Operative versus Non-Operative Management of Traumatic Thoracolumbar Injuries according to the AO Spine Thoracolumbar Spine Injury Classification System

Introduction The AOSpine Thoracolumbar Spine Injury Classification (AOSTSIC) system has been proposed to better characterize injury morphologies and improve the classification of thoracolumbar (TL) spine trauma. However, the indications for surgical treatment according to the AOSTSIC system are still debated. Additionally, the proposed Thoracolumbar AOSpine Injury Score (AOSIS) is quite complex, which may preclude its use in daily practice. The objective of this reviewis to discuss the AOSTSIC systemand its indications for initial nonoperative versus surgical management of acute TL spine trauma. Methods We analyzed the literature for each injury type (and subtype, when pertinent) according to the AOSTSIC system as well as their potential treatment options. Results Patients with AOSTSIC subtypes A0, A1, and A2 are neurologically intact in the vast majority of the cases and initially managed nonoperatively. The treatment of A3- and A4-subtype injuries (burst fractures) in neurologically-intact patients is still debated with great controversy, with initially nonoperative management being considered an option in select patients. Surgery is recommended when there are neurological deficits or failure of nonoperativemanagement,with the role of magnetic resonance findings in the Posterior Ligamentous Complex (PLC) evaluation still being considered controversial. Injuries classified as type B1 in neurologically-intact patients may be treated, initially, with nonoperative management, provided that there are no ligamentous injury and non-displacing fragments. Due to severe ligamentous injury, type-B and type-C injuries should be considered as unstable injuries that must be surgically treated, regardless of the neurological status of the patient. Conclusions Until further evidence, we provided an easy algorithm-based guide on the spinal trauma literature to help surgeons in the decision-making process for the treatment of TL spine injuries classified according to the new AOSTSIC system.

Follow-up Comparison of Two Different Types of Anterior Thoracolumbar Instrumentations in Trauma Cases : Z-plate vs. Kaneda Device

OBJECTIVE: In a variety of thoracolumbar diseases, corpectomy followed by interbody bone graft and anterior instrumentation has allowed direct neural decompression and reconstruction of the weight-bearing column by short segments fusion. In this study, we compared spinal stability of the two different anterior thoracolumbar instruments : Z-plate and Kaneda device representing plate and two-rods type, respectively. METHODS: A retrospective review was performed for all the patients with thoracolumbar diseases or traumas treated with anterior corpectomy, autologous iliac bone graft, and fixation with instruments from 1996 to 2000. For the anterior instrumentation, Z-plate or Kaneda device was used for 24 (M:F=5:9, average age=37) and 12 (M:F=9:3, average age=41) patients, respectively. The plain AP and lateral flexion-extension films were taken immediately after surgery and at each follow-up. The sagittal and coronal Cobb's angles at the operation segments were used to observe the change of initial fixation status. The surgical time length and bleeding amount of the two groups were compared. Intra-operative and post-operative instrumentassociated complications were evaluated. Student t-test was used for statistical analysis and p-value less than 0.05 was considered to be significant. RESULTS: Mean follow-up durations for Z-plate and Kaneda device were 24 and 21 months, respectively. The fusion rate was 91% for Z-plate and 100% for Kaneda device. Two cases of Z-plate group showed instrumentation failure during the followup period, in which additional surgery was necessary. The mean differences of sagittal Cobb's angles among the AP images immediate after surgery and at follow-up were 7 and 2 degrees for Z-plate and Kaneda device, respectively (p<0.05). The mean differences of coronal Cobb's angles were 5 and 2 degrees for Z-plate and Kaneda device, respectively (p<0.05). No intra-operative complication has occurred in both groups. There was no difference in surgery time and bleeding amount between two groups. CONCLUSION: We think that Kaneda device (rod type) is stronger than Z-plate (plate type) to keep the spinal stability after anterior thoracolumbar surgery.