D, Reilly T, McGuire RA, Jr, Best
NM. Unstable thoracolumbar burst fractures: anterior-only versus short-segment
posterior fixation. J Spinal Disord Tech. 2006;19(4):242-248.
11. Schmid R, Lindtner RA, Lill M, Blauth M, Krappinger D, Kammer-
lander C. Combined posteroanterior fusion versus transforaminal lumbar
interbody fusion (TLIF) in thoracolumbar burst fractures. Injury. 2012;43(4):475-
479.
Acknowledgments
The guidelines task force would like to acknowledge the CNS Guidelines
Committee for their contributions throughout the development of the guideline
and the AANS/CNS Joint Guidelines Review Committee for their review,
comments, and suggestions throughout peer review, as well as the contributions of
Trish Rehring, MPH, CHES, Senior Manager of Clinical Practice Guidelines for
the CNS, and Mary Bodach, MLIS, Guidelines Specialist and Medical Librarian
for assistance with the literature searches. Throughout the review process the
reviewers and authors were blinded from one another. At this time, the guidelines
task force would like to acknowledge the following individual peer reviewers for
their contributions: Maya Babu, MD, MBA, Greg Hawryluk, MD, PhD, Steven
Kalkanis, MD, Yi Lu, MD, PhD, Jeffrey J. Olson, MD, Martina Stippler, MD,
Cheerag Upadhyaya, MD, MSc, and Robert Whitmore, MD.
www.neurosurgery-online.com
 THORACOLUMBAR TRAUMA GUIDELINES

John H. Chi, MD, MPH∗

Kurt M. Eichholz, MD‡
Paul A. Anderson, MD§
Paul M. Arnold, MD¶
Andrew T. Dailey, MD||
Sanjay S. Dhall, MD#
Congress of Neurological Surgeons Systematic
James S. Harrop, MD∗∗
Daniel J. Hoh, MD‡‡ Review and Evidence-Based Guidelines on the
Sheeraz Qureshi, MD, MBA§§
Craig H. Rabb, MD||
P. B. Raksin, MD¶¶
Evaluation and Treatment of Patients With
Michael G. Kaiser, MD||||
John E. O’Toole, MD, MS##
Thoracolumbar Spine Trauma: Novel Surgical

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∗
Department of Neurosurgery, Harvard
Strategies
Medical School, Brigham and Women’s
Hospital, Boston, Massachusetts; ‡ St. Louis
Minimally Invasive Spine Center, St. Louis, BACKGROUND: Treatment of thoracolumbar burst fractures has traditionally involved
Missouri; § Department of Orthopedics and
Rehabilitation, University of Wisconsin,
spinal instrumentation with fusion performed with standard open surgical techniques.
Madison, Wisconsin; ¶ Department of Novel surgical strategies, including instrumentation without fusion and percutaneous
Neurosurgery, University of Kansas School of instrumentation alone, have been considered less invasive and more efficient treatments.
Medicine, Kansas City, Kansas; || Department
of Neurosurgery, University of Utah, OBJECTIVE: To review the current literature and determine the role of fusion in instru-
Salt Lake City, Utah; # Department of mented fixation, as well as the role of percutaneous instrumentation, in the treatment of
Neurological Surgery, University of California,
San Francisco, San Francisco, California;
patients with thoracolumbar burst fractures.
∗∗
Departments of Neurological Surgery METHODS: The task force members identified search terms/parameters and a medical
and Orthopedic Surgery, Thomas Jefferson librarian implemented the literature search, consistent with the literature search protocol
University, Philadelphia, Pennsylvania;
‡‡
Lillian S. Wells Department of Neurological (see Appendix I), using the National Library of Medicine PubMed database and the
Surgery, University of Florida, Gainesville, Cochrane Library for the period from January 1, 1946 to March 31, 2015.
Florida; §§ Department of Orthopaedic
Surgery, Weill Cornell Medical College, New
RESULTS: A total of 906 articles were identified and 38 were selected for full-text review.
York, New York; ¶¶ Division of Neurosurgery, Of these articles, 12 articles met criteria for inclusion in this systematic review.
John H. Stroger, Jr Hospital of Cook County
and Department of Neurological Surgery,
CONCLUSION: There is grade A evidence for the omission of fusion in instrumented
Rush University Medical Center, Chicago, fixation for thoracolumbar burst fractures. There is grade B evidence that percutaneous
Illinois; |||| Department of Neurosurgery, instrumentation is as effective as open instrumentation for thoracolumbar burst fractures.
Columbia University, New York, New York;
##
Department of Neurological Surgery, Rush RECOMMENDATIONS:
University Medical Center, Chicago, Illinois QUESTION: Does the addition of arthrodesis to instrumented fixation improve outcomes
in patients with thoracic and lumbar burst fractures?
Sponsored by: Congress of Neurological
Surgeons and the Section on Disorders of
RECOMMENDATION: It is recommended that in the surgical treatment of patients
the Spine and Peripheral Nerves in with thoracolumbar burst fractures, surgeons should understand that the addition of
collaboration with the Section on arthrodesis to instrumented stabilization has not been shown to impact clinical or radio-
Neurotrauma and Critical Care
logical outcomes, and adds to increased blood loss and operative time.
Endorsed by: The Congress of Strength of Recommendation: Grade A
Neurological Surgeons (CNS) and the
American Association of Neurological QUESTION: How does the use of minimally invasive techniques (including percutaneous
Surgeons (AANS) instrumentation) affect outcomes in patients undergoing surgery for thoracic and lumbar
No part of this article has been published fractures compared to conventional open techniques?
or submitted for publication elsewhere. RECOMMENDATION: Stabilization using both open and percutaneous pedicle screws may
be considered in the treatment of thoracolumbar burst fractures as the evidence suggests
Correspondence:
equivalent clinical outcomes.
John H. Chi, MD, MPH,
Harvard Medical School, Strength of Recommendation: Grade B
Brigham and Women’s Hospital, The full version of the guideline can be reviewed at: https://www.cns.org/guideline-
75 Francis St,
chapters/congress-neurological-surgeons-systematic-review-evidence-based-guidelines/
Boston, MA 02115.
E-mail: jchi@bwh.harvard.edu chapter_12.
KEY WORDS: Arthrodesis, Burst fracture, Fusion, Minimally invasive surgery, Thoracolumbar fracture
Received, May 30, 2018.
Accepted, July 16, 2018.
Neurosurgery 84:E59–E62, 2019 DOI:10.1093/neuros/nyy364 www.neurosurgery-online.com
Published Online, October 8, 2018.

Copyright 
C 2018 by the

Congress of Neurological Surgeons

NEUROSURGERY VOLUME 84 | NUMBER 1 | JANUARY 2019 | E59

CHI ET AL
T
he goal of treatment for thoracolumbar burst fractures
entails stabilization with or without decompression
to prevent progressive deformity and neurological
compromise. Although some burst fractures may be treated
nonoperatively, a certain percentage will require operative
intervention. Formal open surgery for stabilization with instru-
mentation and arthrodesis, as well as decompression, as needed,
has been the primary mode of surgical treatment. However,
more specific surgical strategies, such as instrumentation without
arthrodesis and percutaneous instrumentation alone have all
been offered as faster, safer, and more efficient alternatives to
traditional open fusion surgery.
This guideline focuses on 2 questions: (1) Does the addition
of arthrodesis to instrumented fixation improve outcomes in
patients with thoracic and lumbar fractures? and (2) Does the use
of minimally invasive techniques (including percutaneous instru-
mentation) affect outcomes in patients undergoing surgery for
thoracic and lumbar fractures compared to conventional open
techniques?
METHODS
Details of this systematic review are provided in the full text
of this guideline (https://www.cns.org/guideline-chapters/congress-
neurological-surgeons-systematic-review-evidence-based-guidelines/
chapter_12) and in the methodology (https://www.cns.org/guideline-
chapters/congress-neurological-surgeons-systematic-review-evidence-
based-guidelines/chapter_1) article of this guideline series. The task force
members identified search terms and parameters, and a medical librarian
implemented the literature search, consistent with the literature search
protocol (see Appendix I; https://www.cns.org/guideline-chapters/
congress-neurological-surgeons-systematic-review-evidence-based-
guidelines/chapter_12), using the National Library of Medicine
PubMed database and the Cochrane Library (which included the
Cochrane Database of Systematic Reviews, the Database of Abstracts of
Reviews of Effect, the Cochrane Central Register of Controlled Trials,
the Health Technology Assessment Database, and the National Health
Service Economic Evaluation Database Economic Evaluation Database)
for the period from January 1, 1946, to March 31, 2015, using the
search strategies provided in Appendix I (https://www.cns.org/guideline-
chapters/congress-neurological-surgeons-systematic-review-evidence-
based-guidelines/chapter_12). The guideline task force used a modified
version of the North American Spine Society’s (NASS) evidence-based
guideline development methodology for classification of evidence.
RESULTS
The task force selected 38 full-text articles for review out of 906
abstracts. Of these, 26 were rejected for not meeting inclusion
criteria or for being off-topic. Twelve articles were selected for
ABBREVIATIONS: COIs, conflict of interests
E60 | VOLUME 84 | NUMBER 1 | JANUARY 2019
inclusion in the systematic review (Appendix II; https://www.cns.
org/guideline-chapters/congress-neurological-surgeons-systematic
-review-evidence-based-guidelines/chapter_12).
Regarding whether arthrodesis improves outcomes after instru-
mented stabilization in thoracolumbar burst fractures, there were
2 randomized controlled trials (Level I) with 130 patients,1,2
2 downgraded randomized controlled trials (Level II) with 104
patients,3,4 and 1 prospective observational cohort trial (Level
II) with 42 patients,5 which all showed no difference in clinical
and radiographic outcomes in a patients with and without
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arthrodesis. Patients with arthrodesis did have higher blood loss,
longer surgery times, and higher donor site pain. There was 1
retrospective study (Level III) with 74 patients,6 which found
that patients with arthrodesis had better kyphosis correction and
less hardware issues, but still have more blood loss and longer
surgery times.
Regarding the use of minimally invasive techniques (including
percutaneous instrumentation) on outcomes compared to
conventional open techniques for thoracic and lumbar fractures,
there was 1 prospective observational trial (Level II) with
37 patients7 and 3 retrospective trials (Level III) with 137
patients,8-10 which all showed no difference in outcomes but
with shorter surgery time and less blood loss in the minimally
invasive group On the other hand, there was 1 downgraded
randomized controlled trial (Level II) with 61 patients11 and
1 downgraded retrospective trial (Level IV) with 38 patients,12
which showed that open techniques resulted in better clinical
outcomes, such as maintenance of vertebral body height and
Cobb angle.
DISCUSSION
The literature provides 2 high-quality randomized clinical trials
(Level I), as well as 3 prospective studies (Level II) that show
no difference between fusion and nonfusion groups. There is
only 1 retrospective study (Level III) showing fusion helps to
maintain kyphotic correction and prevents screw loosening. All
studies show less blood loss, shorter surgery times, and no donor
site-related issues in the nonfusion group.
The literature provides 3 Level III studies showing no
difference in outcome with percutaneous fixation vs open
fixation. There are 2 Level II studies that show open fixation is
better at correcting a deformity and maintaining the deformity
correction compared to percutaneous fixation. There is 1 Level
IV paper that shows added time and cost with percutaneous
fixation, but no other difference. Because of the comparable level
of competing evidence, both percutaneous and open fixation may
be considered in treating burst fractures.
Future Research
Further research is needed to clarify the role of fusion in
patients who require a decompression in addition to stabilization
or in the setting of neurological injury, as well as to identify
potential risk factors for screw loosening in nonfusion patients.
www.neurosurgery-online.com

It is unclear whether removal of instrumentation has any role in
patients treated without arthrodesis. Additional randomized trials
are needed to determine the effectiveness of percutaneous fixation
alone compared to open fixation without fusion.
CONCLUSION
The medical literature provides compelling reasons to
recognize that there is little difference when instrumenting thora-
columbar burst fractures with or without fusion. This does not
necessarily apply for more complex fracture patterns, and the
papers used in this guideline generally did not include patients
with neurological injury and need for direct decompression.
Harvesting autograft for fusion predictably led to longer surgery
times, increased blood loss, and more donor site issues. The
medical literature provides comparable and competing evidence
for percutaneous fixation. Percutaneous fixation may be effective
at reducing blood loss and operative time. However, there is no
conclusive evidence that percutaneous fixation is any better or
worse than open fixation.
Disclosures
These evidence-based clinical practice guidelines were funded exclusively by
the Congress of Neurological Surgeons and the Section on Disorders of the Spine
and Peripheral Nerves in collaboration with the Section on Neurotrauma and
Critical Care, which received no funding from outside commercial sources to
support the development of this document.
Potential Conflicts of Interest
The task force members were required to report all possible conflicts of interest
(COIs) prior to beginning work on the guideline, using the COI disclosure
form of the AANS/CNS Joint Guidelines Committee, including potential
COIs that are unrelated to the topic of the guideline. The CNS Guidelines
Committee and Guideline Task Force Chairs reviewed the disclosures and either
approved or disapproved the nomination. The CNS Guidelines Committee
and Guideline Task Force Chairs are given latitude to approve nominations of
Task Force members with possible conflicts and address this by restricting the
writing and reviewing privileges of that person to topics unrelated to the possible
COIs. The conflict of interest findings are provided in detail in the companion
introduction and methods manuscript (https://www.cns.org/guideline-chapters/
congress-neurological-surgeons-systematic-review-evidence-based-guidelines/
chapter_1). The authors have the following potential conflicts of interest: Dr
Anderson: Aesculap-Consultant, SI Bone-Stock shareholder, Spartec-Stock
shareholder, Expanding Orthopedics-Stock shareholder, Titan Spine-Stock
shareholder, RTI-Other, Stryker-Other, Lumbar Spine Research Society-Board
officer position (President). Dr Arnold: Medtronic-Consultant, Sofamor
Danek-Consultant, Spine Wave-Consultant, InVivo-Consultant, Stryker Spine-
Consultant, Evoke Medical-Stock shareholder, Z-Plasty-Stock shareholder, AO
Spine North America-Sponsored or reimbursed travel (for self only). Dr Chi:
DePuy Spine-Consultant, K2M-Consultant. Dr Dailey: K2M-Grants/Research
support/Consultant, Zimmer Biomet-Consultant, Medtronic-Consultant.
Dr Dhall: Globus Medical-Honorarium, Depuy Spine-Honorarium. Dr
Harrop: DePuy Spine-Consultant, Asterias-Other/Scientific advisor, Tejin-
Other/Scientific advisor, Bioventus-Other/Scientific advisor, AO Spine-Board,
trustee, or officer position. Dr O’Toole: Globus Medical-Consultant fee, RTI
Surgical-Consultant, Theracell, Inc.-Stock shareholder.
NEUROSURGERY
NOVEL SURGICAL STRATEGIES
Disclaimer of Liability
This clinical systematic review and evidence-based guideline was developed
by a multidisciplinary physician volunteer task force and serves as an educational
tool designed to provide an accurate review of the subject matter covered. These
guidelines are disseminated with the understanding that the recommendations
by the authors and consultants who have collaborated in their development are
not meant to replace the individualized care and treatment advice from a patient’s
physician(s). If medical advice or assistance is required, the services of a competent
physician should be sought. The proposals contained in these guidelines may not
be suitable for use in all circumstances. The choice to implement any particular
recommendation contained in these guidelines must be made by a managing
Downloaded from https://academic.oup.com/neurosurgery/article-abstract/84/1/E59/5123629 by guest on 16 August 2019
physician in light of the situation in each particular patient and on the basis of
existing resources.
REFERENCES
1. Dai LY, Jiang LS, Jiang SD. Posterior short-segment fixation with or
without fusion for thoracolumbar burst fractures. a five to seven-year prospective
randomized study. J Bone Joint Surg Am. 2009;91(5):1033-1041.
2. Jindal N, Sankhala SS, Bachhal V. The role of fusion in the management of
burst fractures of the thoracolumbar spine treated by short segment pedicle screw
fixation: a prospective randomised trial. J Bone Joint Surg Br. 2012;94(8):1101-
1106.
3. Chou PH, Ma HL, Wang ST, Liu CL, Chang MC, Yu WK. Fusion may
not be a necessary procedure for surgically treated burst fractures of the thora-
columbar and lumbar spines: a follow-up of at least ten years. J Bone Joint Surg Am.
2014;96(20):1724-1731.
4. Wang ST, Ma HL, Liu CL, Yu WK, Chang MC, Chen TH. Is fusion necessary
for surgically treated burst fractures of the thoracolumbar and lumbar spine?: A
prospective, randomized study. Spine. 2006;31(23):2646-2652.
5. Tezeren G, Bulut O, Tukenmez M, Ozturk H, Oztemur Z, Ozturk A.
Long segment instrumentation of thoracolumbar burst fracture: Fusion versus
nonfusion. J Back Musculoskelet Rehabil. 2009;22(2):107-112.
6. Hwang JH, Modi HN, Yang JH, Kim SJ, Lee SH. Short segment pedicle screw
fixation for unstable T11-L2 fractures: with or without fusion? A three-year follow-
up study. Acta Orthop Belg. 2009;75(6):822-827.
7. Vanek P, Bradac O, Konopkova R, de Lacy P, Lacman J, Benes V. Treatment of
thoracolumbar trauma by short-segment percutaneous transpedicular screw instru-
mentation: prospective comparative study with a minimum 2-year follow-up. J
Neurosurg Spine. 2014;20(2):150-156.
8. Grossbach AJ, Dahdaleh NS, Abel TJ, Woods GD, Dlouhy BJ, Hitchon PW.
Flexion-distraction injuries of the thoracolumbar spine: open fusion versus percu-
taneous pedicle screw fixation. Neurosurg Focus. 2013;35(2):E2.
9. Lee JK, Jang JW, Kim TW, Kim TS, Kim SH, Moon SJ. Percutaneous short-
segment pedicle screw placement without fusion in the treatment of thoracolumbar
burst fractures: is it effective?: comparative study with open short-segment pedicle
screw fixation with posterolateral fusion. Acta Neurochir. 2013;155(12):2305-
2312.
10. Dong SH, Chen HN, Tian JW, et al. Effects of minimally invasive percutaneous
and trans-spatium intermuscular short-segment pedicle instrumentation on thora-
columbar mono-segmental vertebral fractures without neurological compromise.
Orthop Traumatol Surg Res. 2013;99(4):405-411.
11. Jiang XZ, Tian W, Liu B, et al. Comparison of a paraspinal approach with a percu-
taneous approach in the treatment of thoracolumbar burst fractures with posterior
ligamentous complex injury: A prospective randomized controlled trial. J Int Med
Res. 2012;40(4):1343-1356.
12. Wang HW, Li CQ, Zhou Y, Zhang ZF, Wang J, Chu TW. Percutaneous
pedicle screw fixation through the pedicle of fractured vertebra in the treatment of
type A thoracolumbar fractures using Sextant system: an analysis of 38 cases. Chin
J Traumatol. 2010;13(3):137-145.
Acknowledgments
The guidelines task force would like to acknowledge the CNS Guidelines
Committee for their contributions throughout the development of the guideline
VOLUME 84 | NUMBER 1 | JANUARY 2019 | E61
CHI ET AL
and the AANS/CNS Joint Guidelines Review Committee for their review,
comments, and suggestions throughout peer review, as well as the contributions
of Trish Rehring, MPH, CHES, Senior Manager of Clinical Practice Guidelines
for the CNS, and Mary Bodach, MLIS, Guidelines Specialist and Medical
Librarian for assistance with the literature searches. Throughout the review
E62 | VOLUME 84 | NUMBER 1 | JANUARY 2019
process the reviewers and authors were blinded from one another. At this time,
the guidelines task force would like to acknowledge the following individual peer
reviewers for their contributions: Maya Babu, MD, MBA, Greg Hawryluk, MD,
PhD, Steven Kalkanis, MD, Yi Lu, MD, PhD, Jeffrey J. Olson, MD, Martina
Stippler, MD, Cheerag Upadhyaya, MD, MSc, and Robert Whitmore, MD.
Downloaded from https://academic.oup.com/neurosurgery/article-abstract/84/1/E59/5123629 by guest on 16 August 2019
www.neurosurgery-online.com
 THORACOLUMBAR TRAUMA GUIDELINES

John E. O’Toole, MD, MS∗

Michael G. Kaiser, MD‡
Paul A. Anderson, MD§
Paul M. Arnold, MD¶
Congress of Neurological Surgeons Systematic
John H. Chi, MD, MPH||
Andrew T. Dailey, MD#
Sanjay S. Dhall, MD∗∗
Review and Evidence-Based Guidelines on the
Kurt M. Eichholz, MD‡‡
James S. Harrop, MD§§
Evaluation and Treatment of Patients with
Daniel J. Hoh, MD¶¶
Sheeraz Qureshi, MD, MBA||||
Craig H. Rabb, MD##
Thoracolumbar Spine Trauma: Executive Summary

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P. B. Raksin, MD∗∗∗

∗
Department of Neurological Surgery, BACKGROUND: The thoracic and lumbar (“thoracolumbar”) spine are the most commonly
Rush University Medical Center, Chicago, injured region of the spine in blunt trauma. Trauma of the thoracolumbar spine is
Illinois; ‡ Department of Neurosurgery,
Columbia University, New York, New frequently associated with spinal cord injury and other visceral and bony injuries.
York; § Department of Orthopedics and
Rehabilitation, University of Wisconsin,
Prolonged pain and disability after thoracolumbar trauma present a significant burden on
Madison, Wisconsin; ¶ Department of patients and society.
Neurosurgery, University of Kansas School of
Medicine, Kansas City, Kansas; || Department OBJECTIVE: To formulate evidence-based clinical practice recommendations for the care
of Neurosurgery, Harvard Medical of patients with injuries to the thoracolumbar spine.
School, Brigham and Women’s Hospital,
Boston, Massachusetts; # Department of METHODS: A systematic review of the literature was performed using the National Library
Neurosurgery, University of Utah, Salt Lake
City, Utah; ∗∗ Department of Neurological
of Medicine PubMed database and the Cochrane Library for studies relevant to thora-
Surgery, University of California, San columbar spinal injuries based on specific clinically oriented questions. Relevant publica-
Francisco, San Francisco, California; ‡‡ St.
Louis Minimally Invasive Spine Center, tions were selected for review.
St. Louis, Missouri; §§ Departments of RESULTS: For all of the questions posed, the literature search yielded a total of 6561
Neurological Surgery and Orthopedic
Surgery, Thomas Jefferson University, abstracts. The task force selected 804 articles for full text review, and 78 were selected for
Philadelphia, Pennsylvania; ¶¶ Lillian S.
Wells Department of Neurological Surgery,
inclusion in this overall systematic review.
University of Florida, Gainesville, Florida;
||||
CONCLUSION: The available evidence for the evaluation and treatment of patients
Department of Orthopaedic Surgery,
Weill Cornell Medical College, New York, with thoracolumbar spine injuries demonstrates considerable heterogeneity and highly
New York; ## Department of Neurosurgery, variable degrees of quality. However, the workgroup was able to formulate a number of
University of Utah, Salt Lake City, Utah;
∗∗∗
Division of Neurosurgery, John H. Stroger, key recommendations to guide clinical practice. Further research is needed to counter the
Jr Hospital of Cook County and Department
of Neurological Surgery, Rush University
relative paucity of evidence that specifically pertains to patients with only thoracolumbar
Medical Center, Chicago, Illinois spine injuries.
The full version of the guideline can be reviewed at: https://www.cns.org/guideline-
Sponsored by: Congress of Neurological
Surgeons and the Section on Disorders of
chapters/congress-neurological-surgeons-systematic-review-evidence-based-guidelines/
the Spine and Peripheral Nerves in chapter_1.
collaboration with the Section on
Neurotrauma and Critical Care KEY WORDS: Clinical practice guideline, Lumbar fracture, Thoracic fracture, Thoracolumbar fracture

Endorsed by: The Congress of Neurosurgery 84:2–6, 2019 DOI:10.1093/neuros/nyy394 www.neurosurgery-online.com

Neurological Surgeons (CNS) and the
American Association of Neurological
Surgeons (AANS)
No part of this article has been published
or submitted for publication elsewhere.
Correspondence:
John E. O’Toole, MD, MS,
Department of Neurosurgery,
Rush University Medical Center,
1725 West Harrison St, Suite 855,
Chicago, IL 60612.
E-mail: john_otoole@rush.edu
Received, May 30, 2018.
Accepted, July 27, 2018.
Published Online, September 6, 2018.
Copyright 
C 2018 by the
Congress of Neurological Surgeons
Goals and Rationale
Traumatic injuries of the thoracic and lumbar
spine (“thoracolumbar”) occur in approximately
7% of all blunt trauma patients and comprise
50% to 90% of the 160 000 annual traumatic
spinal fractures in North America.1-5 Long-term
ABBREVIATIONS: AANS, American Association of
Neurological Surgeons; CNS, Congress of Neuro-
logical Surgeons; COI, conflict of interest
Neurosurgery Speaks! Audio abstracts available for this
article at www.neurosurgery-online.com.
care of patients with persistent disability after
thoracolumbar trauma represents a significant
burden on society’s healthcare resources.1,2,4-6
For the purposes of this guideline, “thora-
columbar” includes the distinct regions of
the rigid thoracic spine (T1-10), transitional
thoracolumbar junction (T10-L2), and flexible
lumbar spine (L3-5).
There remains a lack of consensus on a
number of issues surrounding the care of these
patients including classification, evaluation,
medical management, and nuances of operative
management.1-3,5-11 The American Association
of Neurological Surgeons (AANS)/Congress

2 | VOLUME 84 | NUMBER 1 | JANUARY 2019 www.neurosurgery-online.com


of Neurological Surgeons (CNS) Section on Disorders of the
Spine and Peripheral Nerves and the Section on Neurotrauma
and Critical Care workgroup employed the available evidence
base and a rigorous guideline elaboration methodology to develop
a clinical practice guideline regarding the care of patients with
thoracolumbar trauma using the available evidence base and
employing a rigorous guideline elaboration methodology.
METHODS
Specific patient, intervention, comparison, outcome (PICO)
questions of pressing clinical relevance were formulated prior to
any literature search or evidence abstraction. The guidelines task force
performed a systematic review of the literature relevant to the diagnosis
and treatment of patients with thoracolumbar trauma that utilized
multiple search terms and databases. Evidence from included articles
was abstracted into evidentiary tables and graded for level of evidence,
and recommendations were then elaborated based on this evidence using
a modified version of the North American Spine Society’s evidence-
based guideline development methodology (https://www.spine.org/
ResearchClinicalCare/QualityImprovement/ClinicalGuidelines). “A”
recommendations indicate a test or intervention is “recommended”; “B”
recommendations “suggest” a test or intervention; and “C” recommen-
dations indicate a test or intervention or “is an option.” “Insufficient
Evidence” statements clearly indicate that “there is insufficient evidence
to make a recommendation for or against” a test or intervention. Task
force consensus statements clearly state that “in the absence of reliable
evidence, it is the task force’s opinion that” a test or intervention may be
considered.
GUIDELINE APPROVAL PROCESS
The completed guideline was submitted to the AANS/CNS
Joint Guidelines Review Committee for both peer review for
publications and for societal endorsement. After revisions, the
final guideline was approved and endorsed by the executive
committees of both the AANS and CNS prior to publication
of the summaries in Neurosurgery. The full version of the
guideline can be reviewed at: https://www.cns.org/guidelines/
guidelines-evaluation-treatment-patients-thoracolumbar-spine-
trauma.
RECOMMENDATIONS
Classification of Injury
Questions
1. Are there classification systems for fractures of the thora-
columbar spine that have been shown to be internally valid
and reliable (ie, do these instruments provide consistent infor-
mation between different care providers)?
2. In treating patients with thoracolumbar fractures, does using
a formally tested classification system for treatment decision-
making affect clinical outcomes?
NEUROSURGERY
EXECUTIVE SUMMARY
Recommendations
1. A classification scheme that uses readily available clinical data
(eg, computed tomography scans with or without magnetic
resonance imaging) to convey injury morphology, such as
Thoracolumbar Injury Classification and Severity Scale or the
AO Spine Thoracolumbar Spine Injury Classification System,
should be used to improve characterization of traumatic thora-
columbar injuries and communication among treating physi-
cians.
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Strength of Recommendation: Grade B
2. There is insufficient evidence to recommend a universal
classification system or severity score that will readily guide
treatment of all injury types and thereby affect outcomes.
Strength of Recommendation: Grade Insufficient
Radiological Evaluation
Questions
1. Are there radiographic findings in patients with traumatic
thoracolumbar fractures that can predict the need for surgical
intervention?
2. Are there radiographic findings in patients with traumatic
thoracolumbar fractures that can assist in predicting clinical
outcomes?
Recommendations
1. Because magnetic resonance imaging has been shown to
influence the management of up to 25% of patients with thora-
columbar fractures, providers may use magnetic resonance
imaging to assess posterior ligamentous complex integrity,
when determining the need for surgery.
Strength of Recommendation: Grade B
2. Due to a paucity of published studies, there is insufficient
evidence that radiographic findings can be used as predictors
of clinical outcomes in thoracolumbar fractures.
Strength of Recommendation: Grade Insufficient
Neurological Assessment
Questions
1. Which neurological assessment tools have demonstrated
internal reliability and validity in the management of patients
with thoracic and lumbar fractures (ie, do these instru-
ments provide consistent information between different care
providers)?
2. Are there any clinical findings (eg, presenting neurological
grade/function) in patients with thoracic and lumbar fractures
that can assist in predicting clinical outcomes?
Recommendations
1. Numerous neurological assessment scales (Functional
Independence Measure, Sunnybrook Cord Injury Scale,
VOLUME 84 | NUMBER 1 | JANUARY 2019 | 3
O’TOOLE ET AL
and Frankel Scale for Spinal Cord Injury) have demonstrated
internal reliability and validity in the management of patients
with thoracic and lumbar fractures. Unfortunately, other
contemporaneous measurement scales (ie, American Spinal
Cord Injury Association Impairment Scale) have not been
specifically studied in patients with thoracic and lumbar
fractures.
Strength of Recommendation: Grade C
2. Entry American Spinal Injury Association Impairment Scale
grade, sacral sensation, ankle spasticity, urethral and rectal
sphincter function, and AbH motor function can be used to
predict neurological function and outcome in patients with
thoracic and lumbar fractures.
Strength of Recommendation: Grade B
Pharmacological Treatment
Question
1. Does the administration of a specific pharmacologic agent
(eg, methylprednisolone) improve clinical outcomes in patients
with thoracic and lumbar fractures and spinal cord injury?
Recommendation
1. There is insufficient evidence to make a recommendation;
however, the task force concluded, in light of previously
published data and guidelines, the complication profile should
be carefully considered when deciding on the administration
of methylprednisolone.
Strength of Recommendation: Grade Insufficient
Hemodynamic Management
Question
1. Does the active maintenance of arterial blood pressure after
injury affect clinical outcomes in patients with thoracic and
lumbar fractures?
Recommendations
1. There is insufficient evidence to recommend for or against the
use of active maintenance of arterial blood pressure after thora-
columbar spinal cord injury.
Level of Evidence: Grade Insufficient
2. However, in light of published data from pooled (cervical
and thoracolumbar) spinal cord injury patient populations,
clinicians may choose to maintain mean arterial blood
pressures > 85 mm Hg in an attempt to improve neurological
outcomes.
Consensus Statement by the Workgroup
4 | VOLUME 84 | NUMBER 1 | JANUARY 2019
Prophylaxis and Treatment of Thromboembolic Events
Questions
1. Does routine screening for deep venous thrombosis prevent
pulmonary embolism (or venous thromboembolism-associated
morbidity and mortality) in patients with thoracic and lumbar
fractures?
2. For patients with thoracic and lumbar fractures, is one regimen
of venous thromboembolism prophylaxis superior to others
with respect to prevention of pulmonary embolism (or venous
thromboembolism-associated morbidity and mortality)?
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3. Is there a specific treatment regimen for documented venous
thromboembolism that provides fewer complications than
other treatments in patients with thoracic and lumbar
fractures?
Recommendations
1. There is insufficient evidence to recommend for or against
routine screening for deep venous thrombosis in preventing
pulmonary embolism (or venous thromboembolism-associated
morbidity and mortality) in patients with thoracic and lumbar
fractures.
Strength of Recommendation: Grade Insufficient
2. There is insufficient evidence to recommend a specific
regimen of venous thromboembolism prophylaxis to prevent
pulmonary embolism (or venous thromboembolism-associated
morbidity and mortality) in patients with thoracic and lumbar
fractures.
Strength of Recommendation: Grade Insufficient
3. There is insufficient evidence to recommend for or against
a specific treatment regimen for documented venous throm-
boembolism that would provide fewer complications than
other treatments in patients with thoracic and lumbar fractures.
Strength of Recommendation: Grade Insufficient
4. Based on published data from pooled (cervical and thora-
columbar) spinal cord injury populations, the use of throm-
boprophylaxis is recommended to reduce the risk of venous
thromboembolism events in patients with thoracic and lumbar
fractures.
Consensus Statement by the Workgroup
Nonoperative Care
Question
1. Does the use of external bracing improve outcomes in the
nonoperative treatment of neurologically intact patients with
thoracic and lumbar burst fractures?
Recommendation
1. The decision to use an external brace is at the discretion of
the treating physician, as the nonoperative management of
www.neurosurgery-online.com

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 compared to not bracing.
Strength of Recommendation: Grade B
Operative vs Nonoperative Treatment
Questions
1. Does the surgical treatment of burst fractures of the thoracic
and lumbar spine improve clinical outcomes compared to
nonoperative treatment?
2. Does the surgical treatment of nonburst fractures of the
thoracic and lumbar spine improve clinical outcomes
compared to nonoperative treatment?
Recommendations
1. There is conflicting evidence to recommend for or against the
use of surgical intervention to improve clinical outcomes in
patients with thoracolumbar burst fracture who are neurolog-
ically intact. Therefore, it is recommended that the discretion
of the treating provider be used to determine if the presenting
thoracic or lumbar burst fracture in the neurologically intact
patient warrants surgical intervention.
Strength of Recommendation: Grade Insufficient
2. There is insufficient evidence to recommend for or against the
use of surgical intervention for nonburst thoracic or lumbar
fractures. It is recommended that the decision to pursue surgery
for such fractures be at the discretion of the treating physician.
Strength of Recommendation: Grade Insufficient
Timing of Surgical Intervention
Question
1. Does early surgical intervention improve outcomes for patients
with thoracic and lumbar fractures?
Recommendations
1. There is insufficient and conflicting evidence regarding the
effect of timing of surgical intervention on neurological
outcomes in patients with thoracic and lumbar fractures.
Strength of Recommendation: Grade Insufficient
2. It is suggested that “early” surgery be considered as an option
in patients with thoracic and lumbar fractures to reduce length
of stay and complications. The available literature has defined
“early” surgery inconsistently, ranging from <8 h to <72 h
after injury.
Strength of Recommendation: Grade B
NEUROSURGERY
EXECUTIVE SUMMARY
Surgical Approaches
Question
1. Does the choice of surgical approach (anterior, posterior, or
combined anterior-posterior) improve clinical outcomes in
patients with thoracic and lumbar fractures?
Recommendations
1. In the surgical treatment of patients with thoracolumbar burst
fractures, physicians may utilize an anterior, posterior, or a
combined approach as the selection of approach does not
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appear to impact clinical or neurological outcomes.
Strength of Recommendation: Grade B
2. With regard to radiological outcomes in the surgical treatment
of patients with thoracolumbar fractures, physicians may
utilize an anterior, posterior, or combined approach because
there is conflicting evidence in the comparison among
approaches.
Strength of Recommendation: Grade Insufficient
3. With regard to complications in the surgical treatment of
patients with thoracolumbar fractures, physicians may utilize
an anterior, posterior, or combined approach because there is
conflicting evidence in the comparison among approaches.
Strength of Recommendation: Grade Insufficient
Novel Surgical Strategies
Questions
1. Does the addition of arthrodesis to instrumented fixation
improve outcomes in patients with thoracic and lumbar burst
fractures?
2. How does the use of minimally invasive techniques (including
percutaneous instrumentation) affect outcomes in patients
undergoing surgery for thoracic and lumbar fractures
compared to conventional open techniques?
Recommendations
1. It is recommended that in the surgical treatment of patients
with thoracolumbar burst fractures, surgeons should under-
stand that the addition of arthrodesis to instrumented stabi-
lization has not been shown to impact clinical or radiological
outcomes, and adds to increased blood loss and operative time.
Strength of Recommendation: Grade A
2. Stabilization using both open and percutaneous pedicle screws
may be considered in the treatment of thoracolumbar burst
fractures as the evidence suggests equivalent clinical outcomes.
Strength of Recommendation: Grade B
VOLUME 84 | NUMBER 1 | JANUARY 2019 | 5
O’TOOLE ET AL
CONCLUSION
Ultimately, this clinical practice guideline serves as a critical
reference for clinicians caring for adult patients with thora-
columbar trauma. This synthesis of the most contemporary
evidence using rigorous methodology provides the reader with an
important resource to address key questions in routine clinical
practice. As with all evidence-based guidelines, however, it should
be implemented in conjunction with clinician expertise and
patient preferences.
Disclosures
These evidence-based clinical practice guidelines were funded exclusively by
the CNS and the Section on Disorders of the Spine and Peripheral Nerves in
collaboration with the Section on Neurotrauma and Critical Care, which received
no funding from outside commercial sources to support the development of this
document.
Conflict of Interest
The task force members were required to report all possible conflicts of
interest (COIs) prior to beginning work on the guideline, using the COI
disclosure form of the AANS/CNS Joint Guidelines Committee, including
potential COIs that are unrelated to the topic of the guideline. The CNS
Guidelines Committee and Guideline Task Force Chairs reviewed the disclosures
and either approved or disapproved the nomination. The CNS Guidelines
Committee and Guideline Task Force Chairs are given latitude to approve
nominations of Task Force members with possible conflicts and address this
by restricting the writing and reviewing privileges of that person to topics
unrelated to the possible COIs. The COI findings are provided in detail in
the companion introduction and methods manuscript (https://www.cns.org/
guideline-chapters/congress-neurological-surgeons-systematic-review-evidence-
based-guidelines/chapter_1). The authors have the following potential conflicts
of interest: Dr Anderson: Aesculap—Consultant, SI Bone—Stock shareholder,
Spartec—Stock shareholder, Expanding Orthopedics—Stock shareholder, Titan
Spine—Stock shareholder, RTI—Other, Stryker—Other, Lumbar Spine Research
Society—Board officer position (President). Dr Arnold: Medtronic—Consultant,
Sofamor Danek—Consultant, Spine Wave—Consultant, InVivo—Consultant,
Stryker Spine—Consultant, Evoke Medical—Stock shareholder, Z-Plasty—Stock
shareholder, AO Spine North America—Sponsored or reimbursed travel (for
self only). Dr Chi: DePuy Spine—Consultant, K2M—Consultant. Dr Dailey:
K2M—Grants/Research support/Consultant, Zimmer Biomet—Consultant,
Medtronic—Consultant. Dr Dhall: Globus Medical—Honorarium, Depuy
Spine—Honorarium. Dr Harrop: DePuy Spine—Consultant, Asterias—
Other/Scientific advisor, Tejin—Other/Scientific advisor, Bioventus—
Other/Scientific advisor, AO Spine—Board, trustee, or officer position.
Dr O’Toole: Globus Medical—Consultant fee, RTI Surgical—Consultant,
Theracell, Inc. —Stock shareholder.
Disclaimer of Liability
This clinical systematic review and evidence-based guideline was developed
by a multidisciplinary physician volunteer task force and serves as an educational
tool designed to provide an accurate review of the subject matter covered. These
guidelines are disseminated with the understanding that the recommendations
6 | VOLUME 84 | NUMBER 1 | JANUARY 2019
by the authors and consultants who have collaborated in their development are
not meant to replace the individualized care and treatment advice from a patient’s
physician(s). If medical advice or assistance is required, the services of a competent
physician should be sought. The proposals contained in these guidelines may not
be suitable for use in all circumstances. The choice to implement any particular
recommendation contained in these guidelines must be made by a managing
physician in light of the situation in each particular patient and on the basis of
existing resources.
REFERENCES
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9. Lopez AJ, Scheer JK, Smith ZA, Dahdaleh NS. Management of flexion
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10. Scheer JK, Bakhsheshian J, Fakurnejad S, Oh T, Dahdaleh NS, Smith ZA.
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Neurosurgery Speaks! Audio abstracts available for this article at www.neurosurgery-
online.com.
Acknowledgments
The guidelines task force would like to acknowledge the CNS Guidelines
Committee for their contributions throughout the development of the guideline
and the AANS/CNS Joint Guidelines Review Committee for their review,
comments, and suggestions throughout peer review, as well as the contributions of
Trish Rehring, MPH, CHES, Senior Manager of Clinical Practice Guidelines for
the CNS, and Mary Bodach, MLIS, Guidelines Specialist and Medical Librarian
for assistance with the literature searches. Throughout the review process, the
reviewers and authors were blinded from one another. At this time, the guidelines
task force would like to acknowledge the following individual peer reviewers for
their contributions: Maya Babu, MD, MBA; Greg Hawryluk, MD, PhD; Steven
Kalkanis, MD; Yi Lu, MD, PhD, Jeffrey J. Olson, MD; Martina Stippler, MD;
Cheerag Upadhyaya, MD, MSc; and Robert Whitmore, MD.
www.neurosurgery-online.com