X-ray and CT scan predictors of damage to the posterior ligamentous complex in fractures of the vertebral bodies of the thoracolumbar junction: systematic review and meta-analysis

Objective of the review was to identify, basing on literature data, the most reliable X-ray and CT signs of damage to the posterior ligamentous complex (PLC) in fractures of the vertebral bodies of the thoracolumbar junction, initially interpreted as type A according to the AOSpine classification. The systematic review was carried out according to the recommendations of PRISMA. The search in PubMed, MEDLINE and Cochrane Library databases revealed 491 articles on relevant issues. Once the inclusion and exclusion criteria have been met, 7 original articles from peer-reviewed scientific journals for the last 10 years were selected for a systematic review, 6 of which were included in the meta-analysis. In all articles, the authors identified two groups of patients: with and without damage to the PLC. The PLC damages were confirmed by MRI and intraoperatively. Radiographic and CT spondylometric parameters were identified, which had statistically significant differences between the groups. To determine predictors of PLC damage, the values of these parameters were subjected to regression analysis. This was followed by a meta-analysis of random and fixed effects models depending on the homogeneity of the data. Statistical heterogeneity was assessed using the X-square test with the null hypothesis of the absence of significant differences in all studies, as well as the heterogeneity index – I2. For the graphical display of the results, forest plots were built. Local kyphosis angle >25°, Cobb angle >16° and difference between interspinous distances >2.54 mm are CT scan predictors of PLC damage. The parameters characterizing the interspinous relationship were studied in no more than two studies, but at the same time they always had statistically significant differences between the groups with and without PLC injuries, therefore, they cannot be ignored during diagnosis. Anterior/posterior vertebral height ratio, anterior vertebral height ratio, sagittal index and suprajacent/subjacent parameters are not the predictors of PLC damage.

Use of Computed Tomography Compression Ratio in Diagnosis of Disc Injuries and Posterior Ligamentous Complex Injuries in Osteoporotic Thoracolumbar Compression Fractures

Background: Osteoporotic compression fractures are common among the elderly. It is important to predict the posterior ligamentous complex (PLC) and disc injuries in computed tomography (CT) scans of patients with magnetic resonance imaging (MRI) contraindications. Objectives: To determine the role of the CT compression ratio (CTCR) in diagnosing PLC and disc injuries and to compare it with the loss of vertebral body height (LOVBH) in osteoporotic thoracolumbar compression fractures. Patients and Methods: A total of 91 consecutive patients with vertebral fractures were included as the study population. The PLC and disc injuries were assessed using MRI, and the following radiological parameters were determined based on CT scans for further MRI examinations: CTCR, LOVBH, local kyphosis (LK), interspinous widening (ISW), vertebral translation (VBT), and posterior structures fractures (PSF). Statistical analysis was performed to identify the diagnostic value of CT features in PLC and disc injuries. Results: The PLC injuries were detected in 9/91 cases, and the number of disc injuries was 47/91. Neither CTCR nor LOVBH was associated with PLC injuries (P > 0.05). However, the CTCR was associated with disc injuries (P < 0.05), with an optimal threshold of 1.755 (sensitivity, 68.1%; specificity, 79.5%), while the LOVBH was not significantly associated with disc injuries. Based on the results, VBT was significantly related to PLC and disc injuries (P < 0.05). Conclusion: The injured vertebral CTCR was associated with disc injuries rather than PLC injuries, suggesting that compression fractures are relatively stable with less PLC injury. Overall, CTCR is a useful indicator reflecting the compression degree of the injured vertebrae; it is also a valid predictor of disc injuries.

Posterior Ligamentous Complex Reconstruction for Cervical Dislocation and Instability in Patients without Vertebral Fracture with Artificial Ligaments: A Technical Note

Introduction: The posterior ligamentous complex (PLC) offers restraints to deformation in a complex and interconnected manner. The stability and range of motion (ROM) of the posterior cervical spine is greatly restricted when the PLC is damaged, even without bone disruptions. We describe a novel surgical technique, its advantages, and the postoperative condition of the first patient to use artificial ligament in a reconstruction surgery of PLC injuries in patients without lower cervical vertebral fracture. This technique aimed to fully retain the mobility of the injured segment based on spinal stability and apply dynamic reconstruction in patients’ treatment.Method: We present a detailed description of the reconstruction surgery with artificial ligaments performed on C4-6 PLC injuries in a 27-year-old male presented with neck pain and restricted movement following a high fall injury accompanied by impaired movement of limbs. Results: Immediately postsurgery, the patient’s neck pain and quadriparesis had been improved. The spinal canal decompression and cervical spine sequence results were satisfactory, the facet joint face was in a good position, and the spinous process spacing returned to normal. After three months of rehabilitation, the patient reported improvement of symptoms and the physical and imaging examination showed a significant improvement in the patient’s condition. The patient’s neck mobility motor function had improved further.Conclusion: The present data demonstrate that the novel technique for reconstruction of PLC injury is feasible and safe. However, familiarity with cervical anatomy and adequate experience in lateral mass screws placement during surgery is crucial for this procedure. Therefore, a highly experienced cervical surgery team is recommended to perform the surgery.

The Reliability and Validity of the Thoraco-Lumbar Injury Classification and Severity score

Background The TLICS/TLISS is a recently introduced classification system for thoracolumbar spinal column injures designed to simplify injury classification and facilitate treatment decision making. Before being widely adopted, the reliability and validity of the TLICS/TLISS must be studied. Aim of the Work To determine the interrater and intrarater reliability and the validity of the TLICS score and its predecessor the TLISS scoring system in the clinical practice. Patients and Methods A total of 7 articles with 10 datasets were used to test the inter- and intrarater reliability and validity of the TLICS/TLISS score for thoracolumbar spine trauma. Included studies presented Thoracolumbar trauma cases’ details (including clinical data, plain radiographs, CT scans and MRI) to spine surgeons allowing them to score them using the TLICS/TLISS score in each of its components (neurologic status, PLC integrity and fracture morphology/mechanism), the final score and surgeons’ agreement with the scores treatment recommendations; as well as comparing the treatment recommendations (surgical vs non-surgical management) with the treatment the patients actually received. At a later time the surgeons were assigned the task with the cases reordered. The interrater reliability, as well as the intrarater reliability of the score for each component and sum, were evaluated by Cohen’s unweighted k-value and Spearman’s rank order correlation. In addition, the sensitivity and specificity of the score (validity) were evaluated by the percent of correct treatment recommendations according to the sum of the TLICS/TLISS and the treatment actually received by the patients. Results Interrater reliability assessed by generalized kappa coefficients was 0.45 ±0.17 for injury morphology/mechanism, 0.91 ±0.03 for neurologic status, 0.42 ±0.13 for posterior ligamentous complex status, 0.36 ±0.14 for TLICS/TLISS total, and 0.59 ±0.10 for treatment recommendation. Respective results using the Spearman correlation were 0.52 ±0.18, 0.95 ±0.05, 0.57 ±0.13, 0.75 ±0.10, and 0.64 ±0.20. Intrarater kappa coefficients were 0.53 ±0.14 for injury morphology/mechanism, 0.89 ±0.07 for neurologic status, 0.53 ±0.15 for posterior ligamentous complex status, 0.46 ±0.16 for TLICS/TLISS total, and 0.61 ±0.02 for treatment recommendation. Respective results using the Spearman correlation were 0.63 ±0.08, 0.90 ±0.03, 0.64 ±0.10, 0.77 ±0.03, and 0.60 ±0.02. The percent of correct treatment recommendation by the score and the treatment actually received by the patients was 94.4% ±1.5, with sensitivity of 0.91 ±0.06, specificity of 0.94 ±0.01, PPV of 0.94 ±0.01, NPV of 0.93 ±0.02. Conclusions The TLICS/TLISS score has good reliability and validity and it compares favorably to other contemporary and old thoracolumbar fracture classification systems.