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Neurology Modifiers
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Appendix C: AO Spine Thoracolumbar Fracture Classication
ART
Type Type
N0
N1
N2
N3
N4
NX
Displacement/
Dislocation
NO
Anterior
Tension band
injury
NO
Vertebral body
fracture
NO
Vertebral process
fracture
NO
YES
Posterior
YES
Posterior wall involvement
NO
YES
No injury
Neurological Description
Neurology intact
Transient neurolocic deficit
Radicular symptoms
Incomplete spinal cord injury or
any degree of cauda equina injury
Complete spinal cord injuryl
Cannot be examined
Continued spinal cord compression
+
YES
Osseoligamentous
disruption
Mono-segmental
osseous disruption
Both endplates
involved
YES
Both endplates
involved
M1
M2
C Translation
B3
YES
YES
YES
YES
NO
YES
NO
Hyperextension
Osseoligamentous
B2
disruption
Pure transosseous
B1
disruption
A4
Complete burst
A3
Incomplete burst
A2
Split/Pincer
A1
Wedge/Impaction
A0
Insignificant injury
This modifier is used to designate
fractures with an indeterminate
injury to the tension band based
on spinal imaging with or without
MRI. This modifier is important for
designating those injuries with stable
injuries from a bony standpoint for
which ligamentous insufficiency may
help determine whether operative
stabilization is a consideration.
Is used to designate a patient-specific
comorbidity, which might argue either
for or against surgery for patients with
relative surgical indications, Examples
of an M2 modifier include ankylosing
spondylitis or burns affecting the skin
overlying the injured spine.
https://aospine.aofoundation.org/clinical- library- and- tools/ao-spine-classicationsystems
Appendix D: Sacral Fractures (AO Spine
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Classication System)
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2022
A. Şenköylü, F. Canavese (eds.), Essentials of Spıne Surgery,
https://doi.org/10.1007/978-3-030-80356-8
437
Appendix E: Osteoporotic Vertebra Fracture
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Classication
Denition: The Spine Section of the German Society for Orthopaedics and Trauma
(DGOU) described a classication for osteoporotic thoracolumbar fractures.
Content: The classication includes ve groups: OF 1 no vertebral deformation
(vertebral edema); OF 2, deformation with no or minor (<1/5) involvement of the
posterior wall; OF 3, deformation with distinct involvement (>1/5) of the posterior
wall; OF 4, loss of integrity of the vertebral frame or vertebral body collapse or
pincer-type fracture; OF 5, injuries with distraction or rotation (Table E.1 and
Fig. E.1).
Table E.1 Detailed explanation of the subgroups in the classication
OF 1 No vertebral deformation (vertebral body edema in MRI-STIR only). This type is rare.
The stable injury is clearly visible on MRI-STIR sequence only. X-rays and CT scans
do not show vertebral deformation.
OF 2 Deformation with no or only minor involvement of the posterior wall (<1/5). This type
of fracture affects one endplate only (impression fracture). OF 2 are stable injuries.
OF 3 Deformation with distinct involvement of the posterior wall (>1/5). This type of fracture
affects one endplate only but shows distinct involvement of the anterior and posterior
wall (incomplete burst fracture). The fracture can be unstable and may collapse further
over time.
OF 4 Loss of integrity of the vertebral frame structure, or vertebral body collapse, or
pincer-type fracture. Both endplates and posterior wall are involved (complete burst
fracture). A vertebral body collapse is typically seen as a nal consequence of a failed
conservative treatment and can impose as a vertebra plana. Pincer-type fractures involve
both endplates and may lead to severe deformity of the vertebral body. OF 4 are
unstable fractures and intravertebral vacuum clefts are often visible.
OF 5 Injuries with distraction or rotation. This group is rare but shows substantial instability.
The injury includes both anterior and posterior columns consisting of ligamentous
structures. OF 5 injuries can be caused either by trauma directly or by ongoing
collapsing of an OF 4.
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2022
A. Şenköylü, F. Canavese (eds.), Essentials of Spıne Surgery,
https://doi.org/10.1007/978-3-030-80356-8
439
440
OF 1
OF 4 OF 5
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OF 2
OF 3
Fig. E.1 Representation of subgroups
Appendix E: Osteoporotic Vertebra Fracture Classication
Clinical Application: Types OF 1 and OF 2 can be treated conservatively whereas
treated either surgically or conservatively.
Further Reading
1. Schnake K, Blattert T, Hahn P, etal. Classication of osteoporotic thoracolum-
bar spine fractures: recommendations of the spine section of the German Society
for Orthopaedics and Trauma (DGOU). Global Spine J. 2018;8(2 Suppl):46S–49S.
Appendix F: Glasgow Coma Scale
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Denition: The Glasgow Coma Scale (GCS) is a widely accepted neurological
scale that is used to measure a patient’s level of neurological status. Additionally, it
eases communication between health professionals regarding their patients’ neurological situation.
Content: The GCS is composed of three layers. Eye, verbal, and motor responses
of a patient either to pain or verbal commands are recorded (Table F. 1 ). It can range
from 3 points to 15 points.
Table F.1 Glasgow Coma Scale, response, and score
Glasgow Coma Scale
Response Score
Eye opening response Spontaneous 4
To speech 3
To pain 2
None 1
Best verbal response Orientated 5
Confused 4
Inappropriate 3
Incomprehensible 2
None 1
Best motor response Obeying 6
Localizing 5
Flexing 4
Abnormal exion
(decorticate)
Abnormal extension
(decerebrate)
None 1
3
2
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2022
A. Şenköylü, F. Canavese (eds.), Essentials of Spıne Surgery,
https://doi.org/10.1007/978-3-030-80356-8
441
442
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Clinical Application: Although it was designed for and best used after head trauma,
today it is one of the main scales used to evaluate a patient with any kind of cranial
neurological insult.
Appendix F: Glasgow Coma Scale
Further Reading
1. Teasdale G, Jennett B.Assessment of coma and impaired consciousness. A prac-
tical scale. Lancet. 1974;2(7872):81–4.
Appendix G: ASIA Scale
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Denition: Based on the sensorimotor scores, the level and the severity of the spinal
cord injury can be determined. The scale most commonly used to classify the severity of the injury is the American Spinal Injury Association (ASIA)/International
Spinal Cord Society (ISCoS) neurological standard scale (AIS), better known as the
ASIA Impairment Scale.
Content: The AIS is a standardized examination consisting of a myotomal based
motor examination, dermatomal based sensory examination, and an anorectal
examination. Based on the ndings of these examinations, an injury severity or
grade and level are assigned (Fig. G.1). The AIS further classies injuries as a complete or incomplete spinal cord injury (Table G.1).
Clinical Application: The purpose of the AIS is to standardize careful, detailed
documentation of an injury; guide further radiographic assessment and treatment;
and determine whether injuries are complete or incomplete, an important and sometimes subtle neurologic distinction that has tremendous prognostic implications.
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2022
A. Şenköylü, F. Canavese (eds.), Essentials of Spıne Surgery,
https://doi.org/10.1007/978-3-030-80356-8
443
444
https://t.me/medicina_free
Appendix G: ASIA Scale
Fig. G.1 The American Spinal Injury Association International Standards for Neurological
Classication of Spinal Cord Injury form
Table G.1 The American Spinal Injury Association/International Spinal Cord Society
Neurological Standard Scale (better known as the “ASIA Impairment Scale”)
ASIA Impairment Scale Lesion
A No motor or sensory function is preserved in the sacral segments S4–S5 Complete
B Sensory but not motor function is preserved below the neurological level
and includes the sacral segments S4–S5
C Motor function is preserved below the neurological level, and more than
half of the key muscles below the neurological level have a muscle grade
less than 3
D Motor function is preserved below the neurological level, and at least half
of the key muscles below the neurological level have a muscle grade of 3 or
more
E Motor and sensory functions are normal Normal
Incomplete
Incomplete
Incomplete
Further Readings
1. American Spinal Injury Association. International standards for neurological
classication of spinal cord injury, 2002 revision. Chicago, IL: American Spinal
Injury Association; 2002.
2. Roberts TT, etal. Classications in brief: American Spinal Injury Association
(ASIA) Impairment Scale. Clin Orthop Relat Res. 2017;475(5):1499–504.
3. van Middendorp JJ, et al. Diagnosis and prognosis of traumatic spinal cord
injury. Global Spine J. 2011;1(1):1–8.
Appendix H: King etal. Classication System
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ofAdolescent Idiopathic Scoliosis
Denition: King etal.’s classication identies ve types of curve patterns in adolescent idiopathic scoliosis and it helps to properly select the level of fusion and
instrumentation in order to preserve motion as much as possible.
Content: King etal. introduced for the rst time the concept of stable vertebra (the
vertebra most closely bisected by the center sacral vertical line) and of structural/
compensatory curves depending on their exibility on side-bending lms.
Clinical Relevance: This system was developed on the experience with Harrington
rod instrumentation and with the advent of segmental instrumentation it failed to
give accurate and reliable guidelines for choosing the proper levels for fusion.
Type I: S-shaped or double curve in which both the thoracic and lumbar curves
cross the center sacral vertical line; the lumbar curve is larger and stiffer than the
thoracic curve.
Treatment: Fuse down to L4 (via a posterior approach) or down to L3 (anterior
approach).
Type II: S-shaped or double curve in which both the thoracic and lumbar curve
cross the center sacral vertical line; the thoracic curve is larger (or equal) and
stiffer than the lumbar curve; type II curves are also called “false double major.”
Treatment: Often a thoracic fusion (or down to L1) is indicated.
Type III: Single (major) thoracic curve; only the thoracic curve is structural and
crosses the center sacral vertical line. The lumbar curve does not cross the
midline.
Treatment: Thoracic fusion.
Type IV: Long C-shaped thoracic curve in which L5 is centered over the sacrum and
L4 is tilted into the thoracic curve.
Treatment: Fuse down to L4.
Type V: Double-thoracic curve; T1 tilts to the upper curve.
Treatment: Make sure that the upper (left) thoracic curve is nonstructural; if not,
fuse the upper thoracic spine as well as the lower thoracic spine.
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2022
A. Şenköylü, F. Canavese (eds.), Essentials of Spıne Surgery,
https://doi.org/10.1007/978-3-030-80356-8
445
446
https://t.me/medicina_free
Appendix H: King etal. Classication System ofAdolescent Idiopathic Scoliosis
Further Reading
1. King HA, etal. The selection of fusion levels in thoracic idiopathic scoliosis. J
Bone Joint Surg Am. 1983;65:1302–13.
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