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European Spine Journal

, Volume 25, Issue 4, pp 1087–1094 | Cite as

The surgical algorithm for the AOSpine thoracolumbar spine injury classification system

  • Alexander R. VaccaroEmail author
  • Gregory D. Schroeder
  • Christopher K. Kepler
  • F. Cumhur Oner
  • Luiz R. Vialle
  • Frank Kandziora
  • John D. Koerner
  • Mark F. Kurd
  • Max Reinhold
  • Klaus J. Schnake
  • Jens Chapman
  • Bizhan Aarabi
  • Michael G. Fehlings
  • Marcel F. Dvorak
Original Article

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.

Keywords

TL AOSIS AOSpine thoracolumbar spine injury classification system Thoracolumbar trauma Thoracolumbar trauma treatment algorithm Spine trauma 

Notes

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.

References

  1. 1.
    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 CrossRefGoogle Scholar
  2. 2.
    Magerl F, Aebi M, Gertzbein SD, Harms J, Nazarian S (1994) A comprehensive classification of thoracic and lumbar injuries. Eur Spine J 3:184–201CrossRefPubMedGoogle Scholar
  3. 3.
    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) CrossRefGoogle Scholar
  4. 4.
    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 Google Scholar
  5. 5.
    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–E503CrossRefGoogle Scholar
  6. 6.
    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)Google Scholar
  7. 7.
    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 JGoogle Scholar
  8. 8.
    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)Google Scholar
  9. 9.
    Linstone HA (2002) The Delphi method: techniques and applications, Murray Turoff and Harold A. Linstone, PortlandGoogle Scholar
  10. 10.
    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 CrossRefPubMedPubMedCentralGoogle Scholar
  11. 11.
    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 CrossRefGoogle Scholar
  12. 12.
    Anderson PA, Henley MB, Rivara FP, Maier RV (1991) Flexion distraction and chance injuries to the thoracolumbar spine. J Orthop Trauma 5:153–160CrossRefPubMedGoogle Scholar
  13. 13.
    Gumley G, Taylor TK, Ryan MD (1982) Distraction fractures of the lumbar spine. J Bone Joint Surg Br 64:520–525PubMedGoogle Scholar
  14. 14.
    LeGay DA, Petrie DP, Alexander DI (1990) Flexion-distraction injuries of the lumbar spine and associated abdominal trauma. J Trauma 30:436–444CrossRefPubMedGoogle Scholar
  15. 15.
    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 CrossRefPubMedGoogle Scholar
  16. 16.
    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 CrossRefPubMedGoogle Scholar
  17. 17.
    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 CrossRefPubMedPubMedCentralGoogle Scholar
  18. 18.
    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 Google Scholar
  19. 19.
    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 CrossRefPubMedPubMedCentralGoogle Scholar
  20. 20.
    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 CrossRefPubMedGoogle Scholar
  21. 21.
    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 CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2015

Authors and Affiliations

  • Alexander R. Vaccaro
    • 1
    Email author
  • Gregory D. Schroeder
    • 1
  • Christopher K. Kepler
    • 1
  • F. Cumhur Oner
    • 2
  • Luiz R. Vialle
    • 3
  • Frank Kandziora
    • 4
  • John D. Koerner
    • 1
  • Mark F. Kurd
    • 1
  • Max Reinhold
    • 5
  • Klaus J. Schnake
    • 6
  • Jens Chapman
    • 7
  • Bizhan Aarabi
    • 8
  • Michael G. Fehlings
    • 9
  • Marcel F. Dvorak
    • 10
  1. 1.The Rothman Institute at Thomas Jefferson UniversityPhiladelphiaUSA
  2. 2.University Medical CenterUtrechtThe Netherlands
  3. 3.Catholic UniversityCuritibaBrazil
  4. 4.Berufsgenossenschaftliche Unfallklinik FrankfurtCenter for Spinal Surgery and NeurotraumatologyFrankfurt/MainGermany
  5. 5.Klinikum Suedstadt RostockDepartment of Orthopaedic and Trauma SurgeryRostockGermany
  6. 6.Schön Klinik Nürnberg FürthCenter for Spinal TherapyFürthGermany
  7. 7.The Swedish Neuroscience InstituteSeattleUSA
  8. 8.University of Maryland School of MedicineBaltimoreUSA
  9. 9.University of TorontoTorontoCanada
  10. 10.University of British ColumbiaVancouverCanada

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