A Proposal for a Standardized Imaging Algorithm to Improve the Accuracy and Reliability for the Diagnosis of Thoracolumbar Posterior Ligamentous Complex Injury in Computed Tomography and Magnetic Resonance Imaging

Abstract

Study Design Systematic Literature Review. Objective To propose a systematic imaging algorithm for diagnosing posterior ligamentous complex (PLC) injury in computed tomography (CT) and magnetic resonance imaging (MRI) to improve the reliability of PLC assessment. Methods A systematic review was conducted following PRISMA guidelines. The Scopus database was searched from its inception until July 21, 2022, for studies evaluating CT or MRI assessment of the PLC injury following thoracolumbar trauma. The studies extracted key findings, objectives, injury definitions, and radiographic modalities. Results Twenty-three studies were included in this systematic review, encompassing 2021 patients. Five studies evaluated the accuracy of MRI in detecting thoracolumbar PLC injury using intraoperative findings as a reference. These studies indicate that black stripe discontinuity due to supraspinous or ligamentum flavum rupture is a more specific criterion of PLC injury than high-signal intensity. Thirteen papers evaluated the accuracy or reliability of CT in detecting thoracolumbar PLC injury using MRI or intraoperative findings as a reference. The overall accuracy rate of CT in detecting PLC injury was 68-90%. Two studies evaluate the accuracy of combined CT findings, showing that ≥2 CT findings are associated with a positive predictive value of 88-91 %. Vertebral translation, facet joint malalignment, spinous process fracture, horizontal laminar fracture, and interspinous widening were independent predictors of PLC injury. Conclusion We provided a comprehensive imaging algorithm for diagnosing PLC in CT and MRI based on available literature and our experience. The algorithm will potentially improve the accuracy and reliability of PLC assessment, however it needs multicentre prospective validation.

Predictive Algorithm for Surgery Recommendation in Thoracolumbar Burst Fractures Without Neurological Deficits

“…As per a recent systematic review by Aly et al the overall accuracy of CT in detecting PLC injury is between 68-90%. [5][6][7][8][9] The systematic review suggested that the CT findings of facet joint malalignment, spinous process fractures, interspinous widening, and horizontal laminar fractures are independently associated with PLC injury on MRI. A single positive CT finding yielded a predictive positive value (PPV) of 31% while ≥2 CT findings yielded a PPVof 82-90%.…”

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

“…26 The previous results imply that confusion about PLC status on CT images may have overestimated the impact of PLC injury in the decision-making process around TL burst fractures. The practicalities of MRI for TL burst fractures without neurological deficits may be simple; MRI can be conducted non-urgently within days of the injury, ensuring an accurate PLC evaluation 23 Alternatively, standing X-rays may demonstrate kyphosis consistent with a ligamentous injury, or these patients can be closely observed for their pain and early development of kyphosis.…”

Towards a standardized reporting of the impact of magnetic resonance imaging on the decision-making of thoracolumbar fractures without neurological deficit: Conceptual framework and proposed methodology

“…The accuracy of image interpretation relies on numerous variables, including imaging acquisition protocol, the validity of PLC classifying criteria, reviewers' experience, consensus training, and image analysis. ( Aly et al, 2023a )…”

“…3 ). ( Aly et al, 2023a ), ( Pizones et al, 2012a ) PLC injury on CT can be defined by at least one of the following CT finding: spinous process fracture, interspinous widening, laminar fracture ( Aly et al, 2021b ), and facet diastasis. ( Aly et al, 2023b ) ( Khurana et al, 2018 ), ( Aly et al, 2023b )Recently, two studies have proposed CT criteria for PLC injury based on the number of positive findings as follows: ( Khurana et al, 2018 ), ( Aly et al, 2021a ) Disrupted PLC, at least two positive findings, indeterminate (AKA M1modifier), single positive finding, intact PLC, negative CT for all findings ( Fig.…”