Abstract
Purpose
The goal of the current study is to establish a surgical algorithm to accompany the AOSpine thoracolumbar spine injury classification system.
Methods
A survey was sent to AOSpine members from the six AO regions of the world, and surgeons were asked if a patient should undergo an initial trial of conservative management or if surgical management was warranted. The survey consisted of controversial injury patterns. Using the results of the survey, a surgical algorithm was developed.
Results
The AOSpine Trauma Knowledge forum defined that the injuries in which less than 30 % of surgeons would recommend surgical intervention should undergo a trial of non-operative care, and injuries in which 70 % of surgeons would recommend surgery should undergo surgical intervention. Using these thresholds, it was determined that injuries with a thoracolumbar AOSpine injury score (TL AOSIS) of three or less should undergo a trial of conservative treatment, and injuries with a TL AOSIS of more than five should undergo surgical intervention. Operative or non-operative treatment is acceptable for injuries with a TL AOSIS of four or five.
Conclusion
The current algorithm uses a meaningful injury classification and worldwide surgeon input to determine the initial treatment recommendation for thoracolumbar injuries. This allows for a globally accepted surgical algorithm for the treatment of thoracolumbar trauma.
Similar content being viewed by others
References
Vaccaro AR, Oner C, Kepler CK, Dvorak M, Schnake K, Bellabarba C, Reinhold M, Aarabi B, Kandziora F, Chapman J, Shanmuganathan R, Fehlings M, Vialle L (2013) AOSpine thoracolumbar spine injury classification system: fracture description, neurological status, and key modifiers. Spine (Phila Pa 1976) 38:2028–2037. doi:10.1097/BRS.0b013e3182a8a381
Magerl F, Aebi M, Gertzbein SD, Harms J, Nazarian S (1994) A comprehensive classification of thoracic and lumbar injuries. Eur Spine J 3:184–201
Vaccaro AR, Lehman RA Jr, Hurlbert RJ, Anderson PA, Harris M, Hedlund R, Harrop J, Dvorak M, Wood K, Fehlings MG, Fisher C, Zeiller SC, Anderson DG, Bono CM, Stock GH, Brown AK, Kuklo T, Oner FC (2005) A new classification of thoracolumbar injuries: the importance of injury morphology, the integrity of the posterior ligamentous complex, and neurologic status. Spine (Phila Pa 1976) 30:2325–2333 (pii:00007632-200510150-00015)
Kepler CK, Vaccaro AR, Koerner JD, Dvorak MF, Kandziora F, Rajasekaran S, Aarabi B, Vialle LR, Fehlings MG, Schroeder GD, Reinhold M, Schnake KJ, Bellabarba C, Cumhur Oner F (2015) Reliability analysis of the AOSpine thoracolumbar spine injury classification system by a worldwide group of naive spinal surgeons. Eur Spine J. doi:10.1007/s00586-015-3765-9
Schroeder GD, Vaccaro AR, Kepler CK, Koerner JD, Oner C, Dvorak M, Vialle L, Aarabi B, Bellabarba C, Fehlings MG, Kandziora F (2015) Establishing the injury severity of thoracolumbar trauma: confirmation of the hierarchical structure of the AOSpine thoracolumbar spine injury classification system. Spine (Phila Pa 1976) 40:E498–E503
Schroeder GD, Kepler CK, Koerner JD, Chapman J, Bellabarba C, Oner FC, Reinhold M, Dvorak M, Aarabi B, Vialle L, Fehlings MG, Rajasekaran S, Kandziora F, Vaccaro AR (2015) Is there a regional difference in morphology interpretation of A3/A4 fractures among different cultures (manuscript submitted for publication)
Schroeder GD, Kepler CK, Koerner JD, Dvorak M, Vialle L, Aarabi B, Bellabarba C, Kandziora F, Chapman J, Koerner JD, Schnake KJ, Reinhold M, Rajasekaran S, Fehlings MG, Oner FC, Vaccaro AR (2015) A worldwide analysis of the reliability and perceived importance of an injury to the posterior ligamentous complex in AO A type fractures. Global Spine J
Kepler CK, Vaccaro AR, Schroeder GD, Koerner JD, Dvorak M, Vialle L, Aarabi B, Bellabarba C, Kandziora F, Chapman J, Koerner JD, Schnake KJ, Reinhold M, Rajasekaran S, Fehlings MG, Oner FC (2015) The thoracolumbar AOSpine injury score (TL AOSIS) (manuscript submitted for publication)
Linstone HA (2002) The Delphi method: techniques and applications, Murray Turoff and Harold A. Linstone, Portland
Fehlings MG, Vaccaro A, Wilson JR, Singh A, Cadotte DW, Harrop JS, Aarabi B, Shaffrey C, Dvorak M, Fisher C, Arnold P, Massicotte EM, Lewis S, Rampersaud R (2012) Early versus delayed decompression for traumatic cervical spinal cord injury: results of the surgical timing in acute spinal cord injury study (STASCIS). PLoS One 7:e32037. doi:10.1371/journal.pone.0032037
Miyanji F, Fisher CG, Keynan O, Wing PC, Boyd M, Dvorak MF (2006) Flexion-distraction injuries of the thoracolumbar spine: health-related quality of life and radiographic outcomes. Top Spinal Cord Inj Rehabil 12(1):58. doi:10.1310/2vg7-9b1e-kxyh-f2kq
Anderson PA, Henley MB, Rivara FP, Maier RV (1991) Flexion distraction and chance injuries to the thoracolumbar spine. J Orthop Trauma 5:153–160
Gumley G, Taylor TK, Ryan MD (1982) Distraction fractures of the lumbar spine. J Bone Joint Surg Br 64:520–525
LeGay DA, Petrie DP, Alexander DI (1990) Flexion-distraction injuries of the lumbar spine and associated abdominal trauma. J Trauma 30:436–444
Wood KB, Li W, Lebl DS, Ploumis A (2014) Management of thoracolumbar spine fractures. Spine J 14:145–164. doi:10.1016/j.spinee.2012.10.041
Schnake KJ, Stavridis SI, Kandziora F (2014) Five-year clinical and radiological results of combined anteroposterior stabilization of thoracolumbar fractures. J Neurosurg Spine 20:497–504. doi:10.3171/2014.1.SPINE13246
Reinhold M, Knop C, Beisse R, Audige L, Kandziora F, Pizanis A, Pranzl R, Gercek E, Schultheiss M, Weckbach A, Buhren V, Blauth M (2010) Operative treatment of 733 patients with acute thoracolumbar spinal injuries: comprehensive results from the second, prospective, Internet-based multicenter study of the spine study group of the German Association of Trauma Surgery. Eur Spine J 19:1657–1676. doi:10.1007/s00586-010-1451-5
Bailey CS, Urquhart JC, Dvorak MF, Nadeau M, Boyd MC, Thomas KC, Kwon BK, Gurr KR, Bailey SI, Fisher CG (2013) Orthosis versus no orthosis for the treatment of thoracolumbar burst fractures without neurologic injury: a multicenter prospective randomized equivalence trial. Spine J. doi:10.1016/j.spinee.2013.10.017
Reinhold M, Audige L, Schnake KJ, Bellabarba C, Dai LY, Oner FC (2013) AO spine injury classification system: a revision proposal for the thoracic and lumbar spine. Eur Spine J 22:2184–2201. doi:10.1007/s00586-013-2738-0
Joaquim AF, Daubs Lawrence BD, Brodke DS, Cendes F, Tedeschi H, Patel AA (2013) Retrospective evaluation of the validity of the thoracolumbar injury classification system in 458 consecutively treated patients. Spine J 13:1760–1765. doi:10.1016/j.spinee.2013.03.014
Schnake KJ (2014) Expert’s comment concerning grand rounds case entitled “progressive kyphotic deformity in comminuted burst fractures treated non-operatively: the achilles tendon of the thoracolumbar injury classification and severity score (TLICS)” (T. A. Mattei, J. Hanovnikian, D. Dinh). Eur Spine J 23:2263–2264. doi:10.1007/s00586-014-3591-5
Acknowledgment
This work was supported by AOSpine. AOSpine is a clinical division of the AO Foundation—an independent medically guided not-for-profit organization. The AO has a strong financial independence thanks to the foundations endowment. The annual operating activities are financed through three pillars: Collaboration and support agreements with DePuy Synthes and other industrial partners, return on own financial assets, and other third party income (e.g., participant fees, R&D projects, memberships). The AOSpine Knowledge Forums are pathology focused working groups acting on behalf of AOSpine in their domain of scientific expertise. Each forum consists of a steering committee of up to 10 international spine experts who meet biannually to discuss research, assess the best evidence for current practices, and formulate clinical trials to advance their field of spine expertise. Authors are compensated for their travel and accommodation costs. Study support is provided directly through AOSpine’s Research department and AO’s Clinical Investigation and Documentation unit. There are no other institutional subsidies, corporate affiliations, or funding sources supporting this work unless clearly documented and disclosed.
Conflict of interest
None.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Vaccaro, A.R., Schroeder, G.D., Kepler, C.K. et al. The surgical algorithm for the AOSpine thoracolumbar spine injury classification system. Eur Spine J 25, 1087–1094 (2016). https://doi.org/10.1007/s00586-015-3982-2
Received:
Revised:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00586-015-3982-2