AOSpine Thoracolumbar Spine Injury Classification Research Articles

The Influence of Spine Surgeons' Experience on the Classification and Intraobserver Reliability of the Novel AOSpine Thoracolumbar Spine Injury Classification System-An International Study.

International validation study. To investigate the influence of the spine surgeons' level of experience on the intraobserver reliability of the novel AOSpine Thoracolumbar Spine Injury Classification system, and the appropriate classification according to this system. Wide variability has been demonstrated for intraobserver reliability of the AOSpine classification system. The spine surgeons' level of experience may play a crucial role in the appropriate classification of thoracolumbar fractures, and the degree of reproducibility of the same observer on separate occasions. However, this has not been previously investigated. After a training on the classification system, high quality CT images together with clinical data from 25 patients with thoracolumbar fractures were independently assessed by 100 spine surgeons from across the world on 2 different occasions, 1 month apart from each other. The spine surgeons were allocated to a subgroup, according to their years of experience. Intraobserver reliability was calculated for each individual surgeon and for each subgroup, using the Kappa statistics (κ). Descriptive statistics was used to describe any differences between the subgroups. Analysis of any misclassifications was performed by calculating sensitivity and specificity estimates. Almost all surgeons demonstrated at least moderate intraobserver reliability. All surgeon subgroups demonstrated substantial reliability (κ = 0.67-0.69) for fracture subtype grading, and almost all subgroups demonstrated excellent reliability (κ = 0.79-0.83) for fracture morphology type regardless of subtype identified. In general, the fractures were most frequently misclassified by the most experienced surgeons. No major differences were observed among the subgroups when comparing the sensitivity and specificity rates. This international study demonstrated that the spine surgeons' level of experience does not substantially influence the classification and intraobserver reliability of the recently described AOSpine Thoracolumbar Spine Injury Classification System. 4.

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.

Is there a regional difference in morphology interpretation of A3 and A4 fractures among different cultures?

OBJECT The aim of this study was to determine if the ability of a surgeon to correctly classify A3 (burst fractures with a single endplate involved) and A4 (burst fractures with both endplates involved) fractures is affected by either the region or the experience of the surgeon. METHODS A survey was sent to 100 AOSpine members from all 6 AO regions of the world (North America, South America, Europe, Africa, Asia, and the Middle East) who had no prior knowledge of the new AOSpine Thoracolumbar Spine Injury Classification System. Respondents were asked to classify 25 cases, including 6 thoracolumbar burst fractures (A3 or A4). This study focuses on the effect of region and experience on surgeons' ability to properly classify these 2 controversial fracture variants. RESULTS All 100 surveyed surgeons completed the survey, and no significant regional (p > 0.50) or experiential (p > 0.21) variability in the ability to correctly classify burst fractures was identified; however, surgeons from all regions and with all levels of experience were more likely to correctly classify A3 fractures than A4 fractures (p < 0.01). Further analysis demonstrated that no region predisposed surgeons to increasing their assessment of severity of burst fractures. CONCLUSIONS A3 and A4 fractures are the most difficult 2 fractures to correctly classify, but this is not affected by the region or experience of the surgeon; therefore, regional variations in the treatment of thoracolumbar burst fractures (A3 and A4) is not due to differing radiographic interpretation of the fractures.

The Thoracolumbar AOSpine Injury Score.

Study Design Survey of 100 worldwide spine surgeons. Objective To develop a spine injury score for the AOSpine Thoracolumbar Spine Injury Classification System. Methods Each respondent was asked to numerically grade the severity of each variable of the AOSpine Thoracolumbar Spine Injury Classification System. Using the results, as well as limited input from the AOSpine Trauma Knowledge Forum, the Thoracolumbar AOSpine Injury Score was developed. Results Beginning with 1 point for A1, groups A, B, and C were consecutively awarded an additional point (A1, 1 point; A2, 2 points; A3, 3 points); however, because of a significant increase in the severity between A3 and A4 and because the severity of A4 and B1 was similar, both A4 and B1 were awarded 5 points. An uneven stepwise increase in severity moving from N0 to N4, with a substantial increase in severity between N2 (nerve root injury with radicular symptoms) and N3 (incomplete spinal cord injury) injuries, was identified. Hence, each grade of neurologic injury was progressively given an additional point starting with 0 points for N0, and the substantial difference in severity between N2 and N3 injuries was recognized by elevating N3 to 4 points. Finally, 1 point was awarded to the M1 modifier (indeterminate posterolateral ligamentous complex injury). Conclusion The Thoracolumbar AOSpine Injury Score is an easy-to-use, data-driven metric that will allow for the development of a surgical algorithm to accompany the AOSpine Thoracolumbar Spine Injury Classification System.

Vertebral Bone Marrow Edema (VBME) in Conservatively Treated Acute Vertebral Compression Fractures (VCFs): Evolution and Clinical Correlations.

Prospective observational study. To assess (1) the evolution of vertebral bone marrow edema (VBME) in patients with A1 vertebral compression fractures (VCFs) conservatively treated and (2) the relationship between VBME and clinical symptoms, evaluated as Visual Analogue Scale (VAS) back pain and Oswestry Disability Index (ODI). VBME is a marker of acute-subacute vertebral fractures. Little is known about the evolution of VBME in conservatively managed VCFs, as well as its clinical meaning. 82 thoracic or lumbar VCFs (21 post-traumatic; 61 osteoporotic VCFs), type A1 according to the AOSpine thoracolumbar spine injury classification system, in 80 patients were treated with C35 hyperextension brace for 3 months, bed rest for the first 25 days. Patients with osteoporotic fractures also received antiresorptive therapy and vitamin D supplementation. At 0 (T0), 30 (T1), 60 (T2), and 90 (T3) days, patients underwent magnetic resonance imaging evaluation and clinical evaluation, using VAS for pain and ODI.The paired t test was used to compare changes within groups at each follow-up versus baseline. The unpaired t test after ANOVA (analysis of variance) was used to compare the 2 groups at each follow-up.The association between VBME area, VAS score, and ODI score was analyzed by the Pearson correlation test. The tests were 2-tailed with a confidence level of 5%. A significant VBME mean area, VAS, and ODI scores reduction was recorded at 60 and 90-days follow-ups versus baseline. A positive correlation between VBME reduction and clinical symptoms improvement (VAS and ODI scores improvement) was found in both traumatic and osteoporotic VCFs. In benign A1 VCFs conservatively managed, VBME slowly decreases in the first 3 months of magnetic resonance imaging follow-up. This VBME reduction is related to clinical symptoms improvement. 4.

The surgical algorithm for the AOSpine thoracolumbar spine injury classification system.

The goal of the current study is to establish a surgical algorithm to accompany the AOSpine thoracolumbar spine injury classification system. A survey was sent to AOSpine members from the six AO regions of the world, and surgeons were asked if a patient should undergo an initial trial of conservative management or if surgical management was warranted. The survey consisted of controversial injury patterns. Using the results of the survey, a surgical algorithm was developed. The AOSpine Trauma Knowledge forum defined that the injuries in which less than 30% of surgeons would recommend surgical intervention should undergo a trial of non-operative care, and injuries in which 70% of surgeons would recommend surgery should undergo surgical intervention. Using these thresholds, it was determined that injuries with a thoracolumbar AOSpine injury score (TL AOSIS) of three or less should undergo a trial of conservative treatment, and injuries with a TL AOSIS of more than five should undergo surgical intervention. Operative or non-operative treatment is acceptable for injuries with a TL AOSIS of four or five. The current algorithm uses a meaningful injury classification and worldwide surgeon input to determine the initial treatment recommendation for thoracolumbar injuries. This allows for a globally accepted surgical algorithm for the treatment of thoracolumbar trauma.

Establishing the Injury Severity of Thoracolumbar Trauma: Confirmation of the Hierarchical Structure of the AOSpine Thoracolumbar Spine Injury Classification System

Introduction The AOSpine Thoracolumbar Spine Injury Classification System was recently published and combines elements of both the Magerl system and the Thoracolumbar Injury Classification System (TLICS); however, the injury severity of each fracture has yet to be established. The objective of this study is to develop a validated regional and global injury severity scoring system for thoracolumbar trauma. Material and Methods A survey was sent to 100 AOSpine members from all six AO regions of the world (North America, South America, Europe, Africa, Asia, and the Middle East). Each respondent was asked to numerically grade the severity of each variable of the AOSpine Thoracolumbar Spine Injury Classification System including the morphology, neurologic grade, and patient-specific modifiers. A grade of zero was considered to be not severe at all, and a grade of 100 was the most severe injury possible. Results A total of 74 AOSpine surgeons from all six AO regions of the world numerically graded the severity of each variable of the AOSpine Thoracolumbar Spine Injury Classification System to establish the injury severity score. The reported fracture severity increased significantly ( p &lt; 0.0001) as the subtypes of fracture type A and type B increased, and a significant difference ( p &lt; 0.0001) in severity was established for burst fractures with involvement of two versus one end plates. Finally, no regional or experiential difference in severity or classification was identified. Conclusion Development of a globally applicable injury severity scoring system for thoracolumbar trauma is possible. This study demonstrates no regional or experiential difference in perceived severity or thoracolumbar spine trauma. The AOSpine Thoracolumbar Spine Injury Classification System provides a logical approach to assessing these injuries and enables rational strategies for treatment.

Reliability Analysis of the AOSpine thoracolumbar Spine Injury Classification System by a Worldwide Group of Naive Spinal Surgeons

Introduction The AOSpine Thoracolumbar Spine Injury Classification System was recently published and combines elements of both the Magerl system and the Thoracolumbar Injury Classification System (TLICS); however, the worldwide applicability has yet to be established. Material and Methods A previously described classification system of thoracolumbar injuries which consists of a morphologic classification of the fracture, a grading system for the neurologic status and relevant patient-specific modifiers was applied to 25 cases by 100 spinal surgeons from across the world twice independently, in grading sessions 1 month apart. The results were analyzed for classification reliability using the Kappa coefficient (κ). Results The overall Kappa coefficient for all cases was 0.56 which represents moderate reliability. Kappa values describing interobserver agreement were 0.80 for type A injuries, 0.68 for type B injuries, and 0.72 for type C injuries, all representing substantial reliability. The lowest level of agreement for specific subtypes was for fracture subtype A4 (Kappa = 0.19). Intraobserver analysis demonstrated overall average Kappa statistic for subtype grading of 0.68 also representing substantial reproducibility. Conclusion In a worldwide sample of spinal surgeons without previous exposure to the recently described AOSpine Thoracolumbar Spine Injury Classification System, we demonstrated moderate interobserver and substantial intraobserver reliability. These results suggest that most spine surgeons can reliably apply this system to spine trauma patients as or more reliably than previously described systems.

Is there a Regional Difference in Morphology Interpretation of A3/A4 Fractures among Different Cultures?

Introduction The AOSpine Thoracolumbar Spine Injury Classification System was recently published, but before establishing a treatment algorithm to accompany the classification, further investigation on the cause of current regional treatment variations is required. The objective of this study is to determine if the ability of a surgeon to correctly classify A3 (burst fractures with a single endplate involved) and A4 (burst fractures with both end plates involved) fractures were affected by either the region or the experience of the surgeon. Material and Methods A survey was sent to 100 AOSpine members from all six AO regions of the world (North America, South America, Europe, Africa, Asia, and the Middle East) that had no prior knowledge of the new AOSpine Thoracolumbar Spine Injury Classification System. Respondents were asked to classify 25 cases, including 6 thoracolumbar burst fractures (A3 or A4). The current analysis focuses on the effect of region and experience on surgeons' ability to properly classify these controversial fractures. Results All 100 surveyed surgeons completed the survey, and no significant regional variability in the ability to correctly classify burst fractures was identified ( p &gt; 0.50). Further analysis demonstrated that no region predisposed surgeons increasing the severity of burst fractures. Similarly, experience did not affect surgeons' ability to correctly classify burst fracture ( p &gt; 0.21). Conclusion Regional variation in the treatment of thoracolumbar burst fractures (A3 and A4) is not because of the differing radiographic interpretation of the fractures.

Establishing the injury severity of thoracolumbar trauma: confirmation of the hierarchical structure of the AOSpine Thoracolumbar Spine Injury Classification System.

Survey of spine surgeons. To develop a validated regional and global injury severity scoring system for thoracolumbar trauma. The AOSpine Thoracolumbar Spine Injury Classification System was recently published and combines elements of both the Magerl system and the Thoracolumbar Injury Classification System; however, the injury severity of each fracture has yet to be established. A survey was sent to 100 AOSpine members from all 6 AO regions of the world (North America, South America, Europe, Africa, Asia, and the Middle East). Each respondent was asked to numerically grade the severity of each variable of the AOSpine Thoracolumbar Spine Injury Classification System including the morphology, neurological grade, and patient specific modifiers. A grade of zero was considered to be not severe at all, and a grade of 100 was the most severe injury possible. Seventy-four AOSpine surgeons from all 6 AO regions of the world numerically graded the severity of each variable of the AOSpine Thoracolumbar Spine Injury Classification System to establish the injury severity score. The reported fracture severity increased significantly (P < 0.0001) as the subtypes of fracture type A and type B increased, and a significant difference (P < 0.0001) in severity was established for burst fractures with involvement of 2 versus 1 endplates. Finally, no regional or experiential difference in severity or classification was identified. Development of a globally applicable injury severity scoring system for thoracolumbar trauma is possible. This study demonstrates no regional or experiential difference in perceived severity or thoracolumbar spine trauma. The AOSpine Thoracolumbar Spine Injury Classification System provides a logical approach to assessing these injuries and enables rational strategies for treatment. 4.

Can a Thoracolumbar Injury Severity Score be Uniformly Applied from T1 to L5 or Are Modifications Necessary?

Study Design Literature review. Objective The aim of this review is to highlight challenges in the development of a comprehensive surgical algorithm to accompany the AOSpine Thoracolumbar Spine Injury Classification System. Methods A narrative review of the relevant spine trauma literature was undertaken with input from the multidisciplinary AOSpine International Trauma Knowledge Forum. Results The transitional areas of the spine, in particular the cervicothoracic junction, pose unique challenges. The upper thoracic vertebrae have a transitional anatomy with elements similar to the subaxial cervical spine. When treating these fractures, the surgeon must be aware of the instability due to the junctional location of these fractures. Additionally, although the narrow spinal canal makes neurologic injuries common, the small pedicles and the inability to perform an anterior exposure make decompression surgery challenging. Similarly, low lumbar fractures and fractures at the lumbosacral junction cannot always be treated in the same manner as fractures in the more cephalad thoracolumbar spine. Although the unique biomechanical environment of the low lumbar spine makes a progressive kyphotic deformity less likely because of the substantial lordosis normally present in the low lumbar spine, even a fracture leading to a neutral alignment may dramatically alter the patient's sagittal balance. Conclusion Although the new AOSpine Thoracolumbar Spine Injury Classification System was designed to be a comprehensive thoracolumbar classification, fractures at the cervicothoracic junction and the lumbosacral junction have properties unique to these junctional locations. The specific characteristics of injuries in these regions may alter the most appropriate treatment, and so surgeons must use clinical judgment to determine the optimal treatment of these complex fractures.

A Worldwide Analysis of the Reliability and Perceived Importance of an Injury to the Posterior Ligamentous Complex in AO Type A Fractures.

Study Design Survey of spine surgeons. Objective To determine the reliability with which international spine surgeons identify a posterior ligamentous complex (PLC) injury in a patient with a compression-type vertebral body fracture (type A). Methods A survey was sent to all AOSpine members from the six AO regions of the world. The survey consisted of 10 cases of type A fractures (2 subtype A1, 2 subtype A2, 3 subtype A3, and 3 subtype A4 fractures) with appropriate imaging (plain radiographs, computed tomography, and/or magnetic resonance imaging), and the respondent was asked to identify fractures with a PLC disruption, as well as to indicate if the integrity of the PLC would affect their treatment recommendation. Results Five hundred twenty-nine spine surgeons from all six AO regions of the world completed the survey. The overall interobserver reliability in determining the integrity of the PLC was slight (kappa = 0.11). No substantial regional or experiential difference was identified in determining PLC integrity or its absence; however, a regional difference was identified (p < 0.001) in how PLC integrity influenced the treatment of type A fractures. Conclusion The results of this survey indicate that there is only slight international reliability in determining the integrity of the PLC in type A fractures. Although the biomechanical importance of the PLC is not in doubt, the inability to reliably determine the integrity of the PLC may limit the utility of the M1 modifier in the AOSpine Thoracolumbar Spine Injury Classification System.

Reliability analysis of the AOSpine thoracolumbar spine injury classification system by a worldwide group of naïve spinal surgeons.

The aims of this study were (1) to demonstrate the AOSpine thoracolumbar spine injury classification system can be reliably applied by an international group of surgeons and (2) to delineate those injury types which are difficult for spine surgeons to classify reliably. A previously described classification system of thoracolumbar injuries which consists of a morphologic classification of the fracture, a grading system for the neurologic status and relevant patient-specific modifiers was applied to 25 cases by 100 spinal surgeons from across the world twice independently, in grading sessions 1 month apart. The results were analyzed for classification reliability using the Kappa coefficient (κ). The overall Kappa coefficient for all cases was 0.56, which represents moderate reliability. Kappa values describing interobserver agreement were 0.80 for type A injuries, 0.68 for type B injuries and 0.72 for type C injuries, all representing substantial reliability. The lowest level of agreement for specific subtypes was for fracture subtype A4 (Kappa = 0.19). Intraobserver analysis demonstrated overall average Kappa statistic for subtype grading of 0.68 also representing substantial reproducibility. In a worldwide sample of spinal surgeons without previous exposure to the recently described AOSpine Thoracolumbar Spine Injury Classification System, we demonstrated moderate interobserver and substantial intraobserver reliability. These results suggest that most spine surgeons can reliably apply this system to spine trauma patients as or more reliably than previously described systems.

An independent interobserver reliability and intraobserver reproducibility evaluation of the new AOSpine Thoracolumbar Spine Injury Classification System.

Agreement study. To perform an independent interobserver and intraobserver agreement evaluation of the new AOSpine Thoracolumbar Spine Injury Classification System. The new AOSpine Thoracolumbar Spine Injury Classification System was recently published. It showed substantial reliability and reproducibility among the surgeons who developed it; however, an independent evaluation has not been performed. Anteroposterior and lateral radiographs, and computed tomographic scans of 70 patients with acute traumatic thoracolumbar injuries were selected and classified using the morphological grading of the new AOSpine Thoracolumbar Spine Injury Classification System by 6 evaluators (3 spine surgeons and 3 orthopedic surgery residents). After a 6-week interval, the 70 cases were presented in a random sequence to the same evaluators for repeat evaluation. The Kappa coefficient (κ) was used to determine the interobserver and intraobserver agreement. The interobserver reliability was substantial when considering the fracture type (A, B, or C), with a κ= 0.62 (0.57-0.66). The interobserver agreement when considering the subtypes was moderate; κ= 0.55 (0.52-0.57). The intraobserver reproducibility was also substantial, with 85.95% full intraobserver reproducibility considering the fracture type, with κ= 0.77 (0.72-0.83), and was also substantial when considering subtypes with 75.71% full agreement and κ= 0.71 (0.67-0.76). No significant differences were observed between spine surgeons and orthopedic residents in the overall interobserver reliability and intraobserver reproducibility, or in the inter- and intraobserver agreement of specific A, B, or C types of injuries. This classification allows adequate agreement among different observers and by the same observer on separate occasions. Future prospective studies should evaluate whether this classification improves clinical decision making.

Percutaneous dorsal instrumentation for thoracolumbar extension-distraction fractures in patients with ankylosing spinal disorders: a case series

Background contextThoracolumbar extension-distraction fractures are rare injuries mainly restricted to patients suffering from ankylosing spinal disorders. The most appropriate surgical treatment of these unstable spinal injuries remains to be clarified. PurposeTo report on a cohort of 10 patients treated with closed reduction and percutaneous dorsal instrumentation. Study designCase series. Patient sampleTen consecutive patients with ankylosing spinal disorders and thoracolumbar extension-distraction fractures (Type B3 according to the AOSpine Thoracolumbar Spine Injury Classification System). Outcome measuresPostoperative reduction, alignment, and implant position were analyzed by computed tomography. Loss of reduction was assessed on lateral radiographs by using the Cobb technique. Ambulation ability and pain were assessed at follow-up. MethodsMinimally invasive dorsal percutaneous instrumentation was performed in 10 consecutive patients (3 men, 7 women) with a mean age of 81.5 (range 72–90) years between May 2010 and December 2012. The mean postoperative follow-up time was 7.9 (range 4–28) months. ResultsAll 10 patients were treated with closed reduction and dorsal instrumentation; in no case was conversion to an open approach required. The mean operation time was 60.2 (range 32–135) minutes. None of the patients presented neurologic deficits. Cement-augmented screws were implanted in two cases. Sufficient radiographic correction was achieved in all patients; no case of loss of reduction was noted at final follow-up. In one case, complete hardware removal was performed 9 months after the index operation because of persistent back pain at the level of the implant. One patient died of postoperative inferior vena cava obstruction. At discharge, all patients were able to ambulate without the need for crutches or opioid analgesics. At final follow-up, all patients ambulated with full weight bearing; four patients reported persistent back pain. ConclusionsIn fragile patients with ankylosing spinal disorders and thoracolumbar extension-distraction fractures, closed reduction and percutaneous dorsal instrumentation provide a satisfying midterm functional outcome while minimizing perioperative risks compared with conventional dorsoventral procedures.

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.