History of Management of Thoracolumbar Spine Trauma in Children

History of Management of Thoracolumbar Spine Trauma in Children
Improved ICU care has led to better outcomes in patients with spinal cord injury. More reliable, accessible, and improved imaging (such as CT and MRI) has helped diagnose, classify, and assist surgeons in determining the best treatment for patients. Overall, treatment has evolved from immobilization and bed-rest for many weeks to rigid surgical fixation and early mobilization.

Understanding of Disease

Classification

Our system for classifying pediatric thoracolumbar trauma has progressed over time.

• Five-category model: In 1929, Böhler introduced the five-category model of spine fractures: compression fractures; flexion-distraction fractures; extension fractures; shear fractures; and rotational injuries (3).
• Three-column model: Denis’s 3-column model was originally described for fractures at the thoracolumbar junction. This model divides the spine into the anterior, middle, and posterior columns and describes fracture patterns depending on the combination of columns injured (11).
• AOSpine fracture classification: AOSpine group fracture classification is comprehensive and consensus-based, but also can be cumbersome to apply in practice (35,36). An updated system was developed, to incorporate elements of the Magerl and TLICS (37).
• TLICS: The TLICS was developed to include fracture morphology, neurologic involvement, and posterior ligamentous complex integrity. This can be used as a guide for the need for surgical intervention and has been validated in the pediatric population (10,32,35,36).

Technological Development

• Bedrest: Without rigid fixation, bedrest was the main treatment of unstable thoracolumbar spine fractures.
• Pedicle screw fixation: As instrumentation has improved, pedicle screw fixation is now utilized as the most common surgical technique for rigid fixation. Hooks and wires are occasionally used in patients with unusual anatomy.
• Image guidance: Image-guided systems are sometimes employed for accurate placement of hardware.

Surgical Technique

• Posterior approach: The posterior approach remains most commonly used in thoracolumbar spine injury repair.
• Anterior/lateral approaches: In patients with significant retropulsion of bone, or anterior compression of the spine or nerve roots, anterior or lateral approaches can be utilized. This may require the assistance of an appropriate surgeon for exposure (general, vascular).
• Minimally invasive approach: In specific types of fracture patterns (e.g., pure bony chance fracture), a minimally invasive approach with percutaneous screw placement under fluoroscopy or image-guidance can be used.