The AO Spine Thoracolumbar Injury Classification System and Treatment Algorithm in Decision Making for Thoracolumbar Burst Fractures Without Neurologic Deficit

Barry T S Kweh; Jin Wee Tee; Charlotte Dandurand; Alexander R Vaccaro; Benneker M Lorin; Klaus Schnake; Emiliano Vialle; Shanmuganathan Rajasekaran; Mohammad El-Skarkawi; Richard J Bransford; Rishi M Kanna; Mohamed M Aly; Martin Holas; Jose A Canseco; Sander Muijs; Eugen C Popescu; Gaston Camino-Willhuber; Andrei F Joaquim; Harvinder S Chhabra; Sebastian Frederick Bigdon; Ulrich Spiegel; Marcel Dvorak; Cumhur F Öner; Gregory Schroeder

doi:10.1177/21925682231195764

The AO Spine Thoracolumbar Injury Classification System and Treatment Algorithm in Decision Making for Thoracolumbar Burst Fractures Without Neurologic Deficit

Global Spine J. 2024 Feb;14(1_suppl):32S-40S. doi: 10.1177/21925682231195764.

Authors

Barry T S Kweh^{1

2

3}, Jin Wee Tee^{1

2

4}, Charlotte Dandurand⁵, Alexander R Vaccaro⁶, Benneker M Lorin⁷, Klaus Schnake^{8

9}, Emiliano Vialle¹⁰, Shanmuganathan Rajasekaran¹¹, Mohammad El-Skarkawi¹², Richard J Bransford¹³, Rishi M Kanna¹¹, Mohamed M Aly^{14

15}, Martin Holas¹⁶, Jose A Canseco⁶, Sander Muijs¹⁷, Eugen C Popescu¹⁸, Gaston Camino-Willhuber¹⁹, Andrei F Joaquim²⁰, Harvinder S Chhabra²¹, Sebastian Frederick Bigdon²², Ulrich Spiegel²³, Marcel Dvorak⁵, Cumhur F Öner¹⁷, Gregory Schroeder⁶

Affiliations

¹ National Trauma Research Institute, Melbourne, VIC, Australia.
² Department of Neurosurgery, The Alfred Hospital, Melbourne, VIC, Australia.
³ Department of Neurosurgery, Royal Melbourne Hospital, Parkville, VIC, Melbourne.
⁴ Central Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, VIC, Australia.
⁵ Combined Neurosurgical and Orthopedic Spine Program, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada.
⁶ Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University Hospital, Philadelphia, PA, USA.
⁷ Spine Unit, Sonnenhof Spital, University of Bern, Bern, Switzerland.
⁸ Center for Spinal and Scoliosis Surgery, Malteser Waldkrankenhaus St. Marien, Erlangen, Germany.
⁹ Department of Orthopedics and Traumatology, Paracelsus Private Medical University Nuremberg, Nuremberg, Germany.
¹⁰ Cajuru Hospital, Catholic University of Paraná, Curitiba, Brazil.
¹¹ Department of Orthopaedics and Spine Surgery, Ganga Hospital, Coimbatore, India.
¹² Department of Orthopaedic and Trauma Surgery, Faculty of Medicine, Assiut University, Assiut, Egypt.
¹³ Department of Orthopaedics and Sports Medicine, Harborview Medical Center, University of Washington, Seattle, WA, USA.
¹⁴ Department of Neurosurgery, Prince Mohammed Bin Abdulaziz Hospital, Riyadh, Saudi Arabi.
¹⁵ Department of Neurosurgery, Mansoura University, Mansoura, Egypt.
¹⁶ Klinika Úrazovej Chirurgie SZU a FNsP F.D.Roosevelta, Banská Bystrica, Slovakia.
¹⁷ University Medical Centers, Utrecht, The Netherlands.
¹⁸ Emergency Hospital, Iasi, Romania.
¹⁹ Orthopaedic and Traumatology Department, Institute of Orthopedics "Carlos E. Ottolenghi" Hospital Italiano de Buenos Aires, Buenos Aires, Argentina.
²⁰ Neurosurgery Division, Department of Neurology, State University of Campinas, Campinas-Sao Paulo, Brazil.
²¹ Sri Balaji Action Medical Institute, New Delhi, India.
²² Department of Orthopaedic Surgery and Traumatology, Inselspital, University Hospital, University of Bern, Bern, Switzerland.
²³ Department of Orthopaedics, Trauma Surgery and Plastic Surgery, University of Leipzig, Leipzig, Germany.

Abstract

Study design: Prospective Observational Study.

Objective: To determine the alignment of the AO Spine Thoracolumbar Injury Classification system and treatment algorithm with contemporary surgical decision making.

Methods: 183 cases of thoracolumbar burst fractures were reviewed by 22 AO Spine Knowledge Forum Trauma experts. These experienced clinicians classified the fracture morphology, integrity of the posterior ligamentous complex and degree of comminution. Management recommendations were collected.

Results: There was a statistically significant stepwise increase in rates of operative management with escalating category of injury (P < .001). An excellent correlation existed between recommended expert management and the actual treatment of each injury category: A0/A1/A2 (OR 1.09, 95% CI 0.70-1.69, P = .71), A3/4 (OR 1.62, 95% CI 0.98-2.66, P = .58) and B1/B2/C (1.00, 95% CI 0.87-1.14, P = .99). Thoracolumbar A4 fractures were more likely to be surgically stabilized than A3 fractures (68.2% vs 30.9%, P < .001). A modifier indicating indeterminate ligamentous injury increased the rate of operative management when comparing type B and C injuries to type A3/A4 injuries (OR 39.19, 95% CI 20.84-73.69, P < .01 vs OR 27.72, 95% CI 14.68-52.33, P < .01).

Conclusions: The AO Spine Thoracolumbar Injury Classification system introduces fracture morphology in a rational and hierarchical manner of escalating severity. Thoracolumbar A4 complete burst fractures were more likely to be operatively managed than A3 fractures. Flexion-distraction type B injuries and translational type C injuries were much more likely to have surgery recommended than type A fractures regardless of the M1 modifier. A suspected posterior ligamentous injury increased the likelihood of surgeons favoring surgical stabilization.

Keywords: AO spine thoracolumbar injury classification; AOSIS; burst fracture; spine trauma; thoracolumbar injury classification score; thoracolumbar trauma.