Search

Question 1: Are there classification systems for fractures of the thoracolumbar spine that have been shown to be internally valid and reliable (ie, do these instruments provide consistent information between different care providers)?, Recommendation 1: A classification scheme that uses readily available clinical data (eg, computed tomography scans with or without magnetic resonance imaging) to convey injury morphology, such as Thoracolumbar Injury Classification and Severity Scale or the AO Spine Thoracolumbar Spine Injury Classification System, should be used to improve characterization of traumatic thoracolumbar injuries and communication among treating physicians. Strength of Recommendation: Grade B., Question 2: In treating patients with thoracolumbar fractures, does employing a formally tested classification system for treatment decision-making affect clinical outcomes?, Recommendation 2: There is insufficient evidence to recommend a universal classification system or severity score that will readily guide treatment of all injury types and thereby affect outcomes. Strength of Recommendation: Grade Insufficient The full version of the guideline can be reviewed at: https://www.cns.org/guideline-chapters/congress-neurological-surgeons-systematic-review-evidence-based-guidelines/chapter_2.

Background: The thoracic and lumbar ("thoracolumbar") spine are the most commonly injured region of the spine in blunt trauma. Trauma of the thoracolumbar spine is frequently associated with spinal cord injury and other visceral and bony injuries. Prolonged pain and disability after thoracolumbar trauma present a significant burden on patients and society., Objective: To formulate evidence-based clinical practice recommendations for the care of patients with injuries to the thoracolumbar spine., Methods: A systematic review of the literature was performed using the National Library of Medicine PubMed database and the Cochrane Library for studies relevant to thoracolumbar spinal injuries based on specific clinically oriented questions. Relevant publications were selected for review., Results: For all of the questions posed, the literature search yielded a total of 6561 abstracts. The task force selected 804 articles for full text review, and 78 were selected for inclusion in this overall systematic review., Conclusion: The available evidence for the evaluation and treatment of patients with thoracolumbar spine injuries demonstrates considerable heterogeneity and highly variable degrees of quality. However, the workgroup was able to formulate a number of key recommendations to guide clinical practice. Further research is needed to counter the relative paucity of evidence that specifically pertains to patients with only thoracolumbar spine injuries. The full version of the guideline can be reviewed at: https://www.cns.org/guideline-chapters/congress-neurological-surgeons-systematic-review-evidence-based-guidelines/chapter_1.

Background: Thoracic and lumbar burst fractures in neurologically intact patients are considered to be inherently stable, and responsive to nonsurgical management. There is a lack of consensus regarding the optimal conservative treatment modality. The question remains whether external bracing is necessary vs mobilization without a brace after these injuries., Objective: To determine if the use of external bracing improves outcomes compared to no brace for neurologically intact patients with thoracic or lumbar burst fractures., Methods: A systematic review of the literature was performed using the National Library of Medicine PubMed database and the Cochrane Library for studies relevant to thoracolumbar trauma. Clinical studies specifically comparing external bracing to no brace for neurologically intact patients with thoracic or lumbar burst fractures were selected for review., Results: Three studies out of 1137 met inclusion criteria for review. One randomized controlled trial (level I) and an additional randomized controlled pilot study (level II) provided evidence that both external bracing and no brace equally improve pain and disability in neurologically intact patients with burst fractures. There was no difference in final clinical and radiographic outcomes between patients treated with an external brace vs no brace. One additional level IV retrospective study demonstrated equivalent clinical outcomes for external bracing vs no brace., Conclusion: This evidence-based guideline provides a grade B recommendation that management either with or without an external brace is an option given equivalent improvement in outcomes for neurologically intact patients with thoracic and lumbar burst fractures. The decision to use an external brace is at the discretion of the treating physician, as bracing is not associated with increased adverse events compared to no brace., Question: Does the use of external bracing improve outcomes in the nonoperative treatment of neurologically intact patients with thoracic and lumbar burst fractures?, Recommendation: The decision to use an external brace is at the discretion of the treating physician, as the nonoperative management of neurologically intact patients with thoracic and lumbar burst fractures either with or without an external brace produces equivalent improvement in outcomes. Bracing is not associated with increased adverse events compared to not bracing. Strength of Recommendation: Grade B The full version of the guideline can be reviewed at: https://www.cns.org/guideline-chapters/congress-neurological-surgeons-systematic-review-evidence-based-guidelines/chapter_8.

Background: Radiological evaluation of traumatic thoracolumbar fractures is used to classify the injury and determine the optimal treatment plan. Currently, there remains a lack of consensus regarding appropriate radiological protocol. Most clinicians use a combination of plain radiographs, 3-dimensional computed tomography with reconstructions, and magnetic resonance imaging (MRI)., Objective: To determine, through evidence-based guidelines review: (1) whether the use of MRI to identify ligamentous integrity predicted the need for surgical intervention; and (2) if there are any radiological findings that can assist in predicting clinical outcomes., Methods: A systematic review of the literature was performed using the National Library of Medicine/PubMed database and the Cochrane Library for studies relevant to thoracolumbar trauma. Clinical studies specifically addressing the radiological evaluation of thoracolumbar spine trauma were selected for review., Results: Two of 2278 studies met inclusion criteria for review. One retrospective review (Level III) and 1 prospective cohort (Level III) provided evidence that the addition of an MRI scan in acute thoracic and thoracolumbar trauma can predict the need for surgical intervention. There was insufficient evidence that MRI can help predict clinical outcomes in patients with acute traumatic thoracic and thoracolumbar spine injuries., Conclusion: This evidence-based guideline provides a Grade B recommendation that radiological findings in patients with acute thoracic or thoracolumbar spine trauma can predict the need for surgical intervention. This evidence-based guideline provides a grade insufficient recommendation that there is insufficient evidence to determine if radiographic findings can assist in predicting clinical outcomes in patients with acute thoracic and thoracolumbar spine injuries., Question 1: Are there radiographic findings in patients with traumatic thoracolumbar fractures that can predict the need for surgical intervention?, Recommendation 1: Because MRI has been shown to influence the management of up to 25% of patients with thoracolumbar fractures, providers may use MRI to assess posterior ligamentous complex integrity, when determining the need for surgery. Strength of Recommendation: Grade B., Question 2: Are there radiographic findings in patients with traumatic thoracolumbar fractures that can assist in predicting clinical outcomes?, Recommendation 2: Due to a paucity of published studies, there is insufficient evidence that radiographic findings can be used as predictors of clinical outcomes in thoracolumbar fractures. Strength of Recommendation: Grade Insufficient The full version of the guideline can be reviewed at: https://www.cns.org/guideline-chapters/congress-neurological-surgeons-systematic-review-evidence-based-guidelines/chapter_3.

Question: Does the administration of a specific pharmacologic agent (eg, methylprednisolone) improve clinical outcomes in patients with thoracic and lumbar fractures and spinal cord injury?, Recommendation: There is insufficient evidence to make a recommendation; however, the task force concluded, in light of previously published data and guidelines, that the complication profile should be carefully considered when deciding on the administration of methylprednisolone. Strength of recommendation: Grade Insufficient The full version of the guideline can be reviewed at: https://www.cns.org/guideline-chapters/congress-neurological-surgeons-systematic-review-evidence-based-guidelines/chapter_5.

Question: Does the choice of surgical approach (anterior, posterior, or combined anterior-posterior) improve clinical outcomes in patients with thoracic and lumbar fractures?, Recommendations: In the surgical treatment of patients with thoracolumbar burst fractures, physicians may use an anterior, posterior, or a combined approach as the selection of approach does not appear to impact clinical or neurological outcomes. Strength of Recommendation: Grade B With regard to radiologic outcomes in the surgical treatment of patients with thoracolumbar fractures, physicians may utilize an anterior, posterior, or combined approach because there is conflicting evidence in the comparison among approaches. Strength of Recommendation: Grade Insufficient With regard to complications in the surgical treatment of patients with thoracolumbar fractures, physicians may use an anterior, posterior, or combined approach because there is conflicting evidence in the comparison among approaches. Strength of Recommendation: Grade Insufficient The full version of the guideline can be reviewed at: https://www.cns.org/guideline-chapters/congress-neurological-surgeons-systematic-review-evidence-based-guidelines/chapter_11.

Question 1: Does the surgical treatment of burst fractures of the thoracic and lumbar spine improve clinical outcomes compared to nonoperative treatment?, Recommendation 1: There is conflicting evidence to recommend for or against the use of surgical intervention to improve clinical outcomes in patients with thoracolumbar burst fracture who are neurologically intact. Therefore, it is recommended that the discretion of the treating provider be used to determine if the presenting thoracic or lumbar burst fracture in the neurologically intact patient warrants surgical intervention. Strength of Recommendation: Grade Insufficient., Question 2: Does the surgical treatment of nonburst fractures of the thoracic and lumbar spine improve clinical outcomes compared to nonoperative treatment?, Recommendation 2: There is insufficient evidence to recommend for or against the use of surgical intervention for nonburst thoracic or lumbar fractures. It is recommended that the decision to pursue surgery for such fractures be at the discretion of the treating physician. Strength of Recommendation: Grade Insufficient The full version of the guideline can be reviewed at: https://www.cns.org/guideline-chapters/congress-neurological-surgeons-systematic-review-evidence-based-guidelines/chapter_1.

Question 1: Does routine screening for deep venous thrombosis prevent pulmonary embolism (or venous thromboembolism (VTE)-associated morbidity and mortality) in patients with thoracic and lumbar fractures?, Recommendation 1: There is insufficient evidence to recommend for or against routine screening for deep venous thrombosis in preventing pulmonary embolism (or VTE-associated morbidity and mortality) in patients with thoracic and lumbar fractures. Strength of Recommendation: Grade Insufficient., Question 2: For patients with thoracic and lumbar fractures, is one regimen of VTE prophylaxis superior to others with respect to prevention of pulmonary embolism (or VTE-associated morbidity and mortality)?, Recommendation 2: There is insufficient evidence to recommend a specific regimen of VTE prophylaxis to prevent pulmonary embolism (or VTE-associated morbidity and mortality) in patients with thoracic and lumbar fractures. Strength of Recommendation: Grade Insufficient., Question 3: Is there a specific treatment regimen for documented VTE that provides fewer complications than other treatments in patients with thoracic and lumbar fractures?, Recommendation 3: There is insufficient evidence to recommend for or against a specific treatment regimen for documented VTE that would provide fewer complications than other treatments in patients with thoracic and lumbar fractures. Strength of Recommendation: Grade Insufficient., Recommendation 4: Based on published data from pooled (cervical and thoracolumbar) spinal cord injury populations, the use of thromboprophylaxis is recommended to reduce the risk of VTE events in patients with thoracic and lumbar fractures. Consensus Statement by the Workgroup The full version of the guideline can be reviewed at: https://www.cns.org/guideline-chapters/congress-neurological-surgeons-systematic-review-evidence-based-guidelines/chapter_7.

Question 1: Which neurological assessment tools have demonstrated internal reliability and validity in the management of patients with thoracic and lumbar fractures (ie, do these instruments provide consistent information between different care providers)?, Recommendation 1: Numerous neurologic assessment scales (Functional Independence Measure, Sunnybrook Cord Injury Scale and Frankel Scale for Spinal Cord Injury) have demonstrated internal reliability and validity in the management of patients with thoracic and lumbar fractures. Unfortunately, other contemporaneous measurement scales (ie, American Spinal Cord Injury Association Impairment Scale) have not been specifically studied in patients with thoracic and lumbar fractures. Strength of Recommendation: Grade C., Question 2: Are there any clinical findings (eg, presenting neurological grade/function) in patients with thoracic and lumbar fractures that can assist in predicting clinical outcomes?, Recommendation 2: Entry American Spinal Injury Association Impairment Scale grade, sacral sensation, ankle spasticity, urethral and rectal sphincter function, and AbH motor function can be used to predict neurological function and outcome in patients with thoracic and lumbar fractures (Table I https://www.cns.org/guideline-chapters/congress-neurological-surgeons-systematic-review-evidence-based-guidelines/chapter_4_table1). Strength of Recommendation: Grade B The full version of the guideline can be reviewed at: https://www.cns.org/guideline-chapters/congress-neurological-surgeons-systematic-review-evidence-based-guidelines/chapter_4.

Question: Does early surgical intervention improve outcomes for patients with thoracic and lumbar fractures?, Recommendations: There is insufficient and conflicting evidence regarding the effect of timing of surgical intervention on neurological outcomes in patients with thoracic and lumbar fractures. Strength of Recommendation: Grade Insufficient It is suggested that "early" surgery be considered as an option in patients with thoracic and lumbar fractures to reduce length of stay and complications. The available literature has defined "early" surgery inconsistently, ranging from <8 h to <72 h after injury. Strength of Recommendation: Grade B The full version of the guideline can be reviewed at: https://www.cns.org/guideline-chapters/congress-neurological-surgeons-systematic-review-evidence-based-guidelines/chapter&#95;10.

Question: Does the active maintenance of arterial blood pressure after injury affect clinical outcomes in patients with thoracic and lumbar fractures?, Recommendations: There is insufficient evidence to recommend for or against the use of active maintenance of arterial blood pressure after thoracolumbar spinal cord injury. Grade of Recommendation: Grade Insufficient However, in light of published data from pooled (cervical and thoracolumbar) spinal cord injury patient populations, clinicians may choose to maintain mean arterial blood pressures >85 mm Hg in an attempt to improve neurological outcomes. Consensus Statement by the Workgroup The full version of the guideline can be reviewed at: https://www.cns.org/guideline-chapters/congress-neurological-surgeons-systematic-review-evidence-based-guidelines/chapter&#95;6.

Study Design: The thoracolumbar injury classification system (TLICS) was evaluated in 20 consecutive pediatric spine trauma cases., Objective: The purpose of this study was to determine the reliability and validity of the TLICS in pediatric spine trauma., Summary of Background Data: The TLICS was developed to improve the categorization and management of thoracolumbar trauma. TLICS has been shown to have good reliability and validity in the adult population., Methods: The clinical and radiographical findings of 20 pediatric thoracolumbar fractures were prospectively presented to 20 surgeons with disparate levels of training and experience with spinal trauma. These injuries were consecutively scored using the TLICS. Cohen unweighted κ coefficients and Spearman rank order correlation values were calculated for the key parameters (injury morphology, status of posterior ligamentous complex, neurological status, TLICS total score, and proposed management) to assess the inter-rater reliabilities. Five surgeons scored the same cases 3 months later to assess the intra-rater reliability. The actual management of each case was then compared with the treatment recommended by the TLICS algorithm to assess validity., Results: The inter-rater κ statistics of all subgroups (injury morphology, status of the posterior ligamentous complex, neurological status, TLICS total score, and proposed treatment) were within the range of moderate to substantial reproducibility (0.524-0.958). All subgroups had excellent intra-rater reliability (0.748-1.000). The various indices for validity were calculated (80.3% correct, 0.836 sensitivity, 0.785 specificity, 0.676 positive predictive value, 0.899 negative predictive value). Overall, TLICS demonstrated good validity., Conclusion: The TLICS has good reliability and validity when used in the pediatric population. The inter-rater reliability of predicting management and indices for validity are lower than those in adults with thoracolumbar fractures, which is likely due to differences in the way children are treated for certain types of injuries. TLICS can be used to reliably categorize thoracolumbar injuries in the pediatric population; however, modifications may be needed to better guide treatment in this specific patient population., Level of Evidence: 4.

Safety information in spine surgery is important for informed patient choice and performance-based payment incentives, but measurement methods for surgical safety assessment are not standardized. Published reports of complication rates for common spinal procedures show wide variation. Factors influencing variation may include differences in safety ascertainment methods and procedure types. In a prospective cohort study, adverse events were observed in all patients undergoing spine surgery at two hospitals during a 2-year period. Multiple processes for adverse occurrence surveillance were implemented, and the associations between surveillance methods, surgery invasiveness, and observed frequencies of adverse events were examined. The study enrolled 1,723 patients. Adverse events were noted in 48.3% of the patients. Reviewers classified 25% as minor events and 23% as major events. Of the major events, the daily rounding team reported 38.4% of the events using a voluntary reporting system, surgeons reported 13.4%, and 9.1% were identified during clinical conferences. A review of medical records identified 86.7% of the major adverse events. The adverse events occurred during the inpatient hospitalization for 78.1% of the events, within 30 days for an additional 12.5%, and within the first year for the remaining 9.4%. A unit increase in the invasiveness index was associated with an 8.2% increased risk of a major adverse event. A Current Procedural Terminology-based algorithm for quantifying invasiveness correlated well with medical records-based assessment. Increased procedure invasiveness is associated with an increased risk of adverse events. The observed frequency of adverse events is influenced by the ascertainment modality. Voluntary reports by surgeons and other team members missed more than 50% of the events identified through a medical records review. Increased surgery invasiveness, measured from medical records or billing codes, is quantitatively associated with an increased risk of adverse events.

Assessing local bone quality on CT scans with Hounsfield unit (HU) quantification is being used with increasing frequency. Correlations between HU and bone mineral density have been established, and normative data have been defined throughout the spine. Recent investigations have explored the utility of HU values in assessing fracture risk, implant stability, and spinal fusion success. The information provided by a simple HU measurement can alert the treating physician to decreased bone quality, which can be useful in both medically and surgically managing these patients.

Objectives: To quantify the radiation dose received during thoracic spine computed tomography (CT) versus plain radiographs as well as the theoretical risk of breast cancer induction in a pediatric trauma population., Methods: A retrospective evaluation of 179 female pediatric trauma patients who received CT or plain radiographs for clearance of the thoracic spine was performed. Subjects were secondarily grouped as children (0-<12 years) or adolescents (≥12-17.9 years). Radiation doses were calculated by using the ImPACT Patient Dosimetry Calculator. Excess absolute risk (EAR) of induction of breast cancer was determined by multiplying the radiation dose by breast cancer induction rates taken from the National Academy's Biological Effects of Ionizing Radiation Committee's seventh report., Results: The average radiation dose to the breast from a thoracic spine CT was 41.1 (SD 11.4) mSv and 1.8 (SD 0.9) mSv for plain radiographs. The EAR for plain radiographs was 2.7 (95% confidence interval [CI] 2.48-2.85) excess cases of breast cancer per 10 000 studies for female children and 1.4 (95% CI 1.14-1.55) for female adolescents. The breast cancer EAR for thoracic spine CT was significantly higher -79.6 (95% CI 58.6-100.5) and 45.8 (95% CI 42.0-49.6) excess cases per 10 000 scans for female children and adolescents, respectively. There was a substantially higher risk of breast cancer induction for children receiving thoracic spine CT compared with adolescents., Conclusions: CT clearance of the thoracic spine in the pediatric trauma patient results in a high dose of radiation and an age-dependent increase in theoretical breast cancer induction.

Pediatric cervical spine injuries are rare and are associated with significant morbidity and mortality. Pediatric anatomy and physiology predispose to upper cervical spine injury and spinal cord injury without radiologic abnormality in contrast to lower cervical spine injury seen in adults. Care of pediatric patients is difficult because they have a greater head-to-body ratio than adults and may have difficulty cooperating with a history and physical examination. In evaluating a child with a suspected cervical spine injury, radiography may be supplemented with CT or MRI. Definitive management of pediatric cervical spine trauma must be adapted to the distinctive anatomy and growth potential of the patient. As with all injuries, prevention is necessary to reduce the incidence of trauma to the pediatric spine.

The goal of cervical spine clearance is to establish that injuries are not present. Patients are classified into four groups: asymptomatic, temporarily nonassessable secondary to distracting injuries or intoxication, symptomatic, and obtunded. Level I evidence supports that the asymptomatic patient can be cleared on clinical grounds and does not require imaging. The temporarily nonassessable patient may have short-term mental status changes (eg, intoxication, painful distracting injuries) and can be evaluated by two methods. When there is urgency, the evaluation is similar to that for the obtunded patient. Alternatively, the patient can be reevaluated within 24 to 48 hours, after return of mentation or following treatment of painful injuries. The patient then can be assessed as the asymptomatic patient is. The symptomatic patient requires advanced imaging. The obtunded patient should undergo, at minimum, a multidetector CT scan. Two methods are advocated. One uses only multidetector CT; a normal result is sufficient to clear the obtunded patient. The alternative method is obtaining a magnetic resonance image subsequent to a negative multidetector CT scan. Because at present information is insufficient to determine whether MRI is indicated, this is an area of controversy.

Background: There is a subset of blunt trauma patients that present with symptoms suspicious for cervical spine injury or with unreliable clinical exams whose initial plain radiographs or cervical computed tomography (CT) scan are negative. Uncertainty remains, however, because no gold standard has been established for definitively clearing the cervical spine of injury in this patient cohort. Individual studies have detailed the use of magnetic resonance imaging (MRI) in this patient population without conclusive results., Methods: Comprehensive database searches were conducted for prospective or retrospective diagnostic studies of blunt trauma patients who were entered into a cervical spine clearance protocol that included MRI. Inclusion criteria were minimum 30 patients with clinically suspicious or unevaluatable cervical spines, clinical follow-up as the gold standard, data reported to allow the collection of true positives, true negatives, false positives, and false negatives, MRI obtained within 72 hours of injury, and plain radiographs that disclosed nothing abnormal of the cervical spine with or without a CT scan that disclosed nothing abnormal. Log odds meta-analysis of the sensitivity, specificity, positive, and negative predictive value of MRI was performed., Results: Five Level I diagnostic protocols, enrolling 464 patients receiving MRI, were included. There were zero false negatives in the five studies resulting in a negative predictive value of 100%. Log odds meta-analysis produced a 94.2% positive predictive value (95% confidence interval [CI] 75.0, 989), 97.2% sensitivity (95% CI 89.5, 99.3), and 98.5% specificity (95% CI 91.8, 99.7). Ninety-seven (97 of 464, 20.9%) patients had abnormalities identified by MRI that were not identified by plain radiographs with or without CT., Conclusion: A magnetic resonance image that did not disclose anything abnormal can conclusively exclude cervical spine injury and is established as a gold standard for clearing the cervical spine in a clinically suspicious or unevaluatable blunt trauma patient. An accurate number of false positive MRI scans cannot be determined.

Object The authors review a novel subaxial cervical trauma classification system and demonstrate its application through a series of cervical trauma cases. Methods The Spine Trauma Study Group collaborated to create the Subaxial Injury Classification (SLIC) and Severity score. The SLIC system is reviewed and is applied to 3 cases of subaxial cervical trauma. Results The SLIC system identifies 3 major injury characteristics to describe subaxial cervical injuries: injury morphology, discoligamentous complex integrity, and neurological status. Minor injury characteristics include injury level and osseous fractures. Each major characteristic is assigned a numerical score based upon injury severity. The sum of these scores constitutes the injury severity score. Conclusions By addressing both discoligamentous integrity and neurological status, the SLIC system may overcome major limitations of earlier classification systems. The system incorporates a number of critical clinical variables-including neurological status, absent in earlier systems-and is simple to apply and may provide both diagnostic and prognostic information.

Background Context: Posterior ligamentous complex (PLC), consisting of supraspinous ligament (SSL), interspinous ligament (ISL), ligamentum flavum (LF), and the facet joint capsules is thought to contribute significantly to the stability of thoracolumbar spine. Currently, no consensus exists on radiographic imaging parameters that may indicate injury to the posterior ligamentous complex., Purpose: To identify imaging parameters that may suggest a disruption of the PLC of the thoracolumbar spine., Study Design/setting: A survey analysis of members of the Spine Trauma Study Group., Patient Sample: None., Outcomes Measures: Compilation of survey results., Methods: An extensive review of the literature from 1949 to the present was performed to identify key radiographic elements that have been suggested as indicators of PLC injury. Twelve items identified as such were placed on a survey and sent to the members of the Spine Trauma Study Group. They were asked to rank the items from most important to least important, and the results were compiled for analysis., Results: Twenty-eight surveys were returned for final analysis. Fifty-percent (14/28) of the members ranked "vertebral body translation" on plain radiographs as the most important factor in determining disruption of PLC. Plain radiographic signs were ranked higher than computed tomography or magnetic resonance imaging indicators, and history of the mechanism ranked lowest. The members were also given freedom to add other criteria that they felt were important in determining PLC integrity. "Interspinous spacing 7 mm greater than that of level above or below on antero posterior plain X-rays" was the only new category that was suggested., Conclusion: Plain radiographic findings were felt to be most helpful in determining PLC injury by the members of the Spine Trauma Study Group. Physical examination findings and history of the mechanism of injury were ranked lower than imaging studies. Future analysis should focus on indicators of PLC injury when plain radiographic findings are either subtle or not present.

Study Design: Blinded assessment by multiple observers of consecutive case series., Objectives: Measure the reliability of a new system of determining stability in subaxial cervical spine injuries., Summary of Background Data: Classification is fundamental to allow communication, determine prognosis, and direct treatment. Current systems have many limitations, including difficultly of use, lack of proven reliability and validity, and no assessment of stability. A new system to assess instability is proposed., Methods: A literature review of the most commonly described classification systems is reported. The Cervical Spine Injury Severity Score was tested for reliability by 10 examiners who graded 35 consecutive cases of cervical trauma. Plain radiographs and CT were saved as read using Efilm Lite in random order. Each was scored and intraobserver and interobserver agreement was measured using intraclass correlation coefficients (ICC)., Results: Intraobserver agreement was excellent with ICC ranging from 0.97 to 0.99. Interobserver agreement was also excellent with mean 0.80 ranging from 0.75 to 0.98., Conclusion: A new cervical spine classification system of injury is paramount to treatment and outcomes. A new system may increase reliability and therefore allow more accurate determination of stability and dictate treatment.

Study Design: A new proposed classification system for thoracolumbar (TL) spine injuries, including injury severity assessment, designed to assist in clinical management., Objective: To devise a practical, yet comprehensive, classification system for TL injuries that assists in clinical decision-making in terms of the need for operative versus nonoperative care and surgical treatment approach in unstable injury patterns., Summary of Background Data: The most appropriate classification of traumatic TL spine injuries remains controversial. Systems currently in use can be cumbersome and difficult to apply. None of the published classification schemata is constructed to aid with decisions in clinical management., Methods: Clinical spine trauma specialists from a variety of institutions around the world were canvassed with respect to information they deemed pivotal in the communication of TL spine trauma and the clinical decision-making process. Traditional injury patterns were reviewed and reconsidered in light of these essential characteristics. An initial validation process to determine the reliability and validity of an earlier version of this system was also undertaken., Results: A new classification system called the Thoracolumbar Injury Classification and Severity Score (TLICS) was devised based on three injury characteristics: 1) morphology of injury determined by radiographic appearance, 2) integrity of the posterior ligamentous complex, and 3) neurologic status of the patient. A composite injury severity score was calculated from these characteristics stratifying patients into surgical and nonsurgical treatment groups. Finally, a methodology was developed to determine the optimum operative approach for surgical injury patterns., Conclusions: Although there will always be limitations to any cataloging system, the TLICS reflects accepted features cited in the literature important in predicting spinal stability, future deformity, and progressive neurologic compromise. This classification system is intended to be easy to apply and to facilitate clinical decision-making as a practical alternative to cumbersome classification systems already in use. The TLICS may improve communication between spine trauma physicians and the education of residents and fellows. Further studies are underway to determine the reliability and validity of this tool.

Objective: Significant controversy exists regarding the optimal management of thoracolumbar injuries. This is in part due to the lack of understanding of the natural history of various injury subtypes and the absence of a universally accepted classification scheme that facilitates communication among care providers and assists in directing treatment. The Spine Trauma Study Group has developed an injury severity score based on three major variables: the mechanism of injury determined by radiographic appearance, the integrity of the posterior ligamentous complex, and the neurologic status of the patient. By systematically assigning specific point values within each category based on the severity of injury, a final severity score may be generated that can be used to help direct treatment. The goal of this work is to present a proposal of a detailed treatment algorithm to assist in the nonoperative or operative management of thoracolumbar injuries., Methods: A detailed review of the world's spinal literature was performed to ascertain predictors of instability following thoracolumbar trauma. With use of known biomechanical and clinical outcome measures, an arbitrary assignment of point values to various injury descriptors was performed. The assessment of the validity of the severity score was compared retrospectively with a variety of selected cases representing the typical injury patterns under the three major injury groups: compression, translational/rotational, and distraction injuries., Conclusions: The proposed treatment algorithm is an attempt to assist physicians using best-evidence medicine in managing thoracolumbar spinal injuries. The final point flow chart with graduated treatment recommendations is only preliminary and needs to be validated through prospective cohort analysis. In addition, the importance of the chosen variables determining spinal stability must also be verified.

Study Design: A cadaveric cervical spine specimen fixed between a fiberglass torso and a plastic skull was used as a model to determine the effect of halo structural parameters on motion at a lesion simulated at C5-C6. In a second part, nine commercially available halo devices were compared., Objectives: To define the contributions of the various components of the halo apparatus to reducing motion in an injured cervical spine and to compare the stability offered by a sample of commercially available halo devices. Controversy exists concerning the ability of the halo apparatus to stabilize the injured cervical spine., Summary of Background Data: The halo apparatus has been shown to be the most effective nonsurgical method for stabilizing the fractured spine. Nonetheless, several clinical studies have demonstrated that unacceptably large motions can occur at the injured spinal segment stabilized with a halo apparatus., Methods: Each cadaveric cervical spine was mounted onto a fiberglass torso and a rigid plastic skull was attached to the base of the occiput. A posterior ligamentous lesion was created between C5 and C6. The halo ring was fitted to the skull and a vest to the torso. Loads were applied to the skull in flexion, extension, and lateral bending, and relative angulation between C5 and C6 was measured with electroinclinometers. In the first part, the effect of parameters such as vest tightness, vest-thorax friction, vest deformation, and connecting bar rigidity on spinal angulation were measured using one vest. In the second part, the stability offered by each of nine commercially available halo devices was compared., Results: Increasing chest strap tightness and decreasing vest deformation reduced angulation at the spinal lesion. Once connecting bar joints were tightened to 25% of their recommended torque, increased tightening or adding additional bars had no effect on rigidity. Although specific vests permitted significantly greater motion in specific directions, no vest allowed greater angulation consistently in all loading planes., Conclusions: Increasing vest tightness, decreasing the deformability of the vest, and ensuring a good fit can reduce motion in the fractured spine. Most commercially available halo vests provide similar mechanical stability to the injured cervical spine.

Forty-two patients with cervical spine injuries immobilized in halo vests were studied prospectively to determine in vivo vertebral segmental motion. Lateral radiographs taken in the supine and upright positions within 5 days of injury demonstrated intervertebral motion. At noninjured levels, the positional change accounted for an average 3.9 degrees of angulation with the greatest motion occurring between the occiput and C1 (8.0 degrees). At the injured levels, sagittal plane angulation averaged 7.0 degrees and translation averaged 1.7 mm between the two positions. Fracture site motion did not correlate with either the fracture type or the injury level. Fracture site motion greater than 3 degrees of angulation or 1 mm of translation was observed at 35 (77%) of 45 injured levels. When treating patients who have unstable cervical injuries with halo vests, supine and upright radiographs should be obtained. If excessive motion is present, alternative methods of treatment should be considered.

This study examined the frequency of spine and abdominal injuries to motor vehicle occupant crash victims, the relationship between the two types of injuries, and the association with restraint use. There were 303 motor vehicle occupants treated at a regional trauma center for spine and/or abdominal injuries over a 5-year period. Patients with Chance-type fractures of the lumbar spine were much more likely to be rear seat passengers and to be using a lap belt than were patients with other types of spinal injuries. Similarly, patients with hollow viscus injuries were more likely to be rear seat passengers and to be lap belted than were patients with injuries to the spleen, liver, pancreas, or kidneys. Nearly two thirds of the lumbar Chance-type fractures were associated with hollow viscus injuries, including six of seven children. This increased risk of Chance-type fractures and hollow viscus injuries was associated with increased use of lap-belt seat restraints in the population.