The management of traumatic thoracolumbar spine fractures has been controversial. Most columnar models explain stability based on the sagital profile of the spine. In Denis’ classification, the middle column provides the greatest mechanical stability and bears the greatest axial load of the spine. The load sharing classification scores the extent of damage to the vertebral body, the displacement of fragments at the fracture site, and the amount of corrected kyphosis. Recently, TLICS was devised based upon the currently recognized three most important injury characteristics: radiographic morphology of injury,  integrity of the posterior ligamentous complex, and neurological status of the patient. Subsequently, a composite score (TLISS) can be calculated and patients are stratified into surgical and non-surgical treatment. The emphasis placed on the posterior ligamentous complex as a determinant of spinal stability, encourages magnetic resonance imaging to be the investigation of choice for most thoracolumbar spinal injuries.

Classification systems are generalizations that attempt to identify common attributes within a group to predict the behavior or outcome without sacrificing too much detail. Because of the inherent heterogenecity of fractures, classifying them can be difficult. Despite numerous studies that were conducted, the management of traumatic thoracolumbar spine fractures remains one of the most controversial areas in modern spine surgery. Currently, none of the classification systems published to date have integrated algorithms for the care of patients with thoracolumbar injuries. Available classifications are limited by a number of fundamental problems. They fail either because they are “too simplistic” and each classification group remained varied in their behavior or because they are “too complex” and that made them hard to apply and reproduce. The remaining ones probably fall out of favor due to their lack of clinical applicability and inability to guide decision-making and prognosis. In fact, it may be time we should reflect and see if there really is “the ideal” classification of thoracolumbar spine fractures.

We believe that to properly apply any of the commonly cited classification schemes for thoracolumbar fractures, we must not only know the injury categories described in the original studies but also be familiar with the rationale for developing the classification. Since Bohler’s sentinel attempt at classifying such injuries in 1929, many classification systems have been described. In the 1930s, Watson Jones considered spinal fractures to be pure flexion fractures and treated them with hyperextension casts. In 1949, Nicoll reported on 166 thoracolumbar fractures in coal miners and classified these injuries as anterior wedge fractures, lateral wedge fractures, fracture dislocations, and isolated neural arch fractures. He defined stable versus unstable fractures using an anatomical classification for which the major determinant of stability was the integrity of the interspinous ligament. This serves as a foundation for later classifications.

Thanks & Regards,

ALPINE

Managing Editor

 Journal of Orthopaedics and Trauma

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