Interobserver Reliability in the Classification of Thoracolumbar Fractures Using the AO Spine TL Injury Classification System Among 22 Clinical Experts in Spine Trauma Care

Jose A Canseco¹, Taylor Paziuk¹, Gregory D Schroeder¹, Marcel F Dvorak², Cumhur F Öner³, Lorin M Benneker⁴, Emiliano Vialle⁵, Shanmuganathan Rajasekaran⁶, Mohammad El-Sharkawi⁷, Richard J Bransford⁸, Rishi M Kanna⁶, Martin Holas⁹, Sander Muijs³, Eugen Cezar Popescu¹⁰, Charlotte Dandurand², Jin W Tee¹¹, Gaston Camino-Willhuber¹², Mohamed M Aly^{13

14}, Andrei Fernandes Joaquim¹⁵, Ory Keynan¹⁶, Harvinder Singh Chhabra¹⁷, Sebastian Bigdon¹⁸, Ulrich J Spiegl¹⁹, Klaus Schnake^{20

21}, Alexander R Vaccaro¹

Affiliations

¹ Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA, USA.
² Combined Neurosurgical and Orthopedic Spine Program, Vancouver General Hospital, University of British Columbia, Vancouver, Canada.
³ University Medical Centers, Utrecht, the Netherlands.
⁴ Spine Unit, Sonnenhof Spital, University of Bern, Bern, Switzerland.
⁵ Cajuru Hospital, Catholic University of Paraná, Curitiba, Brazil.
⁶ Department of Orthopaedics and Spine Surgery, Ganga Hospital, Coimbatore, India.
⁷ Department of Orthopaedic and Trauma Surgery, Faculty of Medicine, Assiut University Medical School, Assiut, Egypt.
⁸ Department of Orthopaedics and Sports Medicine, Harborview Medical Center, University of Washington, Seattle, WA, USA.
⁹ Klinika Úrazovej Chirurgie SZU a FNsP F.D.Roosevelta, Banská Bystrica, Slovakia.
¹⁰ Prof. Dr. N. Oblu" Emergency Hospital, Iasi, Romania.
¹¹ Department of Neurosurgery, National Trauma Research Institute (NTRI), The Alfred Hospital, Melbourne, VIC, Australia.
¹² Orthopaedic and Traumatology Department, Institute of Orthopedics "Carlos E. Ottolenghi" Hospital Italiano de Buenos Aires, Buenos Aires, Argentina.
¹³ Department of Neurosurgery, Prince Mohammed Bin Abdulaziz Hospital, Riyadh, Saudi Arabi.
¹⁴ Department of Neurosurgery, Mansoura University, Mansoura, Egypt.
¹⁵ Neurosurgery Division, Department of Neurology, State University of Campinas, Campinas-Sao Paulo, Brazil.
¹⁶ Rambam Health Care Campus, Haifa, Israel.
¹⁷ Sri Balaji Action Medical Institute, New Delhi, India.
¹⁸ Department of Orthopaedic Surgery and Traumatology, Inselspital, University Hospital, University of Bern, Bern, Switzerland.
¹⁹ Department of Orthopaedics, Trauma Surgery and Plastic Surgery, University of Leipzig, Leipzig, Germany.
²⁰ Center for Spinal and Scoliosis Surgery, Malteser Waldkrankenhaus St. Marien Erlangen, Erlangen, Germany.
²¹ Department of Orthopedics and Traumatology, Paracelsus Private Medical University Nuremberg, Nuremberg, Germany.

PMID: 38324600
PMCID: PMC10867533
DOI: 10.1177/21925682231202371

Interobserver Reliability in the Classification of Thoracolumbar Fractures Using the AO Spine TL Injury Classification System Among 22 Clinical Experts in Spine Trauma Care

Jose A Canseco et al. Global Spine J. 2024 Feb.

. 2024 Feb;14(1_suppl):17S-24S.

doi: 10.1177/21925682231202371.

Authors

Affiliations

¹ Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA, USA.
² Combined Neurosurgical and Orthopedic Spine Program, Vancouver General Hospital, University of British Columbia, Vancouver, Canada.
³ University Medical Centers, Utrecht, the Netherlands.
⁴ Spine Unit, Sonnenhof Spital, University of Bern, Bern, Switzerland.
⁵ Cajuru Hospital, Catholic University of Paraná, Curitiba, Brazil.
⁶ Department of Orthopaedics and Spine Surgery, Ganga Hospital, Coimbatore, India.
⁷ Department of Orthopaedic and Trauma Surgery, Faculty of Medicine, Assiut University Medical School, Assiut, Egypt.
⁸ Department of Orthopaedics and Sports Medicine, Harborview Medical Center, University of Washington, Seattle, WA, USA.
⁹ Klinika Úrazovej Chirurgie SZU a FNsP F.D.Roosevelta, Banská Bystrica, Slovakia.
¹⁰ Prof. Dr. N. Oblu" Emergency Hospital, Iasi, Romania.
¹¹ Department of Neurosurgery, National Trauma Research Institute (NTRI), The Alfred Hospital, Melbourne, VIC, Australia.
¹² Orthopaedic and Traumatology Department, Institute of Orthopedics "Carlos E. Ottolenghi" Hospital Italiano de Buenos Aires, Buenos Aires, Argentina.
¹³ Department of Neurosurgery, Prince Mohammed Bin Abdulaziz Hospital, Riyadh, Saudi Arabi.
¹⁴ Department of Neurosurgery, Mansoura University, Mansoura, Egypt.
¹⁵ Neurosurgery Division, Department of Neurology, State University of Campinas, Campinas-Sao Paulo, Brazil.
¹⁶ Rambam Health Care Campus, Haifa, Israel.
¹⁷ Sri Balaji Action Medical Institute, New Delhi, India.
¹⁸ Department of Orthopaedic Surgery and Traumatology, Inselspital, University Hospital, University of Bern, Bern, Switzerland.
¹⁹ Department of Orthopaedics, Trauma Surgery and Plastic Surgery, University of Leipzig, Leipzig, Germany.
²⁰ Center for Spinal and Scoliosis Surgery, Malteser Waldkrankenhaus St. Marien Erlangen, Erlangen, Germany.
²¹ Department of Orthopedics and Traumatology, Paracelsus Private Medical University Nuremberg, Nuremberg, Germany.

PMID: 38324600
PMCID: PMC10867533
DOI: 10.1177/21925682231202371

Abstract

Study design: Reliability study utilizing 183 injury CT scans by 22 spine trauma experts with assessment of radiographic features, classification of injuries and treatment recommendations.

Objectives: To assess the reliability of the AOSpine TL Injury Classification System (TLICS) including the categories within the classification and the M1 modifier.

Methods: Kappa and Intraclass correlation coefficients were produced. Associations of various imaging characteristics (comminution, PLC status) and treatment recommendations were analyzed through regression analysis. Multivariable logistic regression modeling was used for making predictive algorithms.

Results: Reliability of the AO Spine TLICS at differentiating A3 and A4 injuries (N = 71) (K = .466; 95% CI .458 - .474; P < .001) demonstrated moderate agreement. Similarly, the average intraclass correlation coefficient (ICC) amongst A3 and A4 injuries was excellent (ICC = .934; 95% CI .919 - .947; P < .001) and the ICC between individual measures was moderate (ICC = .403; 95% CI .351 - .461; P < .001). The overall agreement on the utilization of the M1 modifier amongst A3 and A4 injuries was fair (K = .161; 95% CI .151 - .171; P < .001). The ICC for PLC status in A3 and A4 injuries averaged across all measures was excellent (ICC = .936; 95% CI .922 - .949; P < .001). The M1 modifier suggests respondents are nearly 40% more confident that the PLC is injured amongst all injuries. The M1 modifier was employed at a higher frequency as injuries were classified higher in the classification system.

Conclusions: The reliability of surgeons differentiating between A3 and A4 injuries in the AOSpine TLICS is substantial and the utilization of the M1 modifier occurs more frequently with higher grades in the system.

Keywords: AO spine thoracolumbar injury classification; reliability; thoracolumbar fractures.

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Conflict of interest statement

Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Figures

**Figure 1.**
Expert survey questionnaire.

See this image and copyright information in PMC

References

1. Denis F. The three column spine and its significance in the classification of acute thoracolumbar spinal injuries. Spine. 1983;8:817. - PubMed
1. Oner FC, Ramos LMP, Simmermacher RKJ, 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. - PMC - PubMed
1. Rometsch E, Spruit M, Hartl R, et al. Does operative or nonoper- ative treatment achieve better results in A3 and A4 spinal fractures without neurological deficit? systematic literature review with meta-analysis. Glob Spine J. 2017;7:350. - PMC - PubMed
1. Vaccaro AR, Oner C, Kepler CK, et al. AOSpine thoracolumbar spine injury classification system: fracture description, neurological status, and key modifiers. Spine. 2013;38(23):2028-2037. doi: 10.1097/BRS.0b013e3182a8a381 - DOI - PubMed
1. Aebi M. AO spine classification system for thoracolumbar fractures. Eur Spine J. 2013;22(10):2147. doi: 10.1007/s00586-013-3062-4 - DOI - PMC - PubMed

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Interobserver Reliability in the Classification of Thoracolumbar Fractures Using the AO Spine TL Injury Classification System Among 22 Clinical Experts in Spine Trauma Care

Affiliations

Interobserver Reliability in the Classification of Thoracolumbar Fractures Using the AO Spine TL Injury Classification System Among 22 Clinical Experts in Spine Trauma Care

Authors

Affiliations

Abstract

Conflict of interest statement

Figures

References

LinkOut - more resources

Full Text Sources