Combination of the AO-Magerl and Load-Sharing Classifications for the Management of Thoracolumbar Burst Fractures
(Impact Factor: 0.96).
03/2010; 33(3):158-163. DOI: 10.3928/01477447-20100129-07
The AO-Magerl classification is widely accepted for the appropriate management of patients with thoracolumbar burst fractures; however, it fails to assess the ability of the injured spine to withstand compressive loading and cannot predict instrumentation failure after short-segment posterior fixation. The load-sharing classification depends on the degree of comminution and apposition of bony fragments.We retrospectively classified according to both classifications 100 consecutive patients with 1-level thoracolumbar burst fractures treated nonoperatively or operatively within a 7-year period. Sixty neurologically intact patients (60%) were treated nonoperatively, 15 (15%) had short posterior instrumentation, 15 (15%) had short anterior instrumentation, and 10 (10%) had combined short posterior instrumentation and anterior strut grafting. Twenty-five of the 40 (60%) surgically treated patients had neurological impairment on admission. Clinical outcome was assessed using a pain and working ability scale. Mean follow-up was 52 months (range, 24-70 months). Function was satisfactory in 55 (92%) nonoperatively treated patients and in 33 (83%) surgically treated patients. Neurological improvement by American Spinal Injury Association (ASIA) grade was observed in patients with incomplete paraplegia (70% of neurologically impaired patients) who were treated operatively.The combination of AO-Magerl and load-sharing classifications provides for accurate selection of treatment, surgical approach, and length of instrumentation, and can guide the decision for additional anterior surgery.
Available from: Maria Fernanda Silber Caffaro
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ABSTRACT: OBJECTIVE: The aim of this study is to analyze the correlation between the manual and digital inter-spinous distance by the Neumann method in burst thoracolumbar fracture, as well as the reproducibility of these two techniques. METHODS: We evaluated 212 x-rays of patients with burst thoracolumbar fracture. There were 60 male and 52 female. The average age at the time of the fracture was 38,9 years (12 - 76 years). RESULTS: The Pearson' coefficient between manual and digital analyses was 0,95 (p<0,01). The agreement coefficient of manual and digital measurements was 0,97 and 0,93, respectively. CONCLUSION: The manual and digital measurements of the inter-spinous distance by the Neumann method presented high correlation and high reproducibility in this series.
Available from: thejns.org
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ABSTRACT: The load-sharing score (LSS) of vertebral body comminution is predictive of results after short-segment posterior instrumentation of thoracolumbar burst fractures. Some authors have posited that an LSS > 6 is predictive of neurological injury, ligamentous injury, and the need for surgical intervention. However, the authors of the present study hypothesized that the LSS does not predict ligamentous or neurological injury.
The prospectively collected spinal cord injury database from a single institution was queried for thoracolumbar burst fractures. Study inclusion criteria were acute (< 24 hours) burst fractures between T-10 and L-2 with preoperative CT and MRI. Flexion-distraction injuries and pathological fractures were excluded. Four experienced spine surgeons determined the LSS and posterior ligamentous complex (PLC) integrity. Neurological status was assessed from a review of the medical records.
Forty-four patients were included in the study. There were 4 patients for whom all observers assigned an LSS > 6, recommending operative treatment. Eleven patients had LSSs ≤ 6 across all observers, suggesting that nonoperative treatment would be appropriate. There was moderate interobserver agreement (0.43) for the overall LSS and fair agreement (0.24) for an LSS > 6. Correlations between the LSS and the PLC score averaged 0.18 across all observers (range -0.02 to 0.34, p value range 0.02-0.89). Correlations between the LSS and the American Spinal Injury Association motor score averaged -0.12 across all observers (range -0.25 to -0.03, p value range 0.1-0.87). Correlations describing the relationship between an LSS > 6 and the treating physician's decision to operate averaged 0.17 across all observers (range 0.11-0.24, p value range 0.12-0.47).
The LSS does not uniformly correlate with the PLC injury, neurological status, or empirical clinical decision making. The LSSs of only one observer correlated significantly with PLC injury. There were no significant correlations between the LSS as determined by any observer and neurological status or clinical decision making.
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ABSTRACT: Surgical indications and optimal techniques for treating thoracolumbar burst fractures remain controversial. This review covers the most recent advances in classification and treatment. The continued validation of the Thoracolumbar Injury Classification and Severity Score (TLICS) has made this the most widely used instrument to guide clinical decision making in thoracolumbar trauma. Based on fracture morphology, neurologic status, and posterior ligamentous complex integrity, this system is excellent in guiding a surgeon to surgical or nonsurgical management. While surgical indications have become clearer, controversy remains as to the optimal surgical treatment. Techniques and concepts that have been the focus of recent studies include vertebral body augmentation, with and without short-segment posterior instrumentation, minimally invasive stabilization, and the need for anterior surgery. While the ability to predict which patients will benefit from surgical intervention has increased significantly with a more reliable classification system, the evidence to support an optimal treatment for each injury remains weak. As novel treatments that are less invasive continue to evolve, it will be increasingly important to have methodologically sound research to evaluate each option.
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