1 Introduction

Classification systems are a potentially powerful tool in patient care, the benefits of which are well documented in the Neuro-surgical and orthopaedic literature. The need for a comprehensive classification system for thoracolumbar spinal injuries is especially critical as greater emphasis on outcome assessment is demanded as resources become less available. Thoracolum-bar spine injuries are among the most commonly encountered skeletal injuries and often stimulate great debate over optimal treatment regimens. Although several classification systems for thoracolumbar injuries have been described [1–10] and promoted since Böhler’s sentinel attempt at classifying these injuries in 1929 [11], none has gained universal acceptance. This lack of acceptance appears to be due to a number of factors. Some classifications are difficult to apply in clinical practice while others lack the reproducibility and validity needed to rationalize their use. Furthermore, the majority of these schemes ignore the severity of the injury and are largely ineffectual at predicting the outcome or natural history of a given fracture pattern respective of its management. In essence, they strive to serve only as descriptors and not predictors.

The deficiencies of many current thoracolumbar injury classifications are well known and documented [12]. Many of these concerns have been present for more than two decades. Surprisingly, despite huge advances in imaging and surgical techniques for treating fractures, these limitations have not been resolved. Currently available classifications are limited by a number of fundamental problems. First, the majority of systems are so complex as to limit their utility in routine clinical practice. Second, many classification systems fail to include certain anatomic or physiologic factors important to clinical decision making such as the status of the posterior ligamentous structures or the neurological status of the patient. And third, most Classification schemes do not help to suggest treatment, taking into account the modern diagnostic and therapeutic techniques available. Instead, the interpretation of the majority of thoracolumbar fracture Classification systems relies on anecdotal surgeon experience, retrospective reconstruction of the mechanism of injury, and non validated predictors of spinal deformity and neurological compromise.

2 Summary

None of the Classification systems published to date have integrated treatment algorithms for the care of patients with tho-racolumbar injuries.

A clinically relevant thoracolumbar spinal Classification system should be both descriptive and prognostic. The system must be easy to remember and to use in clinical practice, based upon a simple algorithm with consistent radiographic and clinical characteristics. Additionally, the system should provide information on the severity and natural history of an injury pattern. Lastly, the system should suggest the prognosis of a given injury and thereby guide clinical decision making. An ideal system incorporating these principles can be a useful tool in clinical studies and can aid us in the advancement of patient care. A new approach in classifying thoracolumbar injuries, such as the thoracolumbar inury Classification and severity score (TLICS) [13] will integrate descriptive elements, neurologic injury status and integrity of the posterior ligamentous complex (PLC) into a meaningful composite score, which will aid communication, research and aid in the decision making process. In addition to these components, a partnering scoring system provides a checklist geared towards systematic patient evaluation and in that capacity serves as a teaching and quality of care i mprovement measu re. A s shou ld be the case for a ny new Classification and scoring system it has been subjected to vigorous inter- and intra-observer reliability testing and is being tested in clinical application scenarios.

3 References

1 Böhler Thoracolumbar Spine Fracture Classification

Böhler L (1930) Die Technik der Knochenbruchbehandlung im Frieden und im Kriege. Verlag von Wilhelm. German

Böhler L (1956) The Treatment of Fractures Vol. 1. Mechanisms of fracture and dislocation of the spine. New York: Grune and Straton.

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2 Chance Fracture

Chance GQ (1948) Note on a type of flexion fracture of the spine. Br J Radiol; 21:452–453.

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3 Denis Classification of Thoracolumbar Fractures

Denis F (1983) The three column spine and its significance in the Classification of acute thoracolumbar spinal injuries. Spine; 8:817–831.

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4 Ferguson and Allen Classification of Thoracolumbar Fractures

Ferguson RL, Allen BL Jr (1984) A mechanistic Classification of thoracolumbar spine fractures. Clin Orthop Relat Res; 189:77-88.

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Vertical compression

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5 Gertzbein Classification of Thoracolumbar Flexion-Distraction Fractures

Gertzbein SD, Court-Brown CM (1988) Flexion-distraction injuries of the lumbar spine. Mechanisms of injury and Classification. Clin Orthop Relat Res; 227:52–60.

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6 Gumley Classification of Thoracolumbar Distraction Fractures

Gumley G, Taylor TK, Ryan MD (1982) Distraction fractures of the lumbar spine. J Bone Joint Surg Br; 64:520–525.

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Classified based on patterns of fracture in the posterior column:

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  Type I–Fracture line traverses the spinous processes, laminae, apophyseal joints, pedicles and transverse processes with a variable direction through the vertebral body

  
  
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  Type II–Fracture line enters the laminae at the base of the spinous process but is otherwise the same as Type I

  
  
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  Type III–Result of distraction with a rotary element, with the fracture line passing through the posterior elements and the vertebral body comparable to Types I and II a

Interpretation:

Descriptive of fracture location. One type not necessarily more severe than the next.

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7 Harborview Flexion-Distraction Injury (FDI) Classification

Chapman JR, Agel J, Jurkovich GJ, et al (2008) Thoracolumbar flexion-distraction injuries: associated morbidity and neurological outcomes. Spine; 33:648–657.

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Related posts:

6.1 General trauma severity measures 6.2 Spinal cord injury severity measures 6.6 Lumbosacral spine trauma classification systems 6.7 Whole spine trauma classification systems 6.4 Lower cervical spine trauma classification systems 6.3 Upper cervical spine trauma classification systems

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