Role of X-ray, CT and MRI in Decision Making of Thoracolumbar Fractures: Prospective Inter-observer Reliability Analysis

Abstract

Background: Thoracolumbar fractures have a varied clinical presentation and surgeons mainly depend on radiological investigations for planning management. Most modern classifications like TLICS (Thoraco-Lumbar Injury Classification and Severity score) and AO classification rely on additional data from CT and MRI which are expensive and not easily available. There are not many studies to document whether addition of CT and MRI changes the classification by an experienced surgeon and his decision-making process. Methods: 40 patients with thoracolumbar spine fractures ranging in severity from the simple to the most complex were selected. Four surgeons of varied experience in spine surgery (15 years, 8 years, 3 and 2 years) assessed these fractures with x-ray radiographs, followed by CT and MRI. The interobserver reliability of each classification, and the reason for the change with addition of CT and MRI was studied. Results: Addition of CT scan to plain radiographs involved a change in classification in 25% of cases in McAfee and AO classification, and 27% in TLICS. This led to a 10% change in management decision amongst surgeons. Assessment with MRI did not produce any major change in McAfee and AO classification but, there was change in classification and management in 47.5 % of cases in TLICS all of which were displaced fractures. The PLC status correlation among the surgeons is moderate with X-ray and CT group (k=0.51), but with addition of the MRI (k=0.92) correlation became very good. Conclusion: X-rays are helpful in initial evaluation of thoracolumbar spine injuries. CT scan provides additional information like fracture pattern, fracture morphology and indirectly determine PLC tear by the presence of displacement of the fragments into the spinal canal. MRI confirms spinal cord compression and PLC injury. PLC was torn in all displaced fractures, so displacement is a criteria to diagnose PLC injury. Hence, Xray, CT Scan and MRI are investigations of choice in that serial order in making decision regarding their management.