1. What is the decision or change (e.g., clinical topic, practice guideline, system design, delivery of care) you are facing or struggling with where a summary of the evidence would be helpful?

The thoracic and lumbar (“thoracolumbar”) spine is 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.

The CNS published a guideline on the Evaluation and Treatment of Patients with Thoracolumbar Spine Trauma in 2018 including supporting evidence published from 1946 through 2015. Since this search, new evidence has been published in the literature. The authors have refined and refocused the PICO questions around this topic as it has been more than 10 years since the guideline was first developed. The authors will develop a new guideline based on a new systematic review from the most current literature on this topic.

2. Why are you struggling with this issue?

There remains a lack of consensus on a number of issues surrounding the care of thoracolumbar trauma patients, including injury classification systems, radiological evaluation, neurological assessment instrument, systemic treatments for blood pressure and spinal cord injury management, venous thromboembolism prophylaxis, nonoperative versus operative management, surgical approach and timing.

Since the publication of the 2018 guideline, new evidence has emerged on this topic. This systematic review would inform clinical practice guidelines that would assist clinicians with evidence-based decision making and help to improve patient outcomes and care.

3. What do you want to see changed? How will you know that your issue is improving or has been addressed?

Assessment

Classification of thoracic and lumbar spine fractures
In adult patients with thoracic and/or lumbar fractures, does the use of a standardized classification system improve clinical outcomes (e.g. mortality, neurologic recovery, complications, re-operation rate) compared to the use of non-standardized assessment based only on individual knowledge/expertise?
Radiologic evaluation of traumatic thoracic and lumbar fractures
In adult patients with thoracic and/or lumbar fractures, does the use of MRI better identify soft tissue injury (e.g. ligamentous injury, epidural hematoma) requiring surgical intervention than CT and/or Xray?
Assessment of neurological impairment following traumatic thoracic and lumbar spine injuries
In adult patients with thoracic and/or lumbar fractures, which neurological assessment tools (compare tools) have demonstrated the best internal reliability and validity?
In adult patients with thoracic and/or lumbar fractures, does presenting neurological grade or function indicate more improvement in clinical outcomes?
In adult patients with thoracic and/or lumbar spine injuries, does the use of standardized neurological assessment scales or non-standardized assessment based on individual knowledge/expertise yield better clinical outcomes (e.g. mortality, neurologic recovery, complications)?

Nonoperative Treatment

Pharmacological treatment of acute traumatic thoracic and lumbar spinal cord injury
Does the administration of a specific pharmacological agent (e.g., methylprednisolone) improve clinical outcomes in patients with thoracic and lumbar fractures and spinal cord injury?
In adult patients with concomitant thoracic and/or lumbar fractures and spinal cord injury does the use of methylprednisolone or other glucocorticoids yield better motor and sensory recovery distal to the site of injury compared to patients who do not receive glucocorticoid treatment?
Non-operative treatment for patients presenting with traumatic thoracic and lumbar spine fractures
In adult patients with thoracic and lumbar burst fractures, does the use of bracing improve fracture site pain, spinal alignment at 3 months and/or the need for surgery compared to no bracing?
Pre-op
Management of arterial blood pressure in patients with traumatic thoracic and lumbar fractures
Does the empiric active maintenance of arterial blood pressure after spinal cord level injury to a targeted level improve clinical outcomes in patients with thoracic and lumbar fractures compared to non-active monitoring of blood pressure?

In the setting of thoracolumbar trauma and concomitant SCI, does lumbar drain insertion for CSF diversion with associated intrathecal pressure monitoring improve mortality, neurologic recovery, and complication rate compared to management without lumbar drain insertion?
In the setting of thoracolumbar trauma and concomitant SCI, does the use of empiric MAP augmentation provide superior outcomes to targeted spinal cord perfusion pressure goals as measured by mortality, neurologic recovery, and complication rate?
In the setting of thoracolumbar trauma is the use of MAP augmentation superior to, the same as, or inferior to LD insertion and CSF diversion as measured by mortality, neurologic recovery, and complication rate?
Prophylaxis and treatment of thromboembolic events following traumatic thoracic and lumbar spine fractures
In patients with thoracic and lumbar fractures does routine screening and treatment for deep venous thrombosis prevent pulmonary embolism (or other venous thromboembolism) associated morbidity and mortality compared to expectant treatment and management of thromboembolic symptoms as they develop?
For patients with thoracic and lumbar fractures, is one regimen of VTE prophylaxis superior to others with respect to prevention of PE (or other VTE)-as measure by morbidity and mortality?
In patients with thoracic and lumbar fractures does treatment with [choose your baseline regimen] for documented VTE provides fewer complications [define them] than treatment with [choose your comparison regimens]?
In patients with thoracic and lumbar fractures, who are otherwise candidates for VTE prophylaxis and / or treatment, what clinical and laboratory situations preclude this intervention so as to provide superior mortality, neurologic recovery, and complication rates?
Surgical Approaches and Timing
Operative versus non-operative treatment for traumatic thoracic and lumbar spine fractures
In adult patients with thoracic and lumbar burst fractures does surgical fixation reduce fracture site pain, spinal alignment at 12 months or the need for surgery compared to expectant management?
In adult patients with thoracic and lumbar non-burst fractures does surgical fixation reduce fracture site pain, spinal alignment at 12 months or the need for surgery compared to expectant management?
Timing of surgical intervention for traumatic thoracic and lumbar spine fractures
In adult patients with thoracic and lumbar fractures treated with surgery does surgery <24 hours from injury decrease medical or surgical complications, neurologic outcomes or length of hospital stay compared to surgery >24 hours from injury?
Surgical approaches for the management of traumatic thoracic and lumbar fractures
In adult patients with thoracic and lumbar fractures treated with surgery does posterior surgery only improve spinal alignment at 12 months, medical or surgical complications, or neurologic outcomes compared to anterior or anterior/ posterior surgery?
Specific surgical strategies for traumatic thoracic and lumbar spine fractures
In adult patients with thoracic and lumbar fractures treated with surgery does posterior instrumented fusion with arthrodesis improve spinal alignment at 12 months, medical or surgical complications, or neurologic outcomes compared to posterior instrumented fusion without arthrodesis?
In adult patients with thoracic and lumbar fractures treated with surgery does minimally invasive surgery improve spinal alignment at 12 months, medical or surgical complications, neurologic outcomes or patient reported outcomes compared to open surgery?

4. When do you need the evidence report?

Fri, 08/29/2025

5. What will you do with the evidence report?

The surgical management of these patients often takes place under a variety of circumstances and by various clinicians. The purpose of this topic nomination is to evaluate all available evidence, from which, the Congress of Neurological Surgeons (CNS) will develop a guideline to serve as an educational tool to guide qualified physicians through a series of diagnostic and treatment decisions in an effort to improve the quality and efficiency of care for thoracolumbar trauma patients.

The CNS maintains in-house infrastructure to lead, promote, and support the creation and methodological processes to produce evidence-based guidelines, which are critical tools to confront a rapidly changing health care environment. Using the CNS’s high quality, rigorous methodological process, a multidisciplinary task force will develop recommendations based on the available evidence provided by the Evidence Based Practice Center. Throughout development, the task force will use evidence-based methodologies and strictly adhere to a priori defined criteria as defined by the Institute of Medicine’s (IOM) standards for conducting systematic reviews and clinical evidence-based guidelines.

This topic was initiated by the AANS/CNS Joint Section on Disorders of the Spine and Peripheral Nerves. The CNS also recruited from a variety of institutions and subspecialty disciplines in an effort to have as broad a representation of opinions and expertise as possible. It is CNS’s goal to follow the IOM recommendations to be inclusive and inter-disciplinary when constructing our guidelines and subsequent recommendations. A conscientious effort will also be made to be sure that any conflict of interest is fully disclosed and avoided. Participants who have published extensively in certain areas will be asked to recuse themselves from voting and will be assigned to evaluate evidence in other topics. Every effort will be made to ensure that the guideline is accurate, reliable, and non-biased.

The CNS guidelines attempt to provide essential information for clinicians, globally, helping to improve patient care and outcomes. In addition to developing high quality guidelines, CNS is also committed to dissemination of guidelines in multiple, open access formats, such as publication in peer-reviewed journals, publication on the CNS webpage, webinars, podcasts, app, conference seminars and courses, as well as other promotional efforts.

Optional Information About You

What is your role or perspective? Neurosurgeon

If you are you making a suggestion on behalf of an organization, please state the name of the organization Congress of Neurological Surgeons

May we contact you if we have questions about your nomination? Yes