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Spine

doi: 10.1097/BOT.0000000000001075
Supplement Article
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Diagnostic and coding process

This classification system includes morphological injury characteristics, as well as neurological and patient-specific modifiers to augment the clinical relevance.

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Algorithm for morphologic classification

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Cervical spine

Location: Spine, upper cervical (C1 or C2) 51.__.X

  • The classification for this region is presently under development
  • The axial spine is defined as cervical vertebra 1 and 2
  • The generic fracture code 51.__.X is used to code these injuries

Location: Spine, subaxial cervical spine (vertebra 3 to 7)

Types: Spine, subaxial cervical, compression injury of the vertebral body 51.__.A

Spine, subaxial cervical, tension band injury 51.__.B

Spine, subaxial cervical, displacement/translational injury 51.__.C

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51.__.A

Type: Spine, subaxial cervical, compression injury of the vertebral body 51.__.A

Group: Spine, subaxial cervical, compression injury, minor nonstructural fracture (eg, spinous process) 51.__.A0

Group: Spine, subaxial cervical, compression injury, compression or impaction fractures of a single endplate without involvement of the posterior wall of the vertebral body 51.__.A1

Group: Spine, subaxial cervical, compression injury, coronal split of pincers type fractures involving both end plates without posterior vertebral wall involvement 51.__.A2

Group: Spine, cervical, compression injuries, incomplete burst fractures involving a single endplate with any involvement of the posterior vertebral wall 51.__.A3

Group: Spine, cervical, compression injuries, complete burst fractures involving both endplates as well as the posterior vertebral wall 51.__.A4

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51._.B

Type: Spine, subaxial cervical, tension band injury 51._.B

Group: Spine, subaxial cervical, tension band injury, monosegmental osseous failure of the posterior tension band extending into vertebral body (Chance Fracture) 51.__.B1*

Group: Spine, subaxial cervical, tension band injury, disruption of the posterior. tension band with or without osseous involvement. Posterior tension band injury maybe bone, capsule or ligament or a combination 51.__.B2*

Group: Spine, subaxial cervical, tension band injury, anterior tension band injury with physical disruption or separation of the anterior structures (bone/disk) with a tethering of the posterior elements 51.__.B3*

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51.__.C

Type: Spine, subaxial cervical, displacement/translational injury 51.__.C*

*Qualifications: bl = Bilateral posterior injuries

Qualifications for neurological deficit grades (applicable to all cervical spine codes):

These grades are added to any spinal code to identify the neurological deficit. They are added to the end of code between ( __ ). Multiple qualifications are separated by a comma.

  • NX cannot be examined
  • N0 neurologically intact
  • N1 transient neurological deficit
  • N2 nerve root injury
  • N3 cauda equina injury or incomplete spinal cord injury
  • N4 complete spinal cord injury (unlikely in sacral fractures)
  • + ongoing cord compression in the setting of an incomplete neurological deficit.

Qualifications for patient specific conditions (applicable to all cervical spine codes):

  • M1 posterior capsuloligamentous complex injury without complete disruption
  • M2 critical disk herniation
  • M3 Stiffening/metabolic bone disease (ie, DISH, AS, OPL, OLF)
  • M4 Vertebral artery abnormality.

Qualifications are added at the end of the code between rounded brackets ( __ ).

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Thoracic or Lumbar spine

Location: Spine, thoracic 52.__. or lumbar 53.__.

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52.__.A or 53.__.A

Type: Spine, thoracic or lumbar, compression injury of the vertebra 52.__.A or 53.__.A

Group: Spine, thoracic or lumbar, compression injury of the vertebra, minor nonstructural fractures (ie, spinous or transverse processes) 52.__.A0 or 53.__.A0

Group: Spine, thoracic or lumbar, compression injury of the vertebra, compression or impaction fractures of a single endplate without involvement of the posterior wall of the vertebral body 52.__.A1 or 53.__.A1

Group: Spine, thoracic or lumbar, compression injury of the vertebra, coronal split of pincers type fractures involving both endplates without posterior vertebral wall involvement 52.__.A2 or 53.__.A2

Group: Spine, thoracic or lumbar, compression injury to the vertebra, incomplete burst fracture involving a single endplate with any involvement of the posterior vertebral wall 52.__.A3 or 53.__.A3

Group: Spine, thoracic or lumbar, compression injury to the vertebra, complete burst fracture involving both endplates as well as the posterior wall 52.__.A4 or 53.__.A4

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52.__.B or 53.__.B

Type: Spine, thoracic or lumbar, tension band injury 52.__.B or 53.__.B

Group: Spine, thoracic or lumbar, distraction injury, monosegmental osseous failure of the posterior tension band extending into thevertebral body (Chance fracture) 52.__.B1 or 53.__.B1

Group: Spine, thoracic or lumbar, distraction injury, disruption of the posterior tension band with or without osseous involvement. Posterior tension band injury maybe bone, capsule, ligament or a combination 52.__.B2 or 53.__.B2

Group: Spine, thoracic or lumbar, distraction injury, anterior tension band injury with disruption or separation of the anterior bone and/or disc with tethering of the posterior elements 52.__.B3 or 53.__.B3

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52.__.C/53.__.C

Type: Spine, thoracic or lumbar, displacement/translational injury 52.__.C or 53.__.C

Failure of all elements leading to dislocation, displacement or translation in any plane or complete disruption of a soft tissue hinge even in the absence of any translation. Can be combined with subtypes of A and B allowing for two separate codes for the injury

Qualifications for neurological deficit grades (applicable to all thoracic or lumbar spine codes):

These grades are added to any spinal code to identify the neurological deficit. They are added to the end of code between ( __ ). Multiple qualifications are separated by a comma.

  • NX cannot be examined
  • N0 neurologically intact
  • N1 transient neurological deficit
  • N2 nerve root injury
  • N3 cauda equina injury or incomplete spinal cord injury
  • N4 complete spinal cord injury
  • + Indicates there is ongoing cord compression in the setting of an incomplete neurological deficit.

Qualifications for patient specific conditions (applicable to all thoracic or lumbar spine codes):

  • M1 Used to designate fractures with an indeterminate injury to the tension band based on spinal imaging with or without MRI. This modifier is important for designating those injuries with stable injuries from a bony standpoint for which ligamentous insufficiency may help determine whether operative stabilization is a consideration.
  • M2 Used to designate a patient-specific comorbidity, which might argue either for or against surgery for patients with relative surgical indications. Examples of an M2 modifier include ankylosing spondylitis or burns affecting the skin overlying the injured spine.
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Sacral spine

Location: Spine, sacrum 54

This classification is intended to be used for isolated sacral fractures not associated with a pelvic ring injury. As the sacrum is part of the posterior pelvic ring arch, sacral fractures are a major component of determining the stability of a pelvic ring injury. Consequently, sacral fractures associated with a pelvic ring injury (61) are recommended to be classified in that category using the qualification modifiers.

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54A

Type: Spine, sacrum, fractures of the lower segments not associated with sacroiliac joint. (Injuries with no impact on pelvic or spino-pelvis stablity They may have a neurological injury.) 54A

Group: Spine, sacrum, fractures of the lower sacral segments not associated with sacroiliac joint, coccygeal or sacral compression injuries 54A1

Group: Spine, sacrum, fractures of the lower sacral segments not associated with sacroiliac joint, transverse fractures, nondisplaced 54A2

Group: Spine, sacrum, fractures of the lower sacral segments not associated with sacroiliac joint, transverse fractures, displaced 54A3

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54B

Type: Spine, sacrum, fractures involving the upper sacral segments associated with sacroiliac joint 54B

These are unilateral longitudinal or vertical fractures that occur through the upper sacral segments that are associated with the sacroiliac joint. These will have an impact on pelvic stability. They may have neurological injury. The groups are ordered differently than the published Denis classification or the former compendiums.

Group: Spine, sacrum, fractures involving the upper sacral segments associated with sacroiliac joint, isolated vertical central fractures medial to the foramina involving the spinal canal (Denis III) 54B1

Group: Spine, sacrum, fractures involving the upper sacral segments associated with sacroiliac joint, transalar fractures lateral to the foramina or spinal canal (Denis I) 54B2

Group: Spine, sacrum, fractures involving the upper sacral segments associated with sacroiliac joint, transforaminal fractures involving the foramina but not the spinal canal (Denis II) 54B3

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54C

Type: Spine, sacrum, injuries resulting in spino-pelvic instability 55C

Group: Spine, sacrum, injuries resulting in spino-pelvic instability, nondisplaced U-type variant (commonly low energy insufficiency fracture) 55C0

Group: Spine, sacrum, injury resulting in spino-pelvic instability, U-type variant without posterior pelvic instability (any unilateral B group fracture where ipsilateral S1 facet is discontinuous with medial part of sacrum) 54C1

Group: Spine, sacrum, injury resulting in spino-pelvic instability, bilateral complete B-type injuries without transverse fracture 54C2

Group: Spine, sacrum, injury resulting in spino-pelvic instability, displaced U-type fracture 54C3

Qualifications for neurological deficit grades (applicable to all sacral spine codes):

These grades are added to any spinal code to identify the neurological deficit. They are added to the end of code between ( __ ). Multiple qualifications are separated by a comma.

  • NX cannot be examined
  • N0 neurologically intact
  • N1 transient neurological deficit
  • N2 nerve root injury
  • N3 cauda equina injury or incomplete spinal cord injury

Qualifications for patient specific conditions (applicable to all sacral spine codes):

  • M1 soft tissue injury
  • M2 metabolic bone disease
  • M3 Anterior pelvic ring injury
  • M4 Sacroiliac joint injury
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References

AOSpine Injury Classification Systems. AOSpine website. https://aospine. aofoundation.org/Structure/education/online-education/classifications/Pages/ classifications.aspx. Accessed July 7, 2017.
    Kepler CK, Vaccaro AR, Koerner JD, et al. Reliability analysis of the AOSpine thoracolumbar spine injury classification system by a worldwide group of naive spinal surgeons. Eur Spine J. 2016 Apr;25(4):1082–1086.
    Schnake KJ, Schroeder GD, Vaccaro AR, et al. AOSpine Classification Systems (Subaxial, Thoracolumbar). J Orthop Trauma. 2017 Sep;31 Suppl 4:S14–s23.
    Vaccaro AR, Koerner JD, Radcliff KE, et al. AOSpine subaxial cervical spine injury classification system. Eur Spine J. 2016 Jul;25(7):2173–2184.
    Vaccaro AR, Oner C, Kepler CK, et al. AOSpine thoracolumbar spine injury classification system: fracture description, neurological status, and key modifiers. Spine (Phila Pa 1976). 2013 Nov 01;38(23):2028–2037.
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