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AOSpine Thoracolumbar Spine Injury Classification System: Fracture Description, Neurological Status, and Key Modifiers

Vaccaro, Alexander R. MD, PhD*; Oner, Cumhur MD, PhD; Kepler, Christopher K. MD, MBA*; Dvorak, Marcel MD; Schnake, Klaus MD§; Bellabarba, Carlo MD; Reinhold, Max MD; Aarabi, Bizhan MD**; Kandziora, Frank MD, PhD§; Chapman, Jens MD††; Shanmuganathan, Rajasekaran MD, PhD‡‡; Fehlings, Michael MD, PhD§§; Vialle, Luiz MD, PhD¶¶for the AOSpine Spinal Cord Injury & Trauma Knowledge Forum

doi: 10.1097/BRS.0b013e3182a8a381

Study Design. Reliability and agreement study, retrospective case series.

Objective. To develop a widely accepted, comprehensive yet simple classification system with clinically acceptable intra- and interobserver reliability for use in both clinical practice and research.

Summary of Background Data. Although the Magerl classification and thoracolumbar injury classification system (TLICS) are both well-known schemes to describe thoracolumbar (TL) fractures, no TL injury classification system has achieved universal international adoption. This lack of consensus limits communication between clinicians and researchers complicating the study of these injuries and the development of treatment algorithms.

Methods. A simple and reproducible classification system of TL injuries was developed using a structured international consensus process. This classification system consists of a morphologic classification of the fracture, a grading system for the neurological status, and description of relevant patient-specific modifiers. Forty cases with a broad range of injuries were classified independently twice by group members 1 month apart and analyzed for classification reliability using the Kappa coefficient (κ).

Results. The morphologic classification is based on 3 main injury patterns: type A (compression), type B (tension band disruption), and type C (displacement/translation) injuries. Reliability in the identification of a morphologic injury type was substantial (κ= 0.72).

Conclusion. The AOSpine TL injury classification system is clinically relevant according to the consensus agreement of our international team of spine trauma experts. Final evaluation data showed reasonable reliability and accuracy, but further clinical validation of the proposed system requires prospective observational data collection documenting use of the classification system, therapeutic decision making, and clinical follow-up evaluation by a large number of surgeons from different countries.

Level of Evidence: 4

Supplemental Digital Content is Available in the Text.A simple and reproducible classification system for thoracolumbar injuries was developed by an international team. This system demonstrates acceptable intra- and interobserver reliability and includes 3 major morphologic types: compression, tension band disruption, and displacement/translation.

*Thomas Jefferson University and The Rothman Institute, Philadelphia, PA

University Medical Center, Utrecht, the Netherlands

Vancouver General Hospital, Vancouver, British Columbia, Canada

§Unfallklinik Frankfurt am Main, Frankfurt, Germany

University of Washington, Seattle, WA

Medical University Innsbruck, Innsbruck, Austria

**University of Maryland School of Medicine, Baltimore, MD

††Harborview Medical Center, Seattle, WA

‡‡Ganga Hospital, Coimbatore, Tamil Nadu, India

§§University of Toronto, Toronto, Ontario, Canada; and

¶¶Catholic University, Curitiba, Brazil.

Address correspondence and reprint requests to Alexander R. Vaccaro, MD, PhD, 925 Chestnut St, Fifth Flr, Philadelphia, PA 19107; E-mail:

Acknowledgment date: April 3, 2013. Revision date: June 14, 2013. Acceptance date: June 24, 2013.

The manuscript submitted does not contain information about medical device(s)/drug(s).

The AOSpine funds were received in support of this work. 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 3 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.

Relevant financial activities outside the submitted work: board membership, consultancy, grants, payment for lecture, payment for manuscript preparation, patents, royalties, stocks.

© 2013 by Lippincott Williams & Wilkins