F. C. Oner

A New Classification of Thoracolumbar Injuries: The Importance of Injury Morphology, the Integrity of the Posterior Ligamentous Complex, and Neurologic Status

Study Design. A new proposed classification system for thoracolumbar (TL) spine injuries, including injury severity assessment, designed to assist in clinical management. Objective. To devise a practical, yet comprehensive, classification system for TL injuries that assists in clinical decision-making in terms of the need for operative versus nonoperative care and surgical treatment approach in unstable injury patterns. Summary of Background Data. The most appropriate classification of traumatic TL spine injuries remains controversial. Systems currently in use can be cumbersome and difficult to apply. None of the published classification schemata is constructed to aid with decisions in clinical management. Methods. Clinical spine trauma specialists from a variety of institutions around the world were canvassed with respect to information they deemed pivotal in the communication of TL spine trauma and the clinical decision-making process. Traditional injury patterns were reviewed and reconsidered in light of these essential characteristics. An initial validation process to determine the reliability and validity of an earlier version of this system was also undertaken. Results. A new classification system called the Thoracolumbar Injury Classification and Severity Score (TLICS) was devised based on three injury characteristics: 1) morphology of injury determined by radiographic appearance, 2) integrity of the posterior ligamentous complex, and 3) neurologic status of the patient. A composite injury severity score was calculated from these characteristics stratifying patients into surgical and nonsurgical treatment groups. Finally, a methodology was developed to determine the optimum operative approach for surgical injury patterns. Conclusions. Although there will always be limitations to any cataloging system, the TLICS reflects accepted features cited in the literature important in predicting spinal stability, future deformity, and progressive neurologic compromise. This classification system is intended to be easy to apply and to facilitate clinical decision-making as a practical alternative to cumbersome classification systems already in use. The TLICS may improve communication between spine trauma physicians and the education of residents and fellows. Further studies are underway to determine the reliability and validity of this tool.

Radiographic measurement parameters in thoracolumbar fractures: a systematic review and consensus statement of the spine trauma study group.

Study Design. Systematic review. Objectives. 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. Summary of Background Data. 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. Methods. 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. Results. 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. Conclusions. Based on a systematic review of theliterature 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.

The surgical approach to subaxial cervical spine injuries: an evidence-based algorithm based on the SLIC classification system.

Study Design. Systematic review of literature and expert clinical opinions of the members of the Spine Trauma Study Group were combined to develop and refine this algorithm. Obejctive. To develop an evidence-based algorithm for surgical approaches to manage subaxial cervical injuries using a systematic review of the literature, expert opinion, and anticipated patient preferences. Summary of Background Data. There is lack of consensus in the management of subaxial cervical spine trauma, in part, because of the lack of a clinically relevant system for classifying these injuries. The newly developed Subaxial Injury Classification scoring system categorizes injury morphology into 3 broad groups, includes an assessment of the integrity of the discoligamentous soft tissue structures and the patients neurologic status, and thus guides surgical or nonsurgical treatment. The choice of a specific surgical technique and approach is currently not evidence based, and this gap in knowledge is one which the current article seeks to address. Methods. A literature review followed by a consensus of experts approach was used to develop the algorithm and to ensure face and content validity. Results. An algorithm is presented to guide the choice of surgical approach in cervical subaxial burst fractures, distraction injuries, and translation or rotation injuries. The burst or compression injuries and distraction injuries are more likely to be treated with a single anterior approach, whereas the more severe translation or rotation injuries may more commonly be approached posteriorly or with combined anterior and posterior surgery. Conclusion. This algorithm; derived from the Subaxial Injury Classification scoring system, will assist surgeons in answering the 2 most common questions they face when managing subaxial cervical spine trauma: “Should I operate?” and “Which surgical approach should I select?”

Thoracolumbar injury classification and severity score: a new paradigm for the treatment of thoracolumbar spine trauma

BackgroundContemporary understanding of the biomechanics, natural history, and methods of treating thoracolumbar spine injuries continues to evolve. Current classification schemes of these injuries, however, can be either too simplified or overly complex for clinical use.MethodsThe Spine Trauma Group was given a survey to identify similarities in treatment algorithms for common thoracolumbar injuries, as well as to identify characteristics of injury that played a key role in the decision-making process.ResultsBased on the survey, the Spine Trauma Group has developed a classification system and an injury severity score (thoracolumbar injury classification and severity score, or TLICS), which may facilitate communication between physicians and serve as a guideline for treating these injuries. The classification system is based on the morphology of the injury, integrity of the posterior ligamentous complex, and neurological status of the patient. Points are assigned for each category, and the final total points suggest a possible treatment option.ConclusionsThe usefulness of this new system will have to be proven in future studies investigating inter- and intraobserver reliability, as well as long-term outcome studies for operative and nonoperative treatment methods.

Agreement between orthopedic surgeons and neurosurgeons regarding a new algorithm for the treatment of thoracolumbar injuries: a multicenter reliability study.

Introduction Considerable variability exists in the management of thoracolumbar (TL) spine injuries. Although there are many influences, one significant factor may be the treating surgeons specialty and training (ie, orthopedic surgery vs. neurosurgery). Our objective was to assess the agreement between spinal orthopedic and neurologic surgeons in rating the severity of TL spine injuries with a new treatment algorithm. This information could be important in establishing consensus-based protocols for managing these challenging injuries. Methods Twenty-eight spinal surgeons (8 neurosurgeons and 20 orthopedic surgeons) reviewed 56 TL injury case histories. Each case was classified and scored according to the TL injury severity score (TLISS). The case histories were reordered and the physicians repeated the exercise 3 months later. At both intervals the surgeons were asked if they agreed with the final treatment recommendation of the TLISS algorithm. The reliability and decision validity of the TLISS was compared. Results Between-group interrater reliability was similar to within group reliabilities. Intrarater reliability was also similar between groups. The between speciality interrater reliability of the TLISS management recommendation was moderate (74% agreement, κ=0.532). Orthopedic and neurosurgeons agreed with the TLISS management recommendation 91.4% and 94.4% of the time, respectively. Conclusions The TLISS demonstrated good reliability in terms of intraobserver and interobserver agreement on the algorithmic treatment recommendations. The recommendation for operation seems to be consistent between fellowship-trained orthopedic and neurosurgical spine surgeons. This type of classification system may reduce the existing variability and initial management decision for treatment of TL injuries.

Validating a newly proposed classification system for thoracolumbar spine trauma: looking to the future of the thoracolumbar injury classification and severity score.

Background: Although numerous systems have been proposed, there is no universally accepted classification or scoring system for thoracolumbar spine injuries. Some have gained popularity, but most systems have never been modified or advanced beyond their initial introductory state. To the authors knowledge, no thoracolumbar classification system has ever been validated in a systematic and scientific manner. Study Purpose: To critically review previous thoracolumbar classification systems, to discuss the proposal of the new Thoracolumbar Injury Classification and Severity Score (TLICS), to review the steps taken thus far in assessing the reliability of this system, and to discuss plans for future clinical validation of TLICS. Methods: The authors performed a comprehensive search and analysis of previously published systems for classifying or scoring thoracolumbar spine injuries. Based on the merits and faults of these systems, among other factors, they have developed TLICS. Conclusions: Of the three phases of validating a fracture classification system described by Audige et al, TLICS has successfully passed through phase 1 (development) and phase 2 (multicenter agreement studies). With modifications made in response to phase 2 studies, TLICS will be ready to enter into the clinical validation phase. Although TLICS will initially be assessed for its ability to predict type of treatment, it is the authors hope that, with appropriate analysis, the system will also be predictive of injury severity and clinical outcomes. These qualities remain to be demonstrated through rigorous prospective clinical investigation.

Posttraumatic kyphosis: current state of diagnosis and treatment: results of a multinational survey of spine trauma surgeons.

Study Design Multinational survey of spine trauma surgeons. Objectives To survey a multinational group of spine trauma surgeons and develop an updated consensus definition of posttraumatic kyphosis (PTK), and the most current methods for diagnosis and treatment. Summary of Background Data PTK remains a potential problematic sequela of thoracolumbar trauma. Although most surgeons have devised their own approaches for detecting and treating this condition, broad agreement in terms of the diagnosis and management of PTK has not been achieved. There is a lack of consensus-based guidelines, as the current literature largely consists of small case series or anecdotal expert opinions. Methods A survey questionnaire was circulated among 35 multinational spine trauma surgeons. The questionnaire consisted of 29 questions divided into 8 domains: definition, diagnosis, risk factors, symptoms, radiographic evaluation, surgical indications, treatment, and expected outcome. Answers from respondents were compiled and evaluated to generate a consensus. Results All 35 surgeons completed the survey. Consensus was achieved that PTK represents “a painful kyphotic angulation that can occur anywhere in the posttraumatic spine.” Agreement was also reached that asymptomatic PTK can exist, although no true consensus could be reached on the extent of angular deformity that results in PTK. Untreated or maltreated flexion-distraction injuries, or severe burst fractures of the thoracolumbar spine, were felt to be the 2 injuries most likely to produce PTK. Computed tomography, magnetic resonance, and dynamic radiographs were all recommended for evaluation. If surgery is necessary, posteriorly based osteotomies, especially pedicle subtraction osteotomies, have become the principal means of correction. Conclusions An updated understanding of PTK and its treatment has been achieved. Posterior osteotomies seem to be the most popular means of surgical correction. In the future, multicenter prospective studies are necessary to ascertain, with greater precision, the most appropriate treatment for this condition.

The value of CT and MRI in the classification and surgical decision-making among spine surgeons in thoracolumbar spinal injuries

PurposeAlthough imaging has a major role in evaluation and management of thoracolumbar spinal trauma by spine surgeons, the exact role of computed tomography (CT) and magnetic resonance imaging (MRI) in addition to radiographs for fracture classification and surgical decision-making is unclear.MethodsSpine surgeons (nxa0=xa041) from around the world classified 30 thoracolumbar fractures. The cases were presented in a three-step approach: first plain radiographs, followed by CT and MRI images. Surgeons were asked to classify according to the AOSpine classification system and choose management in each of the three steps.ResultsSurgeons correctly classified 43.4xa0% of fractures with plain radiographs alone; after, additionally, evaluating CT and MRI images, this percentage increased by further 18.2 and 2.2xa0%, respectively. AO type A fractures were identified in 51.7xa0% of fractures with radiographs, while the number of type B fractures increased after CT and MRI. The number of type C fractures diagnosed was constant across the three steps. Agreement between radiographs and CT was fair for A-type (kxa0=xa00.31), poor for B-type (kxa0=xa00.19), but it was excellent between CT and MRI (kxa0>xa00.87). CT and MRI had similar sensitivity in identifying fracture subtypes except that MRI had a higher sensitivity (56.5xa0%) for B2 fractures (pxa0<xa00.001). The need for surgical fixation was deemed present in 72xa0% based on radiographs alone and increased to 81.7xa0% with CT images (pxa0<xa00.0001). The assessment for need of surgery did not change after an MRI (pxa0=xa00.77).ConclusionFor accurate classification, radiographs alone were insufficient except for C-type injuries. CT is mandatory for accurately classifying thoracolumbar fractures. Though MRI did confer a modest gain in sensitivity in B2 injuries, the study does not support the need for routine MRI in patients for classification, assessing instability or need for surgery.

Surgeon Reported Outcome Measure for Spine Trauma: An International Expert Survey Identifying Parameters Relevant for the Outcome of Subaxial Cervical Spine Injuries

Study Design. International web-based survey. Objective. To identify clinical and radiological parameters that spine surgeons consider most relevant when evaluating clinical and functional outcomes of subaxial cervical spine trauma patients. Summary of Background Data. Although an outcome instrument that reflects the patients’ perspective is imperative, there is also a need for a surgeon reported outcome measure to reflect the clinicians’ perspective adequately. Methods. A cross-sectional online survey was conducted among a selected number of spine surgeons from all five AOSpine International world regions. They were asked to indicate the relevance of a compilation of 21 parameters, both for the short term (3 mo–2 yr) and long term (≥2 yr), on a five-point scale. The responses were analyzed using descriptive statistics, frequency analysis, and Kruskal-Wallis test. Results. Of the 279 AOSpine International and International Spinal Cord Society members who received the survey, 108 (38.7%) participated in the study. Ten parameters were identified as relevant both for short term and long term by at least 70% of the participants. Neurological status, implant failure within 3 months, and patient satisfaction were most relevant. Bony fusion was the only parameter for the long term, whereas five parameters were identified for the short term. The remaining six parameters were not deemed relevant. Minor differences were observed when analyzing the responses according to each world region, or spine surgeons’ degree of experience. Conclusion. The perspective of an international sample of highly experienced spine surgeons was explored on the most relevant parameters to evaluate and predict outcomes of subaxial cervical spine trauma patients. These results form the basis for the development of a disease-specific surgeon reported outcome measure, which will be a helpful tool in research and clinical practice. Level of Evidence: 4

Does the Spine Surgeon’s Experience Affect Fracture Classification, Assessment of Stability, and Treatment Plan in Thoracolumbar Injuries?

Study Design: Prospective survey-based study. Objectives: The AO Spine thoracolumbar injury classification has been shown to have good reproducibility among clinicians. However, the influence of spine surgeons’ clinical experience on fracture classification, stability assessment, and decision on management based on this classification has not been studied. Furthermore, the usefulness of varying imaging modalities including radiographs, computed tomography (CT) and magnetic resonance imaging (MRI) in the decision process was also studied. Methods: Forty-one spine surgeons from different regions, acquainted with the AOSpine classification system, were provided with 30 thoracolumbar fractures in a 3-step assessment: first radiographs, followed by CT and MRI. Surgeons classified the fracture, evaluated stability, chose management, and identified reasons for any changes. The surgeons were divided into 2 groups based on years of clinical experience as <10 years (n = 12) and >10 years (n = 29). Results: There were no significant differences between the 2 groups in correctly classifying A1, B2, and C type fractures. Surgeons with less experience had more correct diagnosis in classifying A3 (47.2% vs 38.5% in step 1, 73.6% vs 60.3% in step 2 and 77.8% vs 65.5% in step 3), A4 (16.7% vs 24.1% in step 1, 72.9% vs 57.8% in step 2 and 70.8% vs 56.0% in step3) and B1 injuries (31.9% vs 20.7% in step 1, 41.7% vs 36.8% in step 2 and 38.9% vs 33.9% in step 3). In the assessment of fracture stability and decision on treatment, the less and more experienced surgeons performed equally. The selection of a particular treatment plan varied in all subtypes except in A1 and C type injuries. Conclusion: Surgeons’ experience did not significantly affect overall fracture classification, evaluating stability and planning the treatment. Surgeons with less experience had a higher percentage of correct classification in A3 and A4 injuries. Despite variations between them in classification, the assessment of overall stability and management decisions were similar between the 2 groups.