AOSpine Thoracolumbar Injury Classification Research Articles

Characterization of the influence of spinopelvic parameters on thoracolumbar trauma.

The current Roussouly classification identifies four groups of "normal" sagittal spine morphology, which has greatly expanded the understanding of normal heterogeneity of the spine. While there has been extensive characterization of the influence of spinopelvic parameters on outcomes after degenerative spine surgery, the influence of spinopelvic parameters on thoracolumbar trauma has yet to be described. The goal of this study was to determine if spinopelvic parameters and global spine morphology influence fracture location, fracture morphology, and rate of neurological deficit in the setting of thoracolumbar trauma. Of 2896 patients reviewed in the authors' institutional spine database between January 2014 and April 2020 with an ICD-9/10 diagnosis of thoracolumbar trauma, 514 met the inclusion criteria of acute thoracolumbar fracture on CT and visible femoral heads on sagittal CT. Pelvic incidence (PI) was calculated on sagittal CT. Demographic and clinical data including age, sex, BMI, smoking status, concomitant cervical fracture, mechanism of injury, major fracture location, neurological deficit, AO Spine thoracolumbar injury classification, and management type (operative vs nonoperative) were collected. Patients were stratified into high-PI (≥ 50°) and low-PI (< 50°) groups. Patients with high PI had a lower incidence of fractures in the lower lumbar spine (below L2) compared with patients with low PI (16% vs 8%, p < 0.01). The last lordotic vertebrae were observed between T10 and L4, and of fractures that occurred at these levels, 75% were at the last lordotic vertebrae. Fall from height was the most common cause of neurological deficit, accounting for 47%. Of the patients presenting with a fall from height, AO Spine type B distraction injuries were more common in the high-PI group (41% vs 18%, p = 0.01). Similarly, within the same subgroup, AO Spine type A compression injuries were more common in the low-PI group (73% vs 53%, p = 0.01). Spinopelvic parameters and sagittal balance influence the location and morphology of thoracolumbar fractures. Fractures of the thoracolumbar junction are strongly associated with the inflection point, which is defined by sagittal alignment. While the importance of considering sagittal balance is known for decision-making in degenerative spinal pathology, further studies are required to determine if spinopelvic parameters and sagittal balance should play a role in the decision-making for management of thoracolumbar fractures.

Validation of the AO Spine Thoracolumbar Injury Classification System Treatment Algorithm: Should it be used to Guide Fracture Management?

Retrospective Cohort Study. To determine how historical management of thoracolumbar spine injuries compares to the recently proposed AO Spine Thoracolumbar Injury Classification System treatment algorithm. Classifications of the thoracolumbar spine are not uncommon. The frequent advent of new classifications is typically due to previous classifications being primarily descriptive or unreliable. Thus, AO Spine created a classification with an associated treatment algorithm to guide injury classification and management. Thoracolumbar spine injuries were retrospectively identified from a prospectively collected spine trauma database at a single, urban, academic medical center during the years 2006 to 2021. Each injury was classified and assigned points based on the AO Spine Thoracolumbar Injury Classification System injury severity score. Patients were grouped into scores of 3 or less (preferred initial conservative treatment) and greater than 6 (preferred initial surgical intervention). Either operative or non-operative treatment was considered appropriate for injury severity scores of 4 or 5. A total of 815 patients (TL AOSIS 0-3: 486, TL AOSIS 4-5: 150, TL AOSIS 6+: 179) met inclusion status. Injury severity scores of 0-3 were more likely to undergo non-operative management compared to scores of 4-5 or 6+ (99.0% vs. 74.7% vs. 13.4%, P <0.001). Thus, guideline congruent treatment was 99.0%, 100%, and 86.6%, respectively ( P <0.001). Most injuries determined to be a 4 or 5 were treated non-operatively (74.7%). Based on the treatment algorithm, 97.5% of patients who received operative treatment and 96.1% who received non-operative treatment were managed in accordance with the algorithm. Of the 29 patients who did not receive algorithm congruent treatment, 5 (17.2%) were treated surgically. A retrospective review of thoracolumbar spine injuries at our urban academic medical center identified that patients are historically treated in accordance with the proposed AO Spine Thoracolumbar Injury Classification System treatment algorithm.

The Impact of Vertebroplasty on Sagittal Parameters in Traumatic Thoracic Vertebral Fractures

Objective: It is well-established that vertebroplasty has effects on sagittal parameters due to various pathologies of the spine. Our objective in the study was to reveal the impact of vertebroplasty that was applied to compression fractures due to trauma on sagittal parameters. Material and Method: Twenty patients were included in the study. Scoliosis radiographs were shot preoperatively and at first month during the postoperative period. Spinopelvic parameters of each patient including pelvic incidence (PI), sacral slope (SS), pelvic tilt (PT), lumbar lordosis (LL), thoracic kyphosis (TK), thoracolumbar kyphosis (TLK), cervical lordosis (CL), and sagittal vertical axis (SVA) were assessed. Visual Analogue Scale (VAS) and Oswestry Disability Index (ODI) assessments of the patients were performed as well. Results: Spinopelvic parameter values of the patients were assessed statistically through the analysis of the Paired sample T test before surgery and in the first month during the postoperative period. It was determined that the changes in the PT, SS and LL values of the patients between preoperative and first month postoperative were at the level of p 0.659, p=0.716, p=0.012; and the changes were not significant. It was determined that the changes in the TL, TK, CL, SVA, VAS and ODI values of the patients between preoperative and first month postoperative were at the level of p &lt;0.001and the changes were significant. Conclusion: Vertebroplasty is an efficient technique for relieving pain in thoracic fractures that have a score of 4 and over, based on the thoracolumbar injury classification score and that are type A, based on the AO Spine thoracolumbar injury classification score. Elimination of pain in the acute period is effective in ameliorating the sagittal parameters of patients.

Thoracolumbar spine trauma: a guide for the FRCS examination.

Thoracolumbar spine injuries are commonly seen in trauma settings and have a high risk of causing serious morbidity. There can be controversy when it comes to classifying thoracolumbar injuries within the spinal community, but there remains a need to classify, evaluate and manage thoracolumbar fractures. This article aims to provide a guide on classification of thoracolumbar spine injuries using the AO Spine Thoracolumbar Injury Classification System (AO TLICS).

Is the AO spine thoracolumbar injury classification system reliable and practical? a systematic review

Controversy surrounding the classification of thoracolumbar injuries has given rise to various classification systems over the years, including the most recent AOSpine Thoracolumbar Injury Classification System (ATLICS). This systematic review aims to provide an up-to-date evaluation of the literature, including assessment of a further three studies not analysed in previous reviews. In doing so, this is the first systematic review to include the reliability among non-spine subspecialty professionals and to document the wide variety between reliability across studies, particularly with regard to sub-type classification. Relevant studies were found via a systematic search of PubMed, EBESCO, Cochrane and Web of Science. Data extraction and quality assessment were conducted in line with Cochrane Collaboration guidelines. Twelve articles assessing the reliability of ATLICS were included in this review. The overall inter-observer reliability varied from fair to substantial, but the three additional studies in this review, compared to previous reviews, presented on average only fair reliability. The greatest variation of results was seen in A1 and B3 subtypes. Least reliably classified on average was A4 subtype. This systematic review concludes that ATLICS is reliable for the majority of injuries, but the variability within subtypes suggests the need for further research in assessing the needs of users in order to increase familiarity with ATLICS or perhaps the necessity to include more subtype-specific criteria into the system. Further research is also recommended on the reliability of modifiers, neurological classification and the application of ATLICS in a paediatric context.

Surgical Management of Thoracolumbar Burst Fractures: Surgical Decision-making Using the AOSpine Thoracolumbar Injury Classification Score and Thoracolumbar Injury Classification and Severity Score.

The management of thoracolumbar burst fractures is controversial with no universally accepted treatment algorithm. Several classification and scoring systems have been developed to assist in surgical decision-making. The most widely accepted are the Thoracolumbar Injury Classification and Severity Score (TLICS) and AOSpine Thoracolumbar Injury Classification Score (TL AOSIS) with both systems designed to provide a simple objective scoring criteria to guide the surgical or nonsurgical management of complex injury patterns. When used in the evaluation and treatment of thoracolumbar burst fractures, both of these systems result in safe and consistent patient care. However, there are important differences between the 2 systems, specifically in the evaluation of the complete burst fractures (AOSIS A4) and patients with transient neurological deficits (AOSIS N1). In these circumstances, the AOSpine system may more accurately capture and characterize injury severity, providing the most refined guidance for optimal treatment. With respect to surgical approach, these systems provide a framework for decision-making based on patient neurology and the status of the posterior tension band. Here we propose an operative treatment algorithm based on these fracture characteristics as well as the level of injury.

Epidemiology of Thoracolumbar Spine Injuries associated with Speedboat Travelling without Collision: A Unique Spine Injury Mechanism.

OBJECTIVE:To evaluate the epidemiology of thoracolumbar spine injuries when travelling by speedboat to our coastal tertiary trauma center, and to identify injury patterns and mechanism of injury of these specific injuries and to determine the link of the position when seated on board with the risk of thoracolumbar injury in this type of transportation.MATERIALS AND METHODS:A retrospective review of a consecutive series of 80 patients sustaining thoracolumbar spine injuries after travelling by speed boat was conducted. The enrolled patients were treated at a Level II trauma center over a 2-year period from July 1, 2016 to May 31, 2018. All the victims were unrestrained passengers on board a speedboat travelling at high speed without any safety regulation except a life jacket. Initially, a full evaluation with advance trauma life support protocol on arrival was performed. Plain radiographs, computed thermography or MRI study was obtained individually. Number, level and type of thoracolumbar injury were recorded and reported based on CT scan and Thoracolumbar Injury Classification by AO group. The link to the position when seated on board with the incidence of thoracolumbar spine injury was then analyzed and compared relatively.RESULTS:There were a total of 80 patients in our study, 48 (60%) were men and 32 (40%) were women with a mean age of 47.50 years (Min 20, Max 71). All the spinal fractures were a single level injury. The injury occurred only at the thoracolumbar area, these involved 6 cases (7.5%) of T11 vertebra, 20 cases (25%) of T12 vertebra, 44 cases (55%) of L1 vertebra and 10 cases (12.5%) of L2 vertebra respectively. No cervical or sacral region injury was observed nor other associated injuries such as traumatic brain injury, intra-abdominal organ injury or long bone fracture. A spinal cord/nerve root injury occurred in the lumbar region in 1 patient (1.25%). All of the 80 injuries were type A injury (compression type), classified by AO Spine Thoracolumbar Injury Classification, and included 32 levels (40%) of subtype A1, 18 levels (22.5%) of subtype A2, 8 levels (10%) of subtype A3 and 22 levels (27.5%) of subtype A4. 50 cases (62.5%) were treated non-operatively with bracing while 30 cases (37.5) were treated operatively with computer navigation spinal surgery using pedicle screws and rods construction before the patient was discharged or repatriated. Patients who sat in the front row seat were significantly at higher risk for thoracolumbar spine injury (p &lt; 0.05; odds ratio = 41.83; 95%CI: 15.24, 114.8). No patient who sat at the rear reported having had this kind of injury.CONCLUSIONS:Our data shows a high incidence of this unique compressive type of thoracolumbar spine injury in patients who sit in the front row seat while travelling on board a speed boat.As a result of an increasing recognition of these regional-specific injuries, practitioners who take responsibility for trauma patients on the coastal area should be aware of the high prevalence of these injuries. Proper universal spinal precautions must be followed to optimize treatment outcomes. Current safety regulations including speed limits, proper safety restraining techniques, bracing position on board and marine rescuers should be reviewed or changed to minimize the number of injuries and degree of damage.

Reliability and Validity of the AOSpine Thoracolumbar Injury Classification System: A Systematic Review.

Study Design:Systematic review.Objectives:The AOSpine thoracolumbar injury classification system (ATLICS) is a relatively simple yet comprehensive classification of spine injuries introduced in 2013. This systematic review summarizes the evidence on measurement properties of this new classification, particularly the reliability and validity of the main morphologic injury types with and without inclusion of the subtypes.Methods:A literature search was performed using PubMed and Embase in September 2016. A revised version of the COSMIN checklist was used for evaluation of the quality of studies. Two independent reviewers performed all steps of the review.Results:Nine articles were included in the final review, all of which evaluated the reliability of the ATLICS and had a fair methodological quality. The reliability of the modifiers was unknown. Overall, the quality of evidence for reliability of the morphologic and neurologic classification sections was low. However, there was moderate evidence for poor interobserver reliability of the morphologic classification when all subtypes were included, and moderate evidence for good intraobserver reliability with exclusion of subtypes. The reliability of the morphologic classification was independent of the observer’s experience and cultural background.Conclusions:ATLICS represents the most current system for evaluation of thoracolumbar injuries. Based on this review, further studies with robust methodological quality are needed to evaluate the measurement properties of ATLICS. Shortcomings of the reliability studies are discussed.

Does the Spine Surgeon's Experience Affect Fracture Classification, Assessment of Stability, and Treatment Plan in Thoracolumbar Injuries?

Study Design:Prospective survey-based study.Objectives:The AO Spine thoracolumbar injury classification has been shown to have good reproducibility among clinicians. However, the influence of spine surgeons’ clinical experience on fracture classification, stability assessment, and decision on management based on this classification has not been studied. Furthermore, the usefulness of varying imaging modalities including radiographs, computed tomography (CT) and magnetic resonance imaging (MRI) in the decision process was also studied.Methods:Forty-one spine surgeons from different regions, acquainted with the AOSpine classification system, were provided with 30 thoracolumbar fractures in a 3-step assessment: first radiographs, followed by CT and MRI. Surgeons classified the fracture, evaluated stability, chose management, and identified reasons for any changes. The surgeons were divided into 2 groups based on years of clinical experience as <10 years (n = 12) and >10 years (n = 29).Results:There were no significant differences between the 2 groups in correctly classifying A1, B2, and C type fractures. Surgeons with less experience had more correct diagnosis in classifying A3 (47.2% vs 38.5% in step 1, 73.6% vs 60.3% in step 2 and 77.8% vs 65.5% in step 3), A4 (16.7% vs 24.1% in step 1, 72.9% vs 57.8% in step 2 and 70.8% vs 56.0% in step3) and B1 injuries (31.9% vs 20.7% in step 1, 41.7% vs 36.8% in step 2 and 38.9% vs 33.9% in step 3). In the assessment of fracture stability and decision on treatment, the less and more experienced surgeons performed equally. The selection of a particular treatment plan varied in all subtypes except in A1 and C type injuries.Conclusion:Surgeons’ experience did not significantly affect overall fracture classification, evaluating stability and planning the treatment. Surgeons with less experience had a higher percentage of correct classification in A3 and A4 injuries. Despite variations between them in classification, the assessment of overall stability and management decisions were similar between the 2 groups.

The AOSpine thoracolumbar spine injury classification system: A reliability and agreement study.

Aim:Recently, AOSpine trauma knowledge forum proposed the AOSpine thoracolumbar injury classification (AOSTLIC) system and suggested that it was reliable. However, reliability data from additional institutions for the AOSTLIC system are not available. This study was to examine the reliability of the AOSTLIC system in patients with thoracolumbar (TL) fractures.Materials and Methods:Between August 2009 and June 2012, 56 patients with 74 levels traumatic TL spinal injuries were recruited. Two classifiers, consisting of two spine surgeons, assessed clinical and imaging data. Initially, one surgeon reviewed the data in order to classify and calculate injury severity score according to the AOSTSIC system. This process was repeated on a 5-week interval by another surgeon. Then we analyzed data for intra-observer and inter-observer reliability using the kappa statistic (k). Finally, validity was assessed using the known-groups comparison.Results:The mean age of patients was 59.5 ± 11.5 years. The κ values for the AOSTSIC system for intra-observer and inter-observer reliability ranged from 0.83 to 0.89, indicating nearly perfect agreement agreements. Known-groups analysis showed satisfactory results. The AOSTSIC system discriminated well between sub-groups of patients who differed in Oswestry disability index.Conclusion:The findings showed that the morphologic classification in AOSTSIC system appears to be reliable and reproducible classification.

Thoracolumbar Injury Severity Scoring Systems: A Review and Rationale for a New System Based on the AOSpine Thoracolumbar Injury Classification System

Numerous classification systems have been developed over the years to describe thoracolumbar injuries, each with their own benefits and limitations. None of these systems have been accepted however, as a universal, comprehensive system to classify these injuries. The AOSpine Thoracolumbar Injury Classification System has recently been developed in order to overcome some of the limitations of previous systems. An injury severity scoring system based on this system would be beneficial to clinicians when treating these complex injuries. This paper will review thoracolumbar injury classification systems, and describe the need for a new severity scoring system based on the AOSpine Thoracolumbar Injury Classification System.

FRACTURES, DISLOCATIONS, AND FRACTURE-DISLOCATIONS OF THE SPINE

Over 1000 patients with traumatic paraplegia or tetraplegia and many more with fractures and dislocations of the spine without damage to the central nervous system have been observed and treated at the Sheffield Spinal Injuries Centre. The vertebral lesions with or without injury to the spinal cord or nerve roots have been classified on the basis of the clinical and roentgenographic findings into five groups: 1. Pure flexion which causes a wedge fracture which is stable. 2. Flexion-rotation which produces an unstable fracture-dislocation with rupture of tue posterior ligament complex, separation of the spinous processes, a slice fracture near the upper border of the lower vertebra, and dislocation of the lower articular processes of the upper vertebra. 3. Extension which causes rupture of the intervertebral disc and the anterior common ligament along with avulsion of a small bone fragment from the anterior border of the dislocated vertebra. The dislocation almost always reduces spontaneously and is stable in flexion. 4. Vertebral compression which results in a fracture of the end plate as the nucleus of the intervertebral disc is forced into the vertebral body and causes it to burst with outward displacement of fragments of the body. Since the ligaments remain intact this comminuted fracture is stable. 5. Shearing which results in forward displacement of the whole vertebra and an unstable fracture of the articular processes or pedicles. Accurate diagnosis and prognosis of the neurological lesion depend on knowledge of the anatomy of the spinal cord and nerve roots, a careful neurological examination shortly after the original injury and repeated examinations thereafter, comparison of the level of spinal injury with the level of paraplegia or tetraplegia, differentiation between paraplegia and tetraplegia of immediate and delayed onset, and the appropriate therapy of the various types and levels of lesion. Simple wedge fractures were treated by bed rest for two to three weeks, mobilization of the back, and ambulation with a back support. Rotational fracture-dislocations in the cervical, thoracolumbar, or lumbar spine were almost invariably associated with tetraplegia or paraplegia. Cervical fracture-dislocations with or without tetraplegia were treated by skull-caliper traction. Thoracolumbar or lumbar fracture-dislocations without paraplegia were treated on a plaster bed for twelve weeks followed by a back support for a few weeks. The thoracolumbar fracture-dislocations with paraplegia were never treated by the plaster bed method but rather by open reduction of the dislocation, and maintenance of the reduction by internal fixation with double plating of the spinous processes. Spontaneous fusion was sufficiently advanced after eight to twelve weeks to get the patient out of bed. If the plates cut out of the bone after twelve weeks, they were removed. Patients with loss of sensation resulting from paraplegia or tetraplegia were turned every two hours to avoid pressure sores. Extension dislocations in the cervical spine, if they had reduced spontaneously, were fitted with a collar to hold the head and neck in sligh flexion for a period of eight to twelve weeks. For dislocations in this region which had not reduced spontaneously, manual manipulation under endotracheal anesthesia was employed. Reduction was maintained by skull tongs applied prior to manipulation. If after four weeks there was roentgenographic evidence of new bone indicating Spontaneous fusion, traction was continued for four to six weeks more followed by a neck collar for an additional six weeks. If new bone did not appear on the roentgenograms after four weeks, anterior fusion was performed followed by skull traction for an additional eight weeks. Vertical compression burst fractures in the cervical spine were treated by skull traction for six weeks followed by a neck collar. In the lumbar spine, burst fractures without paraplegia were treated by immobilization in a plaster bed for eight to twelve weeks followed by back support. The plaster bed was never used in burst fractures with paraplegia. Shear fractures were always associated with complete paraplegia. These fractures were usually stable and did not require operative reduction except when the displacement was great.