Multidisciplinary Evidence-Based Approach (MEBA) to Thoracolumbar Spine Fractures: A Single-Institution Algorithm

Introduction: Thoracolumbar traumatic vertebral injuries account of more than 50% of spine fractures. Surgical management of thoracolumbar spine fractures remains controversial due to the lack of clinical evidence. The aim of the present work is to illustrate a Multimodal Evidence-Based Approach (MEBA) for the acute management of thoracolumbar fractures. Methods: We reviewed the current literature on classification systems and management of thoracolumbar spine trauma. Based on a single-institution experience, we defined a Multidisciplinary Evidence-Based Approach (MEBA) for thoracolumbar traumatic spine fractures classification and treatment. Results: The MEBA protocol suggests several steps. At the arrival in the emergency department, after cardiocirculatory stabilization and whole spine immobilization, patients are clinically evaluated according to nerve root injury, complete spinal cord injury, incomplete (motor or sensory) spinal cord, or cauda equine syndrome. Injury morphology is defined on computed tomography (CT) scan sequences according to the Denis three-column model. All the patients receive magnetic resonance (MR) imaging sequences in the acute setting to assess integrity of posterior ligamentous complex (PLC) and soft tissue damage. Fractures are then classified with the Thoracolumbar Injury Classification System (TLICS) described by Vaccaro et al in 2004 to define surgical indication. For patients with TLICS score ≤3, conservative management is indicated. A TLICS score ≥ 5 suggests surgical management. In case of TLICS score of 4, surgical indication is less straightforward. In these situations, the risk of acute instability is then evaluated according to Benzel score: patients with five or more points are likely to have overt instability and surgical management is suggested. Conclusions: In our institution, the adoption of MEBA algorithm has facilitated management of thoracolumbar vertebral injuries with easier multidisciplinary discussion, standard imaging investigations, and simplified surgical indication. Our algorithm is based on Class II and III literature evidence and it is intended as a tool to promote consistent decision making throughout a multimodal evaluation of morphologic, biomechanical, and clinical features of thoracolumbar vertebral fractures in our institution.