A retrospective cohort study.

This study aims to assess the validity of the Thoracolumbar Injury Classification and Severity Score (TLICS) in patients ≤10 years old.

TLICS is a validated measure developed to help facilitate clinical decision-making regarding thoracolumbar spinal trauma in adults. Studies examining the utility of TLICS in children skew toward older pediatric patients, where the spine's biomechanical properties are more similar to adults. Due to differences in a preadolescent spine compared with a more mature, adolescent spine, it is unclear if TLICS can be applied to younger patients.

A single-center spine trauma registry was queried for patients ≤10 with an acute, traumatic thoracolumbar fracture treated at a level-1 pediatric trauma center between 2006 and 2020. Test characteristics and receiver-operator curve were used to evaluate TLICS based on TLICS <4 recommedning nonsurgical treatment and TLICS >4 recommending surgery.

We identified 94 patients with traumatic thoracolumbar fractures (surgical=20; nonsurgical=74). Despite TLICS-suggested operative management in 28 patients with TLICS >4, nine (32.1%) were initially treated nonoperatively. All patients who deviated from TLICS-suggested treatment had flexion-distraction injuries (FDI). Sensitivity, specificity, positive predictive value, and negative predictive value were 100%, 89.2%, 70.4%, and 100%, respectively. The receiver operating characteristic curve demonstrated a strong diagnostic ability of TLICS in predicting the need for surgery (area under the curve: 0.97, F1-score: 0.86).

TLICS score <4 showed strong validity and is highly specific in predicting non-operative management for patients ≤10 years old with thoracolumbar fractures. However, TLICS >4 has more limited specificity in indicating the necessity for surgical intervention, as many FDIs were successfully treated without surgery. Additional factors other than TLICS score may need to be considered for these more severe injuries to optimize management in this age group.

Recent studies have proposed computed tomography (CT) criteria for posterior ligamentous complex (PLC) injury: disrupted if ≥2 CT findings, indeterminate if single finding, and intact if 0 CT findings. The study aims to validate the CT criteria for PLC injury externally.

Three level 1 trauma centers enrolled 614 consecutive patients with acute thoracolumbar fractures (T1-L5) who received CT and MRI. Three reviewers from each center assessed CT for facet joint malalignment, horizontal laminar fracture, spinous process fracture, and interspinous widening and MRI for disrupted PLC, defined as black stripe discontinuity. The primary outcome is the diagnostic accuracy of CT criteria (0, 1, ≥2 findings) in detecting disrupted PLC on MRI using all CT readings. A subgroup analysis was performed for each participating center and reviewer. The inter-reader agreement on PLC status on MRI and CT criteria was assessed using Fleiss Kappa ( k ).

The positive predictive value for PLC injury was 0 findings 3%, single positive CT 43%, and ≥2 CT findings in 94%. The accuracy measures were consistent across various centers and reviewers. The area under the curve for ≥1 CT finding in detecting PLC injury ranged from 90% to 97%, indicating excellent discrimination for all centers. The inter-reader k on PLC status by MRI and overall CT findings was substantial ( k > 0.60).

This study externally validates the previously proposed CT criteria for PLC injury. A total of ≥2 positive CT findings or 0 CT findings can be used as criteria for a disrupted PLC (B-type injury) or intact PLC (A-type injuries), respectively, without added MRI. A single CT finding implies indeterminate PLC status and the need for further MRI assessment. The CT criteria will potentially guide MRI indications and treatment decisions for neurologically intact thoracolumbar burst fractures.

Short- segment fixation is being increasingly used to minimiz e the number of fixation levels in thoracolumbar burst fractures (TLBFs). This study aims to analyze the radiological, functional, and neurological outcomes of short-segment fixation in TLBF.

A meta-analysis was conducted through a web search on PubMed with the following keywords; thoracolumbar injury, burst fracture, and short- segment fixation. Scientific papers written in English from January 2001 to April 2024 were screened. PubMed search with the keywords revealed 183 articles which were thoroughly reviewed by all the authors. Of these, 11 studies satisfying the inclusion criteria describing short- segment fixation in TLBF s were included in this study. The minimum follow-up duration in each study was 12 months. The appropriate meta-analysis was carried out, and the forest plot for a single group which accounts for interstudy variation and provides a more conservative effect than the fixed effect model. Potential sources of heterogeneity were assessed using the standard chi-square test. In addition, the statistic I2 was used to investigate heterogeneity by examining the extent of inconsistency across the study results. A sensitivity analysis was carried out to assess the robustness of the results of the meta-analysis. Where heterogeneity was present between the studies, differences in study design were examined. All analyses were performed using online free meta-analysis software (https://metaanalysisonline.com).

The results of this meta-analysis suggested that studies with an added intermediate screw at the level of fractured vertebra showed a better radiological appearance at the final follow- up as compared to traditional short-segment instrumentation. However, clinical outcomes showed no significant difference. A post-surgery neurological improvement was noted in all the studies except those with a complete pre-operative neurological deficit.

Short-segment instrumentation with intermediate screw fixation is a safe and effective method with excellent radiological and clinical outcomes with very low rates of failure while treating unstable TLBFs, where as traditional short-segment posterior fixation can lead to progressive loss of kyphosis correction with higher implant failure rate in patients with unstable fractures.

Study DesignSystematic Literature Review.ObjectivesTo address whether TLICS or AOSpine is best used in clinical practice through assessment of interobserver and intraobserver reliability, agreement, and imaging modality performance.MethodsThis systematic literature review was reported in accordance with PRISMA 2020 guidelines. Articles were included based on meeting eligibility criteria: studies evaluating TLICS, AOSpine, and/or TL AOSIS through reliability, agreement, or imaging modality performance with adult patients (≥18) suffering from traumatic thoracolumbar fractures. Articles were acquired in April 2023 from Medline, CINAHL, and Scopus. Risk of bias was assessed through a modified COSMIN checklist. Tabulated results were separated by classification tool (TLICS or AOSpine/TL AOSIS) and reliability, agreement, or imaging modality results.ResultsTwenty-one studies were included in the final review. Interobserver and intraobserver AOSpine morphology reliability was on average superior to TLICS. Increased familiarity with the tool positively influenced both AOSpine and TLICS performance. For surgical treatment recommendation, AOSpine differentiated between stable and unstable burst fractures and guided clinician's more accurately than TLICS. Regarding conservative treatment, both TLICS and AOSpine reported similar clinical accuracy. TLICS performed significantly better when MRI was incorporated compared to CT alone. CT was sufficient as an imaging modality for AOSpine/TL AOSIS performance.ConclusionsAOSpine outperformed TLICS in surgical reliability, agreement and did not require additional MRI imaging to improve accuracy. Limitations of evidence include low quality of available studies and significant heterogeneity in patient and observer number. Future prospective multicentre research is recommended. This study was not funded and not registered on PROSPERO.

Study DesignCross-sectional survey.ObjectivesInjury classifications are important tools to identify fracture patterns, guide treatment-decisions and aid to identify optimal treatment plans. The AO Spine-DGOU Osteoporotic Fracture (OF) classification system was developed, and the aim of this study was to assess the reliability of this new classification system.Methods23 Members of the AO Spine Knowledge Forum Trauma participated in the validation process. Participants were asked to rate 33 cases according to the OF classification at 2 time points, 4 weeks apart (assessment 1 and 2). The kappa statistic (κ) was calculated to assess inter-observer reliability and intra-rater reproducibility. The gold master key for each case was determined by approval of at least 5 out of 7 members of the DGOU.ResultsA total of 1386 ratings (21 raters) were performed. The overall inter-rater agreement was moderate with a combined kappa statistic for the OF classification of 0.496 in assessment 1 and 0.482 in assessment 2. The combined percentage of correct ratings (compared to gold-standard) in assessment 1 was 71.4% and 67.4% in assessment 2. The average intra-rater reproducibility was substantial (κ = 0.74, median 0.76, range 0.55 to 1.00, SD 0.13) for the assessed fracture types.ConclusionsThe assessed overall inter-rater reliability was moderate and substantial in some instances. The average intra-rater reproducibility is substantial. It seems that appropriate training of the classification system can enhance inter- and intra-rater reliability.

Background: This study aims to evaluate how surgical timing and the radiological characteristics of fragment blocks can affect the effectiveness of ligamentotaxis, in restoring the spinal canal area, and local kyphosis in adults with traumatic thoracolumbar A3 burst fractures without neurological impairment treated with percutaneous short-segment fixation. Methods: A retrospective observational study was conducted between January 2016 and December 2022 on neurologically intact adult patients with a single A3 thoracolumbar fracture. Data collected included demographics, injury mechanism, fracture level, and clinical and surgical details. Radiological assessments included spinal canal area, local kyphotic angle, anterior and posterior vertebral heights, and fragment block measurements. Results: Out of 101 treated patients, 9 met the criteria with a mean age of 52.22 years. Most fractures were at L1 (88.89%). All patients had moderate-to-severe pain (NRS 6.22 ± 1.09) at baseline. Five patients (55.55%) underwent surgery within 72 h, with a mean surgical time of 109.22 min. SCA and LKA values improved significantly in all patients post-surgery. Early surgical intervention (<72 h) correlated with greater improvements in spinal canal area (p = 0.016) and local kyphotic angle (p = 0.004). A significant association was found between spinal canal area improvement and the percentage ratio of fragment height to "normal" vertebral height (rho = 0.682; p = 0.043). Conclusions: Early (<72 h) short-segment percutaneous fixation is recommended for adults with high functional demands and moderate-to-severe axial pain due to single traumatic A3N0M0 thoracolumbar fracture. This "upfront" approach is associated with enhanced indirect decompression and better local kyphotic angle restoration. Considering the fragment morphology could also be important in surgical planning.

Management of traumatic spinal cord injury is complex and depends on a multidisciplinary approach involving pre-hospital services, spinal surgery, intensive care unit treatment and specialized rehabilitation. International clinical practice guidelines for the handling of these patients offer specific recommendations regarding transportation, radiological investigations, timing of surgery, intensive care management and rehabilitation. We performed a comprehensive multicenter survey to assess the agreement between the Nordic countries on the different aspects of traumatic spinal cord injury management.

Sequential, cross-sectional, structured survey comprising the key clinical domains (pre-hospital services, spinal surgery, intensive care management and rehabilitation) in all tertiary spine trauma centers in Sweden, Denmark, Norway, Iceland and Finland. Data are presented descriptively.

A total of 109 respondents from 22 Nordic centers were invited to take the survey, with a response rate of 90% (98/109). Overall, clinical practices were comparable within the domains. Prehospital services had similar practices for airway management, clinical spine clearance and patient transport. Preoperative magnetic resonance imaging was available to 33/35 of the spine surgeons (94%) on a 24/7 basis. This examination was considered mandatory prior to surgery by 66% (23/35) of the surgeons. Surgery was defined as early if performed within 24 h of the injury by all surveyed surgeons. Augmented blood pressure regimens were widely applied in the intensive care units, with mean arterial pressure targets varying between > 80 and > 90 mmHg. Postoperative thromboprophylaxis was administered within 48 h by all centers and rehabilitation policies were similar overall. Notable variations in practice were the occasional steroid administration and the use of lumbar drains in 54% (14/26) of intensive care units.

Although there is some variability in the current management of traumatic spinal cord injury in the Nordic countries at the center- and country-level, practices in most key clinical domains are similar and follow established international guidelines.

To review the historical thoracolumbar burst fractures (TLBFs) classifications and discuss the probable gaps for their clinical validation.

Despite multiple classification schemes, the treatment decisions for TLBFs in neurologically intact patients remain controversial. There are gaps between the current classifications and their predictive validation.

A narrative literature review.

The potential barriers to establishing the predictive value of the current classifications of TLBFs could be connected to validation studies' flaws such as nonvalidated outcome measures and challenges of randomization. It could also be related to limited interobserver reliability in diagnosing A3/A4 fractures. Finally, it might be attributed to the inability to incorporate all prognostic variables, such as computed tomography (CT) parameters, patient-related factors, and traumatic disc injury, may result in failed validation.

AOSpine Patient and Clinical Reported Outcome Spine Trauma (PROST) and a recently proposed natural experiment observational study hold promise for mitigating methodological challenges. A structured approach for distinguishing A3/A4 fractures and standardized CT criteria for PLC injury is critical to improving reliability. Finally, a treatment algorithm incorporating all potential prognostic variables, independent of the morphologic classification, may improve the predictive value of the classification. Machine learning techniques could be helpful in this context.

Study DesignCross-sectional survey.ObjectivesA cornerstone of classification systems is good reliability amongst different groups of classification users. Thus, the aim of this international validation study was to assess the reliability of the new AO Spine DGOU Osteoporotic Fracture Classification (OF classification) stratified by surgical specialty, work-setting, work-experience, and trauma center level.Methods320 spine surgeons were asked to rate 27 cases according to the OF classification at 2 time points, 4 weeks apart (assessment 1 and 2) in this online-webinar based validation process. The kappa statistic (κ) was calculated to assess the inter-observer reliability and the intra-rater reproducibility.ResultsA total of 7798 (90.3%) ratings were recorded in assessment 1 and 6621 (76.6%) ratings in assessment 2. Global inter-rater reliability was moderate in both assessments (κ = 0.57; κ = 0.58). Participants with a work-experience of >20 years showed the highest inter-rater agreement in both assessments globally (κ = 0.65; κ = 0.67). Participants from a level-1 trauma center showed the highest agreement (κ = 0.58), whereas participants working at a tertiary trauma center showed higher grade of agreement in the second assessment (κ = 0.66). Participants working in academia showed the highest agreement in assessment 2 (κ = 0.6). Surgeons with academic background and surgeons employed by a hospital showed substantial intra-rater agreement in the second assessment.ConclusionsThe AO Spine-DGOU Osteoporotic Fracture Classification showed moderate to substantial inter-rater agreement as well as intra-rater reproducibility regardless of work-setting, surgical experience, level of trauma center and surgical specialty.

Fractures of the thoracic (Th) and lumbar (L) vertebrae are among the most frequent fracture entities in Germany and particularly affect the thoracolumbar junction (TLJ; Th11-L2). Based on expert recommendations and consensus meetings, the thoracolumbar AOSpine injury score was established for patients with healthy bone and the osteoporotic fracture (OF) score for geriatric patients with the respective classifications for treatment decisions. In both cohorts, the treatment decision is based on the fracture morphology, neurological status and patient-specific contextual factors. In terms of fracture morphology, surgical treatment is generally indicated for distraction and rotation/translation injuries. The treatment decision for compression fractures is more complex as additional factors must be taken into consideration. The decision in patients with healthy bone is primarily influenced by imaging morphological criteria (deformity and destruction) whereas in osteoporotic patients the decision is influenced by individual criteria, such as the general condition, the possibility of low pain mobilization and concomitant diseases. Overall, the treatment decision for fractures of the TLJ is not dogmatic as individual factors must be considered and high-quality studies are lacking.

The posterior ligamentous complex (PLC) provides critical structural support in the thoracolumbar spine. Its role in resisting progressive flexion is particularly important at the thoracolumbar junction due to the transition from the rigid thoracic spine to the more mobile lumbar region. Each component of the PLC contains anatomic features that contribute to both the structure and function of the PLC as a whole. Understanding the nuances of each structure is important in determining injury severity and may serve as a foundation for future directions of research. Violation of the PLC results in an unstable spine, thus requiring surgical management. It is associated with greater injury severity and neurologic deficit in patients who sustain thoracolumbar fractures, which adds complexity to the postoperative course and patient outcomes. Although plain radiographs and CT scans provide reliable indirect measures of PLC disruption, these modalities may be subject to diminished sensitivity based on patient positioning and do not directly measure soft-tissue injury. Modern classification systems include the integrity of the PLC in surgical decision making, and care must be taken to scrutinize the possibility of ligamentous disruption before proceeding with nonsurgical management to avoid adverse patient outcomes.

The most common thoracolumbar trauma classification systems are the Thoracolumbar Injury Classification and Severity Score (TLICS) and the Thoracolumbar AO Spine Injury Score (TL AOSIS). Predictive accuracy of treatment recommendations is a historical limitation. Our objective was to validate and compare TLICS, TL AOSIS, and a modified TLICS (mTLICS) that awards 2 points for the presence of fractured vertebral body height loss >50% and/or spinal canal stenosis >50% at the fracture site.

The medical records of adult patients with acute, traumatic thoracolumbar injuries at an urban, Level 1 trauma center were retrospectively reviewed. TLICS, mTLICS, and TL AOSIS scores were calculated for 476 patients using computed tomography, MRI, and the documented neurological examination. Treatment recommendations were compared with treatment received. Standard validity measures were calculated.

Treatment recommendations matched actual treatments in 95.6% (455/476) of patients for mTLICS, 91.3% (435/476) for TLICS, and 92.6% (441/476) for TL AOSIS. The differences between the accuracy of mTLICS and TLICS (95.6% vs 91.3%, P < .001) and between mTLICS and TL AOSIS (95.6% vs 91.3%, P = .003) were significant. The sensitivity of mTLICS was higher than that of TLICS (96.3% vs 81.3%, P < .001), and the sensitivity of TL AOSIS was higher than that of TLICS (92.5% vs 81.3%, P < .001). The specificity of mTLICS was equal to that of TLICS (95.3%) and higher than that of TL AOSIS (95.3% vs 92.7%, P = .02). The modifier led to substantial outperformance of mTLICS over TLICS due to 38 patients (20 of whom received surgery) moving from a TLICS score of <4 to a mTLICS score equal to 4.

All systems performed well. The mTLICS had improved sensitivity and accuracy compared with TLICS and higher accuracy and specificity than TL AOSIS. The sensitivity of TL AOSIS was higher than that of TLICS. Prospective, multi-institutional reliability and validity studies of this mTLICS are needed for adoption.

Spinal cord injury (SCI) following high-energy trauma often leads to lasting neurologic deficits and severe socioeconomic impact. Effective neurointensive care, particularly in the early stages post-injury, is essential for optimizing outcomes. This review discusses the role of neurointensive care in managing SCI, emphasizing early assessment, stabilization, and intervention strategies based on recent evidence-based practices. SCI results from primary mechanical damage to the spinal cord, triggering secondary injuries involving vascular and cellular dysfunction. Early neurointensive care focuses on stabilizing airway, breathing, and circulation while preventing further spinal damage. Imaging and neurologic assessments, including the ASIA scale, guide the management plan. Early decompressive surgery within 24 hours is widely supported for patients with spinal instability or cord compression. Pharmacologic strategies aim to reduce secondary injury, though standardization remains limited. Prophylaxis for deep vein thrombosis and pulmonary embolism, intensive pulmonary support, and monitoring for pressure sores are critical in early-phase SCI. Early neurointensive care and surgical interventions play a pivotal role in mitigating SCI progression. Optimal care requires a multifaceted approach addressing both neurologic and systemic complications, significantly influencing recovery and long-term quality of life. Further research is needed to standardize pharmacologic treatments and optimize surgical timing.

This study aims to analyze the diagnosis and treatment conditions of polytrauma patients with spinal injuries, to clarify the site of the first surgical intervention, the timing of the surgery, and factors influencing prognosis.

This study collected and analyzed data on polytrauma patients with spinal injuries who were treated from January 2017 to January 2023. Data collected primarily included basic patient information, treatment strategy-related information, clinical scoring systems, imaging parameters, and prognosis. The impacts of relevant variables on postoperative survival outcomes were analyzed.

This study included 60 patients. There was no significant change in the number of patients rated ASIA grade E after 90 days of admission, while there was a significant increase in those rated grade D (P<0.001). Among the groups, patients operated on within less than 12 h had the highest number of ASIA grade A, while those operated on after more than 48 h had the highest number of ASIA grade E (P=0.003). The survival rate of patients who underwent their first spinal surgery between 12 and 48 h was significantly better than those operated earlier than 12 h or later than 48 h (P=0.047). Patients who experienced hemorrhagic shock postsurgery had the lowest survival rate (P<0.001). Only age (P=0.004) and the number of surgeries outside the spine (P=0.033), as covariates, were significantly correlated with patient mortality (R2=0.519).

Performing spinal surgery too early or too late can adversely affect patient outcomes; the appropriate timing of surgery should be chosen based on the specific characteristics of the patient. In polytrauma patients under emergency conditions, the use of combined surgical treatments should be minimized to prevent the occurrence of a 'second hit'. Patients who experience hemorrhagic shock have the worst postsurgical survival; targeted treatment should be administered upon hospital admission.

Surgical intervention for unstable thoracolumbar spine fractures is common, but delayed management and complications can impact outcomes. This study compares perioperative outcomes between patients directly admitted and those transferred from another facility for thoracolumbar spine surgery, aiming to identify predictors of complications and mortality.

A multicenter retrospective cohort study used the American College of Surgeons National Surgical Quality Improvement Program database from 2011 to 2021 identified 61,626 patients undergoing fusion surgeries for thoracolumbar spine fractures, excluding spinal cord injury or pathological fractures. Patients were categorized as Direct (admitted from the emergency department) and Transfer (transferred from another facility). Perioperative outcomes, including operative time, length of stay (LOS), 30-day mortality, and complications, were compared.

Our patient population (54.3% female, mean age 62.4 ± 12.9 years) comprised 12.2% Transfer and 87.8% Direct patients. Following propensity score matching, Transfer patients had a longer hospital LOS (5.1 ± 5.7 days vs. 4.5 ± 4.6 days, P < 0.001). Transfer exhibited higher rates of superficial incisional surgical site infection (1.7% vs. 1.1%, P = 0.003), sepsis (1.7% vs. 1.3%, P = 0.038), pneumonia (1.7% vs. 1.2%, P = 0.019), postoperative reintubation (0.9% vs. 0.6%, P = 0.036), and failure to wean off ventilator >48 hours postsurgery (0.7% vs. 0.3%, P = 0.005) compared to Direct admissions. Direct group had a higher rate of perioperative transfusion (16.5% vs. 13.4%, P < 0.001). Transfer patients also had a higher 30-day mortality rate compared to Direct admissions (1.1% vs. 0.6%, P = 0.002).

Interhospital transfers significantly affect hospital LOS, postoperative morbidity, and mortality in thoracolumbar spine surgery. Enhancing postoperative monitoring for transfer patients is crucial.

The information contained in this article is suitable for clinicians practicing in the United States desiring a general overview of the assessment and management of spinal cord injury (SCI), focusing on initial care, assessment, acute management, complications, prognostication, and future research directions. SCI presents significant challenges, affecting patients physically, emotionally, and financially, with variable recovery outcomes ranging from full functionality to lifelong dependence on caregivers. Initial care aims to minimize secondary injury through thorough neurological evaluations and imaging studies to assess the severity of the injury. Acute management prioritizes stabilizing respiratory and cardiovascular functions and maintaining proper spinal cord perfusion. Patients with unstable or progressive neurological decline benefit from timely surgical intervention to optimize neurological recovery. Subacute management focuses on addressing common complications affecting the respiratory, gastrointestinal, and genitourinary systems, emphasizing a holistic, multidisciplinary approach. Prognostication is currently based on neurological assessments and imaging findings, but emerging biomarkers offer the potential to refine outcome predictions further. Additionally, novel therapeutic interventions, such as hypothermia therapy and neuroprotective medications are being explored to mitigate secondary damage and enhance recovery. This paper serves as a high-yield refresher for clinicians for the assessment and management of acute spinal cord injury during index admission.

To retrospectively assess the Thoracolumbar Injury Classification and Severity Score (TLICS) in patients with osteoporotic vertebral compression fractures (OVCF) and compare the treatment given with that predicted by the TLICS score.

All medical records of patients presenting from January 2014 to November 2017 for acute atraumatic or low impact OVCF were screened, and eligible patients were retrospectively reviewed. The TLICS score was determined based upon magnetic resonance imaging (MRI) findings and clinical records. Clinical records (including pain score data), imaging data, operative procedures, and stability of neurological examination were tracked over three months for each patient.

Of the 56 patients included, 36 patients had a TLICS score of 1, 18 had a TLICS score of 2, and two had a TLICS score of 4. Only one patient with a TLICS score of 4 underwent surgical stabilization, while the rest of the cohort was managed non-operatively, with or without kyphoplasty. TLICS score 1 corresponded to simple compression and TLICS score 2 corresponded to burst morphology with retropulsion and without neurological deficits. Of the patients with a TLICS score of 1 and 2 who underwent kyphoplasty, there was a statistically significant improvement in pain scores in both groups; however no significant difference was observed, between each TLICS score (i.e., 1 or 2). None of the patients developed instability or neurological decline.

TLICS score correctly predicted operative versus non-operative management in all patients with OVCF. TLICS may be used in making management decisions, and in the triage of these patients for operative versus non-operative evaluations. Our study suggests that patients with TLICS score of 4 or higher require surgical evaluation, while those with TLICS of 1 or 2 are likely to have satisfactory non-surgical management with augmentation or conservative care. In general, patients with OVCF typically present with low TLICS score. Kyphoplasty appears to be similarly beneficial in patients with a TLICS score of 1 or a TLICS score of 2. A modification of the TLICS score by adding TLICS Zero to include uncompressed OVCF with edema is suggested. The limitations of this study include a small size; a larger study is needed to confirm these findings.

This study aimed to assess the outcomes of conservative management in patients with thoracolumbar fractures classified with a Thoracolumbar Injury Classification and Severity (TLICS) score of 4 or 5, and to analyze initial imaging findings and clinical risk factors associated with treatment failure.

In this retrospective analysis, patients with thoracolumbar fractures and a TLICS score of 4 or 5, determined through MRI from January 2017 to December 2020, were included. Patients undergoing conservative treatment were categorized into two groups: Group 1 (treatment success) and Group 2 (treatment failure), based on initial and 6-month follow-up outcomes. Clinical data were compared between the two groups. Initial radiological assessments included three kyphosis measurements (Cobb angle, Gardner angle, and sagittal index [SI]), anterior and posterior wall height, and central canal compromise (CC). Additionally, risk factors contributing to treatment failure were analyzed.

The conservative treatment group comprised 84 patients (mean age, 60.25 ± 15.53; range 22-85; 42 men), with 57 in Group 1 and 27 in Group 2. Group 2 exhibited a higher proportion of women, older age, and lower bone mass density (p = 0.001-0.005). Initial imaging findings in Group 2 revealed significantly greater values for Cobb angle, SI, and CC (p = 0.001-0.045 or < 0.001; with cutoff values of 18.2, 12.8, and 7.8%, respectively), and lower anterior wall height (p = 0.001), demonstrating good to excellent interobserver agreement (0.72-0.99, p < 0.001). Furthermore, osteoporosis was identified as a significant risk factor (odds ratio = 5.64, p = 0.008).

Among patients with TLICS scores of 4 or 5, those experiencing conservative treatment failure exhibited unfavorable initial radiological findings, a higher proportion of women, advanced age, and osteoporosis. Additionally, osteoporosis emerged as a significant risk factor for treatment failure.

» Pediatric thoracolumbar trauma, though rare, is an important cause of morbidity and mortality and necessitates early, accurate diagnosis and management.» Obtaining a detailed history and physical examination in the pediatric population can be difficult. Therefore, the threshold for advanced imaging, such as magnetic resonance imaging, is low and should be performed in patients with head injuries, altered mental status, inability to cooperate with examination, and fractures involving more than 1 column of the spine.» The classification of pediatric thoracolumbar trauma is based primarily on adult studies and there is little high-level evidence examining validity and accuracy in pediatric populations.» Injury pattern and neurologic status of the patient are the most important factors when determining whether to proceed with operative management.

CVFs are common, with several classification systems available. We have encountered osteoporotic vertebral fractures (OVFs) with PDF, a never-described fracture pattern.This study evaluates this unique fracture's characteristics.

Retrospective study of surgically treated OVFs during 2016 to 2020.

Of 105 patients, 85 had classifiable OVFs and 20 had uni-PDF (n = 10, 9.5%) or bi-PDF (n = 10, 9.5%). Both cohorts mainly had single vertebral fractures and upper end plate involvement with cleft sign found in 30% of PDFs versus 15.3% of OVFs (P < 0.001), higher incidence of burst fractures (40% vs. 25.9%; P < 0.001). Posterior vertebral body collapse was higher for PDFs (13.2 ± 9.3% vs. 18.3 ± 8.5%; P = 0.02). Most OVFs underwent balloon kyphoplasty (BKP) (94%). Most bi-PDFs were regarded unstable; six patients underwent PSF (2 short PSF, 1 PSF + BKP, and 3 BKP with intravertebral pedicular lag screws at the fractured vertebra). Half of the bi-PDFs underwent BKP-developed nonunion.

Our study is novel in describing an unrecognized OVF pattern disregarded in current classification systems. We found notable differences in fracture characteristics, prefracture functional status, and surgical results between OVF and PDF cohorts. We suggest adding this fracture pattern as a unique OF-4 subtype or a specific entity between OF-4 and 5, with uni-PDF as type A and bi-PDF as type B.

This was a systematic review and meta-analysis.

The clinical outcomes, radiologic outcome, and complications were compared between surgical treatment and conservative treatment of thoracolumbar fractures with a Thoracolumbar Injury Classification and Severity (TLICS) score of 4.

The thoracolumbar fracture is the main reason leading to the spinal cord injury. Some studies suggested that the treatment of TLICS=4 is a "gray zone." Hence, the efficacy and safety of surgical treatment and conservative treatment of thoracolumbar fractures with scores 4 TLICS was still debated.

A comprehensive search of PubMed, Embase, and the Cochrane Library, Chinese National Knowledge Infrastructure (CNKI), Chongqing VIP Database (VIP), and Wan Fang Database was performed up to October 2021. Relevant studies were identified using specific eligibility criteria and data was extracted and analyzed based on primary and secondary outcomes.

A total of 10 studies involving 555 patients were included (3 randomized controlled trials and 7 retrospective studies). There was no significant difference of hospital time (standardized mean difference=0.24, 95% CI: -1.50 to 1.97, P =0.79) and Oswestry Disability Index (mean difference=2.97, 95% CI: -1.07 to 7.01, P =0.15) between surgery and nonsurgery. The length of returning to work was shorter in surgical treatment (standardized mean difference=1.27, 95% CI: 0.07-2.46, P =0.04). Visual Analog Scale in surgical treatment was lower at 1, 3, and 6 months (respectively, P <0.00001, P =0.003, and P =0.02). However, there existed no significant difference between surgical treatment and nonsurgical treatment at 12 and >24 months (respectively, P =0.18 and 0.17). Cobb angle was lower in surgical treatment at postoperative at 6, 12, and >24 months (respectively, P =0.005, P <0.00001, P =0.002, and P =0.0002). Finally, the surgical treatment had a lower incidence of complications (odds ratio=3.89, 95% CI: 1.90-7.94, P =0.0002).

Current evidence recommended that surgical treatment is superior to conservative treatment of TLICS score of 4 at the early follow-up. Surgical treatment had lower Cobb angle, Visual Analog Scale scores, and complications compared with a nonsurgical TLICS score of 4. However, these findings needed to be verified further by multicenter, double-blind, and large-sample randomized controlled trials.

Burst fractures of vertebrae are usually caused by high-energy axial compression force, mostly caused by fall from height or road traffic accidents. They frequently occur at the thoracolumbar junction mostly requiring surgery. Contiguous burst fractures involving multiple lumbar vertebrae are uncommon. This case is a male in his early 40s presented with low back pain and weakness of lower limbs following an injury sustained during a road traffic accident. Clinically, the patient had a bilateral foot drop. On radiological evaluation, he was diagnosed to have L3 and L4 burst fractures with spinal canal occlusion. He underwent posterior stabilization from L2-L5 and decompression at the L3-L4 level. At one-year follow-up, the patient was pain-free with complete neurological recovery. Contiguous lumbar spine burst fractures are very rare in occurrence. Though burst fractures are managed surgically to provide stability, the surgical approaches depend on the individual fracture pattern, degree of spinal canal occlusion, and neurological status.

In this article, we attempted to identify risk factors affecting the loss of vertebral height and kyphosis correction on type A thoracolumbar fractures. Patients with type A thoracolumbar fractures who underwent short segments with intermediate screws at the fracture level management between 2017 and 2022 were included in this study. Clinical factors including patients' demographic characteristics (age, sex), history (smoking, hypertension and/or diabetes), value of height/kyphosis correction, the thoracolumbar injury classification and severity score (TLICS), the load sharing classification (LSC) scores and bone mineral density were collected. Correlation coefficient, simple linear regression analysis and multivariate regression analysis were performed to identify the clinical factors associated with the loss of vertebral height/kyphosis correction. Finally, 166 patients were included in this study. The mean height and kyphosis correction were 21.8% ± 7.5% and 9.9° ± 3.8°, respectively, the values of the loss were 6.5% ± 4.0% and 3.9° ± 1.9°, respectively. Simple linear regression analysis and multivariate regression analysis showed that age, value of height correction, LSC scores and bone mineral density were significantly associated with the loss of vertebral height and kyphosis correction (P < .01) We could draw the conclusion that patients with older age, lower bone mineral density, higher LSC scores and diabetes are at higher risk of vertebral height and kyphosis correction loss increase. For these patients, appropriate clinical measures such as long segment fixation, control of blood glucose, and increase of bone density must be taken to reduce the loss of correction.

Surgical outcomes of open anterior and open posterior approaches, for thoracolumbar A3 to C3/AO type fractures, are compared.

A PubMed search was conducted from 1990 to 2024 related to anterior, posterior, and combined approaches. Inclusion criteria: Fresh traumatic T10 to L2 fractures, age ≥13 years, ≥10 cases, minimum follow-up 6 months. Exclusion criteria: Cadaveric studies, pathological fractures, reviews, thoracoscopy-assisted, mini-open lateral (MOLA) and minimal invasive anterior or posterior approaches. Coleman Methodology Scores (CMS) (modified for spinal trauma) indicated potential selection bias in the selected studies. PRISMA guidelines were adapted.

Nineteen studies with 847 participants were selected. The average CMS quality score was fair. The anterior approach, although it better decompresses the compromised spinal canal, it is also associated with increased surgical complications compared to the posterior approach. The neurological outcome, the loss of correction and the reoperation rate, were similar to both approaches. This systematic review favors posterior approach.

The anterior approach is demanding and is associated with a higher rate of surgical complications compared to the posterior approach. The limitations of the selected studies included inconsistence in the: 1) approaches selection, 2) classifications of the fracture types and the neurological status and 3) variety of instrumentations used.

CRD42023484222.

Both Orthopedic Surgery (OS) and Neurosurgery (NS) perform spine surgery in the setting of trauma. However, it is unknown whether outcomes differ between these specialties. This study compares management and outcomes for vertebral fractures between NS and OS, hypothesizing similar operation rate, length of stay (LOS), and readmission.

Do outcomes differ between NS and OS in the management of vertebral fractures following trauma?

A retrospective single-center study was conducted on adult patients with cervical, thoracic, lumbar, and sacral fractures treated at a single trauma center, where no standardized pathway exists across NS and OS. Patients were compared for injury profile, diagnostic imaging, and operative techniques as well as LOS, mortality, and complications.

A total of 630 vertebral fracture patients (OS:350 (55.6%); NS:280 (44.4%)) were included. NS utilized magnetic resonance imaging (MRI) more commonly (36.4% vs. 22.6%, p < 0.001). NS patients more often underwent operation (13.2% vs. 7.4%, p = 0.016) despite similar fracture number and severity (p > 0.05). Post-operative complications, LOS, and readmission rates were similar between cohorts (p > 0.05).

Despite similar injury profiles, NS had higher rates of MRI usage and operative interventions in the context of traumatic spine fractures. Despite differences in management, major clinical outcomes were similar between NS and OS. However, we do call for further standardization of evaluation and treatment of patients based on established algorithms from such as the AOSpine Thoracolumbar Spine Injury Classification System (ATLICS).

To provide the first meta-analysis of the impact of magnetic resonance imaging (MRI) on thoracolumbar fractures (TLFs) classification and decision-making.

A systematic review was conducted following PRISMA guidelines. We searched PubMed, Scopus, Cochrane, and Web of Science from inception to June 30, 2023 for studies evaluating the change in TLFs classification and treatment decisions after MRI. The studies extracted key findings, objectives, and patient population. A meta-analysis was performed for the pooled frequency of change in AO fracture classification or treatment decisions from surgical to conservative or vice versa after MRI.

This meta-analysis included four studies comprising 554 patients. The pooled frequency of change in TLFs classification was 17% (95% CI 9-31%), and treatment decision was 22% (95% CI 11-40%). An upgrade from type A to type B was reported in 15.7% (95% CI 7.2-30.6%), and downgrading type B to type A in 1.2% (95% CI 0.17-8.3%). A change from conservative to surgery recommendation of 17% (95% CI 5.0-43%) was higher than a change from surgery to conservative 2% (95% CI 1-34%).

MRI can significantly change the thoracolumbar classification and decision-making, primarily due to upgrading type A to type B fractures and changing from conservative to surgery, respectively. These findings suggest that MRI could change decision-making sufficiently to justify its use for TLFs. Type A subtypes, indeterminate PLC status, and spine regions might help to predict a change in TLFs' classification. However, more studies are needed to confirm the association of these variables with changes in treatment decisions to set the indications of MRI in neurologically intact patients with TLFs. An interactive version of our analysis can be accessed from here: https://databoard.shinyapps.io/mri_spine/ .

Although vertical laminar fracture (VLF) is generally considered a severity marker for thoracolumbar fractures (TLFs), its exact role in decision-making has never been established. This scoping review aims to synthesize the research on VLF's role in the decision-making of TLFs.

A systematic review was conducted following PRISMA guidelines. We searched PubMed, Scopus, and Web of Science from inception to  June 11, 2023, for studies examining the association of VLF in thoracolumbar fractures with dural lacerations, neurological deficits, radiographic parameters, or treatment outcomes. Additionally, experimental studies that analyze the biomechanics of burst fractures with VLF were included. The studies extracted key findings, objectives, and patient population. A meta-analysis was performed for the association of VLF with dural laceration and neurological deficit, and ORs were pooled with a 95% confidence interval (CI).

Twenty-eight studies were included in this systematic review, encompassing 2021 patients, and twelve were included in the meta-analysis. According to the main subject of the study, the association of VLF with a dural laceration (n = 14), neurological deficit (n = 4), radiographic parameters (n = 3), thoracolumbar fracture classification (n = 2), and treatment outcome (n = 2). Seven studies with a total of 1010 patients reported a significant association between VLF and neurological deficit (OR = 7.35, 95% CI [3.97, 14.25]; P < 0.001). The pooled OR estimates for VLF predicting dural lacerations were 7.75, 95% CI [2.41, 24.87]; P < 0.001).

VLF may have several important diagnostic and therapeutic implications in managing TLFs. VLF may help to distinguish AO type A3 from A4 fractures. VLF may help to predict preoperatively the occurrence of dural laceration, thereby choosing the optimal surgical strategy. Clinical and biomechanical data suggest VLF may be a valuable modifier to guide the decision-making in burst fractures; however, more studies are needed to confirm its prognostic importance regarding treatment outcomes.

To compare post-operative outcomes of percutaneous pedicle screw fixation (PPSF) vs open pedicle screw fixation (OPSF) in patients with thoracolumbar spine fractures with no neurological deficits.

In a randomised controlled trial, patients received short-segment fixation with intermediate screws. We assessed post-operative back pain (Visual Analog Scale or VAS), blood loss, operative/fluoroscopy times, radiographic parameters, and oswestry disability index (ODI) scores at 1, 2, 3, 6, 9, and 12 months.

Between January 2018 and October 2019, 31 patients received PPSF and 30 OPSF. Mean intra-operative blood loss was 66.45 (±44.29) ml for PPSF vs 184.83 (±128.36) ml for OPSF (p<0.001). Fluoroscopy time averaged 2.36 (±0.76) minutes for PPSF vs 0.58 (±0.51) minutes for OPSF (p<0.001). No significant differences existed in operative time or post-operative VAS scores. Radiographic parameters (kyphosis angle and vertebral height ratios) didn't significantly differ post-operatively or at 12 months. However, ODI scores differed significantly at 6 months (p=0.025), with no difference at 12 months.

In this trial, PPSF was comparable to OPSF in improving ODI scores at 12 months but showed earlier improvement at 6 months and reduced blood loss. Radiographic outcomes remained similar between groups over 12 months.

Magnetic resonance imaging (MRI) is increasingly used as an adjunct to spinal soft tissue evaluation in cervical spine (C-spine) trauma; however, the utility of this information remains controversial. In this consecutive observational study, we reviewed the utility of MRI in patients with C-spine trauma.

We identified patients in real time over a 2-year period as they presented to our level 1 trauma center for C-spine computed tomography (CT) scan followed by MRI. MRI was obtained by the trauma team prior to the spine service consultation if (1) they were unable to clear the C-spine according to protocol or (2) if the on-call radiologist reported a concern for ligamentous integrity from the CT findings.

Thirty-three patients, including 19 males (58%) and 14 females, with a mean age of 54 years, were referred to the spine service for concerns of ligamentous instability. The most common mechanisms of injury were motor vehicle accidents (n = 13) and falls (n = 11). MRI demonstrated ligamentous signal change identified by the radiologist as potentially unstable in all patients. Fifteen patients (45%) had multiple C-spine ligaments affected. The interspinous ligament was involved most frequently (28%), followed by the ligamentum flavum (21%) and supraspinous ligament (15%). All patients underwent dynamic upright C-spine X-rays that were interpreted by both the ordering surgeon and radiologist. There was no evidence of instability in any patient; concurrence between X-ray interpretation was 100%. The cervical collar was successfully removed in all cases. No patients required late surgical intervention, and there were no return visits to the emergency department of a spinal nature.

MRI signal change within the ligaments of the C-spine should be interpreted with caution in the setting of trauma. To physicians less familiar with spinal biomechanics, MRI findings may be perceived in an inadvertently alarming manner. Bony alignment and, when indicated, dynamic upright X-rays remain the gold standard for evaluating the ligamentous integrity of the C-spine.

Predictive algorithm via decision tree.

Artificial intelligence (AI) remain an emerging field and have not previously been used to guide therapeutic decision making in thoracolumbar burst fractures. Building such models may reduce the variability in treatment recommendations. The goal of this study was to build a mathematical prediction rule based upon radiographic variables to guide treatment decisions.

Twenty-two surgeons from the AO Knowledge Forum Trauma reviewed 183 cases from the Spine TL A3/A4 prospective study (classification, degree of certainty of posterior ligamentous complex (PLC) injury, use of M1 modifier, degree of comminution, treatment recommendation). Reviewers' regions were classified as Europe, North/South America and Asia. Classification and regression trees were used to create models that would predict the treatment recommendation based upon radiographic variables. We applied the decision tree model which accounts for the possibility of non-normal distributions of data. Cross-validation technique as used to validate the multivariable analyses.

The accuracy of the model was excellent at 82.4%. Variables included in the algorithm were certainty of PLC injury (%), degree of comminution (%), the use of M1 modifier and geographical regions. The algorithm showed that if a patient has a certainty of PLC injury over 57.5%, then there is a 97.0% chance of receiving surgery. If certainty of PLC injury was low and comminution was above 37.5%, a patient had 74.2% chance of receiving surgery in Europe and Asia vs 22.7% chance in North/South America. Throughout the algorithm, the use of the M1 modifier increased the probability of receiving surgery by 21.4% on average.

This study presents a predictive analytic algorithm to guide decision-making in the treatment of thoracolumbar burst fractures without neurological deficits. PLC injury assessment over 57.5% was highly predictive of receiving surgery (97.0%). A high degree of comminution resulted in a higher chance of receiving surgery in Europe or Asia vs North/South America. Future studies could include clinical and other variables to enhance predictive ability or use machine learning for outcomes prediction in thoracolumbar burst fractures.

We propose that the key to improving care for these patients is to truly understand the processes that take place from the interpretation of radiographic findings, through the assessment of the severity of various injuries, to inclusion within a classification category and finally to selecting a specific treatment.

Reliability study utilizing 183 injury CT scans by 22 spine trauma experts with assessment of radiographic features, classification of injuries and treatment recommendations.

To assess the reliability of the AOSpine TL Injury Classification System (TLICS) including the categories within the classification and the M1 modifier.

Kappa and Intraclass correlation coefficients were produced. Associations of various imaging characteristics (comminution, PLC status) and treatment recommendations were analyzed through regression analysis. Multivariable logistic regression modeling was used for making predictive algorithms.

Reliability of the AO Spine TLICS at differentiating A3 and A4 injuries (N = 71) (K = .466; 95% CI .458 - .474; P < .001) demonstrated moderate agreement. Similarly, the average intraclass correlation coefficient (ICC) amongst A3 and A4 injuries was excellent (ICC = .934; 95% CI .919 - .947; P < .001) and the ICC between individual measures was moderate (ICC = .403; 95% CI .351 - .461; P < .001). The overall agreement on the utilization of the M1 modifier amongst A3 and A4 injuries was fair (K = .161; 95% CI .151 - .171; P < .001). The ICC for PLC status in A3 and A4 injuries averaged across all measures was excellent (ICC = .936; 95% CI .922 - .949; P < .001). The M1 modifier suggests respondents are nearly 40% more confident that the PLC is injured amongst all injuries. The M1 modifier was employed at a higher frequency as injuries were classified higher in the classification system.

The reliability of surgeons differentiating between A3 and A4 injuries in the AOSpine TLICS is substantial and the utilization of the M1 modifier occurs more frequently with higher grades in the system.

Retrospective analysis of prospectively collected data.

To compare decision-making between an expert panel and real-world spine surgeons in thoracolumbar burst fractures (TLBFs) without neurological deficits and analyze which factors influence surgical decision-making.

This study is a sub-analysis of a prospective observational study in TL fractures. Twenty two experts were asked to review 183 CT scans and recommend treatment for each fracture. The expert recommendation was based on radiographic review.

Overall agreement between the expert panel and real-world surgeons regarding surgery was 63.2%. In 36.8% of cases, the expert panel recommended surgery that was not performed in real-world scenarios. Conversely, in cases where the expert panel recommended non-surgical treatment, only 38.6% received non-surgical treatment, while 61.4% underwent surgery. A separate analysis of A3 and A4 fractures revealed that expert panel recommended surgery for 30% of A3 injuries and 68% of A4 injuries. However, 61% of patients with both A3 and A4 fractures received surgery in the real world. Multivariate analysis demonstrated that a 1% increase in certainty of PLC injury led to a 4% increase in surgery recommendation among the expert panel, while a .2% increase in the likelihood of receiving surgery in the real world.

Surgical decision-making varied between the expert panel and real-world treating surgeons. Differences appear to be less evident in A3/A4 burst fractures making this specific group of fractures a real challenge independent of the level of expertise.

Prospective Observational Study.

To determine the alignment of the AO Spine Thoracolumbar Injury Classification system and treatment algorithm with contemporary surgical decision making.

183 cases of thoracolumbar burst fractures were reviewed by 22 AO Spine Knowledge Forum Trauma experts. These experienced clinicians classified the fracture morphology, integrity of the posterior ligamentous complex and degree of comminution. Management recommendations were collected.

There was a statistically significant stepwise increase in rates of operative management with escalating category of injury (P < .001). An excellent correlation existed between recommended expert management and the actual treatment of each injury category: A0/A1/A2 (OR 1.09, 95% CI 0.70-1.69, P = .71), A3/4 (OR 1.62, 95% CI 0.98-2.66, P = .58) and B1/B2/C (1.00, 95% CI 0.87-1.14, P = .99). Thoracolumbar A4 fractures were more likely to be surgically stabilized than A3 fractures (68.2% vs 30.9%, P < .001). A modifier indicating indeterminate ligamentous injury increased the rate of operative management when comparing type B and C injuries to type A3/A4 injuries (OR 39.19, 95% CI 20.84-73.69, P < .01 vs OR 27.72, 95% CI 14.68-52.33, P < .01).

The AO Spine Thoracolumbar Injury Classification system introduces fracture morphology in a rational and hierarchical manner of escalating severity. Thoracolumbar A4 complete burst fractures were more likely to be operatively managed than A3 fractures. Flexion-distraction type B injuries and translational type C injuries were much more likely to have surgery recommended than type A fractures regardless of the M1 modifier. A suspected posterior ligamentous injury increased the likelihood of surgeons favoring surgical stabilization.

To compare the clinical and radiological outcomes of monoplanar screws (MSs) versus hybrid fixed axial and polyaxial screws (HSs) in percutaneous short-segment intermediate screw fixation (PSISF) for traumatic thoracolumbar burst fractures (TTBFs) in patients without neurologic impairment.

A consecutive series of 100 patients with single-segment TTBFs and no neurologic impairment who underwent PSISF with 6 monoplanar screws (MS group) or correct were retrospectively enrolled. The demographic data, radiologic evaluation indicators, perioperative indicators and clinical assessment indicators were analysed between the MS group and HS group.

The demographic data and perioperative indicators were not significantly different in the two groups (P > 0.05). The postoperative anterior vertebral height ratio (AVHR), kyphosis Cobb angle (KCA), vertebral wedge angle (VWA) and spinal canal encroachment rate (SCER) were significantly improved in both groups (*P < 0.05). The MS group obtained better correction than the HS group in terms of improvement in the AVHR, KCA and VWA after surgery (*P < 0.05). At the last follow-up, the MS group had less correction loss of AVHR, KCA and VWA (*P < 0.05). The MS group presented greater improvement in the SCER at the last follow-up (*P < 0.05). The visual analogue scale (VAS) score and Oswestry Disability Index (ODI) score of all patients were significantly better postoperatively than those preoperatively (*P < 0.05), and the scores collected at each follow-up visit did not differ significantly between the two groups (P > 0.05). In the MS group, no internal fixation failure was observed during the follow-up period, but, in the HS group, two cases of internal fixation failure were observed at the last follow-up (one case of rod loosening and one case of screw breakage).

Both MSs and HSs fixation are effective treatments for TTBFs and have comparable clinical outcomes. In contrast, MSs fixation can improve the correction effect, better improve the SCER, and further reduce correction loss as well as reduce the incidence of instrumentation failure. Therefore, MSs fixation might be a better option for treating TTBFs in patients without neurological deficits.

Purely isolated spinous processes fractures are rare and are usually treated conservatively, although a few authors have reported cases of nonunion that ultimately required surgical resection.

We present a case of an isolated T6 spinous process pseudoarthrosis that was treated by surgical resection of the tip of the spinous process. A 34-year-old Caucasian male patient was complaining of mid-thoracic back pain without neurologic impairment more than 2 years after an isolated spinous process fracture. Magnetic Resonance Imaging (MRI) and Single Photon Emission Computed Tomography (SPECT) revealed a nonunion. We performed a resection without further complication.

Although spinous process nonunions may in some cases be well tolerated, surgical resection appears to be a reliable option in case of persistent symptoms. This illustrated case shows the description of an isolated thoracic spinous process nonunion and its surgical treatment.