The Influence of Fracture Mechanism and Morphology on the Reliability and Validity of Two Novel Thoracolumbar Injury Classification Systems

Whang, Peter G.; Vaccaro, Alexander R.; Poelstra, Kornelius A.; Patel, Alpesh A.; Anderson, D. Greg; Albert, Todd J.; Hilibrand, Alan S.; Harrop, James S.; Sharan, Ashwini; Ratliff, John K.; Hurlbert, R. John; Anderson, Paul A.; Aarabi, Bizhan; Sekhon, Lali H.S.; Gahr, R. H.; Carrino, John A.

doi:10.1097/01.brs.0000258882.96011.47

Cited by 88 publications

(67 citation statements)

References 8 publications

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“…In general, the main concern of contemporary classification systems for TL injuries is that they are limited either by excessive complexity or the lack of inclusiveness [10,27]. Many original reports describing common TL injury classifications lack a rigorous scientific foundation [10].…”

Section: Discussionmentioning

confidence: 99%

AO spine injury classification system: a revision proposal for the thoracic and lumbar spine

et al. 2013

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Purpose The AO Spine Classification Group was established to propose a revised AO spine injury classification system. This paper provides details on the rationale, methodology, and results of the initial stage of the revision process for injuries of the thoracic and lumbar (TL) spine. Methods In a structured, iterative process involving five experienced spine trauma surgeons from various parts of the world, consecutive cases with TL injuries were classified independently by members of the classification group, and analyzed for classification reliability using the Kappa coefficient (j) and for accuracy using latent class analysis. The reasons for disagreements were examined systematically during review meetings. In four successive sessions, the system was revised until consensus and sufficient reproducibility were achieved. Results The TL spine injury system is based on three main injury categories adapted from the original Magerl AO concept: A (compression), B (tension band), and C (displacement) type injuries. Type-A injuries include four subtypes (wedge-impaction/split-pincer/incomplete burst/ complete burst); B-type injuries are divided between purely osseous and osseo-ligamentous disruptions; and C-type injuries are further categorized into three subtypes (hyperextension/translation/separation). There is no subgroup division. The reliability of injury types (A, B, C) was good (j = 0.77). The surgeons' pairwise Kappa ranged from 0.69 to 0.90. Kappa coefficients j for reliability of injury subtypes ranged from 0.26 to 0.78. Conclusions The proposed TL spine injury system is based on clinically relevant parameters. Final evaluation data showed reasonable reliability and accuracy. Further validation of the proposed revised AO Classification requires follow-up evaluation sessions and documentation by more surgeons from different countries and backgrounds and is subject to modification based on clinical parameters during subsequent phases.

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Section: Discussionmentioning

confidence: 99%

AO spine injury classification system: a revision proposal for the thoracic and lumbar spine

et al. 2013

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“…Injuries were classified using the AO classification as well as the TLICS for thoracolumbar injuries. 2,10,14,16,20,23,25,27,29 Total operative time, blood loss, and length of hospital stay were obtained via chart review from the surgeon's operative note, the operating room records, and the discharge summary. Results are summarized in Table 1.…”

Section: Methodsmentioning

confidence: 99%

Flexion-distraction injuries of the thoracolumbar spine: open fusion versus percutaneous pedicle screw fixation

Grossbach¹,

Dahdaleh

Abel³

et al. 2013

FOC

107

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Object Flexion-distraction injuries occur due to distractive forces causing disruption of the posterior and middle spinal columns. These fractures classically consist of a fracture line through the posterior bony elements; involvement of the posterior ligamentous complex is, however, common. Surgical treatment is often required for these unstable injuries to avoid neurological deterioration and posttraumatic kyphosis, and the surgery traditionally consists of an open posterior approach with instrumented fusion. Percutaneous pedicle screw fixation for these injuries, with the goal of minimal tissue disruption and preservation of normal anatomy while achieving adequate stabilization, has recently been reported in the literature, but to date, a direct comparative study comparing open and percutaneous fixation has not been reported. The authors report their experience treating these fractures with both techniques and review the available literature. Methods Patients with flexion-distraction injury who were treated between May 2003 and March 2013 were prospectively followed. American Spinal Injury Association scores and degree of kyphotic angulation were recorded at admission, discharge, and follow-up. Data regarding intraoperative blood loss and operative time were obtained from a chart review. Patients treated with open versus minimally invasive procedures were compared. Results The authors identified 39 patients who suffered flexion-distraction injuries and were treated at their institution during the specified period; one of these patients declined surgery. All had injury to the posterior ligamentous complex. Open surgical procedures with pedicle screw fixation and posterolateral fusion were performed in 27 patients, while 11 patients underwent minimally invasive pedicle screw placement. Overall, there was improvement in kyphotic angulation at the time of discharge as well as most recent follow-up in both the open surgery and minimally invasive surgery (MIS) groups. The authors found no significant difference in American Spinal Injury Association score or the degree of kyphotic angulation between the MIS and open surgery groups. There was a trend toward shorter operative time for the MIS group, and patients who underwent minimally invasive procedures had significantly less blood loss. Conclusions Minimally invasive percutaneous pedicle screw fixation appears to have similar efficacy in the treatment of flexion-distraction injuries and it allows for reduced blood loss and tissue damage compared with open surgical techniques. Therefore it should be considered as an option for the treatment of this type of injury.

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“…This resulted in a total number of 21 included articles of this review. Eight studies evaluated the agreement on PLC injury evaluation [15][16][17][18][19][20][21][22], another eight studies evaluated the accuracy of detecting PLC injuries [23][24][25][26][27][28][29][30] and one study evaluated both agreement and accuracy [31]. Four studies reported on different validity components of PLC injuries [32][33][34][35].…”

Section: Search and Screening Resultsmentioning

confidence: 99%

“…In these classification validation studies, the assessment of the PLC status was part of the validation process of the TLISS [18][19][20][21][22] and TLICS [16,22]. Taking a closer look at the original paper introducing the TLISS classification, it becomes clear that neither the PLC, nor an injury of this structure, has been defined in detail [5].…”

Section: Discussionmentioning

confidence: 99%

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The precision, accuracy and validity of detecting posterior ligamentous complex injuries of the thoracic and lumbar spine: a critical appraisal of the literature

et al. 2012

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Purpose The diagnostic assessment and prognostic value of the posterior ligamentous complex (PLC) remains a controversial topic in the management of patients with thoracolumbar spinal injury. The purpose of this review was to critically appraise the literature and present an overview of the: (1) precision, (2) accuracy, and (3) validity of detecting PLC injuries in patients with thoracic and lumbar spine trauma. Methods Studies evaluating the precision, accuracy and/or validity of detecting and managing PLC injuries in patients with thoracic and/or lumbar spine injuries were searched through the Medline database (1966 to September 2011). References were retrieved and evaluated individually and independently by two authors. Results Twenty-one eligible studies were identified. Few studies reported the use of countermeasures for sampling and measurement bias. In nine agreement studies, the PLC was assessed in various ways, ranging from use of booklets to a complete set of diagnostic imaging. Inter-rater and intra-rater kappa values ranged from 0.188 to 0.915 and 0.455 to 0.840, respectively. In nine accuracy studies, magnetic resonance (MR) imaging was most often (n = 6) compared with intra-operative findings. In general, MR imaging tended to demonstrate relatively high negative predictive values and relatively low positive predictive values for PLC injuries. Conclusions A wide variety of methods have been applied in the evaluation of precision and accuracy of PLC injury detection, leaving spinal surgeons with a multitude of variable results. There is scant clinical evidence demonstrating the true prognostic value of detected PLC injuries in patients with thoracic and lumbar spine injuries. We recommend the conduct of longitudinal clinical follow-up studies on those cases assessed for precision and/or accuracy of PLC injuries.

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The Influence of Fracture Mechanism and Morphology on the Reliability and Validity of Two Novel Thoracolumbar Injury Classification Systems

Cited by 88 publications

References 8 publications

AO spine injury classification system: a revision proposal for the thoracic and lumbar spine

AO spine injury classification system: a revision proposal for the thoracic and lumbar spine

Flexion-distraction injuries of the thoracolumbar spine: open fusion versus percutaneous pedicle screw fixation

The precision, accuracy and validity of detecting posterior ligamentous complex injuries of the thoracic and lumbar spine: a critical appraisal of the literature

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