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Spinal trauma and fracture classification

99 citationsUpdated Oct 2026

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Overview

Spinal injuries must be assumed present in all multiply injured patients until proven otherwise, as 10% to 15% of severe head injury patients have associated cervical spine trauma [1]. Pain or tenderness from the occiput to the sacrum warrants concern, though most spine injuries do not present with neurologic impairment [1]. The diagnostic workup includes plain radiographs, CT scans, and MRI for soft-tissue visualization, with whole-body CT largely replacing conventional radiographs for initial assessment [1]. MRI is reserved for hemodynamically stable patients [1]. Additional vertebral fractures occur in approximately 10% of cases [1]. Neurologic status is classified using the American Spinal Injury Association (ASIA) Impairment Scale, stratifying injuries into complete (Grade A) or incomplete (Grades B-D), with Grade E indicating normal status [1]. Incomplete injuries preserve some neurologic function below the injury level and carry a better prognosis than complete injuries [1].

Spinal fractures are classified using the AO/Orthopaedic Trauma Association alphanumeric system [1]. Spinal stability refers to the ability to maintain alignment and protect neural structures during physiologic loading [1]. Unstable injuries risk progressive deformity and neurologic compromise, often requiring early stabilization and decompression [1]. Urgent decompressive surgery is indicated for most traumatic spinal cord injuries [1]. The concept of spine damage control involves early posterior instrumentation of unstable thoracolumbar fractures in polytrauma patients, with delayed definitive surgery after resuscitation [1]. Early stabilization within 24 to 36 hours is associated with fewer complications and shorter hospital stays [1]. Definitive management of subaxial cervical spine trauma depends on mechanical instability, neurologic impairment, and patient factors [22].

Major trauma patients exhibit more complex spinal injuries, including increased instability and multi-level fractures [4]. Injuries to C1 and C2 commonly occur together, with upper and lower cervical spine involvement in 9% of patients with C1-C2 fractures [7]. The incidence of multiple level cervical spine injuries was 24% in one cohort, potentially due to advanced imaging [13]. Patients with ankylosing spondylitis are at high risk for unstable spinal fractures, particularly in the cervical spine, often requiring surgery after minor injuries [10, 36]. In a cohort of 1000 patients, 25 presented with vertebral fractures, with over two-thirds treated surgically and a 6.3% complication rate [12]. Diagnosis of cervical spine injuries follows a three-step process involving risk assessment, imaging, and classification [16].

Anatomy & Pathophysiology

Osseous Anatomy

The bony spine comprises 7 cervical, 12 thoracic, 5 lumbar, 5 fused sacral, and 4 or 5 fused coccygeal vertebrae [43]. Each vertebral body is a cylindrical mass connected by pedicles to the posterior arch, which consists of the lamina and spinous process [43]. These structures form the spinal canal, bounded anteriorly by the body, posteriorly by the lamina, and laterally by the pedicles, through which the spinal cord passes [43]. Vertebral bodies primarily bear weight and transfer forces to the pelvis and hips, while the posterior elements protect neural structures and function as a tension band [43].

The thoracic spine represents two transitional zones: from the highly mobile cervical spine to the rigid thoracic region, and then to the mobile lumbar spine [75]. Its rigidity, combined with the ribs and sternum, forms a stable bony "cube" [75]. Thoracic vertebral bodies are larger than cervical but smaller than lumbar vertebrae, and the posterior arch encloses the spinal canal, which is narrowest in this region [75]. Lumbar vertebral bodies are large, with a transverse diameter exceeding the anterior-posterior diameter [82]. Lumbar pedicles arise from the superior aspect of the vertebral bodies and project more horizontally than thoracic pedicles [82]. The sagittal orientation of lumbar facet joints allows flexion and extension while resisting axial rotation and translation [82].

Spinal Cord Anatomy

Within the spinal cord, dorsal cells are primarily sensory and ventral cells are primarily motor [79]. The dorsal columns transfer vibration, deep pressure, and proprioception, while the lateral spinothalamic tract transmits pain and temperature sensation [79]. The ventral spinothalamic tract transmits light touch, and efferent voluntary motor function travels along the lateral corticospinal tracts [79]. Upper extremity fibers are located deeper within the spinal column, with torso and lower extremity fibers located sequentially more superficially [79]. The conus medullaris lies around L3 at birth but shifts to L1-L2 by adulthood [79]. The 31 pairs of spinal nerves consist of 8 cervical, 12 thoracic, 5 lumbar, 5 sacral, and 1 coccygeal nerves [79]. In the cervical spine, nerve roots exit above the same-numbered pedicle, except for the eighth nerve root which exits under the C7 pedicle; from T1 distally, nerve roots exit below the same-numbered pedicle [79]. The central gray matter contains nerve cell bodies and has a higher metabolic requirement than white matter, making it more susceptible to trauma and ischemia [14].

Vascular Anatomy

Thoracic and lumbar levels are supplied by paired segmental arteries originating directly from the posterior surface of the aorta [77]. The cervical spine derives circulation primarily from vertebral arteries, which typically enter the transverse foramen at C6 [77]. Spinal cord supply comes primarily from medullary branches of segmental spinal arteries, which merge to feed the anterior spinal artery, responsible for approximately 80% of the cord's vascular supply [77]. The arteria medullaris magna (AMM), or artery of Adamkiewicz, is the largest anterior segmental artery, typically arising on the left side between T8 and L1 [77]. Blood supply is narrowest and poorest at T4-9, the critical vascular zone where interference most likely results in paraplegia [80]. Longitudinal arterial trunks are largest in cervical and lumbar regions near ganglionic enlargements and smaller in the thoracic region due to lower metabolic demands of white matter compared to gray matter [80].

Ligaments

The anterior longitudinal ligament (ALL) is strong, thickest at the center of the vertebral body, and resists hyperextension [87]. The posterior longitudinal ligament (PLL) is weaker than the ALL, extends from the occiput to the posterior sacrum, and is hourglass-shaped with wider sections over the discs; ruptured discs tend to be lateral to these expansions [87]. The ligamentum flavum is a strong yellow elastic ligament connecting laminae, running from the anterior surface of the superior lamina to the posterior surface of the inferior lamina [87]. The supraspinous ligament lies dorsal to the spinous processes and begins at C7 in continuity with the ligamentum nuchae [87]. The integrity of the posterior ligamentous complex has implications for operative versus non-operative treatment [87].

Biomechanics

Normal cervical alignment is approximately 15° of lordosis, thoracic kyphosis ranges from 20° to 40°, and lumbar lordosis is approximately 40° to 50° [76]. Kyphotic segments (thoracic, sacral) are "primary" curvatures present in utero and at birth, while lordotic curvatures (cervical, lumbar) develop secondarily later in life [76]. The functional spinal unit consists of two vertebrae, the intervening disk, and the facet joints with their capsules [76]. Vertebral bodies bear 70% to 90% of the static axial load, while facet joints support 10% to 20% of axial load in standing, neutral alignment [76]. In extension, facet joints may bear up to 30% of the axial load, whereas in flexion, they may be burdened with up to 50% of the anterior shear load [76]. The intervertebral disk absorbs axial loads by deforming the nucleus pulposus, redistributing forces radially to be resisted by the tensile properties of the anulus fibrosus [76]. The high incidence of fractures at the thoracolumbar junction results from its location at the biomechanical transition zone between the rigid thoracic rib cage and flexible lumbar spine [8]. The relatively narrow spinal canal in the thoracic region increases the risk of injury-associated compression and neurologic deficits [8].

Pathophysiology of Injury

Unstable spine injuries risk progressive deformity and neurologic compromise [1]. Spinal cord injury (SCI) comprises compression, distraction, and shearing forces exerted directly on the spinal cord [27], often resulting in irreversible sensory, motor, and autonomic dysfunction [33]. The incidence of SCI is approximately 54 cases per one million people in the United States [33], with approximately 400,000 people having spinal cord damage and an incidence of about 10,000 per year [14].

Tetraplegia refers to loss or impairment of motor or sensory function in cervical segments, resulting in impairment of arms, trunk, legs, and pelvic organs [14]. Paraplegia refers to loss or impairment of motor or sensory function in thoracic, lumbar, or sacral segments [14]. A complete injury is defined as no spared motor or sensory function in the lowest sacral segments, while an incomplete injury involves partial preservation of sensory or motor function below the neurologic level, including the lowest sacral segments [14]. The diagnosis of complete SCI cannot be made until spinal shock resolves, evidenced by the return of the bulbocavernosus reflex [14]. Spinal shock may last from several hours to several months [14]. Patients with complete SCI who have recovered from spinal shock have a negligible chance for useful motor return [14].

Anterior cord syndrome commonly results from direct contusion to the anterior cord by bone fragments or damage to the anterior spinal artery [14]. Central cord syndrome often results from minor injuries, such as a fall in an older patient with cervical spinal canal stenosis [14]. Brown-Séquard syndrome is caused by complete hemisection of the spinal cord, classically by a stab wound [14].

Neurogenic shock is characterized by hypotension with bradycardia due to disruption of the sympathetic pathway within the spinal cord [39]. It is most common in patients with cervical or upper thoracic spinal cord injury [39]. Hypotension results from decreased systemic vascular resistance, and bradycardia results from disruption of the sympathetic pathway with unopposed vagal activity [39]. Splanchnic outflow conveying sympathetic fibers to the lower body exits at T8, making patients with lesions above T8 prone to autonomic dysreflexia [52]. Autonomic dysreflexia presents with episodes of hypertension heralded by dizziness, sweating, and headaches [52]. A classic cause is a kinked Foley catheter, and relieving the kink can relieve autonomic symptoms [52]. Only 4 hours of continuous pressure on the sacrum is sufficient to cause full-thickness skin necrosis in patients with spinal cord injury [52].

Classification

General Principles and History

Standardization of terminology regarding treatment decisions and prognosis is essential for an improved understanding of the clinical behavior of thoracic and lumbar fractures [2]. The classification of pediatric thoracolumbar trauma is based primarily on adult studies, with little high-level evidence examining validity and accuracy in pediatric populations [25]. Injuries of the cervical spine with spinal-cord damage can be classified according to the clinical pattern of neurological damage [29]. Furthermore, the mechanism of injury in most cases of cervical-spine injuries can be diagnosed from routine roentgenograms of the cervical spine [29].

AO/OTA Classification System

The AO thoracolumbar injury classification system categorizes each injury based on injury morphology (A–C), neurologic status (N), and two case-specific modifiers (M) [8]. Morphologic patterns are grouped based on the failure mode of the spinal column [32]. Type A injuries involve compression fractures, Type B injuries involve failure of the anterior or posterior tension band without gross translation, and Type C injuries include dislocation or rotational or displacement-type injuries [32]. Within each AO type, subgroups are defined by increasing severity and instability [32].

Type A (Compression): * A0: Mechanically insignificant fractures of the spinous or transverse processes [8, 32]. * A1: Fracture of a single end plate without involvement of the posterior vertebral wall [8, 32]. * A2: Coronal split of pincer-type fractures involving both endplates, without involvement of the posterior vertebral wall [8, 32]. * A3: Incomplete burst fractures involving a single end plate with involvement of the posterior vertebral wall but no disruption of the posterior tension band [8, 32]. * A4: Complete burst fractures affecting both end plates with involvement of the posterior vertebral wall [8, 32].

Type B (Tension Band): * B1: Monosegmental osseous failure of the posterior tension band extending into the vertebral body, also defined as “chance fractures” [8, 32]. * B2: Injury of the posterior tension band (bony, capsuloligamentous or ligamentous) with or without osseous involvement [8, 32]. * B3: Injury of the anterior tension band with disruption of anterior bone/disk with tethering of posterior elements; these hyperextension injuries are more common in patients with an ankylosed spine [8, 32].

Type C (Displacement): Type C injuries do not have any subtypes because they are unstable injuries that lead to surgical stabilization [32].

Neurologic Status (N): Neurologic injury is graded at admission into N0 (intact), N1 (transient deficits), N2 (symptoms of radiculopathy), N3 (cauda equina), N4 (complete spinal cord), and NX (neurology undetermined) [8].

Modifiers (M): * M1: Denotes a possible injury to the tension band based on imaging [8]. * M2: Designates patient-specific comorbidities such as ankylosing spondylitis, rheumatologic conditions, and diffuse idiopathic skeletal hyperostosis [8].

Inter- and intra-observer agreement for the main types of AO classifications was comparable to agreement evaluating fractures of the trochanteric area of the proximal femur [17]. In a validation study of an interactive 3D model for thoracic and lumbar spinal fractures, the AO Spine classification was adhered to in 92% of cases [126].

TLICS (Thoracolumbar Injury Classification and Severity)

The Thoracolumbar Injury Classification and Severity Score (TLICS) was developed to address limitations of previous systems that demonstrated poor reliability, yielded little prognostic information, and were not widely used [38]. The TLICS defines injury based on three clinical characteristics: injury morphology, integrity of the posterior ligamentous complex, and neurologic status of the patient [38]. The TLICS severity score offers prognostic information and is helpful in medical decision making [38]. Initial application of the TLICS has shown good to excellent reliability and validity [38]. The AO Classification system has largely replaced the contemporary TLICS and Denis classification scale [8].

Scoring Criteria: * Morphology: 1 point for compression, +1 point for burst, 3 points for translation/rotation, and 4 points for distraction [8]. * Posterior Ligamentous Complex: 0 points for intact, 2 points for suspected/indeterminate disruption, and 3 points for injury [8]. * Neurologic Status: 0 points for intact, 2 points for nerve root, 2 points for cord conus medullaris complete, 3 points for cord conus medullaris incomplete, and 3 points for cauda equina [8].

The modified TLICS system is a practical tool for the classification and assessment of thoracolumbar fractures with guiding significance for clinical treatment [49]. The operation rate for the modified TLICS system was slightly lower than that of the standard TLICS system [49].

Other Classification Systems

Gertzbein: The Gertzbein classification correlates fracture type with mechanical instability and neurologic lesion [154].

Load Sharing: The load sharing classification correlates comminution and displacement with stability and implant failure [154]. The standard Cohen's kappa values for the Load Sharing Classification of spinal fractures can be rated as fair to moderate, indicating that the inter- and intraobserver reliability of the classification is fair [53].

Osteoporotic Fractures: A new classification system for chronic symptomatic osteoporotic thoracolumbar fracture demonstrated excellent reliability in an initial assessment [158].

Clinical Presentation

General Assessment and Initial Survey

Spinal injuries are typically identified during the secondary survey, following the primary assessment of airway, breathing, and circulation [151, 48]. The initial neurologic evaluation is limited to assessing the patient’s level of alertness and mental status [48]. Adherence to advanced trauma life support protocols is imperative, as spinal trauma often results from high-energy mechanisms with associated injuries [39]. Maintenance of oxygenation and hemodynamic stability is paramount to attenuate secondary injury to the damaged spinal cord [48]. When securing an airway, manual in-line immobilization of the head and neck must be maintained whenever immobilization devices are removed [48]. All trauma patients should be assumed to have a spinal injury, particularly those with altered mental status or blunt head trauma [48]. Specific mechanisms warrant targeted suspicion: motorcyclists are more likely to sustain thoracic spinal injuries, while thoracolumbar flexion-distraction injuries should be suspected in the presence of abdominal ecchymoses or abrasions from seat belts [48].

Patients with ankylosing spondylitis (AS) or diffuse idiopathic skeletal hyperostosis (DISH) require extra vigilance due to an increased risk of fractures and potential neurologic deterioration from epidural hematoma [48]. AS patients are at high risk for spinal fractures and associated spinal cord injury, particularly in the cervical spine [36]. Fractures in these populations are typically unstable and can lead to spinal cord injury if not stabilized appropriately [48]. Nondisplaced fractures are common in AS and DISH patients and carry a high rate of delayed or missed diagnosis [48]. Even minor trauma resulting in neck or back pain warrants supplemental CT evaluation in these patients [48]. If conventional radiographs fail to delineate a spinal fracture in a patient with AS and persistent pain, an isotope bone scan is indicated [41]. Spinal injuries are rare in pediatric patients and require an individualized approach due to unique injury patterns, spinal plasticity, and diagnostic difficulty [37].

Imaging and Diagnostic Workup

A rapid radiologic workup including anteroposterior (AP) chest, AP pelvis, and lateral cervical spine views is standard [39]. The lateral cervical radiograph must include the C7–T1 junction to be considered adequate [39]. Radiographic lines assessed for continuity include anterior soft tissue shadows, the anterior spinal line, posterior spinal line, spinolaminar line, and spinous process line [39]. Anterior soft tissue shadow measurements are 6 mm at C2 and 20 mm at C6 [39]. CT of the cervical spine is replacing lateral cervical spine radiography for trauma evaluation due to its availability and greater processing speed [39]. Sagittal CT views detect 85% of cervical spine fractures [39]. CT is useful for evaluating C1 fractures and assessing bone in the canal but may miss an axial plane fracture, such as a type II odontoid fracture [39]. CT scan remains the most sensitive modality to evaluate suspected cervical spine injuries due to its ability to accurately predict fracture type and patterns at difficult locations, such as the craniocervical junction [48]. CT angiography can be used to identify possible concomitant vertebral artery injuries [48].

Cervical spine radiographs are required in trauma patients with neck pain, tenderness, neurologic deficit, altered mental status, or distracting injuries [48]. Conversely, radiographs are not indicated in trauma patients with low-risk mechanisms who are alert and awake and do not have neck pain, tenderness, or a history of distracting injuries [48]. Injuries can be ruled out via the National Emergency X-radiography Utilization Study (NEXUS) or Canadian Cervical Spine Rule (CCR) criteria in asymptomatic patients [48]. A cervical spine series consisting of AP, lateral, and odontoid views is recommended [48]. An estimated 15% to 17% of injuries are missed even with adequate plain radiographs [48]. Supplemental CT examination is recommended to provide more detailed images of inadequately visualized levels, particularly the occipitoatlantoaxial region or the cervicothoracic junction [48]. A three-view cervical spine series and CT scan have a negative predictive value greater than 99% in certain instances [48].

MRI has advantages for demonstrating soft tissue abnormalities, including the integrity of the posterior ligamentous complex, disc herniation, canal compromise, spinal cord injury and edema, and the presence or absence of epidural hematoma [39]. MRI is increasingly used in cervical spine clearance, which remains controversial [39]. Instability can exist as a result of soft-tissue injury to the ligaments, facet capsule, and disks even if no apparent osseous injury is present [48]. MRI may be utilized to assess soft-tissue injury when no apparent osseous injury is present; however, abnormalities are found incidentally on MRI in 25% to 40% of patients, suggesting that this modality may be oversensitive [48]. MRIs are also of particular use when assessing the severity of spinal cord injury [48]. Flexion-extension radiographs are frequently obtained to rule out instability; however, their sensitivity is low in the acute setting [48]. Flexion-extension views can be obtained in a patient with neck pain and a negative CT scan 7 to 10 days after injury [48]. The most controversial issue is cervical spine clearance in the obtunded patient [48].

Once a thoracolumbar spine fracture has been detected, the remaining spine should be imaged to rule out noncontiguous spinal injury, which may occur in up to 12% of patients [8]. Vertebral fracture is common on chest radiographs but is often ignored by radiologists [61]. Underdiagnosis of osteoporotic vertebral fractures is a common problem due to a lack of radiographic detection [102]. Rib fractures are relatively common in patients with traumatic thoracic vertebral fractures and may be underdiagnosed, especially in the absence of clear symptoms [143]. Nineteen percent of patients with near-hanging injuries sustained an injury, and in 5% the injury was a cervical spine fracture; therefore, liberal screening using CT scans is warranted [64]. Discontinuous thoracolumbar fractures have distinct epidemiological and morphological characteristics, including clustering at the thoracolumbar-lumbar junction, a predominance of compression-based AO combinations, and a high rate of initially missed diagnoses [18]. The diagnosis of the double level fracture was initially overlooked at two different hospitals [54].

Neurologic Assessment and Classification

The neurologic examination is critical to the classification and treatment of spinal injuries because it determines the patient’s potential level of recovery [14]. When assessing neurologic impairment, it is crucial to document the time of the assessment because neurologic deterioration may occur [1]. The neurologic level of the lesion refers to the highest neural segment having normal motor and sensory function [14]. According to the standards of the American Spine Injury Association (ASIA), the neurologic level is the most cephalad level with normal bilateral motor and sensory function [39]. Careful neurologic examination to document the lowest remaining functional level and to assess the patient for the possibility of sacral sparing, indicating an incomplete spinal cord injury, is essential [39]. Patients are further subdivided according to whether they have complete or incomplete spinal cord function, determined by the absence or presence of motor or sensory function in the most distal part of the spinal cord innervating the sacral nerves [14]. The presence of sacral nerve function is critical because patients with incomplete injuries have the potential to recover normal neurologic function over a time span of up to 2 years even if paralysis is initially complete [14].

Sacral motor function is assessed by testing contraction of the external anal sphincter, graded as present or absent [14]. Sacral sensation is tested at the anal mucocutaneous junction [14]. Testing of the external anal sphincter is performed by assessing perceived deep sensation as present or absent when the examiner’s finger is inserted [14]. To elicit the bulbocavernosus reflex, the clinician examines the patient’s rectum digitally, feeling for contraction of the anal sphincter while squeezing the glans penis or clitoris [14]. In a patient with complete spinal cord injury, spinal shock may last for as little as several hours or as long as several months [14]. Patients with complete spinal cord injury who have recovered from spinal shock have a negligible chance for any useful motor return [14].

The ASIA Impairment Scale grades are defined as follows: * Grade A (Complete): No motor or sensory function is preserved in sacral segments S4-S5 [1]. * Grade B (Incomplete): Sensory function, but not motor function, is preserved below the neurologic level and includes sacral segments S4-S5 [1]. * Grade C (Incomplete): Motor function is preserved below the neurologic level, and more than half of the key muscles below the neurologic level have a muscle grade <3 [1]. * Grade D (Incomplete): Motor function is preserved below the neurologic level, and at least half of the key muscles below the neurologic level have a muscle grade of ≥3 [1]. * Grade E (Normal): Motor and sensory functions are normal [1].

Tetraplegia refers to loss or impairment of motor or sensory function (or both) in the cervical segments of the spinal cord with resulting impairment of function in the arms, trunk, legs, and pelvic organs [14]. Paraplegia refers to loss or impairment of motor or sensory function (or both) in the thoracic, lumbar, or sacral segments of the spinal cord [14]. Complete injury refers to an injury with no spared motor or sensory function in the lowest sacral segments [14]. Incomplete injury refers to an injury with partial preservation of sensory or motor function (or both) below the neurologic level and includes the lowest sacral segments [14].

Depending on the extent of cord involvement in anterior cord syndrome, only posterior column function (proprioception and light touch) may be present [14]. The ability to respond to pain and to light touch signifies that the entire posterior half of the cord has some intact function and thus offers a better prognosis for motor recovery [14]. If there is no recovery of motor function and pain sensation 4 weeks after injury in anterior cord syndrome, the prognosis for significant motor return is poor [14]. The overall prognosis for patients with central cord syndrome is variable [14]. Most patients with central cord syndrome are able to walk despite severe paralysis of the upper extremity [14]. Brown-Séquard syndrome is caused by complete hemisection of the spinal cord [14]. It results in a greater ipsilateral proprioceptive motor loss and greater contralateral loss of pain and temperature sensation (two to three segments below) [52]. Affected patients with Brown-Séquard syndrome have an excellent prognosis and usually will be able to ambulate [52]. Mixed syndrome is characterized by diffuse involvement of the entire spinal cord [52]. Affected patients with mixed syndrome have a good prognosis for recovery [52]. As with all incomplete spinal cord injury syndromes, early motor recovery is the best prognostic indicator [52].

The change in ASIA motor score (AMS) between successive neurologic examinations should be determined [52]. The AMS is the sum of strength grades from 0 to 5 for each of the 10 key muscles, tested bilaterally, that represent neurologic segments C5 through T1 and L2 through S1, for a total possible AMS of 100 points [52]. Male gender, having a spinal fracture, having a thoracic injury, and having complications were the major risk factors for a complete injury [59].

Fracture Classification Systems

Type A and Type B fractures are subclassified more granularly in the AO system [8]. The specific classifications are: * A0: Mechanically insignificant fractures of the spinous or transverse processes [8]. * A1: Fracture of a single end plate without any involvement of posterior vertebral wall [8]. * A2: Coronal split of pincer-type fractures involving both endplates, without any involvement of posterior vertebral wall [8]. * A3: Incomplete burst fractures involving a single end plate with any involvement of posterior vertebral wall [8]. * A4: Complete burst fractures affecting both end plate with any involvement of posterior vertebral wall [8]. * B1: Monosegmental osseous failure of posterior tension band extending into vertebral body, also defined as “chance fractures” in thoracolumbar injuries [8]. * B2: Injury of posterior tension band (bony, capsuloligamentous or ligamentous) with or without osseous involvement [8]. * B3: Injury of anterior tension band with disruption of anterior bone/disk with tethering of posterior elements [8].

Neurologic injury is graded at the time of admission into N0 (intact), N1 (transient deficits), N2 (symptoms of radiculopathy), N3 (cauda equina), N4 (complete spinal cord), and NX (neurology undetermined) [8]. Thoracolumbar case-specific modifier M1 is used to denote a possible injury to tension band based on imaging [8].

Investigations

Imaging Modalities and Protocols

CT: Whole-body CT scans providing thin-section images of the entire spine with two-dimensional and three-dimensional reconstructions have largely replaced conventional radiographs for the initial assessment of multiply injured patients [1]. CT is the preferred initial examination in trauma patients due to inherent bone contrast and unmatched spatial resolution [94]. Multidetector CT (MDCT) has a sensitivity of 97% to 100% for patients with neck tenderness and pain [90]. Conventional imaging with anterior and posterior projections is insufficient in detecting all spinal fractures in multiply injured patients [71]. CT may miss complex rotation fractures, making MRI warranted in such cases [174].

MRI: MRI is the modality of choice for evaluating ligamentous and other soft-tissue structures, discs, the spinal cord, and occult osseous injuries [181]. It is indicated for patients with presumed spinal cord injury to determine the location and severity of the injury and identify the cause of spinal cord compression [90]. MRI should only be obtained for patients who are hemodynamically stable and adequately resuscitated [1]. Edema increases with time, reducing the ability to properly evaluate spinal cord lesions on MRI [90]. Ligamentous injury of the cervical spine may not be clearly identifiable from MDCT images, but MRI can reliably identify such injuries [90]. Patients presenting with a Glasgow Coma Scale of less than 15 and midline tenderness with neurological symptoms should be evaluated with MRI for possible ligamentous injury [90].

Plain radiography: Plain radiographs, including flexion-distraction or neutral views, have limited utility in the acute setting due to high false-negative and false-positive rates [90]. In alert, asymptomatic patients without neck pain or distracting injury, with a normal neurological examination and complete range of motion, radiographic evaluation is not recommended and only clinical clearance is necessary [90]. Lateral radiographs in flexion and extension should be performed about 10 days after cervical spinal injury in patients with persistent pain or following transient neurological symptoms to demonstrate pathology such as spinous process fractures not visible on plain radiographs or MRI [170]. Upright radiographs are useful in guiding management decisions for traumatic vertebral fractures [173].

Bone scan: An isotope bone scan is indicated if conventional radiographs fail to delineate a spinal fracture in a patient with ankylosing spondylitis and persistent pain [41].

Diagnostic Findings and Incidence

Noncontiguous spinal injury may occur in up to 12% of patients once a thoracolumbar spine fracture has been detected [8]. Major trauma patients have more complex spinal injuries than non-major trauma counterparts, demonstrated by increased levels of instability and fractures at more than one level [4]. The incidence of multiple level injuries of the cervical spine was 24% in a group of 105 patients, which is higher than previously reported, probably due to increasingly elaborate investigations [13]. Injuries involving the upper and lower cervical spine in the same individual occurred in 9% of patients with fractures of C1 and C2 [7]. Discontinuous thoracolumbar fractures have a high rate of initially missed diagnoses [18].

Vertebral fracture is common on chest radiographs but is often ignored by radiologists [61]. An important proportion of patients over 60 years old evaluated with chest plus abdominal and pelvic CT scans present vertebral compression fractures [180]. Nineteen percent of near-hanging injury patients sustained an injury, and in 5% the injury was a cervical spine fracture, warranting liberal screening using CT scans [64]. The most common injuries in vertical deceleration injuries were fractures of the thoracic and lumbar spine (83.0%), especially of the thoracolumbar junction [21].

Classification Systems

AO System: The AO system categorizes thoracolumbar injury morphology into type A (compression injuries), type B (tension band injuries), and type C (displacement/translational injuries) [8]. Neurologic injury in the AO thoracolumbar classification is graded at the time of admission into N0 (intact), N1 (transient deficits), N2 (symptoms of radiculopathy), N3 (cauda equina), N4 (complete spinal cord), and NX (neurology undetermined) [8]. In C type thoracolumbar fractures, correct surgical indication must be evaluated on an individual basis [6].

AOSpine Subaxial Spine Classification: The AOSpine subaxial spine classification system accounts for morphological features of the fracture, facet involvement, neurologic status, and case-specific modifiers [99]. The AOSpine subaxial classification system divides cervical injuries into type A (compression), type B (tension band), type C (translation), and type F (facet) [99].

TLICS: The Thoracolumbar Injury Classification and Severity (TLICS) scale assigns points based on morphology, integrity of the posterior ligamentous complex, and neurologic status [8]. Standardization of terminology as related to treatment decisions and prognosis is key to an improved understanding of the clinical behavior of thoracic and lumbar fractures [2].

Neurologic Assessment

ASIA Grading: ASIA grade A indicates a complete injury with no motor or sensory function preserved in sacral segments S4–S5 [1]. ASIA grade B indicates an incomplete injury where sensory function, but not motor function, is preserved below the neurologic level and includes sacral segments S4–S5 [1]. ASIA grade C indicates an incomplete injury where motor function is preserved below the neurologic level, and more than half of the key muscles below the neurologic level have a muscle grade <3 [1]. ASIA grade D indicates an incomplete injury where motor function is preserved below the neurologic level, and at least half of the key muscles below the neurologic level have a muscle grade of ≥3 [1]. ASIA grade E reflects a normal neurologic status with normal motor and sensory functions [1].

Sacral Function and Prognosis: The presence or absence of sacral function determines the completeness of the injury [14]. Sacral motor function is assessed by testing contraction of the external anal sphincter, and sacral sensation is tested at the anal mucocutaneous junction [14]. Patients with incomplete injuries have the potential to recover normal neurologic function over a time span of up to 2 years even if paralysis is initially complete [14].

Other Considerations: The four CT parameters most strongly associated with neurologic deficit in thoracolumbar burst fractures are AO classification, compression ratio of median sagittal diameter, anterior vertebral compression ratio, and distance from the posterior margin to the vertebral body above [183]. A novel scoring system using MRI and CT radiologic findings to differentiate malignant from osteoporotic vertebral fractures was efficient with high accuracy and good applicability [66]. The combination of intensity change in the posterior wall on MRI and AVHR >75% on X-ray indicates a high probability of acute osteoporotic fracture [172].

Treatment

General Principles and Assessment

Definitive management, whether surgical or nonsurgical, relies on the assessment of mechanical instability, the presence or absence of neurologic impairment, and patient-specific factors influencing outcome [22]. The primary goal of treatment for spinal cord injury is stabilization [39]. Prognosis is significantly better for incomplete injuries compared to complete injuries, where the outlook is dismal [1]. Fracture-specific classification systems, such as the thoracolumbar injury classification and severity score (TLICS), are valuable for clinical decision-making and possess prognostic value [27]. The modified TLICS system serves as a practical tool for classification and assessment, with a slightly lower operation rate than the standard TLICS [49]. Type A injuries are compression injuries, Type B are tension band injuries, and Type C are displacement/translational injuries [8]. The thoracolumbar case-specific modifier M2 designates patient comorbidities such as ankylosing spondylitis, rheumatologic conditions, and diffuse idiopathic skeletal hyperostosis [8].

Non-Operative

The majority of thoracolumbar injuries are treated nonoperatively with cast or brace immobilization and early ambulation [104]. Historically, thoracic spinal injuries have predominantly been managed non-operatively [130]. A primarily non-operative approach is justified for type A2 and A3 fractures of the thoracic spine [130]. Patients who are neurologically intact, have less than 25° kyphosis, less than 50% loss of vertebral height, less than 50% canal compromise, and an intact posterior ligamentous complex are best candidates for nonsurgical treatment using a hyperextension thoracolumbar orthosis or casting for three months [8]. In properly selected neurologically intact patients, stable thoracolumbar burst fractures treated nonoperatively demonstrate significantly better long-term outcomes for pain and function [63]. Non-operative treatment for stable thoracolumbar burst fractures offers excellent long-term outcomes and lower complication rates compared to instrumented approaches [166]. Patients with stable vertebral compression fractures without neurological deficit generally function well long-term, with no deformity progression after three months [19]. The functional outcome of thoracolumbar vertebrae fractures without neurological deficit is not significantly affected by fracture type, severity, region, or treatment received [24]. For patients with incomplete paralysis, early stabilization and mobilization should be weighed against surgical risks, while stable fractures are best treated non-operatively [179]. Conservative management of thoracolumbar and lumbar spine compression and burst fractures is of limited value in lumbar fractures and in burst type fractures with posterior column involvement [42]. Current evidence does not support the widespread use of soft and rigid orthoses in the nonoperative treatment of osteoporotic vertebral compression fractures [175]. Following non-operative treatment of thoracic type A fractures, tight follow-up reviews after 1, 2, 4, and 6 weeks are essential for recognizing early evidence of secondary vertebral collapse [130].

Operative

Indications: Surgical treatment is indicated for unstable fractures and/or patients with neurologic deficits [8]. Unstable injuries (types B and C), serial fractures, and injuries associated with symptoms of complete spinal cord injury have a better outcome after surgical management [130]. For patients with incomplete neurologic deficits and ongoing spinal cord compression from retropulsed fragments, anterior decompression and stabilization is typically required [8]. Early stabilization of patients with neurologic injuries facilitates early rehabilitation and improved outcomes [8]. Surgical stabilisation of the spine can be reserved for severe progressive deformities unresponsive to conservative treatment [177].

Surgical Approach / Technique: Patients with unstable burst fractures that include failure of the posterior ligamentous complex, fracture-dislocations, and/or fractures with significant rotational displacement should undergo initial posterior stabilization [8]. If canal clearance from reduction and ligamentotaxis is not adequate, staged anterior decompression and reconstruction is warranted for unstable burst fractures [8]. Adjunctive posterior stabilization may be necessary in injuries with posterior column involvement [8]. The concept of spine damage control has been proposed using early posterior instrumentation of unstable thoracolumbar fractures in patients with polytrauma, with delayed definitive surgery occurring once patients are fully resuscitated and physiologically stabilized [1]. Open surgery is the standard of care for many surgical teams for spinal fractures in patients with ankylosing spondylitis [124]. Management of thoracolumbar fractures in France has progressed with increased use of percutaneous approaches (46% vs 28% in 2013) and posterior-only approaches (90% vs 83% in 2013) [178]. The technique of novel screw placement under navigation guidance is feasible, safe, and effective for treating traumatic thoracolumbar vertebral fractures [149]. Vertebroplasty delivered superior clinical and radiological outcomes over the first year from intervention when compared to conservative treatment of patients with osteoporotic compression fractures without neurological deficit [157]. The authors do not recommend standalone kyphoplasty for all types of burst fractures, specifically recommending additional techniques like posterior instrumentation for A3.2 and A3.3 fractures [69]. The modified bone-disc-bone osteotomy technique demonstrates stability of the correction effect and clinical efficacy and safety for treating kyphosis caused by old thoracolumbar vertebral fractures [162].

Implant Selection: The long-term results of short segmental fixation with and without fusion for burst fractures of the thoracolumbar and lumbar spine were comparable [34]. Evidence supports the successful treatment of non-fusion short-segment posterior fixation for a certain type of thoracolumbar and lumbar burst fractures [165]. The goals of fracture treatment, including prevention of neurological damage, decompression, and stabilization, were achieved using fusion and Harrington instrumentation [155]. The effective use of the Williams plate in the correction of spinal fractures depended on the severity of the injury and the degree of the primary traumatic deformation of kyphosis [51].

Other Considerations: Bracing is challenging in patients with ankylosing spondylitis due to unyielding kyphotic deformity, making spinal stabilisation in a brace inadequate in most patients [124]. Conventional open surgery for spinal fractures in ankylosing spondylitis has a high post-operative morbidity rate of up to 51% [124]. Pedicle screw loosening is common in ankylosing spondylitis patients due to limited bone stock, with a frequency of up to 15% [124]. Immune response impairments in patients with ankylosing spondylitis translate into a 14% infection rate [124]. Although immediate postoperative outcomes for spine trauma patients with ankylosing spondylitis and diffuse idiopathic skeletal hyperostosis were comparable with those of unaffected individuals, tailored management strategies are needed [74].

Classification and Prognosis

Conserved sagittal balance appeared to be associated with better functional outcome [23]. Outcome is particularly affected by multiple fractures in the thoracolumbar and lumbar regions and by failure to prevent kyphosis [160]. Unlike compression fractures, the vertebral body with traumatic VBB found in adult patients with nonosteoporotic spinal fractures of AO classification A or B types did not develop collapse [30].

Complications

Injury Complexity: Major trauma patients with spinal fractures present with more complex injuries than non-major trauma counterparts, demonstrated by increased levels of instability and fractures at more than one level [4]. The incidence of multiple level injuries of the cervical spine was 24 per cent in a group of 105 patients, which is higher than previously reported [13]. Injuries involving the upper and lower cervical spine in the same individual occurred in 9 per cent of patients with fractures of C1 and C2 [7].

Age-Related Risk: The incidence of subsequent vertebral fracture in patients aged 70 years and older was significantly higher than in patients aged under 70 years of age [72]. The incidence of extension injury to the cervical spine complicated by damage to the spinal cord shows a marked increase with age, with 84 per cent occurring during and after the fifth decade [73].

Other Considerations: A 6.3% complication rate was observed in a cohort where over two-thirds of patients with vertebral fractures were treated surgically [12]. Health-related quality of life is affected several years after short segment posterior instrumentation of thoracolumbar fractures without neurological deficit [62].

Recovery

Neurologic Prognosis and Assessment: Incomplete spinal cord injuries are associated with a better outcome compared to complete injuries, where the prognosis is dismal [1]. The American Spinal Injury Association (ASIA) Impairment Scale classifies spinal cord injuries into complete (ASIA grade A) or incomplete (ASIA grades B–D), with ASIA grade E reflecting a normal neurologic status [1]. Spinal cord injury is stratified into paraplegia resulting from thoracic and lumbar spine injuries and quadriplegia from cervical spine injuries [1]. Neurologic deterioration may occur after a spine injury, making it crucial to document the time of the neurologic assessment [1].

Long-Term Functional Outcomes: The long-term reduction of health-related quality of life in women with vertebral fracture emerged clearly in a seven-year follow-up study [152]. Conserved sagittal balance appeared to be associated with better functional outcome in patients undergoing surgery for vertebral fracture [23].

Natural History and Deformity Progression: The natural history of thoracolumbar burst fractures without neurology appears to be benign [55]. A study clarified the natural history of the progression pattern of vertebral deformities in radiographic prevalent vertebral fractures in elderly individuals [58].

Pediatric Recovery: Appropriate early diagnosis, management, and long-term follow-up are imperative for pediatric thoracolumbar spine trauma due to the potential for substantial healing and remodeling as well as the risk of late deformity and neurologic injury [161]. Routine radiographic follow-up may not be necessary in carefully selected patients with stable vertebral compression fractures who remain clinically asymptomatic, based on findings of minimal kyphotic progression following pediatric vertebral fractures [168].

Complications and Secondary Fractures: The incidence of subsequent vertebral fracture in patients aged 70 years and older was significantly higher than in patients aged under 70 years of age following posterior fusion with pedicle screw fixation for degenerative lumbar pathology [72]. Patients treated with long segmental stabilization for unstable midthoracic spine fractures had a significantly lower rate of sequential vertebral body fractures during follow-up [163]. A vertebral compression fracture in a fused and instrumented lumbar segment healed without incident and had no adverse effect on the patient's ultimate outcome [68].

Key Evidence

• [L5] Although the ideal classification for thoracic and lumbar fractures does not exist, standardization of terminology as related to treatment decisions and prognosis is key to an improved understanding of the clinical behavior of these injuries. [2] (10.5435/00124635-200209000-00008)
• [L5] A complete classification scheme for thoracolumbar fractures that incorporates the mechanism of injury, a description of osseous and ligamentous destruction, and the degree of neurologic damage is still lacking. [3] (10.5435/00124635-199511000-00005)
• [L3] Major trauma patients differ from non-major trauma counterparts and have more complex spinal injuries, demonstrated by increased levels of instability and fractures at more than one level. [4] (10.1302/0301-620x.97b2.34392)
• [L3] A reliable classification for assessing the stability of a healed vertebra was developed. [5] (10.1186/s12891-020-03386-z)
• [L3] In C type fractures, correct surgical indication must be evaluated on an individual basis. [6] (10.1016/j.injury.2016.07.052)
• [L4] Injuries of the first and second cervical vertebrae commonly occurred together, and injuries involving the upper and lower cervical spine in the same individual occurred in 9 per cent of patients with fractures of C1 and C2. [7] (10.1016/0020-1383(92)90123-a)
• [Case_report] Spinal fractures in patients with AS can occur after minor injuries and are often unstable, requiring surgery. [10] (10.1016/j.otsr.2012.09.018)
• [L3] Twenty-five out of 1000 patients presented with a vertebral fracture, with over two-thirds treated surgically and a 6.3% complication rate. [12] (10.1186/s13018-022-03147-9)
• [L4] The incidence of multiple level injuries of the cervical spine was 24 per cent in this group of 105 patients, which is higher than previously reported, probably due to increasingly elaborate investigations. [13] (10.1016/0020-1383(85)90013-0)
• [L5] Diagnosis of cervical spine injuries is a three-step process involving risk assessment, imaging, and classification. [16] (10.1302/2058-5241.3.170076)
• [L3] Using the main types of AO classifications, inter- and intra-observer agreement of thoraco-lumbar spinal injuries were comparable to agreement evaluating fractures of the trochanteric area of the proximal femur; including sub-types, agreement evaluating thoraco-lumbar spinal injuries was significantly better than assessing fractures of the trochanteric area of the proximal femur. [17] (10.1016/j.injury.2015.11.016)
• [L3] Discontinuous thoracolumbar fractures have distinct epidemiological and morphological characteristics, including clustering at the thoracolumbar-lumbar junction, a predominance of compression-based AO combinations, and a high rate of initially missed diagnoses. [18] (10.1016/j.injury.2026.113702)
• [L4] Patients with stable vertebral compression fractures without neurological deficit generally function well long-term, with no deformity progression after three months. [19] (10.2106/00004623-198870090-00007)
• [L4] The most common injuries were fractures of the thoracic and lumbar spine (83.0 per cent) especially of the thoracolumbar junction. [21] (10.1016/s0020-1383(96)00083-6)
• [L5] Definitive management (surgical or nonsurgical) is based on the assessment of the mechanical instability of the injury, the presence or absence of neurologic impairment, and various patient factors that may influence outcome. [22] (10.5435/00124635-200602000-00003)
• [L3] Conserved sagittal balance appeared to be associated with better functional outcome. [23] (10.1016/j.otsr.2014.11.012)
• [L3] The functional outcome was not significantly affected by the fracture type, severity, region or treatment received. [24] (10.1016/0020-1383(95)00074-j)
• [L4] The classification of pediatric thoracolumbar trauma is based primarily on adult studies and there is little high-level evidence examining validity and accuracy in pediatric populations. [25] (10.2106/jbjs.rvw.24.00045)
• [L4] [29] (10.2106/00004623-197456080-00015)
• [L3] Unlike compression fractures, the vertebral body with traumatic VBB found in adult patients with nonosteoporotic spinal fractures of AO classification A or B types did not develop collapse. [30] (10.1186/s12891-022-05405-7)
• [L4] For all AO type-B injuries without neurologic deficits, there is a notable consensus to treat these fractures with percutaneous techniques, with the potential addition of anterior support in the presence of significant vertebral body comminution. [31] (10.1016/j.injury.2024.111389)
• [L5] [32] (10.1097/corr.0000000000001086)
• [L2] The long-term results of short segmental fixation with and without fusion for burst fractures of the thoracolumbar and lumbar spine were comparable. [34] (10.2106/jbjs.m.01486)
• [L4] AS patients are at high risk for spinal fractures and associated SCI, particularly in the cervical spine. [36] (10.1186/s13018-026-06871-8)
• [L4] Pediatric spine injuries are rare and require an individualized approach due to unique injury patterns, plasticity of the spine, and difficulty of diagnosis. [37] (10.1016/j.injury.2005.06.021)
• [L5] [38] (10.5435/00124635-201002000-00001)
• [L4] If conventional radiographs fail to delineate a spinal fracture in a patient with persistent pain an isotope bone scan is indicated. [41] (10.1016/0020-1383(91)90118-x)
• [L4] It is of limited value in lumbar fractures and in burst type fractures with posterior column involvement. [42] (10.1007/s00402-008-0780-x)
• [L3] The modified TLICS system is a practical tool for the classification and assessment of thoracolumbar fractures with guiding significance for clinical treatment, and the operation rate was slightly lower than that of the TLICS system. [49] (10.1186/s13018-023-03958-4)
• [L4] The effective use of the Williams plate in the correction of spinal fractures depended on the severity of the injury and the degree of the primary traumatic deformation of kyphosis. [51] (10.1016/0020-1383(88)90004-6)
• [L4] The standard Cohen's kappa values for the Load Sharing Classification of spinal fractures can be rated as fair to moderate, indicating that the inter- and intraobserver reliability of the classification is fair. [53] (10.1016/j.injury.2011.05.013)
• [L5] The diagnosis of the double level fracture was initially overlooked at two different hospitals. [54] (10.1016/0020-1383(81)90087-5)
• [L4] The natural history of thoracolumbar burst fractures without neurology would appear to be benign. [55] (10.1302/0301-620x.98b1.36121)
• [L2] This study clarified the natural history of the progression pattern of vertebral deformities in radiographic prevalent vertebral fractures in elderly individuals. [58] (10.1186/s12891-024-07254-y)
• [L4] Male gender, having a spinal fracture, having a thoracic injury, and having complications were the major risk factors for a complete injury. [59] (10.1371/journal.pone.0084733)
• [L4] Vertebral fracture is common on chest radiographs but it is often ignored by radiologists. [61] (10.1186/s12891-018-2171-y)
• [L3] Health-related quality of life is affected several years after short segment posterior instrumentation of thoracolumbar fractures without neurological deficit. [62] (10.1016/j.injury.2013.06.012)
• [L1] In properly selected neurologically intact patients, stable thoracolumbar burst fractures are best treated nonoperatively, as long-term outcomes for pain and function were significantly better for the nonoperatively treated patients. [63] (10.2106/jbjs.n.01092)
• [L4] Nineteen percent of patients sustained an injury, and in 5% the injury was a cervical spine fracture; therefore, liberal screening using CT scans is warranted. [64] (10.1016/j.injury.2005.12.013)
• [L4] Large well-controlled prospective studies are needed to draw up guidelines for less invasive procedures in spine trauma. [65] (10.1016/j.otsr.2012.09.014)
• [L3] This novel scoring system using MRI and CT radiologic findings to differentiate malignant vertebral fractures from osteoporotic vertebral fractures in Chinese patients was efficient with high accuracy and good applicability. [66] (10.1186/s12891-018-2331-0)
• [L4] The fracture healed without incident and had no adverse effect on the patient's ultimate outcome. [68] (10.1097/blo.0b013e3180315082)
• [Letter] The authors clarify that they do not recommend standalone kyphoplasty for all types of burst fractures, specifically recommending additional techniques like posterior instrumentation for A3.2 and A3.3 fractures. [69] (10.1016/j.injury.2011.02.008)
• [Paper] Posterior monosegmental fixation is an adequate and satisfactory procedure for specific types of thoracolumbar spine fractures, particularly when the vertebral body is intact. [70] (10.1016/j.injury.2005.06.019)
• [L4] However, conventional imaging with anterior and posterior projections seems to be insufficient in detecting all of the spinal fractures. [71] (10.1016/0020-1383(93)90152-v)
• [L3] The incidence of subsequent vertebral fracture in patients aged 70 years and older was significantly higher than in patients aged under 70 years of age. [72] (10.1186/s12891-019-2534-z)
• [L4] The incidence of extension injury to the cervical spine complicated by damage to the spinal cord shows a marked increase with age, with 84 per cent occurring during and after the fifth decade. [73] (10.1016/0020-1383(87)90002-7)
• [L3] Although immediate postoperative outcomes were comparable with those of unaffected individuals, these findings underscore the need for tailored management strategies for spine trauma patients with AS and DISH. [74] (10.5435/jaaos-d-25-00785)
• [L3] Underdiagnosis of osteoporotic vertebral fractures is a common problem due to a lack of radiographic detection. [102] (10.1016/j.injury.2018.10.006)
• [L5] [104] (10.5435/00124635-199511000-00006)
• [L4] [124] (10.1016/j.otsr.2017.07.023)
• [L4] The 3D model was positively validated by 92% of surgeons for anatomical realism, 88% for fracture representation, and 92% for adherence to the AO Spine classification. [126] (10.1016/j.otsr.2024.104084)
• [Paper] [130] (10.1055/a-1144-3846)
• [L3] Rib fractures are relatively common in patients with TVFs and may be underdiagnosed, especially in the absence of clear symptoms. [143] (10.1016/j.injury.2025.112728)
• [L3] The technique is feasible, safe, and effective for treating traumatic thoracolumbar vertebral fractures. [149] (10.1186/s12891-025-09071-3)
• [L2] The long-term reduction of HRQOL in women with vertebral fracture emerged clearly in this study. [152] (10.1186/1471-2474-10-135)
• [L4] The Gertzbein classification correlates fracture type with mechanical instability and neurologic lesion, while the load sharing classification correlates comminution and displacement with stability and implant failure. [154] (10.1097/01.blo.0000068187.83581.5d)
• [L4] The goals of fracture treatment, including prevention of neurological damage, decompression, and stabilization, were achieved. [155] (10.1007/bf00422835)
• [L3] Vertebroplasty delivered superior clinical and radiological outcomes over the first year from intervention when compared to conservative treatment of patients with osteoporotic compression fractures without neurological deficit. [157] (10.1007/s00264-017-3409-2)
• [L4] The new classification system for CSOTF demonstrated excellent reliability in this initial assessment. [158] (10.1186/s13018-020-01882-5)
• [L4] Outcome is particularly affected by multiple fractures in the thoracolumbar and lumbar regions and by failure to prevent kyphosis. [160] (10.1302/0301-620x.98b9.37786)
• [L5] Appropriate early diagnosis, management, and long-term follow-up are imperative due to the potential for substantial healing and remodeling as well as the risk of late deformity and neurologic injury. [161] (10.5435/00124635-201312000-00001)
• [L4] The study demonstrates the stability of the correction effect and the clinical efficacy and safety of this modified technique for treating kyphosis caused by old thoracolumbar vertebral fractures. [162] (10.1186/s13018-026-06867-4)
• [L3] Patients treated with long segmental stabilization had a significantly lower rate of sequential vertebral body fractures during follow-up. [163] (10.1186/s12891-021-04049-3)
• [L5] This study presented evidence of successful treatment of non-fusion short-segment posterior fixation for a certain type of thoracolumbar and lumbar burst fractures. [165] (10.2106/jbjs.n.00751)
• [L5] Non-operative treatment for stable thoracolumbar burst fractures and uninstrumented fusion for low-grade lytic spondylolisthesis demonstrate established clinical proficiency with excellent long-term outcomes and lower complication rates compared to instrumented approaches. [166] (10.1302/0301-620x.98b1.37508)
• [L5] The optimal surgical approach for specific thoracolumbar fractures remains a matter of controversy, warranting multiple clinical cohort studies to establish a comprehensive surgical protocol. [167] (10.5435/00124635-200807000-00008)
• [L3] The present study suggests that routine radiographic follow-up may not be necessary in carefully selected patients with stable vertebral compression fractures who remain clinically asymptomatic. [168] (10.1007/s00402-026-06482-2)
• [L4] Lateral radiographs in flexion and extension should be performed about 10 days after cervical spinal injury in patients with persistent pain or following transient neurological symptoms, as they can demonstrate pathology such as spinous process fractures that are not visible on plain radiographs or MRI. [170] (10.1007/bf00572919)
• [L2] The combination of intensity change in the posterior wall on MRI and AVHR >75% on X-ray indicates a high probability of acute fracture. [172] (10.1186/s13018-014-0096-1)
• [L3] Upright radiographs are useful in guiding traumatic vertebral fracture management decisions. [173] (10.1186/s12891-022-05243-7)
• [L4] CT may miss complex rotation fractures, making MRI warranted in such cases. [174] (10.1016/s0020-1383(99)00235-1)
• [L5] The current evidence does not support the widespread use of soft and rigid orthoses in the nonoperative treatment of osteoporotic vertebral compression fractures (OVCFs). [175] (10.1016/j.injury.2024.111752)
• [L4] Surgical stabilisation of the spine can be reserved for severe progressive deformities unresponsive to conservative treatment. [177] (10.1302/0301-620x.97b7.35665)
• [L4] Management of thoracolumbar fractures has progressed in France with increased use of percutaneous approaches (46% vs 28% in 2013) and posterior-only approaches (90% vs 83% in 2013). [178] (10.1016/j.otsr.2020.02.023)
• [L5] For patients with incomplete paralysis, early stabilization and mobilization should be weighed against surgical risks, while stable fractures are best treated non-operatively. [179] (10.2106/00004623-198466070-00032)
• [L3] An important proportion of patients over 60 years old evaluated with chest plus abdominal and pelvic CT scans present vertebral compression fractures. [180] (10.1007/s00402-019-03177-9)
• [L5] MRI is the modality of choice for evaluation of ligamentous and other soft tissue structures, disc, spinal cord, and occult osseous injuries. [181] (10.1186/s12891-016-1169-6)
• [L3] The four CT parameters most strongly associated with neurologic deficit in thoracolumbar burst fractures are AO classification, compression ratio of median sagittal diameter, anterior vertebral compression ratio, and distance from the posterior margin to the vertebral body above. [183] (10.1186/s13018-016-0448-0)

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