Traumatic Thoracolumbar Injuries Research Articles

In-hospital mortality trends after surgery for traumatic thoracolumbar injury: A national inpatient sample database study

IntroductionGiven the increasing incidence of traumatic thoracolumbar injuries in recent years, studies have sought to investigate potential risk factors for outcomes in these patients. Research questionThe aim of this study was to investigate trends and risk factors for in-hospital mortality after fusion for traumatic thoracolumbar injury. Materials and methodsPatients undergoing thoracolumbar fusion after traumatic injury were queried from the National Inpatient Sample (NIS) from 2012 to 2017. Analysis was performed to identify risk factors for inpatient mortality after surgery. ResultsPatients in 2017 were on average older (51.0 vs. 48.5, P = 0.004), had more admitting diagnoses (15.5 vs. 10.7, p < 0.001), were less likely to be White (75.8% vs. 81.2%, p = 0.006), were from a ZIP code with a higher median income quartile (Quartile 1: 31.4% vs. 28.6%, p = 0.011), and were more likely to have Medicare as a primary payer (22.9% vs. 30.1%, p < 0.001). Bivariate analysis of demographics and surgical characteristics demonstrated that patients in the in-hospital mortality group (n = 90) were older (70.2 vs. 49.6, p < 0.001), more likely to be male (74.4% vs. 62.8%, p = 0.031), had a great number of admitted diagnoses (21.3 vs. 12.7, p < 0.001), and were more likely to be insured by Medicare (70.0% vs. 27.0%, p < 0.001). Multivariate regression analysis found age (OR 1.06, p < 0.001) and Black race (OR 3.71, p = 0.007) were independently associated with in-hospital mortality. ConclusionOur study of nationwide, traumatic thoracolumbar fusion procedures from 2012 to 2017 in the NIS database found older, black patients were at increased risk for in-hospital mortality after surgery.

Percutaneous pedicle screw fixation without arthrodesis of 368 thoracolumbar fractures: long-term clinical and radiological outcomes in a single institution.

Traumatic thoracolumbar (TL) fractures are the most common vertebral fractures. Although a consensus on the preferred treatment is missing, percutaneous pedicle screw fixation (PPSF) has been progressively accepted as treatment option, since it is related to lower soft tissues surgical-injury and perioperative complications rate. This study aims to evaluate the long-term clinical-radiological outcomes after PPSF for TL fractures at a single tertiary academic hospital. This is a retrospective cohort study. Back pain was obtained at preoperative, postoperative and final follow-up using Visual Analog Scale. Patient-reported outcomes, the Oswestry Disability Index and the 36-Item Short Form, were obtained to asses disability during follow-up. Radiological measures included Cobb angle, mid-sagittal index, sagittal index (SI) and vertebral body height loss. A multivariate regression analysis on preoperative radiological features was performed to investigate independent risk factors for implant failure. A total of 296 patients with 368 TL fractures met inclusion criteria. Mean follow-up was 124.3months. The clinical and radiological parameters significantly improved from preoperative to last follow-up measurements. The multivariate analysis showed that Cobb angle (OR = 1.3, p < 0.001), SI (OR = 1.5, p < 0.001) and number of fractures (OR = 1.1, p = 0.05), were independent risk factors for implant failure. The overall complication rate was 5.1%, while the reoperation rate for implant failure was 3.4%. In our case series, PPSF for TL injuries demonstrated good long-term clinical-radiological outcomes, along with low complication and reoperation rates. Accordingly, PPSF could be considered as a valuable treatment option for neurologically intact patients with TL fractures. Additionally, in this cohort, number of fractures ≥ 2, Cobb angle ≥ 15° and sagittal index ≥ 21° were independent risk factors for implant failure.

Predicting Length of Stay After Thoracolumbar Trauma: A Single-Center, Retrospective Analysis.

Length of stay (LOS) is a meaningful outcome measure for more efficient and effective quality of care. However, algorithms to predict LOS have yet to be created for patients who undergo surgical management for traumatic spinal fractures. The objectives of this study were to (1) identify preoperative, perioperative, and postoperative factors associated with increased LOS and (2) create predictive formulas to estimate LOS in thoracolumbar trauma patients who undergo surgical correction. This is a retrospective case series of 196 patients operated for thoracolumbar spine trauma from January 2012 to December 2017 at a level 1 trauma and academic institution. Bivariate analysis between LOS and various preoperative, perioperative, and postoperative factors was conducted to identify significant associations. Multivariate analysis was conducted to create models capable of predicting LOS. LOS was significantly associated with various preoperative (eg, Charlson Comorbidity Index, Glasgow Coma Scale [GCS], injury severity score), operative (eg, length of surgery, number of instrumented segments, surgical technique), and postoperative variables (eg, complications, discharge location). Multivariate analysis of preoperative variables identified 5 significant independent predictors that could predict LOS with strong correlation with observed LOS (ρ = 0.63). With all variables considered, multivariate analysis identified 8 variables (GCS, American Society of Anesthesiologists score, neurological status, polytrauma, packed red blood cell transfusion, number of unique postoperative complications, skin complications, and discharge facility) that could predict LOS with strong correlation (ρ = 0.80). Various preoperative, perioperative, and postoperative factors are significantly associated with LOS in traumatic thoracolumbar spine patients. We developed models with good predictive capacity for LOS. If validated, these models should help in risk stratifying patients for increased LOS and consequently improve perioperative patient counseling. This article contributes to identifying and predicting patients who are high risk for extended LOS after traumatic thoracolumbar injuries.

Surgical treatment of traumatic thoracolumbar fractures: a retrospective review of 101 cases.

To evaluate the outcomes of vertebral stabilisation after acute traumatic thoracolumbar fractures, correlating the outcome with patient clinical data, type and location of fracture, presence of neurological damage, timing of surgical intervention and number of instrumented levels. The results have been evaluated also through the AO classification and AOSIS score. Retrospective analysis of 101 patients with traumatic thoracolumbar injuries from T3 to L5 operated 2011-2016 by posterior or antero-posterior fixation. The demographic data, trauma dynamics, number and type of fractures, associated lesions, timing of surgery, hospital stay, AOSIS score, RKA, SF-36 and ODI scores, pre- and post-operative neurological condition (ASIA grade), possible complications and re-interventions were evaluated for each patient. Fractures mainly involved the region between T11 and L2. The probability of medullary involvement increases with the increase in severity of the main fracture type with no relation with the vertebral region. Type B and C fractures were common in the thoracic region and rare in the thoracolumbar junction. ODI and SF-36 scores were significantly better in patients with a lower AOSIS score, specifically in lesions classified as type A, amyelic and with no comorbidity. No difference was found in the clinical scores between thoracic, thoracolumbar and lumbar fractures, nor between male and female patients. None of the 10 patients with ASIA A lesion at presentation achieved any degree of recovery: 50% of them had a thoracic lesion. Re-intervention rate was 15%. Hospital stay was significantly higher in patients with type C fractures, and complication rate was on average 14% (7% in type A fractures, 16% in B and 25% in C). This study confirmed the validity of the posterior approach in the surgical treatment of thoracolumbar fractures. Outcomes and complication risks are related to fracture severity. Surgical treatment can be recommended even with an AOSIS score of two or three. The combined antero-posterior approach could be useful in cases with LSC > 8, especially in the thoracolumbar region. The degree of neurological recovery depends on fracture type, location, ASIA score and presence of comorbidities. Early intervention in myelic patients allows for a better prognosis. Level of evidence III retrospective case series.

Minimally Invasive Surgery in Treatment of Traumatic Thoracolumbar Spinal Injuries: A 2-Year Experience

Introduction: Majority of the traumatic spine injuries are located at the thoracolumbar region. They can be compression fractures, burst fractures, flexionextension injuries (Chance fractures), dislocations, or any of the combination. Surgery is indicated for patients with thoracolumbar injury classification scoring (TLICS) of 4 or more. Traditionally, surgical approaches for thoracolumbar spinal injuries involve open surgery, instrumentation with/without decompression. In our previous study, open surgery for traumatic thoracolumbar injuries and history of blood transfusion have been found to be associated with higher risk of deep surgical site infection requiring surgical debridement. With the advent of modern implants and equipments, minimally invasive surgery (MIS) has been made possible for spine surgeries. We report our two-year experience in utilizing MIS to treat traumatic thoracolumbar spinal injuries. Materials and method: Patients who underwent spinal surgeries at Hospital Tengku Ampuan Afzan, Kuantan from July 2017 to July 2019 were screened for suitability to be included in this study. Only patients who underwent spinal minimally invasive surgeries have been included in this study. Patients who underwent open spinal surgeries were excluded. Results: A total of 8 patients were included in this study. There were 3 burst fractures and 5 chance fractures. All patients underwent a minimum of 4-level posterior spinal instrumented fusion with MIS techniques and 2 patients had laminectomy at the injured level for decompression. All but one patient did not require blood transfusion and there was no incidence of surgical site infection among these patients. Conclusion: Minimally invasive surgery (MIS) is a better option compared to open surgery in treating traumatic thoracolumbar spinal injuries. By minimizing the surgical incision, we are able to reduce blood loss and avoid deep surgical site infection.

Operative versus Non-Operative Management of Traumatic Thoracolumbar Injuries according to the AO Spine Thoracolumbar Spine Injury Classification System

AbstractIntroduction The AOSpine Thoracolumbar Spine Injury Classification (AOSTSIC) system has been proposed to better characterize injury morphologies and improve the classification of thoracolumbar (TL) spine trauma. However, the indications for surgical treatment according to the AOSTSIC system are still debated. Additionally, the proposed Thoracolumbar AOSpine Injury Score (AOSIS) is quite complex, which may preclude its use in daily practice. The objective of this review is to discuss the AOSTSIC system and its indications for initial nonoperative versus surgical management of acute TL spine trauma.Methods We analyzed the literature for each injury type (and subtype, when pertinent) according to the AOSTSIC system as well as their potential treatment options.Results Patients with AOSTSIC subtypes A0, A1, and A2 are neurologically intact in the vast majority of the cases and initially managed nonoperatively. The treatment of A3- and A4-subtype injuries (burst fractures) in neurologically-intact patients is still debated with great controversy, with initially nonoperative management being considered an option in select patients. Surgery is recommended when there are neurological deficits or failure of nonoperative management, with the role of magnetic resonance findings in the Posterior Ligamentous Complex (PLC) evaluation still being considered controversial. Injuries classified as type B1 in neurologically-intact patients may be treated, initially, with nonoperative management, provided that there are no ligamentous injury and non-displacing fragments. Due to severe ligamentous injury, type-B and type-C injuries should be considered as unstable injuries that must be surgically treated, regardless of the neurological status of the patient.Conclusions Until further evidence, we provided an easy algorithm-based guide on the spinal trauma literature to help surgeons in the decision-making process for the treatment of TL spine injuries classified according to the new AOSTSIC system.

The Utility of In-Hospital Postoperative Radiographs Following Surgical Treatment of Traumatic Thoracolumbar Injuries.

A retrospective cohort study. The objective of this study was to assess the utility of routine in-hospital postoperative radiographs for identifying hardware failure following surgical treatment of traumatic thoracolumbar (TL) injuries. Postoperative radiographs following spine surgery are considered standard of care despite a lack of evidence supporting their utility. Previous studies have concluded that postoperative radiographs following lumbar fusion for degenerative conditions have limited clinical value. A retrospective chart review was performed on patients who underwent surgical treatment of traumatic TL injuries between December 2006 and October 2015 at a level I trauma center. Before discharge, postoperative upright anteroposterior and lateral radiographs were obtained and reviewed by 1 surgeon and 1 radiologist as per protocol. Patients who subsequently underwent revision surgery during their initial hospital stay were identified. These patients were further analyzed to identify the indications for surgery and determine if the results of the radiographs obtained led to the subsequent revision surgery. A total of 463 patients were identified who underwent surgical treatment following TL trauma. The rate of revision surgery during the initial hospitalization was 1.3% (6/463). Three patients underwent revision surgery due to worsening neurological status. One patient underwent reoperation because of advance imaging obtained for abdominal trauma. Two patients underwent revision surgery due to abnormal findings on postoperative radiographs. The overall sensitivity and specificity of routine postoperative radiographs was 33.3% and 100%, respectively. In the absence of new clinical signs and symptoms, obtaining routine in-hospital postoperative radiographs following surgical treatment of TL injuries provides minimal value. Clinical assessment should help determine if additional imaging is indicated for the patient. Avoiding unnecessary inpatient tests such as routine postoperative radiograph may offer multitude of benefits including lowering patient radiation exposure, reducing health care costs and better allocation of hospital resources. Level III.

Congress of Neurological Surgeons Systematic Review and Evidence-Based Guidelines on the Evaluation and Treatment of Patients With Thoracolumbar Spine Trauma: Classification of Injury

Are there classification systems for fractures of the thoracolumbar spine that have been shown to be internally valid and reliable (ie, do these instruments provide consistent information between different care providers)? A classification scheme that uses readily available clinical data (eg, computed tomography scans with or without magnetic resonance imaging) to convey injury morphology, such as Thoracolumbar Injury Classification and Severity Scale or the AO Spine Thoracolumbar Spine Injury Classification System, should be used to improve characterization of traumatic thoracolumbar injuries and communication among treating physicians. Strength of Recommendation: Grade B. In treating patients with thoracolumbar fractures, does employing a formally tested classification system for treatment decision-making affect clinical outcomes? There is insufficient evidence to recommend a universal classification system or severity score that will readily guide treatment of all injury types and thereby affect outcomes. Strength of Recommendation: Grade Insufficient The full version of the guideline can be reviewed at: https://www.cns.org/guideline-chapters/congress-neurological-surgeons-systematic-review-evidence-based-guidelines/chapter_2.

82 - The Utility of In-Hospital Postoperative Radiographs following Surgical Treatment of Traumatic Thoracolumbar Injuries

82 - The Utility of In-Hospital Postoperative Radiographs following Surgical Treatment of Traumatic Thoracolumbar Injuries

The Role of Minimally Invasive Techniques in the Treatment of Thoracolumbar Trauma

Context: Thoracolumbar injuries are common manifestations of spinal trauma. While non-operative therapy is indicated in certain cases of isolated injury, operative therapy via open approaches are widely utilized. Recently, minimally invasive surgical (MIS) approaches have been adapted for the management of thoracolumbar trauma in an effort to avoid the operative morbidity of open thoracolumbar procedures.Purpose: The purpose of this review is to perform a critical analysis of the literature regarding the clinical efficacy and safety of MIS procedures in the management of thoracolumbar trauma.Evidence Acquisition: PubMed and MEDLINE databases were searched for articles published on the topic of MIS treatment of traumatic thoracolumbar injuries. Studies included in this review were comprised of clinical case series, retrospective cohort studies, non-randomized prospective cohort studies, prospective randomized controlled trials, and meta-analyses.Results: The majority of published studies were retrospective clinical case series comprising level IV evidence. The majority of studies demonstrated the viability of MIS approaches as a treatment modality for thoracolumbar trauma in regards to clinical outcomes, radiographic outcomes, and complication rates. Additionally, MIS procedures were associated with reductions in operative time, intraoperative blood loss, and immediate postoperative pain.Conclusions: MIS approaches to thoracolumbar trauma are viable treatment strategies in regards to clinical efficacy and safety. While the results for MIS procedures are promising, more high-quality prospective studies are necessary in order to make definitive conclusions regarding the superiority of MIS over open surgical strategies.

Diagnostic Value of Clinical Findings in Evaluation of Thoracolumbar Blunt Traumas.

Necessity of imaging for symptom-free conscious patients presented to emergency department (ED) following traumatic thoracolumbar spine injuries has been a matter of debate. The present study was aimed to evaluate the diagnostic value of clinical findings in prediction of traumatic thoracolumbar injuries compared tocomputed tomography (CT) scan. The present diagnostic value study was carried out using non-random convenience sampling during the time between October 2013 and March 2014. All trauma patients > 15 years old underwent thoracolumbar CT scan were included. Correlation between clinical and CT findings was measured using SPSS 21.0 and screening performance characteristics of clinical findings in prediction of thoracolumbar fracture were calculated. 169 patients with mean age of 37.8 ± 17.3 years (rage: 15-86) were evaluated (69.8% male). All fracture patients had at least 1 positive finding in history and physical examination. The fracture was confirmed in only 24.6% of the patients with positive findings in history or physical examination. In 37.5% of patients the location of fracture, matched the area of positive physical examinations. Sensitivity, specificity, PPV, NPV, PLR, and NLR of clinical findings in comparison to thoracolumbar CT scan were 100 (95% CI: 89 - 100), 1.5 (95% CI: 0.2-6), 24.5 (95% CI: 18.3-31.9), 100 (95% CI: 19.7-100), 32.5 (95% CI: 24.6-43.03), and infinite, respectively. The results of the present study, show the excellent screening performance characteristics of clinical findings in prediction of traumatic thoracolumbar fracture (100% sensitivity). It could be concluded that in conscious patients with stable hemodynamic, who have no distracting pain and are not intoxicated, probability of thoracolumbar fracture is very low and near to zero in case of no positive clinical finding.

A Comparative Inter- and Intraobserver Agreement Evaluation of Thoracolumbar Spine Injury Classification Systems and Limb Fracture Classification Schemes

Introduction It has been postulated that the complex patterns of thoracolumbar spinal injuries have prevented an adequate inter- and intraobserver agreement for the most widespread classification schemes; however, limb fracture classifications have also shown variable agreements. Using trochanteric fractures of the proximal femur (TFPF) as contrast model, we evaluated if two thoracolumbar spine injuries classification systems exhibit different agreement than one limb fracture classification schemes. Patients and Methods Six evaluators (three spine surgeons and three orthopedic surgery residents) classified the radiographs and computed tomography scans of 70 patients with acute traumatic thoracolumbar injuries using the four main types of the Denis classification and the morphologic grading of the new AO Thoracolumbar Spine Injury Classification System. In addition, six evaluators (three hip specialists and the same three orthopedic surgery residents) classified the radiographs of 70 patients with TFPF using the Tronzo and the AO classification schemes. The evaluators were unaware of the patients' identification, the original classification used in their clinical care, and the treatment they received. Overall, 6 weeks later, all cases were presented in a random sequence for repeat assessment. The Kappa coefficient (κ) was used to determine inter- and intraobserver agreement. Results Interobserver agreement: For spinal injuries, using the AO classification, the mean κ was 0.62 (95% CI, 0.57–0.66) considering fracture types, and 0.55 (95% CI, 0.52–0.57) considering subtypes; using the Denis classification, κ was 0.62 (95% CI, 0.59–0.65). For TPFP, with the AO scheme, the mean κ was 0.58 (95% CI, 0.54–0.63) considering fracture types and 0.31 (95% CI, 0.28–0.33) considering subtypes; for the Tronzo classification, κ was 0.54 (95% CI, 0.50–0.57). Intraobserver agreement: For spinal injuries, using the AO classification, the mean κ was 0.77 (95% CI, 0.72–0.83) considering fracture types, and 0.71 (95% CI, 0.67–0.76) considering subtypes; for the Denis classification, κ was 0.76 (95% CI, 0.71–0.81). For TPFP, with the AO scheme, the mean κ was 0.75 (95% CI, 0.69–0.81) considering fracture types and 0.45 (95% CI, 0.39–51) considering subtypes; for the Tronzo classification, κ was 0.64 (95% CI, 0.58–0.70). Conclusion Considering the main three groups, inter- and intraobserver agreement for the AO Spine TL classification were comparable to inter- and intraobserver agreement observed for the AO classification of TPFP. What is more, if the subtypes were included, inter- and intraobserver agreement evaluating TL spine injuries were significantly better than inter- and intraobserver agreement assessing TFPF with the AO classifications. In addition, inter- and intraobserver agreement evaluations of the Denis classification of TL spine injuries were significantly better than the agreement obtained for the Tronzo classification of TFPF. Current TL spine injuries classifications allow an adequate communication among treating physicians, and they demonstrated equivalent or better inter- and intraobserver agreement than TFPF classification systems.

An Independent Inter- and Intraobserver Agreement Evaluation of the New AO Spine Thoracolumbar Spine Injury Classification System

Introduction Thoracolumbar fracture classification systems have failed to demonstrate adequate comprehensiveness, or have demonstrated low reliability and reproducibility. The new AO Spine Thoracolumbar Spine Injury Classification System was recently published. It showed substantial reliability and reproducibility among the surgeons who developed it; however, an independent evaluation has not been performed. We performed an independent interobserver and intraobserver agreement evaluation of the new AO Spine Thoracolumbar Spine Injury Classification System. Patients and Methods Anteroposterior and lateral radiographs, and computed tomography scans of 70 patients with acute traumatic thoracolumbar injuries were selected and classified by six evaluators (three spine surgeons and three orthopedic surgery residents). The evaluators were unaware of the patients' identification, the original classification used in their clinical care, and the treatment they received. They classified the lesions according to the morphologic grading of the new AO Spine thoracolumbar spine injury classification system as an A, B, or C type injury; in cases with type A or type B injuries, an analysis for A or B subtypes lesions was also performed. After a 6-week interval, the 70 cases were presented in a random sequence to the same evaluators for repeat evaluation. The Kappa coefficient (κ) was used to determine the interobserver and intraobserver agreement. Results All the different fracture patterns as described by the new AO Spine thoracolumbar spine injury classification system were identified by at least one evaluator. The interobserver reliability was substantial when considering the fracture types (A, B, or C), with k = 0.62 (0.57–0.66). The interobserver agreement when considering the subtypes was moderate; k = 0.55 (0.52–0.57). The intraobserver reproducibility was also substantial, with 85.95% full intraobserver reproducibility considering the fracture type, with k = 0.77 (0.72–0.83), and it was also substantial when considering subtypes with 75.71% full agreement and k = 0.71 (0.67–0.76). No significant differences were observed between spine surgeons and orthopedic residents in the overall interobserver reliability and intraobserver reproducibility, or in the interobserver and intraobserver agreement of specific A, B, or C types of injuries. Conclusion Our study showed substantial agreement among different observers and by the same observer on separate occasions. Considering that this classification allows a better communication among physicians than previous schemes, it could be employed as a practical tool for everyday clinical use. Furthermore, clinical studies employing this classification should be considered more accurate, and their conclusions become more relevant to guide treatment decision making than studies using other classification schemes, especially in case of multicenter studies.

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

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

Applicability of thoracolumbar injury classification and severity score to criteria of korean health insurance review and assessment service in treatment decision of thoracolumbar injury.

ObjectiveFor improving the drawbacks of previous thoracolumbar spine trauma classification, the Spine Trauma Study Group was developed new classification, Thoracolumbar Injury Classification and Severity Score (TLICS). The simplicity of this scoring system makes it useful clinical application. However, considering criteria of Korean Health Insurance Review and Assessment Service (HIRA), the usefulness of TLICS system is still controversial in the treatment decision of thoracolumbar spine injury.MethodsTotal 100 patients, who admitted to our hospital due to acute traumatic thoracolumbar injury, were enrolled. In 45, surgical treatment was performed and surgical treatment was decided following the criteria of HIRA in all patients. With assessing of TLICS score and Denis's classification, the treatment guidelines of TLICS and Denis's classification were applied to the criteria of Korean HIRA.ResultsAccording to the Denis's three-column spine system, numbers of patients with 2 or 3 column injuries were 94. Only 45 of 94 patients (47.9%) with middle column injury fulfilled the criteria of HIRA. According to TLICS system, operation required fractures (score>4) were 31 and all patients except one fulfilled the criteria of HIRA. Conservative treatment required fractures (score<4) were 52 and borderline fracture (score=4) were 17.ConclusionThe TLICS system is very useful system for decision of surgical indication in acute traumatic thoracolumbar injury. However, the decision of treatment in TLICS score 4 should be carefully considered. Furthermore, definite criteria of posterior ligamentous complex (PLC) injury may be necessary because the differentiation of PLC injury between TLICS score 2 and 3 is very difficult.

Variability in Rates of Arthrodesis for Patients With Thoracolumbar Spine Fractures With and Without Associated Neurologic Injury

Retrospective cohort study using a large clinical database. Assess hospital-based rates of thoracolumbar spine arthrodesis within the United States for patients with a thoracolumbar spine fracture. Substantial variation has been documented in per capita rates of elective lumbar spinal arthrodesis. Similar data regarding rates of arthrodesis for traumatic thoracolumbar injuries have not been reported. Data from the Health Care Cost and Utilization Project Nationwide Inpatient Sample from 1998 to 2002 was used. ICD-9-CM codes were used to identify patients with thoracolumbar vertebral fractures with and without associated neurologic injury. Hospitals were grouped by teaching status and volume of thoracolumbar fracture patients and compared for rates of arthrodesis. Arthrodesis rates for the 25 highest fracture volume hospitals in the database were compared individually. A total of 24,098 patients with thoracolumbar fracture were identified: 91.7% had a thoracolumbar fracture without neurologic injury, while 8.3% had a thoracolumbar fracture with neurologic injury. Overall, 9.1% of thoracolumbar fracture patients without neurologic injury underwent arthrodesis, while 61.4% of thoracolumbar fracture patients with neurologic injury underwent arthrodesis. For all patients, rates of arthrodesis at high-volume hospitals were significantly greater than arthrodesis rates at lower-volume hospitals. Similarly, urban teaching hospitals had higher rates of arthrodesis than those at urban nonteaching hospitals. Among the 25 highest-volume hospitals in our sample, spinal arthrodesis rates for patients without associated neurologic injury ranged from 4% to 23%, a 5.8-fold variation. Among fracture patients with neurologic injury, arthrodesis rates ranged from 50% to 91%, a 1.8-fold variation. Hospital teaching status and spine fracture volume affected rates of spine arthrodesis in thoracolumbar fracture patients with and without neurologic injury. Variability in fusion rate for thoracolumbar spine trauma appears to be lower than that reported for elective spine procedures, especially in the presence of a neurologic injury.

Radiographic Measurement Parameters in Thoracolumbar Fractures: A Systematic Review and Consensus Statement of the Spine Trauma Study Group

Systematic review. To review the various radiographic parameters currently used to assess traumatic thoracolumbar injuries, emphasizing the validity and technique behind each one, to formulate evidence-based guidelines for a standardized radiographic method of assessment of these fractures. The treatment of thoracolumbar fractures is guided by various radiographic measurement parameters. Unfortunately, for each group of parameters, there has usually been more than 1 proposed measurement technique, thus creating confusion when gathering data and reporting outcomes. Ultimately, this effect results in clinical decisions being based on nonstandardized, nonvalidated outcome measures. Computerized bibliographic databases were searched up to January 2004 using key words and Medical Subject Headings on thoracolumbar spine trauma, radiographic parameters, and methodologic terms. Using strict inclusion criteria, 2 independent reviewers conducted study selection, data abstraction, and methodologic quality assessment. There were 18 original articles that ultimately constituted the basis for the review. Of radiographic measurement parameters, 3 major groups were identified, depicting the properties of the injured spinal column: sagittal alignment, vertebral body compression, and spinal canal dimensions, with 14 radiographic parameters reported to assess these properties. Based on a systematic review of the literature and expert opinion from an experienced group of spine trauma surgeons, it is recommended that the following radiographic parameters should be used routinely to assess thoracolumbar fractures: the Cobb angle, to assess sagittal alignment; vertebral body translation percentage, to express traumatic anterolisthesis; anterior vertebral body compression percentage, to assess vertebral body compression, the sagittal-to-transverse canal diameter ratio, and canal total cross-sectional area (measured or calculated); and the percent canal occlusion, to assess canal dimensions.