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Abstract
Objectives
We assessed the intraobserver and interobserver reliability of TLICS classification in the thoracolumbar injuries, which had been evaluated in our hospital. It was compared with that of the older, McAfee classification and discussed for clinical validation.
Summary of Literature Review
Among the numerous literatures regarding the thoracolumbar injury, there is no consensus on the most useful classification, and there is nothing comparing the McAfee classification with the TLICS classification.
Materials and Methods
Among the 230 patients that were treated with conservative care or operation from January 1, 2005 to January 1, 2010 in our hospital, 185 patients with initial CT and MRI images were assessed. Five orthopedic surgeons reviewed histories, plain film, CT and MRI of the 185 thoracolumbar injury cases, respectively. Each case was classified and scored according to the McAfee classification and the TLICS classification. The case assessment was recorded and the orthopedic surgeons repeated the assessment 1 month later. Intraobserver and interobserver reliability were assessed by statistical analysis. The actual management of each case was compared with the treatment recommended by TLICS classification to calculate the validity of the indexes.
Results
Intraobserver and interobserver reliability in TLICS were higher than those in the McAfee classification. Agreement of the TLICS classification for treatment recommendation was 81.7%, comparing with the actual management of previous McAfee classification. Validity indexes were satisfactory in therapeutic decision making, especially specificity.
Conclusions
TLICS classification has a relative high K-value, when compared with that of the McAfee classification for intraobserver and interobserver reliability. Through clinical studies, including prospective observational analysis, TLICS classification can be applied and adjusted more adequately.
REFERENCES
1.Denis F. The three column spine and its significance in the classification of acute thoracolumbar spinal injuries. Spine (Phila Pa 1976). 1983. 8:817–31.
2.McAfee PC., Yuan HA., Fredrickson BE., Lubicky JP. The value of computed tomography in thoracolumbar fractures. An analysis of one hundred consecutive cases and a new classification. J Bone Joint Surg Am. 1983. 65:461–73.
3.Oner FC., Ramos LM., Simmermacher RK, et al. Classification of thoracic and lumbar spine fractures: problems of reproducibility. A study of 53 patients using ct and mri. Eur Spine J. 2002. 11:235–45.
4.Wood KB., Khanna G., Vaccaro AR., Arnold PM., Harris MB., Mehbod AA. Assessment of two thoracolumbar fracture classification systems as used by multiple surgeons. J Bone Joint Surg Am. 2005. 87:1423–9.
5.Panjabi MM., Oxland TR., Kifune M, et al. Validity of the three-column theory of thoracolumbar fractures: a biomechanic investigation. Spine (Phila Pa 1976). 1995. 20:1122–7.
6.Willé n JA., Gaekwad UH., Kakulas BA. Acute burst fractures. A comparative analysis of a modern fracture classification and pathologic findings. Clin Orthop Relat Res. 1992. 276:169–75.
7.Vaccaro AR., Zeiller SC., Hulbert RJ, et al. The thoracolumbar injury severity score: a proposed treatment algorithm. J Spinal Disord Tech. 2005. 18:209–15.
8.Raja Rampersaud Y., Fisher C., Wilsey J, et al. Agreement between orthopedic surgeons and neurosurgeons regarding a new algorithm for the treatment of thoracolumbar injuries: a multicenter reliability study. J Spinal Disord Tech. 2006. 19:477–82.
9.Koh YD., Kim DJ., Koh YW. Reliability and Validity of Thoracolumbar Injury Classification and Severity Score (TLICS). Asian Spine J. 2010. 4:109–17.
10.Whang PG., Vaccaro AR., Poelstra KA, et al. The influence of fracture mechanism and morphology on the reliability and validity of two novel thoracolumbar injury classification systems. Spine (Phila Pa 1976). 2007. 32:791–5.
11.Schweitzer KM., Vaccaro AR., Harrop JS, et al. Interrater reliability of identifying indicators of posterior ligamentous complex disruption when plain films are indeterminate in thoracolumbar injuries. J Orthop Sci. 2007. 12:437–42.
12.Moon SH., Park MS., Suk KS, et al. Feasibility of ultrasound examination in posterior ligament complex injury of thoracolumbar spine fracture. Spine (Phila Pa 1976). 2002. 27:2154–8.
13.Roh JH., Chung NS., Park JW., Shin DS., Jeon CH. Clinical Importance of MRI in Thoracolumbar Spinal Fracture. J Korean Soc Spine Surg. 2008. 15:67–72.
14.Landis JR., Koch GG. The measurement of observer agreement for categorical data. Biometrics. 1977. 33:159–74.
15.Sanders R. Editorial. The problems with apples and oranges. J orthop Trauma. 1997. 11:465–6.
16.Garbuz DS., Masri BA., Esdaile J., Duncan CP. Classification systems in orthopaedics. J Am Acad Orthop Surg. 2002. 10:290–7.
17.Bö hler L. The treatment of fractures. 5th ed.New York: Grune & Stratton;1956. p. 300–29.
18.Watson-Jones R. The results of postural reduction of fractures of the spine. J Bone Joint Surg Am. 1938. 20:567–86.
19.Nicoll EA. Fractures of the dorso-lumbar spine. J Bone Joint Surg Br. 1949. 31:376–94.
20.Daffiner RH., Deeb ZL., Rothfus WE. The posterior vertebral body line: importance in the detection of burst fracture. AJR. 1987. 148:93–6.
21.Hackney DB., Asato R., Joseph PM, et al. Hemorrhage and edema in acute spinal cord compression: demonstrated by MRI imaging. Radiology. 1986. 161:387–90.
22.Goldberg AL., Rothfus WE., Vital JM, et al. The impact of magnetic resonance on the diagnostic evaluation of acute cervicothoracic spinal trauma. Skeletal Radiol. 1988. 17:89–95.
23.Grenier N., Gresselle JF., Vital JM, et al. Normal and disrupted lumbar longitudinal ligaments: correlative MR and anatomic study. Radiology. 1989. 171:197–205.
24.Kliewer MA., Gray L., Paver J, et al. Acute spinal ligament disruption: MR imaging with anatomic correlation. J Magn Reson Imaging. 1993. 3:855–61.
25.Lee KY., Lee MJ., Sohn SK., Kim HJ. The Analysis of Prognostic Factors on Unstable Burst Fracture on the Thoracolumbar Spine. J Korean Soc Spine Surg. 2009. 16:1–7.
26.Audigé L., Bhandari M., Hanson B., Kellam J. A concept for the validation of fracture classifications. J Orthop Trauma. 2005. 19:401–6.
27.Schweitzer KM Jr., Vaccaro AR., Lee JY, et al. Confusion regarding mechanisms of injury in the setting of thoracolumbar spinal trauma: a survey of The Spine Trauma Study Group (STSG). J Spinal Disord Tech. 2006. 19:528–30.
28.Glaser JA., Jaworski BA., Cuddy BG, et al. Variation in surgical opinion regarding management of selected cervical spine injuries. A preliminary study. Spine (Phila Pa 1976). 1998. 23:975–83.
29.Grauer JN., Vaccaro AR., Beiner JM, et al. Similarities and differences in the treatment of spine trauma between surgical specialties and location of practice. Spine (Phila Pa 1976). 2004. 29:685–96.
30.Bono CM., Vaccaro AR., Hurlbert RJ, et al. Validating a newly proposed classification system for thoracolumbar spine trauma: looking to the future of the thoracolumbar injury classification and severity score. J Orthop Trauma. 2006. 20:567–72.
Fig. 1.
A 72-year-old male with back pain (A) Preoperative X-ray (B) Preoperative CT (C) Preoperative MRI with T1 and T2 sagital view (D) Postoperative X-ray showing open reduction with instrumented PLF. In McAfee classification, it was unstable bursting fracture. In TLICS classification, burst fractrure(2 point), posterior ligament complex injury(3 point) and neurologically intact state. Total score was 5 point. The therapeutic decision of McAfee classification was coincided with TLICS classification.
Fig. 2.
A 42-year-old male with back pain (A) Preoperative X-ray (B) Preoperative CT (C) Preoperative MRI with T1 and T2 sagital view (D) Postoperative X-ray showing open reduction with instrumented PLF. In McAfee classification, it was unstable bursting fracture. In TLICS classification, burst fractrure was 2 point, but posterior ligament complex and neurologic state were intact. Total score was 2 point. But, the patient was treated with surgery due to multiple trauma and early rehabilitation.
Table 1.
Intraobserver statistics of McAfee classification and TLICS classificatio
| McAfee | TLICS∗ | ||||
|---|---|---|---|---|---|
| K value | P value | K value | P value | ||
| Wedge compression fx.† | 0.621 | <0.05 | Injury morphology | 0.723 | <0.05 |
| Stable burst fx. | 0.710 | <0.05 | PLC‡ integrity | 0.823 | <0.05 |
| Unstable burst fx. | 0.721 | <0.05 | Neurologic status | 0.935 | <0.05 |
| Chance fx. | 0.653 | <0.05 | Total score | 0.708 | <0.05 |
| Flexion-distraction injury | 0.589 | <0.05 | |||
| Translational injury | 0.510 | <0.05 | |||
Table 2.
Interobserver statistics of McAfee classification and TLICS classification
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