Congress of Neurological Surgeons Systematic Review and Evidence-Based Guidelines on the Evaluation and Treatment of Patients With Thoracolumbar Spine Trauma: Novel Surgical Strategies.

Background: Treatment of thoracolumbar burst fractures has traditionally involved spinal instrumentation with fusion performed with standard open surgical techniques. Novel surgical strategies, including instrumentation without fusion and percutaneous instrumentation alone, have been considered less invasive and more efficient treatments.

Objective: To review the current literature and determine the role of fusion in instrumented fixation, as well as the role of percutaneous instrumentation, in the treatment of patients with thoracolumbar burst fractures.

Congress of Neurological Surgeons Systematic Review and Evidence-Based Guidelines on the Evaluation and Treatment of Patients with Thoracolumbar Spine Trauma: Surgical Approaches.

Question: Does the choice of surgical approach (anterior, posterior, or combined anterior-posterior) improve clinical outcomes in patients with thoracic and lumbar fractures?

Recommendations: In the surgical treatment of patients with thoracolumbar burst fractures, physicians may use an anterior, posterior, or a combined approach as the selection of approach does not appear to impact clinical or neurological outcomes. Strength of Recommendation: Grade B With regard to radiologic 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 With regard to complications in the surgical treatment of patients with thoracolumbar fractures, physicians may use an anterior, posterior, or combined approach because there is conflicting evidence in the comparison among approaches.

Congress of Neurological Surgeons Systematic Review and Evidence-Based Guidelines on the Evaluation and Treatment of Patients With Thoracolumbar Spine Trauma: Nonoperative Care.

Background: Thoracic and lumbar burst fractures in neurologically intact patients are considered to be inherently stable, and responsive to nonsurgical management. There is a lack of consensus regarding the optimal conservative treatment modality. The question remains whether external bracing is necessary vs mobilization without a brace after these injuries.

Congress of Neurological Surgeons Systematic Review and Evidence-Based Guidelines on the Evaluation and Treatment of Patients With Thoracolumbar Spine Trauma: Neurological Assessment.

Question 1: Which neurological assessment tools have demonstrated internal reliability and validity in the management of patients with thoracic and lumbar fractures (ie, do these instruments provide consistent information between different care providers)?

Recommendation 1: Numerous neurologic assessment scales (Functional Independence Measure, Sunnybrook Cord Injury Scale 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.

Congress of Neurological Surgeons Systematic Review and Evidence-Based Guidelines on the Evaluation and Treatment of Patients With Thoracolumbar Spine Trauma: Prophylaxis and Treatment of Thromboembolic Events.

Question 1: Does routine screening for deep venous thrombosis prevent pulmonary embolism (or venous thromboembolism (VTE)-associated morbidity and mortality) in patients with thoracic and lumbar fractures?

Recommendation 1: There is insufficient evidence to recommend for or against routine screening for deep venous thrombosis in preventing pulmonary embolism (or VTE-associated morbidity and mortality) in patients with thoracic and lumbar fractures. Strength of Recommendation: Grade Insufficient.

Question 2: For patients with thoracic and lumbar fractures, is one regimen of VTE prophylaxis superior to others with respect to prevention of pulmonary embolism (or VTE-associated morbidity and mortality)?

Recommendation 2: There is insufficient evidence to recommend a specific regimen of VTE prophylaxis to prevent pulmonary embolism (or VTE-associated morbidity and mortality) in patients with thoracic and lumbar fractures.

Congress of Neurological Surgeons Systematic Review and Evidence-Based Guidelines on the Evaluation and Treatment of Patients with Thoracolumbar Spine Trauma: Operative Versus Nonoperative Treatment.

Question 1: Does the surgical treatment of burst fractures of the thoracic and lumbar spine improve clinical outcomes compared to nonoperative treatment?

Recommendation 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 neurologically 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.

Congress of Neurological Surgeons Systematic Review and Evidence-Based Guidelines on the Evaluation and Treatment of Patients With Thoracolumbar Spine Trauma: Radiological Evaluation.

Background: Radiological evaluation of traumatic thoracolumbar fractures is used to classify the injury and determine the optimal treatment plan. Currently, there remains a lack of consensus regarding appropriate radiological protocol. Most clinicians use a combination of plain radiographs, 3-dimensional computed tomography with reconstructions, and magnetic resonance imaging (MRI).

Congress of Neurological Surgeons Systematic Review and Evidence-Based Guidelines on the Evaluation and Treatment of Patients with Thoracolumbar Spine Trauma: Executive Summary.

Background: The thoracic and lumbar ("thoracolumbar") spine are the most commonly injured region of the spine in blunt trauma. Trauma of the thoracolumbar spine is frequently associated with spinal cord injury and other visceral and bony injuries. Prolonged pain and disability after thoracolumbar trauma present a significant burden on patients and society.

Congress of Neurological Surgeons Systematic Review and Evidence-Based Guidelines on the Evaluation and Treatment of Patients With Thoracolumbar Spine Trauma: Pharmacological Treatment.

Question: 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: 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.

Congress of Neurological Surgeons Systematic Review and Evidence-Based Guidelines on the Evaluation and Treatment of Patients With Thoracolumbar Spine Trauma: Hemodynamic Management.

Question: Does the active maintenance of arterial blood pressure after injury affect clinical outcomes in patients with thoracic and lumbar fractures?

Recommendations: There is insufficient evidence to recommend for or against the use of active maintenance of arterial blood pressure after thoracolumbar spinal cord injury. Grade of Recommendation: Grade Insufficient 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 The full version of the guideline can be reviewed at: https://www.

Congress of Neurological Surgeons Systematic Review and Evidence-Based Guidelines on the Evaluation and Treatment of Patients With Thoracolumbar Spine Trauma: Classification of Injury.

Question 1: Are there classification systems for fractures of the thoracolumbar spine that have been shown to be internally valid and reliable (ie, do these instruments provide consistent information between different care providers)?

Recommendation 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 thoracolumbar injuries and communication among treating physicians. Strength of Recommendation: Grade B.

Question 2: In treating patients with thoracolumbar fractures, does employing a formally tested classification system for treatment decision-making affect clinical outcomes?

Recommendation 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.

Congress of Neurological Surgeons Systematic Review and Evidence-Based Guidelines on the Evaluation and Treatment of Patients With Thoracolumbar Spine Trauma: Timing of Surgical Intervention.

Question: Does early surgical intervention improve outcomes for patients with thoracic and lumbar fractures?

Recommendations: 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 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.

The technological development of minimally invasive spine surgery.

Minimally invasive spine surgery has its roots in the mid-twentieth century with a few surgeons and a few techniques, but it has now developed into a large field of progressive spinal surgery. A wide range of techniques are now called "minimally invasive," and case reports are submitted constantly with new "minimally invasive" approaches to spinal pathology. As minimally invasive spine surgery has become more mainstream over the past ten years, in this paper we discuss its history and development.

Minimally invasive thoracic microendoscopic diskectomy: surgical technique and case series.

Objective: To present operative details and clinical follow-up of a series of patients with thoracic disk herniation treated with the minimally invasive technique of thoracic microendoscopic diskectomy (TMED).

Methods: TMED was performed in 16 consecutive patients (age range, 18-79 years old) with 18 thoracic disk herniations. One patient with a calcified herniation in a direct ventral location was not included in this series.

Surgical site infection rates after minimally invasive spinal surgery.

Object: Postoperative surgical site infections (SSIs) have been reported after 2-6% of spinal surgeries in most large series. The incidence of SSI can be < 1% after decompressive procedures and > 10% after instrumented fusions. Anecdotal evidence has suggested that there is a lower rate of SSI when minimally invasive techniques are used.

Minimally invasive posterolateral thoracic corpectomy: cadaveric feasibility study and report of four clinical cases.

Objective: To demonstrate the feasibility of and initial clinical experience with a novel minimally invasive posterolateral thoracic corpectomy technique.

Methods: Seven procedures were performed on 6 cadavers to determine the feasibility of thoracic corpectomy using a minimally invasive approach. The posterolateral thoracic corpectomies were performed with expandable 22 mm diameter tubular retractor paramedian incisions.

Minimally invasive posterior osteotomies.

Objective: Surgery for thoracolumbar deformity can lead to significant muscle injury, excessive blood loss, and severe postoperative pain. The aim of the following studies was to determine the feasibility of minimally invasive posterior thoracic corpectomy and thoracolumbar osteotomy techniques for deformity in human cadavers and select clinical cases.

Methods: Human cadaveric specimens were procured for thoracic corpectomy and Smith-Petersen and pedicle subtraction osteotomy using a minimally invasive approach.

Inability to ventilate the lungs of a patient with tracheal anomaly and in prone position.

We present the case of an otherwise asymptomatic patient with a rare congenital airway abnormality of the tracheobronchial tree, who developed a complete airway obstruction after being placed in the prone position. The tracheal bronchus, accessory bronchus arising from the trachea superior to its bifurcation at the carina, was identified by fiberoptic bronchoscopic examination. An endotracheal tube can migrate into a tracheal bronchus causing pulmonary atelectasis, hypoxia, or both.

Minimally invasive insertion of syringosubarachnoid shunt for posttraumatic syringomyelia: technical case report.

Objective: Symptomatic posttraumatic syringomyelia affects up to 10% of patients with spinal cord injuries and manifests in a delayed manner as progressive sensorimotor changes below the level of the syrinx. Syrinx shunting, and in particular syringosubarachnoid shunting (SSAS), provides neurological improvement or stabilization in at least 50% of these patients. Given the debilitated condition of many of these patients, a minimally invasive approach to the insertion of these devices is desirable.

Minimally invasive far lateral microendoscopic discectomy for extraforaminal disc herniation at the lumbosacral junction: cadaveric dissection and technical case report.

Background Context: Extraforaminal lumbar disc herniations (ELDHs) at the lumbosacral junction are an uncommon cause of L5 radiculopathy. The surgical anatomy of the extraforaminal space at L5-S1 is uniquely challenging for the various open surgical approaches that have been described for ELDHs in general. Reports specifically describing minimally invasive surgical approaches to lumbosacral ELDHs are lacking.

Minimally invasive lumbar spinal decompression in the elderly: outcomes of 50 patients aged 75 years and older.

Objective: Lumbar spinal stenosis and spondylosis are major causes of morbidity among the elderly. Surgical decompression is an effective treatment, but many elderly patients are not considered as candidates for surgery based on age or comorbidities. Minimally invasive surgical techniques have recently been developed and used successfully for the treatment of lumbar spinal disease.

Vertebroplasty and kyphoplasty.

Percutaneous vertebroplasty and kyphoplasty provide minimally invasive options for the management of osteoporotic and osteolytic vertebral compression fractures. These techniques provide substantial pain relief and support without requiring long periods of recumbency, and have an acceptable complication rate. Vertebral augmentation techniques such as vertebroplasty and kyphoplasty provide pain relief and improvement in quality of life in the highly selected patient.

Minimally invasive approaches to vertebral column and spinal cord tumors.

Minimally invasive approaches to spinal tumors have evolved rapidly over the past 15 to 20 years as clinicians seek to avoid the morbidity and long-term dysfunction associated with traditional open surgical procedures. We review the noninvasive, percutaneous, and minimally invasive surgical techniques currently available for the treatment of spinal column and intradural spinal tumors, including minimal access thoracic corpectomy and minimal access intradural tumor surgery. The various advantages and limitations of these approaches as well as their appropriate indications and uses are also presented here.

Thoracic microendoscopic discectomy.

Thoracic microendoscopic discectomy is a safe effective treatment for surgical removal of herniated thoracic intervertebral discs. This approach allows access through a minimally invasive muscle-splitting posterolateral approach that does not place the contents of the thoracic cavity at risk. In the lumbar spine, this approach has been proven effective, with a shorter length of hospital stay, less postoperative pain, decreased blood loss, and shorter recovery time.

Endoscopic posterior cervical foraminotomy and discectomy.

Posterior cervical microendoscopic foraminotomy and discectomy is an effective minimally invasive approach to cervical radiculopathy caused by foraminal osteophytes or lateral disc herniations. This article reviews the technique in detail as well as the advantages over open approaches. Nuances of the technique, including complications and their management, are also explored.