Thoracolumbar Injury Severity Score Research Articles

Can conservative treatment be effective for thoracolumbar injuries patients with TLICS scores of 4 or 5? An analysis of initial radiological findings and clinical risk factors for treatment failure

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.

Does Magnetic Resonance Imaging Predict Neurological Deficit in Patients with Traumatic Lower Lumbar Fractures?

A retrospective cohort study. This study aimed to understand the role of magnetic resonance imaging (MRI) in predicting neurological deficits in traumatic lower lumbar fractures (LLFs; L3-L5). Despite studies on the radiological risk factors for neurological deficits in thoracolumbar fractures, very few have focused on LLFs. Moreover, the potential utility of MRI in LLFs has not been evaluated. In total, 108 patients who underwent surgery for traumatic LLFs between January 2010 and January 2020 were reviewed to obtain their demographic details, injury level, and neurology status at the time of presentation (American Spinal Injury Association [ASIA] grade). Preoperative computed tomography scans were used to measure parameters such as anterior vertebral body height, posterior vertebral body height, loss of vertebral body height, local kyphosis, retropulsion of fracture fragment, interpedicular distance, canal compromise, sagittal transverse ratio, and presence of vertical lamina fracture. MRI was used to measure the canal encroachment ratio (CER), cross-sectional area of the thecal sac (CSAT), and presence of an epidural hematoma. Of the 108 patients, 9 (8.3%) had ASIA A, 4 (3.7%) had ASIA B, 17 (15.7%) had ASIA C, 21 (19.4%) had ASIA D, and 57 (52.9%) had ASIA E neurology upon admission. The Thoracolumbar Injury Classification and Severity score (p =0.000), CER (p =0.050), and CSAT (p =0.019) were found to be independently associated with neurological deficits on the multivariate analysis. The receiver operating characteristic curves showed that only CER (area under the curve [AUC], 0.926; 95% confidence interval [CI], 0.860-0.968) and CSAT (AUC, 0.963; 95% CI, 0.908-0.990) had good discriminatory ability, with the optimal cutoff of 50% and 65.3 mm2, respectively. Based on the results, the optimal cutoff values of CER >50% and CSAT >65.3 mm2 can predict the incidence of neurological deficits in LLFs.

Unilateral Pediculectomy and Reduction with Short-Segment Pedicle Screw Fixation for Thoracolumbar Burst Fracture: A Case Series

This study aimed to evaluate the efficacy of unilateral pediculectomy and reduction with short-segment pedicle screw fixation for thoracolumbar burst fracture. We retrospectively reviewed patients who underwent a unilateral pediculectomy and reduction with short-segment fixation and interbody fusion for thoracolumbar burst fracture. The unilateral pediculectomy created sufficient space to approach the ventral side of the spinal cord for removing bone fragments and insertion of an interbody cage to correct kyphosis. Lumbar lordosis (LL), pelvic incidence (PI) minus LL, and segmental Cobb angle were measured at 3 time points: preoperatively, postoperatively, and final follow-up. Furthermore, sagittal vertical axis (SVA) was measured to assess global sagittal balance at the final follow-up. A total of 10 patients, with a mean age of 39.8±21.0, underwent the surgical procedure. All patients had a thoracolumbar injury classification and severity score > 5. The mean follow-up period was 15.8±13.9months. The mean postoperative LL (46.0±5.8) was significantly higher (P=0.008) than the preoperative measurement (32.8±8.2). The mean postoperative PI minus LL (2.2±8.4) was not significantly lower (P=0.051) than preoperative measurement (15.4±12.6). The mean postoperative segmental Cobb angle (11.4±8.4) was significantly higher (P<0.001) than the preoperative measurement (-11.6±10.9). At the final follow-up, the mean sagittal vertical axiswas 10.0±28.8mm. Unilateral pediculectomy and reduction with short-segment fixation and interbody fusion served as an efficient surgical method for thoracolumbar burst fracture.

The value of the posterior ligamentous complex in traumatic injury of thoracolumbar junction. Part 1. Morphology and biomechanics

According to modern concepts, one of the basic criteria for the stability of the spinal motion segment in case of its traumatic damage is the integrity of the posterior ligamentous complex (PLC). Regarding the thoracolumbar junction (TLJ) as a zone that is most vulnerable to traumatic injuries, the Thoracolumbar Injury Classification and Severity Score and the clinically oriented AO Spine Thoracolumbar Spine Injury Classification System are used in determining therapeutic approaches in which the state of the thoracic spine is one of three key parameters. The term PLC was first proposed in 1963 by F.W. Holdsworth. However, only the widespread introduction of magnetic resonance imaging into clinical practice made it possible to fully reveal the informativeness of the specified parameter. The complex includes the interspinous, supraspinous ligaments, ligamentum flavum and facet joint capsule. The purpose of the review is to organize modern ideas about the morphology, biomechanical features, clinical significance, and diagnostic possibilities of detecting damage to the PLC in traumatic injuries of the TLJ area. In the first part, the morphological and biomechanical features of the PLC of the TLJ zone are considered in detail. When describing the morphology of some ligaments, the main attention is paid to their length, fixation zones, and certain layers, if such are distinguished. In addition, the relative anatomical location of the considered structures was taken into account. Histological features are indicated only in terms of their biomechanical significance. The analysis of literature data made it possible to organize the data characterizing the biomechanical parameters of each ligament of the PLC for each spinal motion segment of the area under consideration. Stiffness indicators, breaking force, fracture energy, strength and deformation limits, maximum deformation and elastic modulus were taken into account. The features of the load-deformation curve of the TLJ ligaments and methods of calculating the nonlinear change in the stiffness of each ligament of the PLC within the limits of physiological loads are considered. The phenomenon of preload and its clinical significance are described. Some aspects of the interaction between the elements of the passive stabilization system under different load patterns are considered. The data presented in the first part of the review can be useful for a general understanding of the principles of biomechanics of the spinal motion segment and may be used in the construction of highly detailed computer models.

Effectiveness of sagittal top compression reduction technique in treatment of thoracolumbar vertebral fractures

To investigate the effectiveness of sagittal top compression reduction technique in the treatment of thoracolumbar vertebral fractures. A retrospective analysis was conducted on the clinical data of 59 patients with thoracolumbar vertebral fractures who met the selection criteria and were admitted between November 2018 and January 2022. Among them, 34 patients were treated with sagittal top compression reduction technique (top pressure group), and 25 patients were treated with traditional reduction technique (traditional group). There was no significant difference in baseline data between the two groups ( P>0.05), including gender, age, fracture segment, cause of injury, AO classification of thoracolumbar vertebral fractures, thoracolumbar injury classification and severity (TLICS) score, American Spinal Injury Association (ASIA) grading, surgical approach, preoperative vertebral body index, height ratio of the anterior margin of injured vertebra, injured vertebra angle, segmental kyphosis angle, visual analogue scale (VAS) score, and Oswestry disability index (ODI). The operation time, intraoperative blood loss, and incidence of complications between the two groups were recorded and compared. After operation, VAS score and ODI were used to evaluate effectiveness, and X-ray and CT examinations were performed to measure imaging indicators such as vertebral body index, height ratio of the anterior margin of injured vertebra, injured vertebra angle, and segmental kyphosis angle. There was no significant difference in operation time and intraoperative blood loss between the two groups ( P>0.05). No complication such as dural sac, nerve root, or vascular injury was found during operation, and all incisions healed by first intention. Patients in both groups were followed up 6-48 months, with an average of 20.6 months. No loosening, breakage, or failure of internal fixation occurred during follow-up. The imaging indicators, VAS score, and ODI of the two groups significantly improved at 1 week and last follow-up when compared to preoperative ones ( P<0.05). At last follow-up, the VAS score and ODI further significantly improved when compared to 1 week after operation ( P<0.05). At 1 week after operation and last follow-up, the vertebral body index, segmental kyphosis angle, injured vertebra angle, and ODI in the top pressure group were significantly better than those in the traditional group ( P<0.05). There was no significant difference in VAS score and height ratio of the anterior margin of injured vertebra between the two groups at 1 week after operation ( P>0.05), but the two indicators in the top pressure group were significantly better than those in the traditional group at last follow-up ( P<0.05). The treatment of thoracolumbar vertebral fractures with sagittal top compression reduction technique can significantly improve the quality of vertebral reduction, and is superior to traditional reduction techniques in relieving pain and improving spinal function.

Evaluation of the Thoracolumbar Injury Classification and Severity (TLICS) Score Over a Two-Year Period at a Level One Trauma Center.

Introduction The use of the Thoracolumbar Injury Classification and Severity Score (TLICS) and other classification systems for guiding the management of traumatic spinal injuries remains controversial. TLICS is one of the few classifications that provides treatment recommendations.We sought to analyze intervention modality selection based on the TLICS scoring system. Methods A retrospective review of patients presenting with traumatic thoracolumbar fractures at a level 1 trauma center over a two-year period was performed. Primary endpoints for comparison analysis included visual analog scale (VAS) scores and Cobb angles during follow-up. Results There were 272 patients with thoracolumbar fractures, of whom 212 had TLICS of ≤3, six with TLICS of 4, and 54 with TLICS of ≥5. Of the 272 total patients, 59 were treated via surgery and 213 via non-surgical conservative methods. The VAS scores significantly decreased from presentation to last follow-up in both surgically treated and conservative groups (p<0.0001). This remained consistent in subgroup analyses of TLICS ≤ 3, TLICS = 4, and TLICS ≥ 5 (p<0.0001). Burst fractures treated conservatively had larger fracture Cobb angles versus those treated via surgery at the last follow-up, although this was not significantly associated (p=0.07). The only significant relationship with Cobb angles was in distraction fractures of the TLICS > 4 conservative group, who had significantly lower Cobb angles at the last follow-up than the TLICS > 4 surgical group (p<0.04). The "surgeon's choice" for TLICS = 4 was surgical intervention (4/6 patients, 66.7%). Conclusion Using the TLICS score, thoracolumbar injuries in a level 1 trauma center are more commonly TLICS ≤ 3. For patients with TLICS = 4, the surgeon's choice was most commonly surgical repair. VAS scores decreased over time from presentation between surgically and conservatively managed patients (as well as within-group analyses). The data concerning Cobb angles were more ambiguous, as larger Cobb angles in burst fractures treated conservatively did not show statistically significant differences with surgery.

Unipedicular-Screw Index Vertebra Manipulation Technique for Minimally Invasive Short-Segment Thoracolumbar Fracture Fixation.

Minimally invasive spine surgery (MIS) has revolutionized fixation of thoracolumbar fractures with burst elements. Recent studies have proven that percutaneous pedicle screw instrumentation is as effective as open instrumentation but with reduced intraoperative blood loss and operative duration. Techniques such as short-segment pedicle screw fixation including the fractured vertebra have shown satisfactory radiological correction and functional outcomes, avoiding the need for extensile posterior constructs. In the present study, the authors our technique utilizing unipedicular index vertebra fixation and manipulation in MIS for thoracolumbar fractures with burst elements. To our knowledge, this technique is not well described in literature as open approaches are often adopted for the above. The authors sought to highlight the 2-year radiological and functional outcomes of 20 consecutive patients who underwent this technique. A retrospective review of prospectively collected data was conducted on 20 patients with thoracolumbar fractures with burst elements who underwent fixation using our technique. Patient data collected included demographic characteristics, mechanism of injury, associated injuries, neurological deficit at the time of admission, pre- and postoperative neurological evaluation, and length of hospital stay. Radiological investigations included plain radiographs, computed tomography of the spine with reconstruction, and magnetic resonance imaging of the spine, which provided data for radiological fracture classifications such as AO Spine and derivation of Thoracolumbar Injury Classification and Severity Score, as well as preoperative planning. Radiological investigations in the postoperative period were carried out by standing radiographs or EOS whole spine at each postoperative follow-up for up to 2 years. Radiological parameters-vertebral wedge angle, regional kyphosis angle, coronal Cobb angle, and anterior and posterior vertebral body heights-were recorded at preoperative, intraoperative, postoperative, and up to 2-year follow-up. Clinical outcome scores (visual analog score [VAS] and Oswestry Disability Index [ODI]) were also recorded at similar timepoints. Radiological outcomes reflect significant lordotic corrections of the vertebral wedge angles up to 2-year follow-up when compared with preoperative values (intraoperative: P = 0.06; postoperative: P = 0.001; 3 months: P = 0.002; 6 months: P = 0.004; 1 year: P = 0.011; 2 years: P = 0.016). Additionally, significant lordotic corrections of regional kyphosis angles (intraoperative: P = 0.00; postoperative: P = 0.00; 3 months: P = 0.031; 6 months: P = 0.039) and increases in anterior vertebral body heights (postoperative: P = 0.001; 3 months: P = 0.010; 6 months: P = 0.020) at up to 6-month follow-up were found. Preoperatively, median VAS of 85 (range 30-100) and ODI of 90 (range 40-98) were recorded. Statistically significant improvements in VAS and ODI were found across all timepoints when compared with preoperative values, with a mean VAS of 11.5 (SD 4.8) and ODI of 9.9 (SD 4.5) at 2-year follow-up. Surgical management of thoracolumbar fractures with or without neurological deficit has a role in reducing nursing requirements and postoperative morbidity in patients with polytrauma and other associated injuries. Our approach in treating thoracolumbar fractures with burst elements using MIS short-segment fixation and unipedicular screw manipulation technique shows satisfactory radiological correction and high rates of fracture union while reducing approach-related morbidity and improving functional outcomes.

Efficacy and Safety of Conservative Treatment Compared With Surgical Treatment for Thoracolumbar Fracture With Score 4 Thoracolumbar Injury Classification and Severity (TLICS): A Systematic Review and Meta-analysis.

This was a systematic review and meta-analysis. The clinical outcomes, radiologic outcome, and complications were compared between surgical treatment and conservative treatment of thoracolumbar fractures with a Thoracolumbar Injury Classification and Severity (TLICS) score of 4. The thoracolumbar fracture is the main reason leading to the spinal cord injury. Some studies suggested that the treatment of TLICS=4 is a "gray zone." Hence, the efficacy and safety of surgical treatment and conservative treatment of thoracolumbar fractures with scores 4 TLICS was still debated. A comprehensive search of PubMed, Embase, and the Cochrane Library, Chinese National Knowledge Infrastructure (CNKI), Chongqing VIP Database (VIP), and Wan Fang Database was performed up to October 2021. Relevant studies were identified using specific eligibility criteria and data was extracted and analyzed based on primary and secondary outcomes. A total of 10 studies involving 555 patients were included (3 randomized controlled trials and 7 retrospective studies). There was no significant difference of hospital time (standardized mean difference=0.24, 95% CI: -1.50 to 1.97, P =0.79) and Oswestry Disability Index (mean difference=2.97, 95% CI: -1.07 to 7.01, P =0.15) between surgery and nonsurgery. The length of returning to work was shorter in surgical treatment (standardized mean difference=1.27, 95% CI: 0.07-2.46, P =0.04). Visual Analog Scale in surgical treatment was lower at 1, 3, and 6 months (respectively, P <0.00001, P =0.003, and P =0.02). However, there existed no significant difference between surgical treatment and nonsurgical treatment at 12 and >24 months (respectively, P =0.18 and 0.17). Cobb angle was lower in surgical treatment at postoperative at 6, 12, and >24 months (respectively, P =0.005, P <0.00001, P =0.002, and P =0.0002). Finally, the surgical treatment had a lower incidence of complications (odds ratio=3.89, 95% CI: 1.90-7.94, P =0.0002). Current evidence recommended that surgical treatment is superior to conservative treatment of TLICS score of 4 at the early follow-up. Surgical treatment had lower Cobb angle, Visual Analog Scale scores, and complications compared with a nonsurgical TLICS score of 4. However, these findings needed to be verified further by multicenter, double-blind, and large-sample randomized controlled trials.

The difference and clinical application of modified thoracolumbar fracture classification scoring system in guiding clinical treatment

ObjectiveThis study aimed to evaluate the feasibility of the modified thoracolumbar injury classification and severity score system in guiding clinical treatment.MethodsA retrospective study was conducted on a cohort of 120 patients with thoracolumbar fractures who were admitted to the Department of Spinal Surgery at Ningbo Sixth Hospital between December 2019 and June 2021. The study population consisted of 68 males and 52 females, with an average age of 36.7 ± 5.7 years. The severity of the fractures was assessed based on comprehensive scores incorporating fracture morphology, neurological function, posterior ligament complex integrity, and disc injury status. The evaluation was performed using the total score T, which guided the formulation of the clinical treatment strategy. Furthermore, the study compared the treatment options, imaging data, and clinical efficacy between two classification systems.ResultsThe analysis of 120 patients revealed no statistically significant difference in the total score or treatment method between the TLICS system and the modified TLICS system. However, the operation rate for the modified TLICS system (73.3%) was slightly lower compared to the TLICS system (79.2%). All patients were followed up for a mean duration of 19.2 ± 4.6 months, ranging from 11 to 27 months. At the last follow-up, the visual analogue scale score was 1.94 ± 0.52, and the modified Japanese Orthopaedic Association score was 28.8 ± 4.5, indicating a significant improvement compared to the scores obtained prior to treatment. The neurological status exhibited varying degrees of improvement. Notably, the anterior vertebral height ratio was 87.10 ± 7.17%, the sagittal index was 90.35 ± 7.72%, and the Cobb angle was 3.05 ± 0.97 degrees at the last follow-up. All these measurements demonstrated statistically significant differences compared to the values observed prior to treatment (P < 0.05). Additionally, two cases of pedicle screw breakage and seven cases of pedicle screw wear and cutting in the vertebral body were observed at the last follow-up, resulting in varying degrees of low back pain. However, no instances of rod breakage were reported.ConclusionThe modified TLICS system is a practical tool for the classification and assessment of thoracolumbar fractures. It has guiding significance for clinical treatment, and the operation rate was slightly lower than that of TLICS system.

A novel scoring system concept for de novo spinal infection treatment, the Spinal Infection Treatment Evaluation Score (SITE Score): a proof-of-concept study.

De novo infections of the spine are an increasing healthcare problem. The decision for nonsurgical or surgical treatment is often made case by case on the basis of physician experience, specialty, or practice affiliation rather than evidence-based medicine. To create a more systematic foundation for surgical assessments of de novo spinal infections, the authors applied a formal validation process toward developing a spinal infection scoring system using principles gained from other spine severity scoring systems like the Spine Instability Neoplastic Score, Thoracolumbar Injury Classification and Severity Score, and AO Spine classification of thoracolumbar injuries. They utilized an expert panel and literature reviews to develop a severity scale called the "Spinal Infection Treatment Evaluation Score" (SITE Score). The authors conducted an evidence-based process of combining literature reviews, extracting key elements from previous scoring systems, and obtaining iterative expert panel input while following a formal Delphi process. The resulting basic SITE scoring system was tested on selected de novo spinal infection cases and serially refined by an international multidisciplinary expert panel. Intra- and interobserver reliabilities were calculated using the intraclass correlation coefficient (ICC) and Fleiss' and Cohen's kappa, respectively. A receiver operating characteristic analysis was performed for cutoff value analysis. The predictive validity was assessed through cross-tabulation analysis. The conceptual SITE scoring system combines the key variables of neurological symptoms, infection location, radiological variables for instability and impingement of neural elements, pain, and patient comorbidities. Ten patients formed the first cohort of de novo spinal infections, which was used to validate the conceptual scoring system. A second cohort of 30 patients with de novo spinal infections, including the 10 patients from the first cohort, was utilized to validate the SITE Score. Mean scores of 6.73 ± 1.5 and 6.90 ± 3.61 were found in the first and second cohorts, respectively. The ICCs for the total score were 0.989 (95% CI 0.975-0.997, p < 0.01) in the first round of scoring system validation, 0.992 (95% CI 0.981-0.998, p < 0.01) in the second round, and 0.961 (95% CI 0.929-0.980, p < 0.01) in the third round. The mean intraobserver reliability was 0.851 ± 0.089 in the third validation round. The SITE Score yielded a sensitivity of 97.77% ± 3.87% and a specificity of 95.53% ± 3.87% in the last validation round for the panel treatment decision. The SITE scoring concept showed statistically meaningful reliability parameters. Hopefully, this effort will provide a foundation for a future evidence-based decision aid for treating de novo spinal infections. The SITE Score showed promising inter- and intraobserver reliability. It could serve as a helpful tool to guide physicians' therapeutic decisions in managing de novo spinal infections and help in comparison studies to better understand disease severity and outcomes.

Validation of Thoracolumbar Injury Classification and Severity Score in the Management of Acute and Subacute Osteoporotic Vertebral Compression Fractures

Validation of Thoracolumbar Injury Classification and Severity Score in the Management of Acute and Subacute Osteoporotic Vertebral Compression Fractures

Management of late presented thoracolumbar spine fracture: Comparison of clinical and radiological outcome in anterior and posterior approach

Abstract Background: Between 5% and 10% of polytrauma patients suffer spinal fractures or dislocations. The vast majority of these injuries affect the motion segments between T11 and L2 at the thoracolumbar junction. A few thoracolumbar fractures may be treated conservatively by rigid orthosis and prompt mobilisation, but a large number of such injuries are better managed surgically. A variety of surgical approaches viz. Anterior, posterior or circumferential/combined are used to decompress and stabilise injured thoracolumbar spine. The ideal method is still a matter of some debate, and in most cases, the operative plan is influenced by both clinical and radiological conditions. The purpose of this study was to compare the results of anterior versus posterior decompression and reconstruction of the spine in late presentation (&gt;3 weeks). Materials and Methods: A prospective and randomised study was conducted from September 2012 to August 2014. Thirty patients with thoracolumbar spinal fractures (D11–L2) were taken for the study as per inclusion/exclusion criteria. The patients were operated 3 weeks after the injury due to late presentation. All patients underwent decompression and fixation of the spine using various methods either by anterior approach or posterior approach (15 patients in each group). All patients had Thoracolumbar Injury Classification and Severity Score 5 or more with age belonging to the age group of 15–65 years. On admission, American Spinal Injury Association Impairment Score (ASIA score) was evaluated and Frankel grade was assigned to each patient. Operative time, intraoperative blood loss, intraoperative and postoperative complications were noted. Neurology was assessed again at the time of discharge after surgery and at follow-up at month and then at 3-month intervals. Radiological evaluation is done based on a kyphotic angle before surgery and at follow-up visits. Clinical outcome variables analysis was done using an Unpaired t test and Graph Pad software. Significance was set at the P &lt; 0.05 level. Results: Of 30 patients, 15 belonged to each group. Group A (operated with an anterior approach) and group B (operated with a posterior approach) were comparable in terms of patient demographics, type of fracture, and follow-up duration. No patient suffered from neurological deterioration post-surgery. ASIA score improvement in group A is 66 points and in group B is 59 points. Frankel grade improvement is up to 1.3 in group A and 1.2 in group B. Cosmetic results were better in a posterior group with the shorter incision. Conclusion: With this comparative study, we find that the anterior approach is better in overall outcome if operated after 3 weeks of injury.

Thoracolumbar Injury Classification and Severity Score Is Predictive of Perioperative Adverse Events in Operatively Treated Thoracic and Lumbar Fractures.

A retrospective cohort study of patients with surgically treated thoracolumbar fractures. This study aimed to describe the incidence of adverse events (AEs) after surgical stabilization of thoracolumbar spine injuries and to identify predictive factors for the occurrence of AEs. Thoracolumbar spine fractures are frequently present in patients with blunt trauma and are associated with significant morbidity. AEs can occur due to the initial spinal injury or secondary to surgical treatment. There is a lack of emphasis in the literature on the AEs that can occur after operative management of thoracolumbar fractures. We performed a retrospective review of 199 patients with surgically treated thoracolumbar fractures operated between January 2007 and January 2018. The potential risk factors for the development of AEs as well as the development of common complications were evaluated by univariate analysis, and a multivariate logistic regression analysis was performed to identify independent risk factors predictive of the above. The overall rate of AEs was 46.7%; 83 patients (41.7%) had nonsurgical AEs, whereas 24 (12.1%) had surgical adverse events. The most common AEs were urinary tract infections in 43 patients (21.6%), and hospital-acquired pneumonia in 21 patients (10.6%). On multivariate logistic regression, a Thoracolumbar Injury Classification and Severity (TLICS) score of 8-10 (odds ratio [OR], 6.39; 95% confidence interval [CI], 2.33-17.51), the presence of polytrauma (OR, 2.64; 95% CI, 1.17-5.99), and undergoing open surgery (OR, 2.31; 95% CI, 1.09-4.88) were significant risk factors for AEs. The absence of neurological deficit was associated with a lower rate of AEs (OR, 0.47; 95% CI, 0.31-0.70). This study suggests the presence of polytrauma, preoperative American Spinal Injury Association score, and TLICS score are predictive of AEs in patients with surgically treated thoracolumbar fractures. The results might also suggest a role for minimally invasive surgical methods in reducing AEs in these patients.

Nonoperative Management in Intact Burst Fracture Patient With Thoracolumbar Injury Classification and Severity Score of 5: A Case Report

Thoracolumbar fractures are a common consequence of trauma, often a result of motor vehicle accidents or falls. Burst fractures are a morphology of thoracolumbar fracture in which compressive force causes retropulsion of the posterior elements of the vertebral body, potentially leading to neurological deficits. The Thoracolumbar Injury Classification and Severity (TLICS) score is a decision-making tool to help surgeons decide between nonoperative and operative management. For assigned scores of 4, management is at the discretion of the surgeon, and for scores ≥ 5, operative treatment is recommended. Burst fracture patients that are neurologically intact are given a score of 5 if there is a posterior ligamentous complex (PLC) injury and are recommended to undergo operative management. Here we present a neurologically intact patient with an L4 burst fracture with PLC injury that was managed conservatively and demonstrated successful clinical, functional, and radiographic recovery.

Reliability of the thoracolumbar injury classification and severity score compared with the McAfee classification among young neurosurgeons

Objective: The reliability of the thoracolumbar injury classification and severity (TLICS) score is well established; however, its reliability among young neurosurgeons in particular has not been investigated. This study was designed to identify intra- and inter-observer differences between the TLICS system and the McAfee classification among young neurosurgeons, with the goal of facilitating communication between physicians and treatment decision-making for patients with thoracolumbar injuries.Methods: Six young neurosurgeons reviewed thoracolumbar spinal fracture patients between January 2016 and October 2020 and analyzed thoracolumbar fractures according to the 2 classification systems. The intra- and inter-observer reliability of the TLICS and the McAfee scale was assessed with the Cohen and Fleiss kappa tests.Results: The intra-observer kappa value for the TLICS exhibited excellent reliability (κ=0.85) compared to the McAfee classification (κ=0.79). The inter-observer kappa values for each category of the TLICS were 0.69 (morphology), 0.93 (neurologic status), 0.74 (posterior ligamentous complex), and 0.72 (total score). The kappa value of the McAfee classification was lower (κ=0.52).Conclusion: The TLICS system showed higher reliability than the McAfee classification. The TLICS score showed more consistent results for thoracolumbar spinal fractures and may thus serve as a guideline for young neurosurgeons in treating patients with thoracolumbar fractures.

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

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

Radiological outcome of operative treatment with posterior approach in patients with thoracolumbar junction traumatic injuries: A single-center pilot study in a developing country.

Background: The thoracolumbar junction (TLJ) represents a transition zone of the spine that leads to a high incidence of fractures. The treatment of burst fractures remains controversial regarding the ideal management. This study assessed the postoperative radiological outcome of TLJ fixation in patients with TLJ injuries who underwent surgery.Methods: All traumatic patients with TLJ injuries who were referred to the Khatam hospital of Zahedan between 2015 and 2020, with their thoracolumbar injury classification and severity score (TLICS) of four or more and who underwent surgery, were included in this study. The patients who entered the study were called for a follow-up examination. The degree of kyphosis, proximal junctional kyphosis, and fusion were assessed in these patients.Results: Among 273 patients, the average age was 43.5 ± 12.3 (21–73) years. One hundred and ninety-eight patients (72.5%) had no neurological symptoms at admission. Based on the above criteria, the kyphosis angle of these patients was calculated before surgery, which in 46 patients (16.8%), the kyphosis angle was more than 25°. Preoperation kyphosis was significantly associated with follow-up kyphosis (P < 0.001). Evidence of no fusion was also observed in 22 patients (8.1%). According to the Chi-square test, no association was observed between preoperative kyphosis and postoperative complications, including PJK and fusion (P > 0.05).Conclusion: According to our study, the posterior spinal fixation procedure is a low-complication method with an acceptable radiological outcome. Although kyphosis before surgery is a factor in developing long-term kyphosis, it is not associated with nonfusion and PJK.

85. The neurology stability epidural compression assessment: a new score to establish the need for surgery in spinal metastases

85. The neurology stability epidural compression assessment: a new score to establish the need for surgery in spinal metastases

Assessment of Instability in Thoracolumbar Burst Fractures Using a New Bone Scan Scoring System.

Background and Objectives: Unstable thoracolumbar burst fractures require surgical management as they can result in neurological deficits if left untreated. This study aimed to evaluate whether a new bone scan scoring system could accurately assess instability in thoracolumbar burst fractures. Materials and Methods: Fifty-two patients with thoracolumbar burst fractures who underwent bone scans and magnetic resonance imaging prior to surgery between January 2015 and August 2017 at Ulsan University Hospital were selected for inclusion. Instability was determined by clinical assessment and imaging, and the Thoracolumbar Injury Classification and Severity score was determined. Bone scans were visually evaluated using a new bone scan scoring system. Bone scan findings of vertebral body (BB) and posterior column (BP) were scored separately and were summed to produce BTS {BTS (total score) = BB (body score, 5 points) + BP (posterior score, 2 points)}. The diagnostic performance of the scoring system for identifying unstable then thoracolumbar burst fractures were assessed. Results: Of the 52 thoracolumbar burst fractures, 34 (65.4%) were unstable and 31 (59.6%) had a Thoracolumbar Injury Classification and Severity score ≥ 5. The diagnostic performance of using BTS ≥ 4 to identify unstable thoracolumbar burst fractures and those with a Thoracolumbar Injury Classification and Severity score ≥ 5 was as follows: sensitivity, 61.8% and 58.1%; specificity, 94.4% and 81.0%; positive predictive value, 95.5% and 81.8%; and negative predictive value, 56.7% and 56.7%, respectively. Conclusions: The proposed bone scan scoring system has a high specificity and positive predictive value for identifying thoracolumbar burst fractures that are unstable or have a Thoracolumbar Injury Classification and Severity score ≥ 5. This scoring system may help to inform decisions regarding surgical management.

The effect of the sequence of intermediate instrumentation and distraction-reduction of the fractured vertebrae on the surgical treatment of mild to moderate thoracolumbar burst fractures

To investigate the effect of the sequence of intermediate instrumentation with long screws and distraction-reduction on mild to moderate thoracolumbar fractures treated by posterior open and short-segmental fixation. The clinical data of 68 patients with mild to moderate thoracolumbar burst fractures who met the selection criteria between January 2016 and June 2019 were retrospectively analyzed. The patients were divided into group ISDRF (intermediate screws then distraction-reduction fixation, 32 cases) and group DRISF (distraction-reduction then intermediate screws fixation, 36 cases) according to the different operation methods. There was no significant difference between the two groups in age, gender, body mass index, fracture segment, cause of injury, and preoperative load-sharing classification score, thoracolumbar injury classification and severity score, vertebral canal occupational rate, back pain visual analogue scale (VAS) score, anterior height of fractured vertebra, and Cobb angle ( P>0.05). The operation time, intraoperative blood loss, complications, and fracture healing time were recorded and compared between the two groups. The vertebral canal occupational rate, anterior height of fractured vertebra, kyphosis Cobb angle, and back pain VAS score before and after operation were used to evaluate the effectiveness. There was no significant difference in intraoperative blood loss and operation time between the two groups ( P>0.05). No vascular or spinal nerve injury and deep infections or skin infections occurred in both groups. At 1 week after operation, the vertebral canal occupational rate in the two groups was significantly improved when compared with that before operation ( P<0.05), no significant difference was found in the difference of vertebral canal occupational rate before and after operation and improvement between the two groups ( P>0.05). The patients in both groups were followed up 18-24 months, with an average of 22.3 months. All vertebral fractures reached bone union at 6 months postoperatively. At last follow-up, there was no internal fixation failures such as broken screws, broken rods or loose screws, but there were 2 cases of mild back pain in the ISDRF group. The intra-group comparison showed that the back pain VAS score, the anterior height of fractured vertebra, and the Cobb angle of the two groups were significantly improved at each time point postoperatively ( P<0.05); the VAS scores at 12 months postoperatively and last follow-up were also improved when compared with that at 1 week postoperatively ( P<0.05). At last follow-up, the anterior height of fractured vertebra in the ISDRF group was significantly lost when compared with that at 1 week and 12 months postoperatively ( P<0.05), the Cobb angle had a significant loss when compared with that at 1 week postoperatively ( P<0.05); the anterior height of fractured vertebra and Cobb angle in DRISF group were not significantly lost when compared with that at 1 week and 12 months postoperatively ( P>0.05). The comparison between groups showed that there was no significant difference in the remission rate of VAS score between the two groups at 1 week postoperatively ( P>0.05), the recovery value of the anterior height of fractured vertebra in ISDRF group was significantly higher than that in DRISF group ( P<0.05), the loss rate at last follow-up was also significantly higher ( P<0.05); the correction rate of Cobb angle in ISDRF group was significantly higher than that in DRISF group at 1 week postoperatively ( P<0.05), but there was no significant difference in the loss rate of Cobb angle between the two groups at last follow-up ( P>0.05). In the treatment of mild to moderate thoracolumbar burst fractures with posterior short-segment fixation, the instrumentation of long screws in the injured vertebrae does not affect the reduction of the fracture fragments in the spinal canal. DRISF can better maintain the restored anterior height of the fractured vertebra and reduce the loss of kyphosis Cobb angle during the follow-up, indicating a better long-term effectiveness.