Analysis of the Classification Systems for Thoracolumbar Fractures in Adults and Their Evolution and Impact on Clinical Management

Abstract

Although they represent a significant chapter of traumatic pathology with a deep medical and social impact, thoracolumbar fractures have proven to be elusive in terms of a definitive classification. The ever-changing concept of the stability of a thoracolumbar injury (from Holdsworth’s two-column concept to Denis’ three-column theory), the meaningful integration of neurological deficit, and a reliable clinical usability have made reaching a universally accepted and reproductible classification almost impossible. The advent of sophisticated imaging techniques and an improved understanding of spine biomechanics led to the development of several classification systems. Each successive system has contributed significantly to the understanding of physiopathological mechanisms and better treatment management. Magerl et al. developed a comprehensive classification system based on progressive morphological damage determined by the following three fundamental forces: compression, distraction, and axial torque. Vaccaro et al. devised the thoracolumbar injury severity score based on the following three independent variables: the morphology of the injury, posterior ligamentous complex (PLC) integrity, and neurological status at the time of injury. However, there are limitations to the classification system, especially when magnetic resonance imaging yields an uncertain status of PLC. The authors review the various classification systems insisting on their practical relevance and caveats and illustrate the advantages and disadvantages of the most widely used systems with relevant cases from their practice.