Agreement and discordance between the modified thoracolumbar injury classification and severity score and the thoracolumbar AOSpine injury score in guiding surgical decision-making for thoracolumbar fractures: a comparative study.
For burst fractures with intervertebral disc involvement, mTLICS tends to recommend surgery more often, reflecting a difference in classification behaviour rather than a demonstrated clinical advantage, and mTLICS and TL AOSIS show substantial concordance as decision-support tools for thoracolumbar fractures.
Abstract
Purpose
To compare the agreement and the differences between the modified Thoracolumbar Injury Classification and Severity Score (mTLICS) system and the AO Thoracolumbar Spine Injury Score (TL AOSIS) in guiding surgical decision-making for thoracolumbar fractures.
Methods
The clinical and imaging data of 100 patients with thoracolumbar fractures admitted to our hospital between January 2021 and December 2023 were retrospectively analyzed. Two orthopedic surgeons, blinded to the patients' clinical outcomes, independently evaluated the cases using both scoring systems and provided treatment recommendations. Disagreements were resolved by a senior attending surgeon. Agreement between the two systems' treatment categories was quantified by weighted Cohen's κ with 95% confidence intervals from paired 3 × 3 cross-tabulations, and interobserver reliability was assessed before consensus adjudication.
Results
The two systems assigned the same treatment category in 86 of 100 patients (86.0%; unweighted κ = 0.773, 95% CI 0.666-0.881; linear-weighted κ = 0.820), with no significant asymmetry (McNemar-Bowker P = 0.160). Agreement was substantial in both the 57 neurologically intact patients (κ = 0.696) and the 43 patients with neurological impairment (κ = 0.619). Surgery was recommended by mTLICS versus TL AOSIS in 24.6% versus 19.2% of neurologically intact patients and in 90.7% versus 81.4% of those with neurological impairment. Interobserver reliability before consensus was substantial to high (linear-weighted κ = 0.88 for mTLICS and 0.75 for TL AOSIS). The two scoring systems showed substantial agreement in treatment recommendations. In burst fractures with intervertebral disc injury, mTLICS tended to assign cases to higher treatment categories than TL AOSIS, although these subgroup differences were not statistically significant.
Conclusion
mTLICS and TL AOSIS show substantial concordance as decision-support tools for thoracolumbar fractures. For burst fractures with intervertebral disc involvement, mTLICS tends to recommend surgery more often, reflecting a difference in classification behaviour rather than a demonstrated clinical advantage. Because no outcome data were analysed, whether this tendency improves patient outcomes remains to be determined.
BACKGROUND
Thoracolumbar compression fractures (TLCF) are often managed non-operatively with Thoracic-Lumbar-Sacral Orthosis (TLSO) bracing. This study evaluated the safety of a novel remote review protocol for non-operative TLCF management.
METHODS
A single-center retrospective analysis was performed on adult trauma patients with acute TLCF. The PRE cohort (5/2022-4/2023) received formal bedside consultation, while the POST cohort (6/2023-6/2024) underwent remote review by an on-call spine surgery resident. The primary outcome was the incidence of TLCF-related complications.
RESULTS
Of 120 patients, 79 (65.8%) were in the POST cohort. Demographics, injury mechanisms, vitals, and injury severity score were comparable between cohorts (all p > 0.05). Median time to discharge (PRE 28 h vs. POST 26 h, p = 0.61) was similar. No patients developed TLCF-related complications including neurological deficits or TLSO brace-related complications in either group.
CONCLUSIONS
Implementation of a remote review protocol for low-risk acute TLCF appears safe with similar outcomes and time to discharge compared to traditional bedside consultation.
LEVEL OF EVIDENCE
Level III.
Jiabao Nie, Joseph Di Gerolamo, Nicholas Truong et al.· Injury· 0 citations
Accurate evaluation of proximal tibiofibular fractures remains clinically challenging. This study aimed to evaluate the diagnostic applicability and compare the inter-observer reliability and intra-observer reproducibility of the novel modified Wu classification (mWC) against three established systems (AO/OTA, Schatzker, and Luo). A multicenter, retrospective study was conducted analyzing 320 independent proximal tibiofibular fracture cases (comprising 171 cases in males and 149 cases in females; mean patient age, 45.76 ± 15.82 years) treated between January 2010 and October 2023. Four independent observers of varying clinical expertise evaluated plain radiographs, 2D CT, and 3D reconstructions to classify the fractures across the four systems. A second blinded assessment was performed following a four-week washout period. Agreement was quantified utilizing Fleiss’ kappa and Cohen’s kappa coefficients. Traditional systems failed to adequately categorize 26.9% (86/320) of cases, whereas the mWC successfully achieved a 100% classifiability rate. For inter-observer reliability, the mWC demonstrated substantial agreement (κ = 0.616), outperforming the Luo (κ = 0.597), Schatzker (κ = 0.484), and AO/OTA (κ = 0.449) classifications. Regarding intra-observer reproducibility, the mWC showed substantial agreement (mean κ = 0.772), which was statistically secondary to the almost perfect agreement achieved by the Luo system (κ = 0.831), but remained superior to the substantial agreement demonstrated by the Schatzker (κ = 0.700) and AO/OTA (κ = 0.696) systems. Crucially, the specific structural sub-components of the mWC (column, region, and segment) consistently yielded substantial to almost perfect agreement across evaluations.The mWC represents a structured evaluative framework that addresses several morphological gaps of traditional systems for evaluating proximal tibiofibular fractures. By integrating 3D anatomical precision and effectively addressing complex fracture patterns with concomitant fibular involvement, the mWC provides a consistent, reproducible framework that expands taxonomic classifiability, potentially facilitates preoperative surgical planning, and supports the standardization of future clinical research.
Yong Lin, D. Rao, Qin Cai et al.· Scientific Reports· 0 citations
OBJECTIVES
To assess the added value of emergency spine MRI compared with CT alone in patients with AO Spine A/B thoracolumbar trauma without neurological deficit, focusing on clinical management.
MATERIALS & METHODS
This retrospective single-center study included consecutive trauma patients who underwent both CT and spine MRI between November 2023 and October 2025. CT served as the index test and MRI as the adjunct modality for fracture characterization and posterior ligamentous complex (PLC) assessment. MRI was performed according to an indication-driven institutional protocol. Changes in treatment strategy (conservative, minimally invasive, invasive) before versus after MRI were analyzed. Paired Wilcoxon signed-rank, McNemar, and symmetry tests were used as appropriate. Agreement was assessed using Cohen's κ. Predictors of MRI-driven management change were explored using Fisher's exact test and multivariable logistic regression.
RESULTS
A total of 158 patients were included (114 men; mean age, 35.8 ± 12.4 years; range 18-59). MRI detected a higher number of fractured vertebrae than CT (2.2 ± 1.8 vs. 1.5 ± 1.0; p < 0.001). MRI led to a change in treatment strategy in 19 patients (12%), predominantly reflecting escalation of care (p < 0.001). Management change was driven by MRI-detected PLC injury in 17 patients (partial in 8, complete in 9), by occult spinal cord injury without clinical translation in 2 patients, and by both mechanisms simultaneously in 4 patients. AO Spine fracture classification changed after MRI in 39 patients (25%), reflecting substantial overall agreement between MRI and CT (κ = 0.64; p < 0.001). MRI identified significantly more posterior ligamentous complex injuries (AO Spine type B) than CT when comparing fracture classification (48 vs. 16 patients; p < 0.001) and dedicated PLC status assessment (48 vs. 13 patients; p < 0.001). No CT-based variable remained independently associated with management change after adjustment.
CONCLUSION
In selected patients with neurologically intact thoracolumbar trauma, emergency spine MRI modified therapeutic management in 12% of cases, primarily by revealing posterior ligamentous complex injuries and occult spinal cord findings not apparent on CT. These results support an indication-driven rather than systematic use of MRI.
Jean-Baptiste Quilichini, E. Dien, Paul-Alexis Ranc et al.· Injury· 0 citations
BACKGROUND
The optimal surgical approach for thoracolumbar fractures remains debated. However, it is unclear whether surgical technique or preoperative deformity severity better predicts final outcomes.
PURPOSE
This study compares outcomes between MIS and Open surgery and identifies whether surgical approach or preoperative deformity severity better predicts final spinal alignment.
METHODS
In this retrospective comparative study, 92 patients with thoracolumbar fractures (T11-L2) were divided into MIS (n = 46) and Open surgery (n = 46) groups. Radiographic parameters (fracture vertebral angle, Cobb angle, thoracolumbar angle, anterior-posterior height ratio) were assessed preoperatively, postoperatively, and at final follow-up (mean 19.6 ± 1.4 months). Perioperative outcomes and age-dependent correlations were analyzed using appropriate statistical tests (p ≤ 0.05 significant).
RESULTS
The Open group demonstrated superior final fracture vertebral angle (7.1 ± 1.5° vs 8.3 ± 1.2°, p < 0.001) and Cobb angle correction (7.9 ± 1.4° vs 9.3 ± 1.2°, p < 0.001). More importantly, Open surgery showed better immediate anterior-posterior height restoration (80.4 ± 2.7% vs 79.0 ± 2.1%, p = 0.007), while MIS showed advantages in operative time (75.9 ± 10.9 vs 100.8 ± 12.9 min, p < 0.001), blood loss (85.8 ± 18.9 vs 238 ± 72.6 mL, p < 0.001), and hospital stay (5.9 ± 0.91 vs 8.4 ± 1.1 days, p < 0.001). Preoperative deformity severity was the strongest predictor of final Cobb angle in both groups (MIS: r = 0.491; Open: r = 0.646, both p < 0.001), although initial uncorrected analyses suggested some age-related correlations with other radiographic parameters, patient age was not a significant predictor of final alignment after False Discovery Rate correction.
CONCLUSIONS
These study findings support a goal-stratified surgical strategy: prioritizing MIS where rapid rehabilitation is key, and favoring Open techniques where durable anatomical correction is paramount. Surgical approach is the primary determinant of perioperative recovery, whereas preoperative deformity severity is the dominant predictor of final anatomical alignment.
E. Ali, Sherif El-aidy, A. Mashhour et al.· European spine journal· 0 citations
The proposed isthmus-referenced subtype classification demonstrated high interobserver reliability and was associated with operative complexity and 24-week clinical outcomes and may support preoperative planning and risk stratification, although prospective validation is required.
M. Engin, Salih Muhammet Ayas, M. Turgut et al.· BMC Pediatrics· 0 citations
This study aimed to evaluate the clinical efficacy of double-loop plate fixation via the subacromial coracoid approach (modified anterolateral shoulder arthroscopy) for acute acromioclavicular joint dislocation of Rockwood Grade III or higher. A retrospective single-center observational study included 68 patients treated at Weifang People’s Hospital from October 2022 to April 2024. Outcomes included pre- and postoperative pain (Visual Analog Scale), functional recovery (Constant Score), range of motion, and radiographic reduction (coracoclavicular distance [CCD] and acromioclavicular distance [ACD]). Repeated-measures analysis of variance evaluated longitudinal changes; paired t-tests compared CCD and ACD between 2 days and 6 months postoperatively. P < .05 was considered significant. All 68 patients completed ≥ 6-month follow-up. Significant improvements were observed in Visual Analog Scale, Constant Score, and range of motion at 1, 3, and 6 months postoperatively (all P < .01), with stable CCD and ACD radiographically. The modified arthroscopic double-loop plate fixation shows short-term efficacy in acute Rockwood III–VI acromioclavicular joint dislocation, with pain relief, functional recovery, and stable radiographic reduction. Limitations include retrospective, single-center design, lack of comparator, and short-term follow-up; long-term efficacy requires prospective controlled trials.
Longxin An, Zilong Deng, Qiong Wu et al.· Medicine· 0 citations