There is controversy in literature about timing of surgery for thoracolumbar injuries. There is no conclusive evidence that early surgical decompression and stabilization improves neurological recovery, or that a delay in surgery would cause compromised neurological recovery.
However, it is agreed upon that if the neurological deficit is progressive, an emergency decompression is indicated.
Otherwise there are two schools of thought. One advocates early decompression and stabilization. The benefits highlighted are lesser complication rate and shorter duration of hospital stay.
The advocates of delay in surgical procedures to allow resolution of cord edema.
Decompression
The role of decompression also is controversial.
Decompression is relieving of the compression of the neural elements by retropulsed bone fragments.
It can be done either indirectly or directly. Indirect method is by insertion of posterior instrumentation which puts indirect pull on the compressive elements by distracting the vertebrae. This technique relies on intact posterior longitudinal ligament. Direct method is by exploring the spinal canal through a posterolateral or anterior approach and removing the structures that compress.
If surgery is delayed for several weeks or more, indirect reduction may not work satisfactorily.
Indirect reduction does not effectively reduce the comminuted fractures which has multiple pieces of bone pushed into the spinal.
Approaches To Direct Reduction
Posterolateral Approach
At thoracolumbar junction and in the lumbar spine, a posterolateral approach is helpful in decompression. The procedure involves hemilaminectomy and removal of a pedicle with a high-speed.
The technique is not useful in thoracic spine where lesser space is available at neural elements are at higher risk.
Anterior Approach
The anterior approach allows direct decompression of the cord. But the approach is has potential for higher morbidity and unfamiliar approach to many surgeons.
It also puts visceral and vascular structures at risk of injury. Stabilization with anterior implants needs to be done.
Overall, the posterior surgery takes the least time, causes the least blood loss, and is the least expensive.
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Thanks for this post discussing Thoracolumbar injuries. Just what I was looking for!