AO Spine Thoracolumbar and Sacral Injury Classification for the Radiologist

Spine injury and vertebral fractures are common occurrences and can be life changing or fatal. As part of the patient care team, the radiologist is often the first to diagnose spine injury. The AO Spine is the largest spine surgery research institution in the world. AO Spine has developed a standardized spine injury classification for the entire spine which has undergone review and clinical validation with surgeons worldwide to evaluate and demonstrate reproducibility. Using AO Spine classification, the radiologist ensures shared understanding with the surgeon and trauma team, expediting appropriate care for the spine injury patient. This review outlines the classification of spine injuries of the thoracolumbar and sacral spine and provides clinical imaging and reporting examples.

Spinal trauma is rare but associated with considerable morbidity and mortality. Its diagnostic evaluation poses significant challenges for radiologists, particularly in specific patient groups and clinical scenarios. This review article highlights the role of computed tomography and magnetic resonance imaging in acute and specialized imaging of spinal trauma under particular circumstances. Special attention is given to pediatric injuries, normal variants (e.g., pseudosubluxation, os odontoideum), discoligamentous injuries, age- and medication-related osteoporotic fractures, imaging in pregnant patients with strict radiation protection requirements, as well as complex situations such as polytrauma, traumatic brain injury, or coagulopathies. In addition, pathological fractures caused by tumors or infections and imaging in postoperative patients are discussed. Classification systems such as Thoracolumbar Injury Classification and Severity Score (TLICS), AO Spine score, Osteoporotic Fracture (OF) score, and Spinal Instability Neoplastic Score (SINS) provide astructured basis for therapeutic decision-making. Radiologists play a key role, as imaging not only makes the diagnosis, but also directly influences classification and treatment planning. Future developments such as AI-supported fracture detection, dual-energy CT and artefact-reduced MRI sequences will further improve diagnostics.

ABSTRACTBACKGROUND:This study examines the outcomes of conservative versus surgical treatment for Thoracolumbar Injury Classification and Severity Score (TLICS) 4 thoracolumbar fractures in patients injured during the 2023 Türkiye earthquake. It aims to assess clinical and radiographic outcomes while considering the impact of crush syndrome-related complications on treatment decisions.METHODS:Twenty-three patients with TLICS 4 spinal injuries were evaluated and divided into surgical (n=12) and conservative (n=11) groups. Clinical parameters, including age, gender, preoperative spinal measurements, and one-year postoperative outcomes, were assessed. The Roland-Morris score was used to evaluate clinical outcomes. Additionally, complications such as cardiac, renal, and respiratory issues, infections, and length of hospital stay were analyzed.RESULTS:The surgical group had significantly higher Roland-Morris scores (RM: 79.3±12.7 vs. 15.0±8.5, p<0.001). Preoperative acute kidney injury was more common in the conservative group (36.4% vs. 8.3%, p<0.05), whereas preoperative pulmonary complications were more frequent in the surgical group (83.3% vs. 36.4%, p<0.05). No significant differences were found in gender, age, or other complications. Radiological outcomes, including Cobb angle, sagittal index, and anterior central vertebral body height (ACVBH) restoration, showed no significant differences between groups. Length of hospital stay was similar between groups.CONCLUSION:Our study demonstrates that both conservative and surgical treatments are effective for managing TLICS 4 thoracolumbar fractures in disaster settings. Treatment decisions should be guided by patient-specific factors and available resources.

This study aimed to compare long-term clinical and radiological outcomes of conservative treatment using hyperextension casting versus surgical treatment (short-segment instrumentation) for thoracolumbar vertebral fractures classified as Thoracolumbar Injury Classification and Severity Score (TLICS) score 4. Methods. Patients diagnosed with stable compression fractures at T10–L2 who underwent conservative hyperextension casting (Group A, n=28) or surgical short-segment instrumentation (Group B, n=36) between 2004 and 2014 were retrospectively reviewed. Pain levels (Visual Analogue Scale), functional outcomes (Oswestry Disability Index), local kyphosis angle (Cobb Angle), anterior vertebral body height compression (ACVBH), and patient satisfaction were evaluated. Results. There were no significant differences between groups regarding age, gender, BMD, or follow-up duration. Hospital stay was significantly longer in Group B (5.1±2.5 vs. 2.1±0.7 days; p&lt;0.001, Cohen’s d=1.55). Radiological parameters (Cobb angle, ACVBH, SI) showed no significant differences at final follow-up. However, Group B demonstrated significantly superior outcomes in Oswestry Disability Index (ODI) at follow-up (p&lt;0.001, Cohen’s d=1.23) and Visual Analogue Scale (VAS) scores at pre-treatment (p=0.047, Cohen’s d=0.53), post-treatment (p=0.024, Cohen’s d=0.57), and follow-up (p&lt;0.001, Cohen’s d=1.18). Complication rates were comparable between groups. Conclusion. Hyperextension casting provided similar radiological outcomes to surgical treatment, although surgical intervention offered better functional outcomes and pain relief. Treatment choice should consider individual patient factors and fracture characteristics. Keywords: Thoracolumbar fracture, hyperextension cast, short-segment instrumentation, kyphosis angle, functional outcome.

Study DesignSystematic Review.ObjectiveTo describe the historical classifications of thoracolumbar injuries and their evolution into the AO Spine Thoracolumbar Injury Classification System.MethodsA systematic review of MEDLINE, EMBASE and Cochrane Databases was performed in keeping with Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines.Results445 articles were crystallized to 14 included studies. Simple categorization systems offered by Bohler or Watson-Jones merely identify fracture morphology. Holdsworth and Denis conveyed a sense of the stability of injuries by noting columns of stability, but still failed to take into consideration important factors such as neurological status or specific integrity of key stabilizing structures. The AO Spine Thoracolumbar Injury Classification System provides 3 hierarchical categories: type A consisting of compression type injuries, type B composed of distraction injuries and the unstable type C comprising displacement injuries. This communicates the severity of the fracture to clinicians and, with the addition of modifiers, can be synthesised into a scoring system to guide management. This classification is based upon biomechanical stability and increasing likelihood of clinicians offering operative rather than non-operative intervention as fracture severity escalates.ConclusionsA combination of evaluating fracture morphology, integrity of the posterior ligamentous complex and neurological status of the patient in the context of individual patient modifiers is integral to guide surgical decision making. The AO Thoracolumbar Injury Classification System accounts for all of the aforementioned and is the derivative and advancement on existing historical systems. Further nuanced development of scoring systems to guide operative or non-operative management is still required.

Retrospective study. To assess the radiological, clinical, and neurological outcome of patients who had thoracolumbar burst fractures and had undergone short-segment posterior stabilization with single-index screw (SIS) or double-index screws (DIS) at the fractured vertebra. We included patients with AO type A and B with thoracolumbar injury classification and severity score (TLICS) ≥ 5, load-sharing classification (LSC) score ≥ 7, and a follow-up period of more than 2years. Of 94 patients, 45 had DIS fixation, and 49 had SIS fixation. All patients' pre-operative, immediate post-operative, and final follow-up visit X-rays were analyzed for Cobb's angle (CA), vertebral wedge angle (VWA), and vertebral body compression ratio (VBCR) in a neutral lateral view and transverse spinal area (TSA) in axial CT section. Clinical and neurological outcomes were assessed using the Visual Analog Scale (VAS) for back pain, the Oswestry Disability Index (ODI), and the American Spinal Injury Association (ASIA) Impairment Scale (AIS) at their final follow-up visit. The radiological parameters between both groups showed significant differences in terms of CA, VWA, and VBCR at the latest follow-up (SIS: 12.5°, 15°, 80.1% vs DIS: 8.04°, 11.2°, 87.1%) (p < 0.05). VAS and ODI were better in the DIS group but were statistically insignificant (p > 0.05). Short-segment posterior stabilization with DIS in the fractured vertebra resulted in radiologically better maintenance of CA, VWA, and VBCR compared to SIS. There were no significant differences in terms of clinical (VAS and ODI), neurological outcome (AIS), and spinal canal remodeling (TSA).

Introduction: This study aimed to evaluate the value of the modified Thoracolumbar Injury Classification and Severity Score (mTLICS) in diagnosing and guiding the treatment of thoracolumbar spine injuries at Phu Tho Provincial General Hospital. It also compared mTLICS with TLICS and TL AOSIS systems in predicting surgical and conservative treatment decisions. Subjects and Methods: A retrospective study was conducted on 41 patients with thoracolumbar spine injuries from January to April 2025. All patients underwent a 3.0 Tesla MRI. Their injuries were classified using TLICS, TL AOSIS and mTLICS. The classification results were compared with treatment decisions to assess sensitivity, specificity, and accuracy. Results: mTLICS showed superior diagnostic performance with 89% sensitivity, 100% specificity, and 93% accuracy (based on the second reader). Inter-rater agreement was moderate to substantial (Kappa = 0.708 for fracture morphology and 0.8 for posterior ligamentous injury). The mTLICS also highly correlated with surgical decision-making (r = 0.779 and 0.755). Notably, it achieved the highest area under the ROC curve (AUROC: 0.939–0.95), compared to TLICS (0.855–0.874) and TL AOSIS (0.802–0.843). At a cutoff score &gt;3, mTLICS reached 92–100% sensitivity and 81.25% specificity. Conclusion: mTLICS is a reliable and accurate classification system for thoracolumbar injuries, offering better predictive value than TLICS and TL AOSIS. Its implementation may enhance decision-making and treatment outcomes, especially in provincial hospitals.

Letter: Validation and Comparison of Common Thoracolumbar Injury Classification Treatment Algorithms and a Novel Modification.

The susceptibility of the thoracolumbar junction to injury is attributed mainly to the transition from a relatively rigid thoracic kyphosis to a more mobile lumbar lordosis that occurs at thoracic T11 to lumbar L2 level. We present our experience of management of 87 patients of single-level injury who presented with or without neurological deficit between March 2014 and October 2018. All adult patients (18-59 years) were included who were selected for management by single-level posterior transpedicular fixation and followed up for a minimum of 12 months. The male-to-female ratio in our study was 6.3:1 with a mean age of 32 years. Forty-eight percent were in the work-productive age group of 31-40 years. The L1 vertebra was the most commonly fractured (47%) followed by D12, L2, and D11 vertebra, respectively. Thoracolumbar injury classification severity score 6 was the most common score at presentation. More than 80% patients had some degree of neurological deficit on American Spinal Injuries Association grading with Grade C being the most common pattern of presentation of spinal cord neurological deficit. About 25% patients had some degree of neurological improvement at 12 months follow-up. Among them, 10% achieved an ambulatory status from a bed-ridden status signifying the importance of surgical management in appropriately selected patients. Single-level transpedicular fixation can be offered to a group of selected patients for rehabilitative purposes. This is the largest study discussing only junctional thoracolumbar injuries and also outcomes in single-level posterior instrumentation.

Background: Thoracolumbar (TL) fractures are uncommon injuries in the pediatric population. Surgery is recommended for TL fractures with significant deformity, posterior ligamentous complex disruption, or neurological compromise. The Thoracolumbar Injury Classification and Severity Scale (TLICS) has been validated in pediatric populations and serves as a valuable tool for guiding treatment decisions. However, there remains a lack of clarity regarding the appropriate treatment for patients with a TLICS of 4. While conservative and surgical techniques have been described, most studies focused on adult populations, and there is no consensus on the appropriate management in the pediatric population. We reviewed our institutional experience of TL fractures in young children with TLICS of 4, managed both non-operatively and operatively. Methods: A retrospective review of a single institution’s experience managing pediatric patients (&lt;18 years old) with TL fractures receiving a TLICS of 4 from 2015 to 2023 was conducted to determine the clinical outcomes following non-operative and operative treatment. Results: Among 11 pediatric patients, 4 were managed with bracing alone, primarily for posterior column fractures, using a thoracolumbar sacral orthosis (TLSO). Four patients underwent minimally invasive screw fixation (MISF), for Chance or posterior column fractures, with an average operative time of 143 min, blood loss of 29 cc, length of stay (LOS) of 9.8 days, and a follow-up interval of 6 months. Three patients received open posterior screw fixation (OPSF), most commonly for Chance fractures, with averages of 129 min operative time, 225 cc blood loss, 9.7 days LOS, and 4 months follow-up. Both MISF and OPSF utilized intra-operative imaging, with lower radiation exposure in the MISF group. One MISF patients had hardware failure evident by screw lucency on follow-up imaging. Conclusions: Bracing and surgery are safe management options for pediatric TL fractures receiving a TLICS of 4. MISF is an effective alternative treatment strategy, comparable to OPSF, with the advantage of reduced blood loss and radiation exposure. Further studies with age-matched cohorts and long-term outcomes may help determine the optimal management course.

Introduction Thoracolumbar fractures, particularly burst fractures, represent a significant health concern due to their prevalence and functional impact. This study evaluates the efficacy of short-segment posterior fixation with intermediate screw instrumentation in treating unstable thoracolumbar fractures. Methods A prospective study was conducted from July 2022 to December 2023, including 26 patients with traumatic thoracolumbar fractures. Surgical intervention was indicated for patients with a thoracolumbar injury classification and severity (TLICS) score >4. Functional outcomes were assessed using the visual analog scale (VAS), Oswestry Disability Index (ODI), and the American Spinal Injury Association (ASIA) grading system. Radiological outcomes, including the local kyphotic angle (LKA) and anterior vertebral body height ratio (AVBHR), were evaluated preoperatively, postoperatively, and at follow-ups. Results Significant improvements in functional and radiological parameters were observed over 24 weeks. The mean VAS score reduced from 7.50 ± 0.58 preoperatively to 1.42 ± 0.50 (p < 0.001), and the mean ODI improved from 42.23 ± 3.54 to 16.12 ± 3.09 (p < 0.001). Neurological improvements were seen in ASIA grades B-D, with no new deficits. Radiologically, the mean LKA improved from 19.73 ± 1.59° preoperatively to 8.46 ± 1.33° at 24 weeks (p < 0.001), and the AVBHR increased from 34.08 ± 2.25% to 86.64 ± 0.83% (p < 0.001). No implant failures were reported. Conclusion Short-segment fixation with intermediate screws provides effective stabilization and significant functional and radiological improvements in thoracolumbar fractures. It minimizes intraoperative morbidity and preserves motion segments, making it a viable alternative to long-segment fixation, particularly for non-complex fractures. Further randomized controlled trials are recommended to validate these findings.

Thoracolumbar burst fracture treatment in neurologically intact patients is controversial with many classification systems to help guide management. Thoracolumbar Injury Classification and Severity score (TLICS) provides a framework, but evidence is limited, and recommendations are primarily based on expert opinion. In this retrospective cohort study, data was reviewed for patients with thoracolumbar burst fractures at a Level-1 Trauma Center in New England from 2013 to 2018. Neurologically intact patients without subluxation/dislocation on supine computed tomography were included. Multimodal pain control and early mobilization were encouraged. Patients that failed to mobilize due to pain were treated with operative stabilization. Outcome measures include degree of kyphosis, visual analog scale pain scores, and neurological function. Thirty-one patients with thoracolumbar burst fractures with TLICS scores of 4 or 5 were identified, of which 21 were treated nonoperatively. Kyphosis at final follow-up was 26.4 degrees for the nonoperative cohort versus 13.5 degrees for the operative group (P < .001). Nonoperative patients tended towards shorter hospital lengths-of-stay (3.0 vs 7.1 days, P = .085) and lower final pain scores (2.0 vs 4.0, P = .147) compared to the operative group. Two patients (6%) developed radicular pain with mobilization, which resolved after surgical intervention. No patients experienced decline in neurologic function. A trial of mobilization for neurologically intact TLICS grade 4 and 5 thoracolumbar burst fractures is a safe and reasonable treatment option that resulted in successful nonoperative management of 21 out of 31 (68%) patients.

Spinal injuries are complex and often result from traumatic events such as falls, road traffic accidents, and impacts from heavy objects. Proper assessment of the injured spinal region, classification of the injury type, and evaluation of neurological impairment are critical for determining prognosis and guiding management. Objective: This study aims to assess the correlation between spinal regions involved and the mode of trauma, while also comparing the severity and prognosis of spinal injuries using the AO Spine Trauma Classification, Subaxial Cervical Spine Injury Classification (SLICS), Thoracolumbar Injury Classification and Severity Score (TLICS), and American Spinal Injury Association (ASIA) grading systems. Methods: After the ethical approval from the institutional review board, this cross-sectional was conducted at Shaheed Mohtarma Benazir Bhutto Institute of Trauma (SMBBIT), Karachi from 1st June 2022 to 31st December 2023 . Through non-probability consecutive sampling 100 patients aged 15-60 years, both gender, who had a spinal injury due to any sort of trauma (RTA, fall, or impact by an object, etc) were included in the present study. Results: The most common cause of spinal trauma was falls from height, accounting for 59% of cases, followed by road traffic accidents (22%), falls from heavy objects (16%), and assaults (3%) (Table 1). Lumbar spine fractures were the most prevalent, occurring in 41% of participants, followed by thoracic fractures (34%) and cervical fractures (25%). In terms of fracture classification, the AO-spine system identified 51% of subaxial cervical spine fractures as Type A, while thoracolumbar spine fractures were predominantly Type B (58%).SLICS classification revealed that 70% of fractures were compressions, and 51% of patients had nerve root injurie. The ASIA scale revealed 12% of patients had complete motor and sensory loss (Grade A), while 30% retained normal function (Grade E). Conclusion: This study supports the earlier works where spinal injuries are complex trauma and require more elaborate assessment and classification systems for patient management.

A retrospective cohort study. This study aims to assess the validity of the Thoracolumbar Injury Classification and Severity Score (TLICS) in patients ≤10 years old. TLICS is a validated measure developed to help facilitate clinical decision-making regarding thoracolumbar spinal trauma in adults. Studies examining the utility of TLICS in children skew toward older pediatric patients, where the spine's biomechanical properties are more similar to adults. Due to differences in a preadolescent spine compared with a more mature, adolescent spine, it is unclear if TLICS can be applied to younger patients. A single-center spine trauma registry was queried for patients ≤10 with an acute, traumatic thoracolumbar fracture treated at a level-1 pediatric trauma center between 2006 and 2020. Test characteristics and receiver-operator curve were used to evaluate TLICS based on TLICS <4 recommedning nonsurgical treatment and TLICS >4 recommending surgery. We identified 94 patients with traumatic thoracolumbar fractures (surgical=20; nonsurgical=74). Despite TLICS-suggested operative management in 28 patients with TLICS >4, nine (32.1%) were initially treated nonoperatively. All patients who deviated from TLICS-suggested treatment had flexion-distraction injuries (FDI). Sensitivity, specificity, positive predictive value, and negative predictive value were 100%, 89.2%, 70.4%, and 100%, respectively. The receiver operating characteristic curve demonstrated a strong diagnostic ability of TLICS in predicting the need for surgery (area under the curve: 0.97, F1-score: 0.86). TLICS score <4 showed strong validity and is highly specific in predicting non-operative management for patients ≤10 years old with thoracolumbar fractures. However, TLICS >4 has more limited specificity in indicating the necessity for surgical intervention, as many FDIs were successfully treated without surgery. Additional factors other than TLICS score may need to be considered for these more severe injuries to optimize management in this age group.

ObjectiveTo retrospectively assess the Thoracolumbar Injury Classification and Severity Score (TLICS) in patients with osteoporotic vertebral compression fractures (OVCF) and compare the treatment given with that predicted by the TLICS score. MethodsAll medical records of patients presenting from January 2014 to November 2017 for acute atraumatic or low impact OVCF were screened, and eligible patients were retrospectively reviewed. The TLICS score was determined based upon magnetic resonance imaging (MRI) findings and clinical records. Clinical records (including pain score data), imaging data, operative procedures, and stability of neurological examination were tracked over three months for each patient. ResultsOf the 56 patients included, 36 patients had a TLICS score of 1, 18 had a TLICS score of 2, and two had a TLICS score of 4. Only one patient with a TLICS score of 4 underwent surgical stabilization, while the rest of the cohort was managed non-operatively, with or without kyphoplasty. TLICS score 1 corresponded to simple compression and TLICS score 2 corresponded to burst morphology with retropulsion and without neurological deficits. Of the patients with a TLICS score of 1 and 2 who underwent kyphoplasty, there was a statistically significant improvement in pain scores in both groups; however no significant difference was observed, between each TLICS score (i.e., 1 or 2). None of the patients developed instability or neurological decline. ConclusionTLICS score correctly predicted operative versus non-operative management in all patients with OVCF. TLICS may be used in making management decisions, and in the triage of these patients for operative versus non-operative evaluations. Our study suggests that patients with TLICS score of 4 or higher require surgical evaluation, while those with TLICS of 1 or 2 are likely to have satisfactory non-surgical management with augmentation or conservative care. In general, patients with OVCF typically present with low TLICS score. Kyphoplasty appears to be similarly beneficial in patients with a TLICS score of 1 or a TLICS score of 2. A modification of the TLICS score by adding TLICS Zero to include uncompressed OVCF with edema is suggested. The limitations of this study include a small size; a larger study is needed to confirm these findings.

Objective This study aimed to assess the reliability and reproducibility of the AO Spine Thoracolumbar Injury Classification System by using virtual reality (VR). We hypothesized that VR is a highly reliable and reproducible method to classify traumatic spine injuries. Methods VR 3D models were created from CT scans of 26 pediatric patients with thoracolumbar spine injuries. Seven orthopedic trainees were educated on the VR platform and AO Spine Thoracolumbar Injury Classification System. Classifications were summarized by primary class and subclass for both rater readings performed two weeks apart with image order randomized. Intra-observer reproducibility was quantified by Fleiss's kappa (kF) for primary classifications and Krippendorff's alpha (aK) for subclassifications along with 95% confidence intervals (CIs) for each rater and across all raters. Inter-observer reliability was quantified by kFfor primary classifications and aKfor subclassifications along with 95% CIs across all raters for the first read, the second read, and all reads combined. The interpretations were as follows: 0-0.2: slight; 0.2-0.4: fair; 0.4-0.6: moderate; 0.6-0.8: substantial; and >0.8: almost perfect agreement. Results A total of 364 classifications were submitted by seven raters. Intra-observer reproducibility ranged from moderate (kF=0.55) to almost perfect (kF=0.94) for primary classifications and from substantial (aK=0.68) to almost perfect (aK=0.91) for subclassifications. Reproducibility was substantial across all raters for the primary class (kF=0.71; 95% CI=0.61-9.82) and subclass (aK=0.79; 95% CI=0.69-0.86). Inter-observer reliability was substantial (kF=0.63; 95% CI=0.57-0.69) for the first read, moderate (kF=0.58; 95% CI=0.52-0.64) for the second read, and substantial (kF=0.61; 95% CI=0.56-0.65) for all reads for primary classifications. For subclassifications, inter-observer reliability was substantial (aK=0.74; 95% CI=0.58-0.83) for the first read, second read (aK=0.70; 95% CI=0.53-0.80), and all reads (aK=0.72; 95% CI=0.60-0.79). Conclusions Based on our findings, VR is a reliable and reproducible method for the classification of pediatric spine trauma, besides its ability to function as an educational tool for trainees. Further research is needed to evaluate its application for other spine conditions.

BackgroundThis study aimed to assess the outcomes of conservative management in patients with thoracolumbar fractures classified with a Thoracolumbar Injury Classification and Severity (TLICS) score of 4 or 5, and to analyze initial imaging findings and clinical risk factors associated with treatment failure.MethodsIn this retrospective analysis, patients with thoracolumbar fractures and a TLICS score of 4 or 5, determined through MRI from January 2017 to December 2020, were included. Patients undergoing conservative treatment were categorized into two groups: Group 1 (treatment success) and Group 2 (treatment failure), based on initial and 6-month follow-up outcomes. Clinical data were compared between the two groups. Initial radiological assessments included three kyphosis measurements (Cobb angle, Gardner angle, and sagittal index [SI]), anterior and posterior wall height, and central canal compromise (CC). Additionally, risk factors contributing to treatment failure were analyzed.ResultsThe conservative treatment group comprised 84 patients (mean age, 60.25 ± 15.53; range 22–85; 42 men), with 57 in Group 1 and 27 in Group 2. Group 2 exhibited a higher proportion of women, older age, and lower bone mass density (p = 0.001–0.005). Initial imaging findings in Group 2 revealed significantly greater values for Cobb angle, SI, and CC (p = 0.001–0.045 or < 0.001; with cutoff values of 18.2, 12.8, and 7.8%, respectively), and lower anterior wall height (p = 0.001), demonstrating good to excellent interobserver agreement (0.72–0.99, p < 0.001). Furthermore, osteoporosis was identified as a significant risk factor (odds ratio = 5.64, p = 0.008).ConclusionAmong patients with TLICS scores of 4 or 5, those experiencing conservative treatment failure exhibited unfavorable initial radiological findings, a higher proportion of women, advanced age, and osteoporosis. Additionally, osteoporosis emerged as a significant risk factor for treatment failure.

In this article, we attempted to identify risk factors affecting the loss of vertebral height and kyphosis correction on type A thoracolumbar fractures. Patients with type A thoracolumbar fractures who underwent short segments with intermediate screws at the fracture level management between 2017 and 2022 were included in this study. Clinical factors including patients’ demographic characteristics (age, sex), history (smoking, hypertension and/or diabetes), value of height/kyphosis correction, the thoracolumbar injury classification and severity score (TLICS), the load sharing classification (LSC) scores and bone mineral density were collected. Correlation coefficient, simple linear regression analysis and multivariate regression analysis were performed to identify the clinical factors associated with the loss of vertebral height/kyphosis correction. Finally, 166 patients were included in this study. The mean height and kyphosis correction were 21.8% ± 7.5% and 9.9° ± 3.8°, respectively, the values of the loss were 6.5% ± 4.0% and 3.9° ± 1.9°, respectively. Simple linear regression analysis and multivariate regression analysis showed that age, value of height correction, LSC scores and bone mineral density were significantly associated with the loss of vertebral height and kyphosis correction (P < .01) We could draw the conclusion that patients with older age, lower bone mineral density, higher LSC scores and diabetes are at higher risk of vertebral height and kyphosis correction loss increase. For these patients, appropriate clinical measures such as long segment fixation, control of blood glucose, and increase of bone density must be taken to reduce the loss of correction.

Tranexamic acid (TXA), a synthetic antifibrinolytic drug, effectively reduces blood loss by inhibiting plasmin-induced fibrin breakdown. This is the first study in the United Kingdom to investigate the effectiveness of TXA in the surgical management of isolated spine trauma. To assess the safety of TXA in isolated spine trauma. The primary and secondary outcomes are to assess the rate of thromboembolic events and to evaluate blood loss and the incidence of blood transfusion, respectively. This prospective observational study included patients aged ≥ 17 years with isolated spine trauma requiring surgical intervention over a 6-month period at two major trauma centers in the United Kingdom. We identified 67 patients: 26 (39%) and 41 (61%) received and did not receive TXA, respectively. Both groups were matched in terms of age, gender, American Society of Anesthesiologists grade, and mechanism of injury. A higher proportion of patients who received TXA had a subaxial cervical spine injury classification or thoracolumbar injury classification score > 4 (74% vs 56%). All patients in the TXA group underwent an open approach with a mean of 5 spinal levels involved and an average operative time of 203 min, compared with 24 patients (58%) in the non-TXA group who underwent an open approach with an average of 3 spinal levels involved and a mean operative time of 159 min. Among patients who received TXA, blood loss was < 150 and 150-300 mL in 8 (31%) and 15 (58%) patients, respectively. There were no cases of thromboembolic events in any patient who received TXA. Our study demonstrated that TXA is safe for isolated spine trauma. It is challenging to determine whether TXA effectively reduces blood loss because most surgeons prefer TXA for open or multilevel cases. Further, larger studies are necessary to explore the rate, dosage, and mode of administration of TXA.