In Reply: Congress of Neurological Surgeons Systematic Review and Evidence-Based Guidelines on the Evaluation and Treatment of Patients With Thoracolumbar Spine Trauma: Radiological Evaluation.

Abstract

To the Editor: We would like to thank the editor for giving us the opportunity to reply to the letter and comments by Dr Aly.1 Radiological evaluation of thoracolumbar fractures is important for fracture classification and deciding the treatment plan. However, there is no consensus on the imaging protocol followed for the evaluation of these fractures. The primary objective of our systematic review was to determine whether the use of MRI to determine ligamentous integrity, in addition to x-rays and computerized tomography (CT), predicted the need for surgical intervention.2 Two of 2278 studies met the inclusion criteria. Winklhofer et al,3 in their retrospective study of 100 patients with thoracolumbar fractures, found that the Arbeitsgemeinschaft fur Osteosynthesefragen classification changed in 31% and the thoracolumbar injury classification and severity classification changed in 33% of patients after MRI review. With the addition of MRI, the Thoracolumbar Injury Classification and Severity score changed from <5 (indication for conservative treatment) to ≥5 (indication for surgery) in 24% of patients.3 Pizones et al4 conducted a prospective study of 30 patients and found that MRI changed the diagnosis in 40% of patients, fracture classification in 24% of fractures, and treatment plan in 16% of patients. However, both these studies provided only level III evidence and included a heterogeneous patient population. Aly et al,5 in their retrospective review of 244 patients with thoracolumbar fractures, included patients with intact neurological status only and diagnosed posterior ligamentous complex (PLC) injury by ≥2 CT findings (instead of one) and black stripe on MRI (instead of high-signal intensity). They used a more robust methodology compared with the previous 2 studies and found that MRI changed the fracture classification by 10% and Thoracolumbar AOSpine Injury Score (TLAOSIS)–based treatment by 20%. They explained the lower rate of fracture reclassification (10% vs 30% reported previously) by differences in sample size, patient population, and CT/MRI criteria for PLC injury. They also provided detailed fracture reclassification rates after MRI for each fracture subtype and TLAOSIS category which may help guide when to get an MRI in patients with thoracolumbar fracture with no neurological deficit. The study by Aly et al1 is commendable because it adds to the current literature on the topic and also addresses some of the drawbacks of the previous studies. However, there are certain limitations of this study such as retrospective, single-institution design, and lack of external validation. We believe that prospective multicenter studies are required to establish these findings. In addition, radiological studies that focus on the characteristics of PLC injury to differentiate between self-healing injuries and injuries that require surgery would be valuable.