The Influence of Comminution and Posterior Ligamentous Complex Integrity on Treatment Decision Making in Thoracolumbar Burst Fractures Without Neurologic Deficit?

Mohamed M Aly; Charlotte Dandurand; Marcel F Dvorak; Cumhur F Öner; Klaus Schnake; Sanders Mujis; Lorin M Benneker; Emiliano Vialle; Shanmuganathan Rajasekaran; Mohammad El-Skarkawi; Rishi M Kanna; Martin Holas; Eugen Cezar Popescu; Jin W Tee; Gaston Camino-Willhuber; Andrei Fernandes Joaquim; Ory Kenyan; Harvinder Singh Chhabra; Sebastian Bigdon; Ulrich Spiegel; Gregory D Schroeder; Jose A Canseco; Alexander R Vaccaro; Richard J Bransford

doi:10.1177/21925682231196452

The Influence of Comminution and Posterior Ligamentous Complex Integrity on Treatment Decision Making in Thoracolumbar Burst Fractures Without Neurologic Deficit?

Global Spine J. 2024 Feb;14(1_suppl):41S-48S. doi: 10.1177/21925682231196452.

Authors

Mohamed M Aly^{1

2}, Charlotte Dandurand³, Marcel F Dvorak³, Cumhur F Öner⁴, Klaus Schnake^{5

6}, Sanders Mujis⁴, Lorin M Benneker⁷, Emiliano Vialle⁸, Shanmuganathan Rajasekaran⁹, Mohammad El-Skarkawi¹⁰, Rishi M Kanna⁹, Martin Holas¹¹, Eugen Cezar Popescu¹², Jin W Tee¹³, Gaston Camino-Willhuber¹⁴, Andrei Fernandes Joaquim¹⁵, Ory Kenyan¹⁶, Harvinder Singh Chhabra¹⁷, Sebastian Bigdon¹⁸, Ulrich Spiegel¹⁹, Gregory D Schroeder²⁰, Jose A Canseco²⁰, Alexander R Vaccaro²⁰, Richard J Bransford^{19

21}

Affiliations

¹ Department of Neurosurgery, Mansoura University, Mansoura, Egypt.
² Department of Neurosurgery, Prince Mohammed Bin Abdelaziz Hospital, Riyadh, Saudi Arabia.
³ Combined Neurosurgical and Orthopedic Spine Program, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada.
⁴ University Medical Centers, Utrecht, The Netherlands.
⁵ Center for Spinal and Scoliosis Surgery, Malteser Waldkrankenhaus St. Marien, Erlangen, Germany.
⁶ Department of Orthopedics and Traumatology, Paracelsus Private Medical University Nuremberg, Nuremberg, Germany.
⁷ Spine Unit, Sonnenhof Spital, University of Bern, Bern, Switzerland.
⁸ Cajuru Hospital, Catholic University of Paraná, Curitiba, Brazil.
⁹ Department of Orthopaedics and Spine Surgery, Ganga Hospital, Coimbatore, India.
¹⁰ Department of Orthopaedic and Trauma Surgery, Faculty of Medicine, Assiut University, Assiut, Egypt.
¹¹ Klinika Úrazovej Chirurgie SZU a FNsP F.D. Roosevelta, Banská Bystrica, Banska Bystrica, Slovakia.
¹² Prof. Dr. N. Oblu" Emergency Hospital, Iasi, Romania.
¹³ Department of Neurosurgery, National Trauma Research Institute (NTRI), The Alfred Hospital, Melbourne, VIC, Australia.
¹⁴ Orthopaedic and Traumatology Department, Institute of Orthopedics "Carlos E. Ottolenghi" Hospital Italiano de Buenos Aires, Buenos Aires, Argentina.
¹⁵ Neurosurgery Division, Department of Neurology, State University of Campinas, Campinas-Sao Paulo, Brazil.
¹⁶ Rambam Health Care Campus, Haifa, Israel.
¹⁷ Sri Balaji Action Medical Institute, New Delhi, India.
¹⁸ Department of Orthopaedic Surgery and Traumatology, Inselspital University Hospital, University of Bern, Bern, Switzerland.
¹⁹ Department of Orthopaedics, Trauma Surgery and Plastic Surgery, University of Leipzig, Leipzig, Germany.
²⁰ Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University Hospital, Philadelphia, PA, USA.
²¹ Department of Orthopedics and Sports Medicine, Harborview Medical Center, University of Washington, Seattle, WA, USA.

Abstract

Study design: A prospective study.

Objective: to evaluate the impact of vertebral body comminution and Posterior Ligamentous Complex (PLC) integrity on the treatment recommendations of thoracolumbar fractures among an expert panel of 22 spine surgeons.

Methods: A review of 183 prospectively collected thoracolumbar burst fracture computed tomography (CT) scans by an expert panel of 22 trauma spine surgeons to assess vertebral body comminution and PLC integrity. This study is a sub-study of a prospective observational study of thoracolumbar burst fractures (Spine TL A3/A4). Each expert was asked to grade the degree of comminution and certainty about the PLC disruption from 0 to 100, with 0 representing the intact vertebral body or intact PLC and 100 representing complete comminution or complete PLC disruption, respectively.

Results: ≥45% comminution had a 74% chance of having surgery recommended, while <25% comminution had an 86.3% chance of non-surgical treatment. A comminution from 25 to 45% had a 57% chance of non-surgical management. ≥55% PLC injury certainity had a 97% chance of having surgery, and ≥45-55% PLC injury certainty had a 65%. <20% PLC injury had a 64% chance of having non-operative treatment. A 20 to 45% PLC injury certainity had a 56% chance of non-surgical management. There was fair inter-rater agreement on the degree of comminution (ICC .57 [95% CI 0.52-.63]) and the PLC integrity (ICC .42 [95% CI 0.37-.48]).

Conclusion: The study concludes that vetebral comminution and PLC integrity are major dterminant in decision making of thoracolumbar fractures without neurological deficit. However, more objective, reliable, and accurate methods of assessment of these variables are warranted.

Keywords: A3; A4; AO spine thoracolumbar injury classification; burst fractures; computed tomography; equipoise study; magnetic resonance imaging; posterior ligamentous complex; thoracolumbar fractures; vertebral comminution.