Integrity Of Posterior Ligamentous Complex Research Articles

The Influence of Comminution and Posterior Ligamentous Complex Integrity on Treatment Decision Making in Thoracolumbar Burst Fractures Without Neurologic Deficit?

A prospective study. to evaluate the impact of vertebral body comminution and Posterior Ligamentous Complex (PLC) integrity on the treatment recommendations of thoracolumbar fractures among an expert panel of 22 spine surgeons. A review of 183 prospectively collected thoracolumbar burst fracture computed tomography (CT) scans by an expert panel of 22 trauma spine surgeons to assess vertebral body comminution and PLC integrity. This study is a sub-study of a prospective observational study of thoracolumbar burst fractures (Spine TL A3/A4). Each expert was asked to grade the degree of comminution and certainty about the PLC disruption from 0 to 100, with 0 representing the intact vertebral body or intact PLC and 100 representing complete comminution or complete PLC disruption, respectively. ≥45% comminution had a 74% chance of having surgery recommended, while <25% comminution had an 86.3% chance of non-surgical treatment. A comminution from 25 to 45% had a 57% chance of non-surgical management. ≥55% PLC injury certainity had a 97% chance of having surgery, and ≥45-55% PLC injury certainty had a 65%. <20% PLC injury had a 64% chance of having non-operative treatment. A 20 to 45% PLC injury certainity had a 56% chance of non-surgical management. There was fair inter-rater agreement on the degree of comminution (ICC .57 [95% CI 0.52-.63]) and the PLC integrity (ICC .42 [95% CI 0.37-.48]). The study concludes that vetebral comminution and PLC integrity are major dterminant in decision making of thoracolumbar fractures without neurological deficit. However, more objective, reliable, and accurate methods of assessment of these variables are warranted.

An Integrated Voice Recognition and Natural Language Processing Platform to Automatically Extract Thoracolumbar Injury Classification Score Features From Radiology Reports

Many predictive models for estimating clinical outcomes after spine surgery have been reported in the literature. However, implementation of predictive scores in practice is limited by the time-intensive nature of manually abstracting relevant predictors. In this study, we designed natural language processing (NLP) algorithms to automate data abstraction for the thoracolumbar injury classification score (TLICS). We retrieved the radiology reports of all Mayo Clinic patients with an International Classification of Diseases, 9th or 10th revision, code corresponding to a fracture of the thoracolumbar spine between January 2005 and October 2020. Annotated data were used to train an N-gram NLP model using machine learning methods, including random forest, stepwise linear discriminant analysis, k-nearest neighbors, and penalized logistic regression models. A total of 1085 spine radiology reports were included in our analysis. Our dataset included 483 compression, 401 burst, 103 translational/rotational, and 98 distraction fractures. A total of 103 reports had documented an injury of the posterior ligamentous complex. The overall accuracy of the random forest model for fracture morphology feature detection was 76.96% versus 65.90% in the stepwise linear discriminant analysis, 50.69% in the k-nearest neighbors, and 62.67% in the penalized logistic regression. The overall accuracy to detect posterior ligamentous complex integrity was highest in the random forest model at 83.41%. Our random forest model was implemented in the backend of a web application in which users can dictate reports and have TLICS features automatically extracted. We have developed a machine learning NLP model for extracting TLICS features from radiology reports, which we deployed in a web application that can be integrated into clinical practice.

Automated prediction of the Thoracolumbar Injury Classification and Severity Score from CT using a novel deep learning algorithm

Damage to the thoracolumbar spine can confer significant morbidity and mortality. The Thoracolumbar Injury Classification and Severity Score (TLICS) is used to categorize injuries and determine patients at risk of spinal instability for whom surgical intervention is warranted. However, calculating this score can constitute a bottleneck in triaging and treating patients, as it relies on multiple imaging studies and a neurological examination. Therefore, the authors sought to develop and validate a deep learning model that can automatically categorize vertebral morphology and determine posterior ligamentous complex (PLC) integrity, two critical features of TLICS, using only CT scans. All patients who underwent neurosurgical consultation for traumatic spine injury or degenerative pathology resulting in spine injury at a single tertiary center from January 2018 to December 2019 were retrospectively evaluated for inclusion. The morphology of injury and integrity of the PLC were categorized on CT scans. A state-of-the-art object detection region-based convolutional neural network (R-CNN), Faster R-CNN, was leveraged to predict both vertebral locations and the corresponding TLICS. The network was trained with patient CT scans, manually labeled vertebral bounding boxes, TLICS morphology, and PLC annotations, thus allowing the model to output the location of vertebrae, categorize their morphology, and determine the status of PLC integrity. A total of 111 patients were included (mean ± SD age 62 ± 20 years) with a total of 129 separate injury classifications. Vertebral localization and PLC integrity classification achieved Dice scores of 0.92 and 0.88, respectively. Binary classification between noninjured and injured morphological scores demonstrated 95.1% accuracy. TLICS morphology accuracy, the true positive rate, and positive injury mismatch classification rate were 86.3%, 76.2%, and 22.7%, respectively. Classification accuracy between no injury and suspected PLC injury was 86.8%, while true positive, false negative, and false positive rates were 90.0%, 10.0%, and 21.8%, respectively. In this study, the authors demonstrate a novel deep learning method to automatically predict injury morphology and PLC disruption with high accuracy. This model may streamline and improve diagnostic decision support for patients with thoracolumbar spinal trauma.

Are "Unstable" Burst Fractures Really Unstable?

ObjectiveThe stability is an important factor to decide the treatment plan in thoracolumbar burst fracture patients. Patients with an unstable burst fracture generally need operative management. Decrease in vertebral body height, local kyphosis, involvement of posterior column, and/or canal compromise are considered important factors to determine the treatment plan. On the other hand, in thoracolumbar injury classification system (TLICS), surgery is recommended in patients with TLICS of more than 5 points. The purpose of this study was to apply the TLICS score in patients with thoracolumbar burst fractures and to distinguish the differences of treatment plan on burst fracture. MethodsAll patients, diagnosed as a thoracolumbar burst fracture between January 2006 and February 2019 were included in this study. Unstable thoracolumbar burst fracture was defined as burst fracture with neurologic deficit, three-column injury, kyphosis over 30 degrees, decrease of anterior body height over 40 percent and canal comprise more than 50%. TLICS score was measured with morphology, neurological involvement and posterior ligamentous complex integrity. The existence of instability was compared with TLICS score. ResultsTotal 233 patients (131 men, 102 women) were included in this study. In Denis classification, 51 patients (21.9%) diagnosed as stable burst fracture while 182 patients (78.1%) had unstable burst fracture. According to TLICS, 72 patients (30.9%) scored less than 4, while 161 patients (69.1%) scored 4 or more. All the patients with stable burst fracture scored 2 in TLICS. Twenty-one patients (9.0) scored 2 in TLICS but diagnosed as unstable burst fracture. Thirteen patients had over 40% of vertebra body compression, four patients had more than 50% of canal compromise, three patients had both body compression over 40% and kyphosis over 30 degrees, one patients had both body compression and canal compromise. Fifteen patients presented kyphosis over 30 degrees, and three (20%) of them scored 2 in TLICS. Seventy-three patients presented vertebral body compression over 40% and 17 (23.3%) of them scored 2 in TLICS. Fifty-three patients presented spinal canal compromise more than 50%, and five (9.4%) of them scored 2 in TLICS. ConclusionAlthough the instability of thoracolumbar burst fracture was regarded as a critical factor for operability, therapeutic strategies by TLICS do not exactly match with the concept of instability. According to the concept of TLICS, it should be reconsidered whether the unstable burst fracture truly unstable to do operation.

Load-Sharing Classification Score as Supplemental Grading System in the Decision-Making Process for Patients With Thoracolumbar Injury Classification and Severity 4.

Patients with Thoracolumbar Injury Classification and Severity (TLICS) score of 4 fall into a gray zone between surgical and conservative management. The integrity of posterior ligamentous complex (PLC) evaluated by magnetic resonance imaging (MRI) contributes to surgical decision-making. Load-sharing classification (LSC) may provide a modifier to further guide decision-making in these patients. To evaluate associations between LSC score and MRI acquisition, compromise of PLC on MRI, and surgical intervention in TLICS 4 patients. A cohort of 111 neurologically intact patients with isolated thoracolumbar burst fracture with TLICS 4 was evaluated. LSC score was determined based on degree of comminution (1-3), apposition (1-3), and kyphosis (1-3), total composite score of 3 to 9. Overall, 44 patients underwent MRI, 15 had PLC injury, and 32 (28.8%) underwent surgery. LSC score was higher in patients who had an MRI (median 6vs 3, P <.001) and patients who had surgery (median 7vs 4, P <.001). In univariate logistic regression, LSC score was associated with MRI acquisition (odds ratio [OR] 1.7; 1.32-2.12; P <.001), presence of PLC injury on MRI (OR 1.5; 1.2-2.0; P=.002) and, in multivariate logistic regression, undergoing surgical intervention (OR 3.7; 2.3-5.9; P <.001), independent of MRI or PLC injury. LSC score in neurologically intact patients with isolated thoracolumbar burst fracture with TLICS 4 was independently associated with operative intervention. The application of LSC may further guide decision-making in this patient group.

The AOSpine thoracolumbar spine injury classification system: A comparative study with the thoracolumbar injury classification system and severity score in children.

Background:There is no uniform classification in the pediatric population for thoracolumbar (TL) fractures, nor any operative guidelines. This study evaluates the AOSpine TL spine injury classification in the pediatric population and compares it to the thoracolumbar injury classification system (TLICS), which has previously been validated in pediatric spine trauma.Methods:Twenty-eight patients with operative TL injuries were identified from 2006 to 2016. Inclusion criteria included available imaging, operative records, age <18, and posterior approach. Each case was classified by AOSpine TL spine injury classification and TLICS. Each classification was compared to documented intraoperative posterior ligamentous complex (PLC) integrity as well as each other.Results:Utilizing the AOSpine TL spine injury classification, 7 patients had type A injuries, 15 patients had type B injuries, and 6 patients had type C injuries; 21 patients had injuries classified as involving the PLC. Using TLICS, 16 patients had burst fractures, 6 patients had distraction injuries, and 6 patients had translation injuries; 21 patients had injuries classified as involving the PLC. Spearman correlation analysis substantiated convergence of AOSpine TL spine injury classification scores to TLICS scores (r = 0.75; 95% confidence interval, CI = 0.51 to 0.98; P < .001). Concordance between PLC integrity by each classification and intraoperative evaluation was 96% (27/28) of cases (k = 0.91; 95% CI = 0.73 to 1.08). Neurologic status was 100% concordant between the AOSpine TL spine injury classification and TLICS.Conclusion:There is high statistical correlation between the AOSpine TL spine injury classification and TLICS, and to intraoperative evaluation of the PLC, suggesting that the AOSpine TL spine injury classification is applicable to the pediatric population.Level of evidence:III.

The radiologic assessment of posterior ligamentous complex injury in patients with thoracolumbar fracture.

To discuss whether radiologic parameters are closely related to posterior ligamentous complex (PLC) injury identified by magnetic resonance imaging (MRI). One hundred and five thoracolumbar fracture (T11-L2) patients were retrospectively analyzed in the study. The patients were divided into different groups by the status of the PLC on MRI: intact, incompletely ruptured and ruptured. The radiographic parameters included the anterior edge-inferior endplate angle (AEIEA), the anterior edge displacement (AED), the Cobb angle (CA), the region angle (RA), the sagittal index (SI), local kyphosis (LK), the anterior/posterior vertebral height ratio (A/P ratio), the anterior vertebral height ratio (AVH ratio), and bony fragment in front of the fractured vertebra (BFOFV). T test, Pearson's Chi-square and multivariate logistic regression were calculated for the variables. Supraspinous ligament (SSL) rupture versus intact was not only associated with the occurrence of AEIEA <70°, LK >25° and BFOFV, but also with increased AED (9.89±3.12mm and 9.34±3.36mm, P=0.034), RA (9.52±3.93° versus 7.91±3.99°, P=0.042), and LK (23.98±5.88° versus 15.55±5.28°, P=0.021). The indications for interspinous ligament (ISL) injury included AEIEA <75°, AEIEA <70° (P=0.004 and P<0.001, respectively), increased AED (P=0.010), LK >25° (P=0.024), AVH (P<0.001), and BFOFV (P<0.001). Multivariate logistic regression analysis revealed that AEIEA <70° and BFOFV were high risk factors for SSL rupture [standard partial regression coefficients (betas) were 0.439 and 0.408, P=0.003 and 0.001, respectively] and ISL rupture (betas were 0.548 and 0.494, P=0.028 and 0.001, respectively). Increased AED and LK >25° were also related to either ISL rupture (P=0.035 and 0.001, respectively) or SSL rupture (P=0.014 and 0.008, respectively). Our data may prove useful in a preliminary assessment of the PLC integrity based on plain radiographic imaging. We show that radiologic indications, such as AEIEA <70°, BFOFV, LK >25°, and increased AED, are correlated with ISL or SSL rupture, while RA, CA, SI, A/P ratio, and AVH ratio are not.

Reliability assessment of AOSpine thoracolumbar spine injury classification system and Thoracolumbar Injury Classification and Severity Score (TLICS) for thoracolumbar spine injuries: results of a multicentre study.

The aim of this multicentre study was to determine whether the recently introduced AOSpine Classification and Injury Severity System has better interrater and intrarater reliability than the already existing Thoracolumbar Injury Classification and Severity Score (TLICS) for thoracolumbar spine injuries. Clinical and radiological data of 50 consecutive patients admitted at a single centre with a diagnosis of an acute traumatic thoracolumbar spine injury were distributed to eleven attending spine surgeons from six different institutions in the form of PowerPoint presentation, who classified them according to both classifications. After time span of 6weeks, cases were randomly rearranged and sent again to same surgeons for re-classification. Interobserver and intraobserver reliability for each component of TLICS and new AOSpine classification were evaluated using Fleiss Kappa coefficient (k value) and Spearman rank order correlation. Moderate interrater and intrarater reliability was seen for grading fracture type and integrity of posterior ligamentous complex (Fracture type: k=0.43±0.01 and 0.59±0.16, respectively, PLC: k=0.47±0.01 and 0.55±0.15, respectively), and fair to moderate reliability (k=0.29±0.01 interobserver and 0.44+/0.10 intraobserver, respectively) for total score according to TLICS. Moderate interrater (k=0.59±0.01) and substantial intrarater reliability (k=0.68±0.13) was seen for grading fracture type regardless of subtype according to AOSpine classification. Near perfect interrater and intrarater agreement was seen concerning neurological status for both the classification systems. Recently proposed AOSpine classification has better reliability for identifying fracture morphology than the existing TLICS. Additional studies are clearly necessary concerning the application of these classification systems across multiple physicians at different level of training and trauma centers to evaluate not only their reliability and reproducibility, but also the other attributes, especially the clinical significance of a good classification system.

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.

MRI Inter-Reader and Intra-Reader Reliabilities for Assessing Injury Morphology and Posterior Ligamentous Complex Integrity of the Spine According to the Thoracolumbar Injury Classification System and Severity Score.

ObjectiveTo evaluate spine magnetic resonance imaging (MRI) inter-reader and intra-reader reliabilities using the thoracolumbar injury classification system and severity score (TLICS) and to analyze the effects of reader experience on reliability and the possible reasons for discordant interpretations.Materials and MethodsSix radiologists (two senior, two junior radiologists, and two residents) independently scored 100 MRI examinations of thoracolumbar spine injuries to assess injury morphology and posterior ligamentous complex (PLC) integrity according to the TLICS. Inter-reader and intra-reader agreements were determined and analyzed according to the number of years of radiologist experience.ResultsInter-reader agreement between the six readers was moderate (k = 0.538 for the first and 0.537 for the second review) for injury morphology and fair to moderate (k = 0.440 for the first and 0.389 for the second review) for PLC integrity. No significant difference in inter-reader agreement was observed according to the number of years of radiologist experience. Intra-reader agreements showed a wide range (k = 0.538-0.822 for injury morphology and 0.423-0.616 for PLC integrity). Agreement was achieved in 44 for the first and 45 for the second review about injury morphology, as well as in 41 for the first and 38 for the second review of PLC integrity. A positive correlation was detected between injury morphology score and PLC integrity.ConclusionThe reliability of MRI for assessing thoracolumbar spinal injuries according to the TLICS was moderate for injury morphology and fair to moderate for PLC integrity, which may not be influenced by radiologist' experience.

Editorial: Evidence-based medicine

Bakhsheshian et al. present a review paper evaluating the current state of evidence-based medicine in the nonoperative management of traumatic thoracolumbar burst fractures.1 They performed a systematic review according to the Cochrane guidelines. This paper is very well written. They identified 45 papers, over 20 years, which primarily investigated nonoperative management, and found 9 of the 45 papers had either Level I or II evidence. The authors have comprehensively reviewed these 9 papers. They excluded papers that assessed osteoporotic or pathological fractures. They determined that for neurologically intact patients, better outcomes were often achieved with conservative treatment regimens compared to operative management. They clearly identified fewer complications in the nonoperative management groups, and often the functional outcomes were superior in the group that did not undergo surgery. The nonoperative management techniques evaluated included bed rest, closed reductions, orthoses, and body casts. They also demonstrated that the presence of a neurological deficit is not necessarily a contraindication to nonoperative treatment; however, they acknowledge that this question has not been satisfactorily addressed in the current literature. They attempted to compare different conservative treatment approaches but their review did not allow for concluding that a specific conservative treatment technique was better than the others. A potential shortcoming of this paper is that the degree of kyphosis present, an indirect indicator of posterior ligamentous complex integrity, was not always stated (it was stated in the paper by Wood et al. and was an exclusion criterion). In reviewing these nonoperative management papers, it appears that they predominantly assessed lesser degrees of severity of bone and/or ligamentous injury. The majority of cases involved patients without neurological deficits. What is readily apparent is that all burst fractures, or what are reported as burst fractures, are not alike. Thoracolumbar burst fractures with significant neurological findings or with gross instability likely require surgical intervention; however, this review paper demonstrates that some lesser “burst” fractures likely are managed quite successfully with conservative treatment regimens. Importantly, the authors recognized the importance of both neurological and functional outcomes in this review. (http://thejns.org/doi/abs/10.3171/2014.5.FOCUS14190)

Prospective Analysis of Magnetic Resonance Imaging Accuracy in Diagnosing Traumatic Injuries of the Posterior Ligamentous Complex of the Thoracolumbar Spine

Prospective cohort study. To study magnetic resonance imaging (MRI) accuracy in diagnosing posterior ligamentous complex (PLC) damage, when applying the new dichotomic instability criteria in a prospective cohort of patients with vertebral fracture. Recent studies dispute MRI accuracy to diagnose PLC injuries. They analyze the complex based on 3 categories (intact/indeterminate/rupture), including the indeterminate in the ruptured group (measurement bias) in the accuracy analysis. Moreover, fractures with conservative treatment (selection bias) are not included. Both facts reduce the specificity. A recent study has proposed new criteria where posterior instability is determined with supraspinous ligament (SSL) rupture. Prospective study of patients with acute thoracolumbar fracture, using radiography and MRI (FS-T2-w/short-tau inversion-recovery sequences). 1. The integrity (ruptured/unruptured) of each isolated component of the PLC (facet capsules, interspinous ligament, SSL, and ligamentum flavum) was assessed via MRI and surgical findings. 2. PLC integrity as a whole was assessed, adopting the new dichotomic stability criteria from previous studies. In the MR images, PLC is considered ruptured when the SSL is found discontinued, and intact when not (this excludes the "indeterminate" category). In surgically treated fractures, PLC stability as a whole was assessed dynamically (ruptured/unruptured). In conservative fractures, PLC stability was assessed according to change in vertebral kyphosis measured with the local kyphotic angle at 2-year follow-up (ruptured if difference is > 5°/unruptured if difference is < 5°).3. Comparative analysis among findings provided MRI accuracy in diagnosing PLC damage. Fifty-eight vertebral fractures were studied (38 surgical, 20 conservative), of which 50% were in males; average age, 40.4 years. MRI sensitivity for injury diagnosis of each isolated PLC component varied between 92.3% (interspinous ligament) and 100% (ligamentum flavum). Specificity varied between 52% (facet capsules) and 100% (SSL). PLC integrity sensitivity and specificity as a whole were 91% and 100%, respectively. Adopting the new stability criteria, MRI accuracy in PLC injury diagnosis increases. Specificity is increased (true positives) both in isolated component analysis and PLC as a whole.

A new classification for complex lumbosacral injuries

The optimal classification and treatment algorithm for complex lumbosacral injuries, in particular high-energy sacral fractures and lumbosacral dissociation (LSD) injuries, remains controversial. Currently used classification systems are largely descriptive, lacking validity, reproducibility, treatment considerations, and prognostic information. We set out to develop a comprehensive, yet practical, classification system for complex lumbosacral injuries that assists in clinical decision making. We developed a new classification system for complex lumbosacral injuries derived through literature review, expert opinion, and our clinical experience treating combat casualties over the past 10 years. We have seen an increased incidence of complex sacral fractures and LSD injuries after high-energy blast trauma, motor vehicle collisions, and aircraft crashes. We performed an extensive literature review and discussed the proposed classification with spinal trauma surgeons from a variety of institutions familiar with the treatment of complex high-energy sacral fractures and LSD injuries. We identified the significant clinical and radiographic variables encountered in the decision-making process for the treatment of complex lumbosacral injuries. Existing classification systems were reviewed in light of these essential characteristics, and their limitations were defined and addressed with the new system. A new classification system called lumbosacral injury classification system (LSICS) was devised based on three injury characteristics: injury morphology, posterior ligamentous complex integrity, and neurologic status. A composite injury severity score was calculated by summing a weighted score from each category, allowing patients to be stratified into surgical and nonsurgical treatment groups based on threshold values. Modifiers to determining appropriate selection for operative treatment include systemic injury load and physiological status of the polytraumatized patient, soft-tissue status, and expected time to mobility. Finally, an algorithm was developed to determine the optimum operative technique based on the previously outlined injury characteristics. The LSICS provides a comprehensive and practical approach for evaluating injury severity and guiding clinical decision making. This system provides common language for surgeons to communicate various injury patterns and formulate treatment modalities. Further studies are necessary to determine the reliability and validity of this new classification system.

Using magnetic resonance imaging to accurately assess injury to the posterior ligamentous complex of the spine: a prospective comparison of the surgeon and radiologist

Magnetic resonance imaging has been proposed as a powerful technique for assessing the integrity of the posterior ligamentous complex (PLC) in spinal trauma. Because MR imaging is often used to determine appropriate treatment, it is important to determine the accuracy and reliability of MR imaging in diagnosing PLC disruption. The purpose of this study is to compare the ability of the radiologist and surgeon to assess disruption of the PLC in the setting of acute cervical and thoracolumbar trauma using MR imaging. The components of the PLC in 89 consecutive patients with cervical or thoracolumbar fractures following acute spinal trauma were evaluated using MR imaging by both a musculoskeletal radiologist and an independent spine surgeon and assessed intraoperatively under direct visualization by the treating surgeon. The MR imaging interpretations of the musculoskeletal radiologist and surgeon were compared with the intraoperative report for accuracy, sensitivity, specificity, and positive and negative predictive values. A comparison between the radiologist's and spine surgeon's accuracy of MR imaging interpretation was performed. The agreement between both the spine surgeon's and radiologist's MR imaging interpretation and the actual intraoperative findings was moderate for most components of the PLC. Overall, the MR imaging interpretation of the surgeon was more accurate than that of the radiologist. The interpretation of MR imaging by the surgeon had negative predictive value and sensitivity of up to 100%. However, the specificity of MR imaging for both the surgeon and radiologist was lower, ranging from 51.5 to 80.5%. Comparison of the MR imaging interpretations between surgeon and radiologist indicates that the surgeon was more accurate for some PLC components. The relatively low positive predictive value and specificity for MR imaging in assessing PLC integrity suggests that both the surgeon and radiologist tend to overdiagnose PLC injury using MR imaging. This can lead to unnecessary surgeries if only MR imaging is used for treatment decision making.

Thoracolumbar spine trauma classification: the Thoracolumbar Injury Classification and Severity Score system and case examples

The aim of this study was to review the Thoracolumbar Injury Classification and Severity Score (TLICS) and to demonstrate its application through a series of spine trauma cases. The Spine Trauma Study Group collaborated to create and report the TLICS system. The TLICS system is reviewed and applied to 3 cases of thoracolumbar spine trauma. The TLICS system identifies 3 major injury characteristics to describe thoracolumbar spine injuries: injury morphology, posterior ligamentous complex integrity, and neurological status. In addition, minor injury characteristics such as injury level, confounding variables (such as ankylosing spondylitis), multiple injuries, and chest wall injuries are also identified. Each major characteristic is assigned a numerical score, weighted by severity of injury, which is then summated to yield the injury severity score. The TLICS system has demonstrated initial success and its use is increasing. Limitations of the TLICS system exist and, in some instances, have yet to be addressed. Despite these limitations, the severity score may provide a basis to judge spinal stability and the need for surgical intervention. By addressing both the posterior ligamentous integrity and the patient's neurological status, the TLICS system attempts to overcome the limitations of prior thoracolumbar classification systems. The TLICS system has demonstrated both validity and reliability and has also been shown to be readily learned and incorporated into clinical practice.

Assessment of injury to the thoracolumbar posterior ligamentous complex in the setting of normal-appearing plain radiography

Background context The posterior ligamentous complex (PLC) is thought to contribute significantly to the stability of thoracolumbar spine. Obvious translation or dislocation of an interspace clearly denotes injury to the PLC. A recent survey of the Spine Trauma Study Group indicated that plain radiographic findings, if present, are most helpful in determining PLC injury. However, confusion exists when plain radiography shows injury to the anterior spinal column without significant kyphosis or widening of the posterior interspinous space. Purpose The objective of this study is to identify imaging parameters that may suggest a disruption of the posterior ligamentous complex of the thoracolumbar spine in the setting of normal-appearing plain radiographs. This study was performed, in part, as a pilot study to determine critical imaging parameters to be included in a future prospective, randomized, multicenter study. Study design/setting Survey analysis of the Spine Trauma Study Group. Patient sample None. Outcome measures Compilation and statistical analysis of survey results. Methods Based on a systematic review of the English literature from 1949 to present, we identified a series of traits not found on plain X-rays that were consistent with PLC injury. This included five imaging findings on either computed tomography (CT) scans or magnetic resonance imaging (MRI) and several physical examination features. These items were placed on a survey and sent to the members of the Spine Trauma Study Group. They were asked to rank the items from most important to least important in representing an injury to the PLC in the setting of normal-appearing plain radiographs. Results Thirty-three of 47 surveys were returned for final analysis. Thirty-nine percent (13/33) of the members ranked “disrupted PLC components (i.e., interspinous ligament, supraspinous ligament, ligamentum flavum) on T1 sagittal MRI” as the most important factor in determining disruption of PLC. When analyzed with a point-weighted system, “diastasis of the facet joints on CT” received the most points, indicating that this category was ranked high by the majority of the members of the group. The members were also given freedom to add other criteria that they believed were important in determining PLC integrity in the setting of normal-appearing plain radiograph. Of the other criteria suggested, one included a physical finding and the other a variant of MR sequencing. Conclusions In a setting of normal-appearing plain radiographs, PLC injury as displayed on T1-weighted MRI and diastasis of the facet joints on CT scan seem to be the most popular determinants of probable PLC injury among members of the Spine Trauma Study Group. Between MRI and CT scan, most members feel that various characteristics on MRI studies were more helpful.

Regional variability in use of a novel assessment of thoracolumbar spine fractures: United States versus international surgeons

BackgroundConsiderable variability exists in clinical approaches to thoracolumbar fractures. Controversy in evaluation and nomenclature contribute to this confusion, with significant differences found between physicians, between different specialties, and in different geographic regions. A new classification system for thoracolumbar injuries, the Thoracolumbar Injury Severity Score (TLISS), was recently described by Vaccaro. No assessment of regional differences has been described. We report regional variability in use of the TLISS system between United States and non-US surgeons.MethodsTwenty-eight spine surgeons (8 neurosurgeons and 20 orthopedic surgeons) reviewed 56 clinical thoracolumbar injury case histories, which included pertinent imaging studies. Cases were classified and scored using the TLISS system. After a three month period, the case histories were re-ordered and the physicians repeated the exercise; 22 physicians completed both surveys and were used to assess intra-rater reliability. The reliability and treatment validity of the TLISS was assessed. Surgeons were grouped into US (n = 15) and non-US (n = 13) cohorts. Inter-rater (both within and between different geographic groups) and intra-rater reliability was assessed by percent agreement, Cohen's kappa, kappa with linear weighting, and Spearman's rank-order correlation.ConclusionNon-US surgeons were found to have greater inter-rater reliability in injury mechanism, while agreement on neurological status and posterior ligamentous complex integrity tended to be higher among US surgeons. Inter-rater agreement on management was moderate, although it tended to be higher in US-surgeons. Inter-rater agreement between US and non-US surgeons was similar to within group inter-rater agreement for all categories. While intra-rater agreement for mechanism tended to be higher among US surgeons, intra-rater reliability for neurological status and PLC was slightly higher among non-US surgeons. Intra-rater reliability for management was substantial in both US and non-US surgeons. The TLISS incorporates generally accepted features of spinal injury assessment into a simple patient evaluation tool. The management recommendation of the treatment algorithm component of the TLISS shows good inter-rater and substantial intra-rater reliability in both non-US and US based spine surgeons. The TLISS may improve communication between health providers and may contribute to more efficient management of thoracolumbar injuries.

Assessment of injury to the posterior ligamentous complex in thoracolumbar spine trauma

Background context Posterior ligamentous complex (PLC), consisting of supraspinous ligament (SSL), interspinous ligament (ISL), ligamentum flavum (LF), and the facet joint capsules is thought to contribute significantly to the stability of thoracolumbar spine. Currently, no consensus exists on radiographic imaging parameters that may indicate injury to the posterior ligamentous complex. Purpose To identify imaging parameters that may suggest a disruption of the PLC of the thoracolumbar spine. Study desing/setting A survey analysis of members of the Spine Trauma Study Group. Patient sample None. Outcomes measures Compilation of survey results. Methods An extensive review of the literature from 1949 to the present was performed to identify key radiographic elements that have been suggested as indicators of PLC injury. Twelve items identified as such were placed on a survey and sent to the members of the Spine Trauma Study Group. They were asked to rank the items from most important to least important, and the results were complied for analysis. Results Twenty-eight surveys were returned for final analysis. Fifty-percent (14/28) of the members ranked “vertebral body translation” on plain radiographs as the most important factor in determining disruption of PLC. Plain radiographic sings were ranked higher than computed tomography or magnetic resonance imaging indicators, and history of the mechanism ranked lowest. The members were also given freedom to add other criteria that they felt were important in determining PLC integrity. “Interspinous spacing 7 mm greater than that of level above or below on antero posterior plain X-rays” was the only new category that was suggested. Conclusion Plain radiographic findings were felt to be most helpful in determining PLC injury by the members of the Spine Trauma Study Group. Physical examination findings and history of the mechanism of injury were ranked lower than imaging studies. Future analysis should focus on indicators of PLC injury when plain radiographic findings are either subtle or not present.

Course of Nonsurgical Management of Burst Fractures with Intact Posterior Ligamentous Complex: An MRI Study

Prospective study. To evaluate the results of nonsurgical management of burst fractures with intact posterior ligamentous complex and to investigate the effect of trauma and/or residual kyphotic deformity on adjacent and next adjacent (neighboring) discs. Conservative treatment based on integrity of posterior ligamentous complex is controversial, probably because of poor evaluation by clinical and indirect radiographic findings. Degenerative changes in the adjacent discs due to trauma and/or residual kyphotic deformity is a common expectation. Fifteen consecutive patients who were intact neurologically with burst fractures (T11-L2) were treated nonsurgically with the indication based solely on the integrity of posterior ligamentous complex determined by MRI. Correction of deformity and stabilization with a total body cast under sedation were the mainstays of treatment. Patients were mobilized the next day, and casts were removed at the end of the third month follow-up period with no further external stabilization. Local kyphosis angle, sagittal index, and percent of compression of anterior body height were measured on pretreatment, post-treatment, third month, and latest follow-up radiographs. All of the preoperative and latest follow-up MRI studies of the patients were obtained to examine the discs adjacent and next adjacent to the fractured levels. The self-reported perceptions of the patients of function, pain and appearance were analyzed using the Likert Questionnaire. There were eight female and seven male patients with an average age of 28 (range, 15-49) years. Average follow-up period was 31 (range, 24-51) months. Average local kyphosis angle was found to be 16.5 degrees (0-34 degrees ) after trauma. It was corrected to 5 degrees (range, 19-25 degrees ) and deteriorated to 14.6 degrees (range, 2-25 degrees ) at the third month and to 17 degrees (range, 2-29 degrees ) at the final follow-up review. There was a similar tendency for both sagittal index and percent anterior body height. The pretreatment MRI analysis revealed changes in the shape of the discs (narrowing or herniation into the body) with no change in the signal intensity of nucleus pulposus in eight of the cranial and four of the caudal adjacent discs. On follow-up MRI, there was only one intact disc with a normal shape cranially. All others had height loss, but only one had complete loss of signal intensity. Caudally, two additional discs had changes in shape without any gross changes in signal intensity of nucleus pulposus, whereas two had changes in signal intensity without change in shape. Only two of the next adjacent discs had changes in shape or signal intensity at the time of injury or at latest follow-up review. Average score of function, pain, and appearance were 3.9 (range, 3-5), 3.7 (range, 2-5), and 3.7 (range, 2-5), respectively, at the latest follow-up review. All patients were back at work in 3.6 (range, 1-9) months on average and all were satisfied with their treatment. The present study revealed that an intact posterior ligamentous complex might not prevent loss of correction gained by nonsurgical management of burst fractures. Significant loss occurs in the first 3 months despite external stabilization. However, the magnitude of residual deformity usually remains close to the initial deformity. Although changes in the shape of adjacent discs occur due to trauma and/or natural course, significant loss in signal intensity of nucleus pulposus is unlikely. Patient outcome seems to be highly satisfactory despite residual deformity.