A Comparison of Thoracolumbar Injury Classification in Spine Trauma Patients Among Neurosurgeons in East Africa Versus North America

Abstract

Background In January 2021, we published findings evaluating the validity of thoracolumbar injury classification and biomechanical approach in the clinical outcome of operative and non-operative treatments. A notable result in our study was patients with unstable burst fractures received an Arbeitsgemeinschaft für Osteosynthesefragen System (AO) score that recommended conservative treatment compared to a Thoracolumbar Injury Classification and Severity Scale (TLICS) score that recommended surgical intervention. We designed a survey to determine reported differences in thoracolumbar injury classification, including the percentage of thoracolumbar spine fractures, type of classification system(s) used, use of classification system by board-certified neurosurgeons and neurosurgical residents, reliance on classification system to guide management, use of MRI in the evaluation of the posterior ligamentous complex, and readmission rate < 90 days at treating facilities. This study aims to determine which areas of neurosurgical practice in spine trauma patients differ among surgeons in North America and East Africa, including Ethiopia, Kenya, and Sudan. Multiple classification systems have been proposed to describe thoracolumbar spine injuries. We hypothesized that there would be marked variability in the classification systems used to evaluate thoracolumbar spine injury among neurosurgeons in North America and East Africa. Methods The survey consisted of seven questions and was sent to 440 neurosurgeons practicing on the continents of North America and East Africa. Results A total of 67 surgeons responded, 50 from North America and 17 from East Africa, including Ethiopia, Kenya, and Sudan. A significant percentage of African respondents reported a higher thoracolumbar spine fracture rate than respondents in North America (53% and 30%, respectively). Regarding the classification system used, 65% of surgeons in East Africa reported using TLICS, whereas 62% of surgeons in North America reported using Denis 3-column classification. For patients with spine trauma, surgeons in East Africa and North America reported a similar percentage of readmission <90 days (47% and 52%, respectively). Conclusion Our findings vary in spine trauma classification for American and East African patients and still highlight crucial areas for improvement due to patient load, education, and resource accessibility.

Keywords: aans; africa; ao; denis 3-column; north america; regional practice; survey; thoracolumbar injury; tlics; trauma.

Figure 1. In response to the question “Which location best describes where you practice medicine?” and given the option of North America or East Africa, 50 responded as North America, 17 as East Africa.

Figure 2. In response to the question “What is the approximate percentage of thoracolumbar spine fractures at your facility?” for surgeons in North America, 21 said 0-20%, 15 said 20-40%, eight said 40-60%, six said 60-80% and 0 said greater than 80%. For surgeons practicing in East Africa, 0 said 0-20%, nine said 20-40%, five said 40-60%, two said 60-80%, and one said greater than 80%.

Figure 3. In response to the question “What classification system(s) do you use in your institution for the evaluation of thoracolumbar injury?” for surgeons in North America, 31 said Denis 3-column classification, 14 said AO classification, 25 said TLICS classification, three said none and 0 said other. For surgeons in East Africa, three said Denis 3-column, one said AO classification, 11 said TLICS classification, 0 said none, and four said other, and all specified the Magerl classification system.

AO: Osteosynthesefragen System; TLICS: Thoracolumbar Injury Classification and Severity Scale.

Figure 4. In response to the question “How often do you rely on the classification systems to guide your management of thoracolumbar injury?” for surgeons in North America, seven said 0-20%, four said 20-40%, 13 said 40-60%, 12 said 60-80%, 14 said greater than 80%. For those practicing in East Africa, 0 said 0-20%, 0 said 20-40%, two said 40-60%, two said 60-80%, 13 said greater than 80%.

Figure 5. In response to the question “Do neurosurgeons and neurosurgical residents at your facility use a classification system for the evaluation of thoracolumbar injury?” for surgeons in North America, 31 said yes, and 19 said no. In East Africa, nine surgeons said yes, and eight surgeons said no.

Figure 6. In response to the question “How often is MRI routinely obtained to evaluate the posterior ligamentous complex?” for those in North America, 12 said 0-20%, four said 20-40%, eight said 40-60%, four said 60-80%, 22 said greater than 80%. For those in East Africa, 12 said 0-20%, 0 said 20-40%, 0 said 40-60%, two said 60-80%, three said greater than 80%.

Figure 7. In response to the question, “For patients with spine trauma, how often is your readmission rate <90 days?” for those in North America, 24 said 0-1%, 26 said 10-20%, and 0 said greater than 20%. For those in East Africa, nine said 0-1%, eight said 10-20% and 0 said greater than 20%.