Load-Sharing Classification Score as Supplemental Grading System in the Decision-Making Process for Patients with Thoracolumbar Injury Classification and Severity 4

BACKGROUND: Patients with Thoracolumbar Injury Classification and Severity (TLICS) score of 4 fall into a gray zone between surgical and conservative management. The integrity of posterior ligamentous complex (PLC) evaluated by magnetic resonance imaging (MRI) contributes to surgical decision-making. Load-sharing classification (LSC) may provide a modifier to further guide decision-making in these patients. OBJECTIVE: To evaluate associations between LSC score and MRI acquisition, compromise of PLC on MRI, and surgical intervention in TLICS 4 patients. METHODS: A cohort of 111 neurologically intact patients with isolated thoracolumbar burst fracture with TLICS 4 was evaluated. LSC score was determined based on degree of comminution (1-3), apposition (1-3), and kyphosis (1-3), total composite score of 3 to 9. RESULTS: Overall, 44 patients underwent MRI, 15 had PLC injury, and 32 (28.8%) underwent surgery. LSC score was higher in patients who had an MRI (median 6 vs 3, P <. 001) and patients who had surgery (median 7 vs 4, P <. 001). In univariate logistic regression, LSC score was associated with MRI acquisition (odds ratio [OR] 1.7; 1.32-2.12; P <. 001), presence of PLC injury on MRI (OR 1.5; 1.2-2.0; P =. 002) and, in multivariate logistic regression, undergoing surgical intervention (OR 3.7; 2.3-5.9; P <. 001), independent of MRI or PLC injury. CONCLUSION: LSC score in neurologically intact patients with isolated thoracolumbar burst fracture with TLICS 4 was independently associated with operative intervention. The application of LSC may further guide decision-making in this patient group.