AOSpine Subaxial Classification System

Type A. Compression Injuries Type B. Tension Band Injuries Type C. Translation Injuries

A0. Minor, nonstructural fractures

No bony injury or minor injury such as an isolated lamina fracture or
spinous process fracture.
B1. Posterior tension band injury (bony)
Physical separation through fractured bony structures only. C. Translational injury in any axis-displacement
or translation of one vertebral body relative
to another in any direction

A1. Wedge-compression
Compression fracture involving a single endplate without
involvement of the posterior wall of the vertebral body.
B2. Posterior tension band injury
(bony capsuloligamentous, ligamentous)
Complete disruption of the posterior capsuloligamentous or bony
Type F. Facet Injuries

F1. Nondisplaced facet fracture

capsuloligamentous structures together with a vertebral body, disk,
and/or facet injury.
With fragment <1cm in height, <40% of lateral mass.

A2. Split
Coronal split or pincer fracture involving both endplates without
involvement of the posterior wall of the vertebral body. F2. Facet fracture with potential for instability
With fragment >1cm, > than 40% lateral mass, or displaced.

B3. Anterior tension band injury

Physical disruption or separation of the anterior structures (bone/disk)
with tethering of the posterior elements.

A3. Incomplete burst

Burst fracture involving a single endplate with involvement of the
F3. Floating lateral mass

posterior vertebral wall.

BL. Bilateral Injuries

BL. Bilateral injury F4. Pathologic subluxation or perched/

dislocated facet

A4. Complete burst

Burst fracture or sagittal split involving both endplates.

Algorithm for morphologic classification Neurology Modifiers

Type Description Type Description
Displacement/
START
Dislocation
YES C Translation
N0 Neurologically intact
M1 Posterior Capsuloligamentous Complex injury without complete disruption.
N1 Transient neurologic deficit, resolved
NO
N2 Radiculopathy M2 Critical disk herniation.
Anterior YES B3 Hyperextension
Tension band
N3 Incomplete spinal cord injury
YES Osseoligamentous Osseoligamentous
injury YES B2 disruption M3 Stiffening/metabolic bone disease (ie DISH, AS, OPLL, OLF).
disruption N4 Complete spinal cord injury
Posterior
Mono-segmental Pure transosseous NX Cannot be examined
osseous disruption
YES B1 disruption
M4 Vertebral artery abnormality.
+ Continued spinal cord compression
NO

Vertebral body Both endplates YES A4 Complete burst Classification nomenclature

YES involved
fracture C6-C7 translation injury (C) C6-C7 flexion-distraction-injury (B2) with perched facet dislocation on right side (F4),
NO A3 Incomplete burst
Posterior wall involvement YES with a C7 compression fracture (A1) facet fracture on the left side (F2), radiculopathy C7 (N2) and ankylosing spondylitis (M3)
YES A2 Split/Pincer
NO
NO Both endplates C6-C7: C Primary injury C6-C7: B2**
involved A1 Wedge/Impaction
NO Neurologic status
Vertebral process (C7: A1) Secondary injury Secondary facet injury (F4*, F2*, N2, M3) and modifiers
fracture YES A0 Insignificant injury

NO No injury *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.

Disclaimer:

1. Vaccaro AR, Koerner JD, Radcliff KE, Oner FC, Reinhold M, Schnake KJ, Kandziora F, Fehlings MG, Dvorak MF, Aarabi B, Rajasekaran S, Schroeder GD, Kepler CK, Vialle LR. “AOSpine subaxial cervical spine injury classification system.” Eur Spine J., February 26, 2015. (e-pub)

© 2018 AOSpine International

This work is licensed under the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.
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www.aospine.org/classification
AOSpine Thoracolumbar Classification System
Type A. Compression Injuries Type B. Distraction Injuries Type C. Translation Injuries

A0. Minor, nonstructural fractures

Fractures, which do not compromise the structural integrity of the
spinal column such as transverse process or spinous process fractures.
B1. Transosseous tension band disruption
Chance fracture C. Displacement or dislocation
There are no subtypes because various configurations are possible due to
dissociation/dislocation. Can be combined with subtypes of A or B.
Monosegmental pure osseous failure of the posterior tension band.
The classical Chance fracture.

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.

A1. Wedge-compression
Fracture of a single endplate without involvement of the posterior
wall of the vertebral body.
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.

A2. Split
Fracture of both endplates without involvement
of the posterior wall of the vertebral body.

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
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.
band failure.

Algorithm for morphologic classification Neurology Modifiers

Type Description Type Description
Displacement/
START
Dislocation
YES C Translation
N0 Neurologically intact
This modifier is used to designate fractures with an indeterminate
injury to the tension band based on spinal imaging with or
NO N1 Transient neurologic deficit, which is no longer present
without MRI. This modifier is important for designating those
M1 injuries with stable injuries from a bony standpoint for which
N2 Radicular symptoms
Anterior YES B3 Hyperextension ligamentous insufficiency may help determine whether operative
Tension band stabilization is a consideration.
YES Osseoligamentous Osseoligamentous N3 Incomplete spinal cord injury or any degree of cauda equina injury
injury YES B2 disruption
disruption
Posterior N4 Complete spinal cord injury
Is used to designate a patient-specific comorbidity, which might
Mono-segmental Pure transosseous
osseous disruption
YES B1 disruption argue either for or against surgery for patients with relative surgical
NX Neurologic status is unknown due to sedation or head injury M2 indications. Examples of an M2 modifier include ankylosing
spondylitis or burns affecting the skin overlying the injured spine.
NO + Continued spinal cord compression

Vertebral body Both endplates YES A4 Complete burst

fracture
YES involved
NO A3 Incomplete burst
Classification nomenclature
Posterior wall involvement YES
YES A2 Split/Pincer Displacement injury of the segment T 8/9 with an incomplete burst Complete burst fracture of L1, neurologically
NO
NO Both endplates fracture of T9, incomplete spinal cord injury, ankylosing spondylitis intact, PLC status unclear
involved A1 Wedge/Impaction
NO
Vertebral process T8-T9: C Primary injury L1: A4
fracture YES A0 Insignificant injury
Secondary injury (T9: A3; N3; M2) Neurologic status and modifiers (N0; M1)
NO No injury

Disclaimer:

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. 2. Kepler, C. K., A. R. Vaccaro, J. D. Koerner, M. F. Dvorak, F. Kandziora, S. Rajasekaran, B. Aarabi, L. R. Vialle, M. G. Fehlings, G. D. Schroeder, M. Reinhold, K. J. Schnake, C. Bellabarba
Trauma Knowledge (2013). “AOSpine thoracolumbar spine injury classification system: fracture description, neurological status, and key modifiers.” Spine (Phila Pa 1976) 38(23): 2028-2037. and F. Cumhur Oner (2015). “Reliability analysis of the AOSpine thoracolumbar spine injury classification system by a worldwide group of naive spinal surgeons.” Eur Spine J. (e-pub)

© 2018 AOSpine International

This work is licensed under the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.
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AOSpine Sacral Classification System
Type A. Type B. Type C.
Lower Sacrococcygeal Injuries Posterior Pelvic Injuries Spino-Pelvic Injuries
No impact on posterior pelvic or spino-pelvic instability Primary impact is on posterior pelvic stability Spino-pelvic instability

A1. Coccygeal or compression vs

ligamentous avulsion fractures B1. Central Fracture–involves spinal canal
• Longitudinal injuries only–rare type of Denis Zone III injuries
• Low likelihood of neurological injury
CO. Nondisplaced sacral U-type variant
• Commonly seen low-energy insufficiency fracture

B2. Transalar Fracture–does not involve

foramina or spinal canal
• Unilateral Denis Zone I injury

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

A2. Non-displaced transverse fractures • May impact spino-pelvic stability (Isler)

below the S-I joint

• No implications on stability
• Low likelihood of cauda equina injury

C2. Bilateral complete Type B injuries

without transverse fracture
• More unstable and higher likelihood of neuro injury than C1

B3. Transforaminal Fracture–involves foramina

but not spinal canal
• Denis Zone II injury

A3. Displaced transverse fractures

below the S-I joint
• Higher likelihood of neuro injury than A1 or A2 (displacement)
C3. Displaced U-type sacral fracture
• Worst combination of instability and likelihood of neuro injury
• Displaced transverse sacral fracture = canal compromise
• May possibly benefit from reduction and stabilization

Sacral Fractures–Overview Neurology Modifiers Classification nomenclature

Hierarchical system progressing from Type Neurological Type Description
least to most unstable Transforaminal fracture (B3) high energy injury
N0 No neurological deficits
M1 Soft tissue injury
associated with soft tissue injury (M1)
Type A. Lower Sacrococcygeal Injuries N1 Transient neurological injury and anterior pelvic ring (M3)
No impact on posterior pelvic or spino-pelvic N2 Nerve root injury M2 Metabolic bone disease
instability
N3 Cauda Equina Syndrome/Incomplete SCI
Primary
injury B3; M1, M3
Type B. Posterior Pelvic Injuries Neurologic status
N4 Complete SCI M3 Anterior pelvic ring injury
Primary impact is on posterior pelvic stability and modifiers

Type C. Spino-Pelvic Injuries NX Cannot be examined

M4 Sacroiliac joint injury
Spino-pelvic instability + Continued spinal cord compression

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AOSpine Upper Cervical Classification System
I. Occipital Condyle and II. C1 Ring and C1-2 Joint III. C2 and C2-3 Joint
Craniocervical junction

Type A. Isolated bony injury (condyle) Type A. Isolated bony only (arch) Type A. Bony injury only without
ligamentous, tension band, discal injury

Type B. Non-displaced ligamentous Type B. Ligamentous injury Type B. Tension band / Ligamentous
injury (craniocervical) (transverse atlantal ligament) injury with or without bony injury

Type C. Any injury with displacement Type C. Atlantoaxial instability / Type C. Any injury that leads to vertebral
on spinal imaging Translation in any plane body translation in any directional plane

Upper Cervical Spine Fractures Overview Neurology Modifiers Classification nomenclature

Type Neurological Type Description
I. Occipital condyle II. C1 ring and C1-2 III. C2 and C2-3 Atlanto-occipital dissociation with a
and occipital cervical complete spinal cord injury.
joint complex injuries joint complex injuries NO Neurologically intact Injuries at High Risk of Non-
joint complex injuries M1
Union with Nonoperative Tx
N1 Transient neurologic deficit

Type A. Type B. Type C. N2 Radiculopathy M2

Injury with significant potential OC Type C , N4
for instability
Bony injury only Tension band/ligamentous injury Translation injury
N3 Incomplete Spinal cord injury
Without significant With or without bony injury Any injury with significant
M3
Patient Specific Factors Primary Neurologic
ligamentous, tension No complete separation of translation in any directional N4 Complete spinal cord injury Affecting Tx injury status and
band, discal injury anatomic integrity plane and separation of
modifiers
Stable injuries anatomic integrity NX Unexaminable patient
Stable or unstable depending Vascular Injury or Abnormality
on injury specifics Unstable injuries M4
Affecting Tx
+ Continued spinal cord compression

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