Therapeutic decision making in thoracolumbar spine trauma.
Systematic literature review. A systematic review was designed to answer 3 primary research questions: (1) What is the most useful classification system for surgical and nonsurgical decision-making with regard to thoracolumbar (TL) spine injuries? (2) For a TL burst fracture with incomplete neurologic deficit, what is the optimal surgical approach and stabilization technique? (3) Is complete disruption of the posterior ligamentous complex an indication for surgical intervention for TL burst fractures? Despite a long history of descriptive and clinical series, there remains considerable controversy and wide variation in the treatment of traumatic TL spine injuries. A comprehensive search of the English literature was conducted using Medline and the Cochrane Database of Systematic Reviews. Standardized grading systems were used to assess the level of evidence and quality of articles impacting the research questions. Recommendations for the primary research questions were as follows: (1) Thoracolumbar Injury Classification System seems to be the best system available for therapeutic decision-making for TL spine injuries (strength of recommendation: weak; quality of evidence: low). (2) There is no specific surgical approach in the case of a TL burst fracture with incomplete neurologic deficit that has any advantage with regard to neurologic recovery (strength of recommendation: weak; quality of evidence: low). (3) Complete disruption of the posterior ligamentous complex as determined collectively by morphologic criteria using plain radiographs and computed tomography is an indication for surgical intervention in TL burst fractures (strength of recommendation: strong; quality of evidence: low). Based on this systematic review of the literature only very low to moderate quality studies could be identified to address clinical questions related to TL spine trauma. These findings suggest the need for further study, including emphasis on higher quality studies.