Spinal Fractures Classification System
an AOSpine Knowledge Forum initiative
Subaxial Spine Fractures
Sacral Spine Fractures
Thoracolumbar Spine Fractures
Spinal Fractures Classification System 2
AOSpine–the leading global academic community
for innovative education and research in spine care,
inspiring lifelong learning and improving patients’ lives.
Spinal Fractures Classification System 3
CONTENT AOSpine Classification and Injury Severity System.. . . . . . . . . . . . . . . . 04
for Traumatic Fractures of the Subaxial Spine
AOSpine Classification and Injury Severity System.. . . . . . . . . . . . . . . . . 37
for Traumatic Fractures of the Thoracolumbar Spine
AOSpine Classification and Injury Severity System.. . . . . . . . . . . . . . . . . 55
for Traumatic Fractures of the Sacral Spine
Spinal Fractures Classification System
an AOSpine Knowledge Forum initiative
Project members
(in alphabetic order)
Disclaimer
Aarabi B, Bellabarba C, Chapman J, Dvorak M, Fehlings M, Kandziora F, Kepler C,
Oner C, Rajasekaran S, Reinhold M, Schnake K, Vialle L and Vaccaro A.
1. Vaccaro, A. R., J. D. Koerner, K. E. Radcliff, F. C. Oner, M. Reinhold, K. J. Schnake, F.
Kandziora, M. G. Fehlings, M. F. Dvorak, B. Aarabi, S. Rajasekaran, G. D. Schroeder, C.
K. Kepler and L. R. Vialle (2015). “AOSpine subaxial cervical spine injury classification
system.” Eur Spine J.
2. International validation process to be completed in 2015.
3. Submitted to AOSpine International Board for endorsement as the official AOSpine
TL Fractures Classification
This is the present form of the classification the AOSpine Knowledge Forum (KF) SCI & Trauma is working on.
It is the aim of the KF to develop a system, which can in the future be used as a tool for scientific research and
a guide for treatment. This system is being subjected to a rigorous scientific assessment.
AOSpine Classification and Injury
Severity System for Traumatic Fractures
of the Subaxial Spine
AOSpine Knowledge Forum
Subaxial Spine Fractures Classification System 5
Compression injuries
Type
AO
A1
A2
A3
A4
Description
No bony injury or minor injury such as an isolated lamina fracture
or spinous process fracture.
Minor, nonstructural fractures
Compression fracture involving a single endplate without involvement
of the posterior wall of the vertebral body.
Wedge-compression
Coronal split or pincer fracture involving both endplates without
involvement of the posterior wall of the vertebral body.
Split
Burst fracture involving a single endplate with involvement of the
posterior vertebral wall.
Incomplete burst
Burst fracture or sagittal split involving both endplates.Complete burst
Subaxial Spine Fractures Classification System 6
Tension band injuries
Type
B1
B2
B3
Description
Physical separation through fractured bony structures only.
Posterior tension band injury
(bony)
Complete disruption of the posterior capsuloligamentous or bony
capsuloligamentous structures together with a vertebral body, disk,
and/or facet injury.
Posterior tension band injury
(bony capsuloligamentous,
ligamentous)
Physical disruption or separation of the anterior structures
(bone/disk) with tethering of the posterior elements.
Anterior tension band injury
Subaxial Spine Fractures Classification System 7
Bilateral injuries
Translation injuries
Type
Type
C
Translational injury in any axis-displacement or translation
of one vertebral body relative to another in any direction
BL Bilateral injury
Subaxial Spine Fractures Classification System 8
Facet injuries
Type
F1
F3
F2
F4
Description
Nondisplaced facet fracture With fragment <1cm in height, <40% of lateral mass.
Floating lateral mass
Facet fracture with potential
for instability
With fragment >1cm, > than 40% lateral mass, or displaced.
Pathologic subluxation or
perched/ dislocated facet
Subaxial Spine Fractures Classification System 9
Neurological status modifier
Type
NO
N3
N1
N4
N2
NX
Description
Neurologically intact
Incomplete spinal cord injury
Transient neurologic deficit, resolved
Complete spinal cord injury
Radiculopathy
Cannot be examined
Neurologic status at the moment of admission should be scored according to the following scheme:
Subaxial Spine Fractures Classification System 10
Case-specific modifiers
Type
M1
M4
M2
M3
Description
Posterior capsuloligamentous complex injury without complete disruption
Vertebral artery abnormality
Critical disk herniation
Stiffening/metabolic bone disease (ie.: DISH, AS, OPLL, OLF)
There are four modifiers, which can be used in addition to ad 1 and 2:
Subaxial Spine Fractures Classification System 11
Injuries are first classified by their level and primary injury type, either C, B, or A. If there are multiple
levels, the most severe level is classified first. The secondary injuries are parenthesized.
For example, a C6-C7 translational injury (C) with a C7 compression fracture (A1) would be classified as:
	 C6-C7:C
	 (C7:A1)
And a C5-C6 flexion distraction injury (B2) with a C6 compression fracture (A1) would be classified as:
	 C5-C6:B2
	 (C6:A1)
Classification nomenclature
Subaxial Spine Fractures Classification System 12
Included in parenthesis are the remaining subgroups in the order of:
facet injuries, neurological status, and any modifiers.
For bilateral facet injuries, the “BL” modifier is added after the facet injury if the injuries are the same.
For example, a C6-C7 flexion distraction injury (B2) with bilateral facet dislocation (F4) would be classified as:
	 C6-C7:B2
	 (F4 BL)
When there are different facet injuries to the same level, the right side is listed first, then the left.
For example, a C6-C7 flexion distraction injury (B2) with right sided facet dislocation (F4)
and a left sided displaced facet fracture (F2) would be classified as:
	 C6-C7:B2
	 (F4, F2)
If there are multiple injuries to the same facet (For example: small fracture (F1) and dislocation (F4),
only the highest level facet injury is classified (F4).
If only facet injuries are identified (No A, B, or C injury), they are listed first after the level of injury.
Classification–Facet Injuries
Subaxial Spine Fractures Classification System 13
No bony injury or minor injury such as an isolated
lamina fracture or spinous process fracture.
A0. Minor, nonstructural fractures
Type A: Compression injuries
Subaxial Spine Fractures Classification System 14
Type A: Compression injuries
A1. Wedge-compression
Compression fracture involving a single endplate without
involvement of the posterior wall of the vertebral body.
Subaxial Spine Fractures Classification System 15
Type A: Compression injuries
A1. Wedge-compression
Compression fracture involving a single endplate without
involvement of the posterior wall of the vertebral body.
Subaxial Spine Fractures Classification System 16
Type A: Compression injuries
A2.Split
Coronal split or pincer fracture involving both endplates without
involvement of the posterior wall of the vertebral body.
Subaxial Spine Fractures Classification System 17
Type A: Compression injuries
A3.Incomplete burst
Burst fracture involving a single endplate with involvement of the posterior vertebral wall.
Subaxial Spine Fractures Classification System 18
Type A: Compression injuries
A3.Incomplete burst
Burst fracture involving a single endplate with
involvement of the posterior vertebral wall.
Subaxial Spine Fractures Classification System 19
Type A: Compression injuries
A4.Complete burst
Burst fracture or sagittal split involving both endplates.
Subaxial Spine Fractures Classification System 20
Type A: Compression injuries
A4.Complete burst
Burst fracture or sagittal split involving both endplates.
Subaxial Spine Fractures Classification System 21
Type A: Compression injuries
A4.Complete burst
Burst fracture or sagittal split involving both endplates.
Subaxial Spine Fractures Classification System 22
Type B: Tension band injuries
B1. Posterior tension band injury (bony)
Physical separation through fractured bony structures only.
Subaxial Spine Fractures Classification System 23
Type B: Tension band injuries
B2.Posterior tension band injury (bony
capsuloligamentous, ligamentous)
Complete disruption of the posterior capsuloligamentous or bony capsuloligamentous
structures together with a vertebral body, disk, and/or facet injury.
Subaxial Spine Fractures Classification System 24
Type B: Tension band injuries
B3.Anterior tension band injury
Physical disruption or separation of the anterior structures
(bone/disk) with tethering of the posterior elements.
Subaxial Spine Fractures Classification System 25
Type C: Translation injuries
C.Translational injury in any axis-displacement or translation
of one vertebral body relative to another in any direction
Subaxial Spine Fractures Classification System 26
Bilateral injuries
BL. Bilateral injury
Subaxial Spine Fractures Classification System 27
Facet injuries
F1.Nondisplaced facet fracture
With fragment <1cm in height, <40% of lateral mass.
Subaxial Spine Fractures Classification System 28
Facet injuries
F2.Facet fracture with potential for instability
With fragment >1cm, > than 40% lateral mass, or displaced.
Subaxial Spine Fractures Classification System 29
Facet injuries
F3. Floating lateral mass
Subaxial Spine Fractures Classification System 30
Facet injuries
F4. Pathologic subluxation or perched/dislocated facet
Subaxial Spine Fractures Classification System 31
Facet injuries
F4. Pathologic subluxation or perched/dislocated facet
Subaxial Spine Fractures Classification System 32
Facet injuries
F4. Pathologic subluxation or perched/dislocated facet
Subaxial Spine Fractures Classification System 33
C7-T1: C
(T1:A1; F4 BL; N4)
(assume bilateral)
Case Example 1.
25 year old male involved in high speed MVA, complete SCI
Subaxial Spine Fractures Classification System 34
C7-T1: C
(T1:A1; F4 BL; N4)
Translational injury (C), with compression fracture
at T1 (A1), bilateral facet dislocations (F4 BL),
complete SCI (N4)
(assume bilateral)
Case Example 1.
25 year old male involved in high speed MVA, complete SCI
Subaxial Spine Fractures Classification System 35
C5: F2, C6: F2
(N2; M1)
Case Example 2.
42 year old male involved in high speed MVA, radiculopathy
Subaxial Spine Fractures Classification System 36
C5: F2, C6: F2
(N2; M1)
C5 and C6 displaced facet fractures (F2),
radiculopathy (N2), posterior capsuloligamentous
complex injury without complete disruption (M1)
Case Example 2.
42 year old male involved in high speed MVA, radiculopathy
AOSpine Classification and Injury
Severity System for Traumatic Fractures
of the Thoracolumbar Spine
AOSpine Knowledge Forum
Project members
(in alphabetic order)
Disclaimer
Aarabi B, Bellabarba C, Chapman J, Dvorak M, Fehlings M, Kandziora F, Kepler C,
Oner C, Rajasekaran S, Reinhold M, Schnake K, Vialle L and Vaccaro A.
1. Vaccaro, A. R., C. Oner, C. K. Kepler, M. Dvorak, K. Schnake, C. Bellabarba, M. Reinhold,
B. Aarabi, F. Kandziora, J. Chapman, R. Shanmuganathan, M. Fehlings, L. Vialle, A. O.
S. C. Injury and F. Trauma Knowledge (2013). “AOSpine thoracolumbar spine injury
classification system: fracture description, neurological status, and key modifiers.” Spine
(Phila Pa 1976) 38(23): 2028-2037.
2. Kepler, C. K., A. R. Vaccaro, J. D. Koerner, M. Dvorak, F. Kandziora, S. Rajasekaran, L. Vialle,
M. Fehlings, G. D. Schroeder, M. Reinhold, K. Schnake, C. Bellabarba and C. Oner (2015).
“Reliability Analysis of the AOSpine thoracolumbar Spine Injury Classification System by a
Worldwide Group of Naïve Spinal Surgeouns.” European Spine Journal. (in press)
3. Submitted to AOSpine International Board for endorsement as the official AOSpine TL
Fractures Classification
This is the present form of the classification and injury severity system the AOSpine Knowledge Forum (KF)
SCI & Trauma is working on. It is the aim of the KF to develop a system, which can in the future be used as a tool
for scientific research and a guide for treatment. This system is being subjected to a rigorous scientific assessment.
Thoracolumbar Spine Fractures Classification System 38
Thoracolumbar Fractures–Overview
This classification and injury severity system is based
on the evaluation of three basic parameters:
1. Morphologic classification of the fracture
2. Neurologic injury
3. Clinical modifiers
Thoracolumbar Spine Fractures Classification System 39
1. Morphologic classification
A. B. C.
This is based on the Magerl classification modified by the AOSpine Classification Group.
For this evaluation radiograms and CT scans with multiplanar reconstructions are essential.
In some cases additional MR images might be necessary. Three basic types are identified
on the basis of the mode of failure of the spinal column:
Type A: Compression injuries. Failure of anterior structures under compression.
Type B: Failure of the posterior or anterior tension band.
Type C: Failure of all elements leading to dislocation or displacement.
Thoracolumbar Spine Fractures Classification System 40
Type A
Describe injury to the vertebral body without tension band (PLC) involvement.
There are five subtypes and no further sub-classification.
These subtypes are also used as description of vertebral body fracture in B and C Types.
Type
A0
A2
A1
A3
A4
Description
Fractures, which do not compromise the structural integrity of the spinal column
such as transverse process or spinous process fractures.
Fracture of both endplates without involvement of the posterior wall
of the vertebral body.
Fracture of a single endplate without involvement of the posterior wall
of the vertebral body.
Fracture with any involvement of the posterior wall; only a single endplate
fractured. Vertical fracture of the lamina is usually present and does not constitute
a tension band failure.
Fracture with any involvement of the posterior wall and both endplates. Vertical fracture
of the lamina is usually present and does not constitute a tension band failure.
Minor, nonstructural
fractures
Split
Wedge-compression
Incomplete burst
Complete burst
Thoracolumbar Spine Fractures Classification System 41
Type B
Describe the failure of posterior or anterior constraints (in case of TL this is the tension band or
PLC / Posterior Ligamentary Complex or the anterior longitudinal ligament).
Is to be combined with subtypes A when appropriate. There are three subtypes:
Type
B1
B3
B2
Description
Monosegmental pure osseous failure of the posterior tension band.
The classical Chance fracture.
Injury through the disk or vertebral body leading to a hyperextended position of the
spinal column. Commonly seen in ankylotic disorders. Anterior structures, especially
the ALL are ruptured but there is a posterior hinge preventing further displacement.
Bony and/or ligamentary failure of the posterior tension band together with
a Type A fracture. Type A fracture should be classified separately.
Transosseous tension
band disruption /
Chance fracture
Hyperextension
Posterior tension
band disruption
Thoracolumbar Spine Fractures Classification System 42
Type C
Describe displacement or dislocation.
There are no subtypes as because of the dissociation between cranial and
caudal segments various configurations are possible in different images.
Is combined with subtypes of A if necessary.
Thoracolumbar Spine Fractures Classification System 43
Type A
A0.Minor, nonstructural fractures
Fractures, which do not compromise the structural integrity of the spinal column
such as transverse process or spinous process fractures.
Thoracolumbar Spine Fractures Classification System 44
Type A
A1. Wedge-compression
Fracture of a single endplate without involvement
of the posterior wall of the vertebral body.
Thoracolumbar Spine Fractures Classification System 45
Type A
A2.Split
Fracture of both endplates without involvement
of the posterior wall of the vertebral body.
Thoracolumbar Spine Fractures Classification System 46
Type A
A3.Incomplete burst
Fracture with any involvement of the posterior wall; only a single endplate fractured.
Vertical fracture of the lamina is usually present and does not constitute a tension band failure.
Thoracolumbar Spine Fractures Classification System 47
Type A
A4.Complete burst
Fracture with any involvement of the posterior wall and both endplates.
Vertical fracture of the lamina is usually present and does not constitute a tension band failure.
Thoracolumbar Spine Fractures Classification System 48
Type B
B1. Transosseous tension band disruption/Chance fracture
Monosegmental pure osseous failure of the posterior tension band.
The classical Chance fracture.
Thoracolumbar Spine Fractures Classification System 49
Example: This should be classified as: T12-L1Type B2
with T12 A4 according to the combination rules.
Type B
B2.Posterior tension band disruption
Bony and/or ligamentary failure of the posterior tension band together with a Type A fracture.
Type A fracture should be classified separately.
Thoracolumbar Spine Fractures Classification System 50
Type B
B3.Hyperextension
Injury through the disk or vertebral body leading to a hyperextended position of the spinal column.
Commonly seen in ankylotic disorders. Anterior structures, especially the ALL are ruptured but there
is a posterior hinge preventing further displacement.
Thoracolumbar Spine Fractures Classification System 51
Type C
C.Displacement or dislocation
There are no subtypes as because of the dissociation between cranial and caudal segments various
configurations are possible in different images. Is combined with subtypes of A if necessary.
Thoracolumbar Spine Fractures Classification System 52
Algorithm for morphologic classification
START Yes
Yes
No
No
No
No
No No injury
No
No
Yes
Yes
Yes
Yes
Yes
Translation
Insignificant injury
Complete burst
Hyperextension
Split/Pincer
Pure transosseous
disruption
Wedge/Impaction
Incomplete burst
Osseoligamentous
disruption
C
A0
A4
B3
A2
B1
A1
A3
B2
Displacement/Dislocation
Vertebral process fracture
Vertebral body fracture
Tension band injury
Both endplates involved
Mono-segmental
osseous disruption
Posterior wall involvement
Posterior
Anterior
Yes
Yes
Yes
Both endplates involved
Osseoligamentous
disruption
Thoracolumbar Spine Fractures Classification System 53
2. Neurologic injury
Neurologic status at the moment of admission should be scored according to the following scheme:
Type
N0
N2
N1
N3
N4
NX
Description
Neurologically intact
Radicular symptoms
Transient neurologic deficit, which is no longer present
Incomplete spinal cord injury or any degree of cauda equina injury
Complete spinal cord injury
Neurologic status is unknown due to sedation or head injury
Thoracolumbar Spine Fractures Classification System 54
3. Modifiers
There are two modifiers, which can be used in addition to ad 1 and 2:
Type
M1
M2
Description
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.
AOSpine Classification and Injury
Severity System for Traumatic Fractures
of the Sacral Spine
AOSpine Knowledge Forum
Project members
(in alphabetic order)
Disclaimer
Xxxxx
1. Xxxxx
Xxxxx
Sacral Spine Fractures Classification System 56
Sacral Fractures: Overview
Sacral Fractures
Lumbosacral Dislocation
(Isler)
Pelvic Ring Fractures
(Tile, Letournel, AO)
Sacral Fractures
(Denis, Roy-Camille)
Sacral Spine Fractures Classification System 57
Implications on Prognosis & Treatment
Degree of instability
• Broadly correlated with:
– Energy of injury
– Amount of displacement
Type of instability
• Location of fracture:
– Lower sacrum (no pelvic or spino-pelvic involvement)
– Posterior pelvic
– Spino-pelvic
– Both posterior pelvic & spino-pelvic
Neurological injury
• Broadly correlated with:
– Energy of injury
– Amount of displacement
Sacral Spine Fractures Classification System 58
Sacral Fractures–Overview
Hierarchical system progressing from least to most unstable
Type A. Lower Sacrococcygeal Injuries
• NO IMPACT ON POSTERIOR PELVIC OR SPINO-PELVIC INSTABILITY
• Eg. Compression/avulsion fractures/injuries below sacroiliac joints
• *Higher grade subtypes may be associated with neuro injury
Type B. Posterior Pelvic Injuries
• PRIMARY IMPACT IS ON POSTERIOR PELVIC STABILITY
• Unilateral longitudinal (vertical) sacral fractures
• No impact on spino-pelvic stability
• Framework is a variation of Denis Zones I through III injuries
Type C. Spino-Pelvic Injuries
• SPINO-PELVIC INSTABILITY
• +/– posterior pelvic instability
• L5-S1 facet involvement, Sacral U variants, bilat longitudinal injuries
• Subtype severity based on instability & likelihood of neuro injury
Sacral Spine Fractures Classification System 59
Type A–Sacrococcygeal Injuries
Definition:
• Injuries below the S-I joint (usually S2)
• No impact on posterior pelvic or spino-pelvic instability
• *May* have impact on neurology
Type A1
• Coccygeal or compression vs ligamentous
avulsion fractures
Type A2
• Non-displaced transverse fractures below the S-I joint
Type A3
• Displaced transverse fractures below the S-I joint
Sacral Spine Fractures Classification System 60
Type A
A1. Coccygeal or compression vs ligamentous avulsion fractures
Sacral Spine Fractures Classification System 61
Type A
A2.Non-displaced transverse fractures below the S-I joint
No implications on stability
Low likelihood of cauda equina injury
Sacral Spine Fractures Classification System 62
Type A
A3.Displaced transverse fractures below the S-I joint
Higher likelihood of neuro injury than A1 or A2 (displacement)
May possibly benefit from reduction & stabilization
Sacral Spine Fractures Classification System 63
Type B–Posterior Pelvic Injuries
Definition:
• Unilateral longitudinal sacral fractures
• Primary impact is on posterior pelvic stability
• Mimimal to no impact on spino-pelvic stability
• Framework is variation of Denis Zones I through III injuries
• Usually treated with sacroiliac screw fixation
Type B1
• Central fracture: Involves spinal canal, but with primarily
longitudinal fracture pattern
Type B2
• Transalar fracture: Does not involve foramina or spinal canal
Type B3
• Transforaminal fracture: Involves foramina but not spinal canal
Sacral Spine Fractures Classification System 64
Type B
B1. Central fracture
Longitudinal injuries only–rare type of Denis Zone III injuries
Low likelihood of neurological injury
Sacral Spine Fractures Classification System 65
Type B
B2.Transalar fracture (may extend into the SI joint)
Unilateral Denis Zone I injury
Sacral Spine Fractures Classification System 66
Type B
B3.Transforaminal fracture
Denis Zone II injury
Sacral Spine Fractures Classification System 67
Type C–Spino-Pelvic Injuries
Definition:
• Injuries resulting in spino-pelvic instability
Type C0
• Nondisplaced sacral U-type variant
Type C1
• Alternative–Sacral U-type variant without posterior pelvic instability
Type C2
• Bilateral complete Type B injuries without transverse fracture
Type C3
• Displaced U-type sacral fracture
Sacral Spine Fractures Classification System 68
Type C
C0.Nondisplaced sacral U-type variant
Commonly seen low-energy insufficiency fracture
Sacral Spine Fractures Classification System 69
Type C
C1.Alternative–Sacral U-type variant without posterior pelvic instability
Any unilateral B-subtype where ipsilateral superior S1 facet is discontinuous with medial part of sacrum
May impact spino-pelvic stability (Isler)
Sacral Spine Fractures Classification System 70
Type C
C2.Bilateral complete Type B injuries without transverse fracture
More unstable and higher likelihood of neuro injury than C1
Sacral Spine Fractures Classification System 71
Type C
C3.Displaced U-type sacral fracture
Worst combination of instability and likelihood of neuro injury
Displaced transverse sacral fracture = canal compromise
Sacral Spine Fractures Classification System 72
Neurology
Type
Nx
N2
NO
N3
N1
N4
Neurological
Cannot be examined
Nerve root injury
No neurological deficits
Cauda Equina Syndrome/Incomplete SCI
Transient neurological injury
Complete SCI
Sacral Spine Fractures Classification System 73
Modifiers
Type
M1
M4
M2
M3
Description
Soft tissue injury
Sacroiliac joint injury
Metabolic bone disease
Anterior pelvic ring injury
Sacral Spine Fractures Classification System 74
Classification nomenclature
Transforaminal fracture (B3) high energy injury associated
with anterior pelvic ring (M1) and soft tissue injury (M3)
Primary
injury B3; M1, M3
Neurologic status
and modifiers
Sacral Spine Fractures Classification System 75
Summary
Morphological basis for new AOSpine sacral fracture classification
Neurological Exam
Modifiers for situations that impact treatment or prognosis
Further information: www.aospine.org/classification
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