BACKGROUND: 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.
METHODS: 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.
RESULTS: 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).
CONCLUSIONS: 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.

UNASSIGNED: A recent meta-analysis showed that only four prior studies have shown that magnetic resonance imaging (MRI) can change the fracture classification in 17% and treatment decisions in 22% of cases. However, previous studies showed a wide methodological variability regarding the study population, the definition of posterior ligamentous complex (PLC) injury, and outcome measures.
UNASSIGNED: How can we standardize the reporting of the impact of MRI for neurologically intact patients with thoracolumbar fractures?
UNASSIGNED: All available literature regarding the impact of MRI on thoracolumbar fracture classification or decision-making were reviewed. Estimating the impact of MRI on the TLFs\' classification is an exercise of analyzing the CTs\' accuracy for PLC injury against MRI as a \'\'Gold standard\'\'and should follow standardized checklists such as the Standards for the Reporting of Diagnostic Accuracy Studies. Additionally, specific issues related to TLFs should be addressed.
UNASSIGNED: A standardized approach for reporting the impact of MRI in neurologically intact TLF patients was proposed. Regarding patient selection, restricting the inclusion of neurologically intact patients with A- and B-injuries is crucial. Image interpretation should be standardized regarding imaging protocol and appropriate criteria for PLC injury. The impact of MRI can be measured by either the rate of change in fracture classification or treatment decisions; the cons and pros of each measure is thoroughly discussed.
UNASSIGNED: We proposed a structured methodology for examining the impact of MRI on neurologically intact patients with TLFs, focusing on appropriate patient selection, standardizing image analysis, and clinically relevant outcome measures.

OBJECTIVE: To determine the impact of magnetic resonance imaging (MRI) on fracture classification for thoracic spine fractures (TSFs) compared to computed tomography (CT) alone.
METHODS: This study was a retrospective review of 63 consecutive patients with TSFs who underwent CT and MRI within ten days of injury. Three reviewers classified all fractures according to the AOSpine Classification and the Thoracolumbar AOSpine Injury severity score (TLAOSIS). Posterior ligamentous complex (PLC) injury on MRI was defined by \"black stripe discontinuity\" and on CT by the presence of vertebral body translation, facet joint malalignment, horizontal laminar or spinous process fracture, and interspinous widening. The proportion of patients with AO type A/B/C and with TLAOSIS ≤ 5 and ≥ 6 was compared between CT and MRI. Classification and regression trees were used to create a series of predictive models for the probability of PLC injury in AO type A fractures.
RESULTS: AO classification using CT was as follows: type A in 35 patients (55%), type B in 18 patients (29%), and type C in 10 patients (16%). Thirty-three patients (52%) had a TLAOSIS ≤5, while the remaining 30 (48%) had TLAOSI ≥6. The addition of MRI after CT upgraded type A to type B fractures in 10 patients (16%) and changed TL AOSIS from ≤5 to ≥6 in 8 cases (12.8%). Type A fractures with load sharing score (LSC) ≥6 had a 60% chance of upgrading to type B, while LSC <6 had a 12.5% chance of upgrading to type B.
CONCLUSIONS: CT yielded (89%) accuracy in diagnosing PLC injury in TSFs. The addition of MRI after CT substantially changed the AO classification or TLAOISS, compared to CT alone, thus suggesting an added value of MRI for PLC assessment for TSFs classification.

OBJECTIVE: To provide the first meta-analysis of the impact of magnetic resonance imaging (MRI) on thoracolumbar fractures (TLFs) classification and decision-making.
METHODS: 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.
RESULTS: 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%).
CONCLUSIONS: 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/ .

METHODS: 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]).
CONCLUSIONS: 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.

OBJECTIVE: Spinal ligament is an important component of the spinal column in mitigating biomechanical stress. Particularly the posterior ligamentous complex, which is composed of the ligamentum flavum, interspinous, and supraspinous ligaments. However, research characterizing the biomechanics and role of ligament health in spinal pathology and clinical context are scarce. This article provides a comprehensive review of the implications of spinal pathology on the structure, function, and biomechanical properties of the posterior ligamentous complex.
RESULTS: Current research characterizing biomechanical properties of the posterior ligamentous complex is primarily composed of cadaveric studies and finite element modeling, and more recently incorporating patient-specific anatomy into finite element models. The ultimate goal of current research is to understand the relative contributions of these ligamentous structures in healthy and pathological spine, and whether preserving ligaments may play an important role in spinal surgical techniques. At baseline, posterior ligamentous complex structures account for 30-40% of spinal stability, which is highly dependent on the intrinsic biomechanical properties of each ligament. Biomechanics vary widely with pathology and following rigid surgical fixation techniques and are generally maladaptive. Often secondary to morphological changes in the setting of spinal pathology, but morphological changes in ligament may also serve as a primary pathology. Biomechanical maladaptations of the spinal ligament adversely influence overall spinal column integrity and ultimately predispose to increased risk for surgical failure and poor clinical outcomes. Future research is needed, particularly in living subjects, to better characterize adaptations in ligaments that can provide targets for improved treatment of spinal pathology.

暂无摘要。

OBJECTIVE: Though magnetic resonance imaging (MRI) is the primary modality of investigation for determining the extent of PLC injuries in lower lumbar fractures (L3-L5), the reliability of computed tomography (CT) has not been well defined. The main objective of this study is to analyze the diagnostic accuracy of combined CT findings for detecting posterior ligamentous complex injury in patients with lower lumbar fractures.
METHODS: We retrospectively analyzed data from 108 patients who presented with traumatic lower lumbar fractures. CT parameters like loss of vertebral body height, local kyphosis, retropulsion of fracture fragment, interlaminar distance (ILD), interspinous distance (ISD), supraspinous distance (SSD), interpedicular distance (IPD), canal compromise, facet joint diastasis in axial images (FJDA) and sagittal images (FJDS), presence of lamina and spinous process fracture were calculated using axial and sagittal CT images. The presence or absence of PLC injury was determined using MRI as a reference standard.
RESULTS: Among 108 patients PLC injury was identified in 57 (52.8%). On univariate analysis local kyphosis, retropulsion of fracture fragment, ILD, IPD, FJDS, FJDA, and the presence of spinous process fracture were found to be significant (P < 0.05) in predicting PLC injury. Whereas on multivariate logistic regression analysis, FJDS (P= 0.039), and FJDA (P= 0.003) were found to be variables independently associated with PLC injury.
CONCLUSIONS: Among the various CT parameters, facet joint diastasis (FJDS > 4.2 mm and FJDA > 3.5 mm) is the most reliable factor in determining PLC injury.

暂无摘要。

The association of various morphological features of facet diastasis with posterior ligamentous complex (PLC) injury has not been previously described. This study aims to determine the diagnostic value of facet diastasis subtypes for diagnosing thoracolumbar PLC injury.
We retrospectively reviewed 337 consecutive patients with acute thoracolumbar fractures who had computed tomography (CT) and magnetic resonance imaging (MRI) within 10 days of injury. Three and 5 reviewers evaluated MRI and CT images, respectively. Facet diastasis was subclassified as follows: Dislocated, no articular surface apposition; subluxed, incomplete articular surface apposition; and facet fracture articular process fractures which may be displaced ≥2 mm or otherwise undisplaced, facet joint widening (FJW) ≥ 3 mm. We examined the diagnostic accuracy and the multivariate associations of facet diastasis subtypes with PLC injury in MRI.
Facet dislocation, subluxation, and displaced facet fracture yielded a high positive predictive value (PPV) for PLC injury (96%, 88%, and 94%, respectively). In contrast, undisplaced facet fracture and FJW yielded a moderate PPV for PLC injury (78%, and 45%, respectively). Facet dislocation, subluxation, and displaced facet fracture showed independent associations with PLC injury (adjusted odds ratio [AOR] = 38.4, 17.1, 13.4, respectively; P < 0.05). Undisplaced facet fracture and FJW were not associated with PLC injury (AOR = 3.9 [95% confidence interval, 0.49-38.4], P = 0.20) and (AOR = 1.94 [95% confidence interval, 0.48-7.13]; P = 0.20; P = 0.33), respectively.
Facet dislocation, subluxation, and displaced facet fracture, but not undisplaced facet fracture or FJW, were independently associated with PLC injury. Therefore, we propose to define facet diastasis as a surrogate marker of PLC injury in MRI based on these morphologies.