The AO Spine TL Injury Classification System Drives Clinical Decision Making in Acute Thoracolumbar Fractures: A Retrospective Evaluation of Clinical Implementation

Study Design Retrospective Cohort Study. Objectives The primary objective was to examine the association between AO Spine Thoracolumbar Injury Classification System and treatment choice in patients with acute traumatic thoracolumbar fractures. The secondary objective was to evaluate the extent to which clinical decision-making adhered to the classification system’s recommendations. Methods All adult patients who presented in the Emergency Department of a Level-I trauma centre with one or more acute thoracolumbar fractures between October 1st, 2016 and June 30th, 2021 were retrospectively included. Exclusion criteria were: pre-existing thoracolumbar fractures; missing data; patients who suffered non-survivable injuries; and pathological fractures. Potential confounders and effect modifiers included parameters related to patient and fracture characteristics. In addition, adherence in treatment decision-making to the classification system guideline was investigated. Results A total of 553 patients were included of whom 30% were treated surgically. Overall, 68% of fractures were classified as A0-A3, 8.3% as A4, 6.2% as B1, 15% as B2, and 2.9% as C. Patients with A4 fractures underwent surgery more often than those with A0-A3 (OR:31.7; 95%CI 13.16-76.32; P < 0.01). None of the investigated variables were effect modifiers (all P > 0.10). Physicians’ adherence to the morphology components of the classification system varied between 86.4% and 100.0%. Conclusions Patients with A4 fractures are treated surgically more frequently compared with those with A0-A3. While adherence to the morphological components of the classification system was excellent, documentation and application of the neurological and modifier components remained limited, underscoring the need for improved implementation in clinical practice in our hospital.