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Updated: May 8, 2026

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The Surgical Algorithm for the AO Spine Sacral Injury Classification System.

Yunsoo Lee¹, Mark Lambrechts¹, Rajkishen Narayanan¹

¹Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, PA.

|November 16, 2023

Summary

A new surgical algorithm for sacral fractures was developed using the AO Spine Sacral Injury Classification System. This algorithm guides operative indications for sacral trauma based on international surgeon consensus.

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Area of Science:

Orthopedic surgery
Trauma surgery
Spine surgery

Background:

The AO Spine Sacral Injury Classification has international validation.
A consensus surgical algorithm for sacral fractures using the Sacral AO Spine Injury Score (Sacral AOSIS) is needed.

Purpose of the Study:

To establish a surgical algorithm for sacral fractures.
To base the algorithm on the AO Spine Sacral Injury Classification System.

Main Methods:

A global cross-sectional survey was conducted.
Orthopedic and neurosurgeons worldwide participated.
Responses informed the development of a surgical algorithm based on Sacral AOSIS.

Main Results:

An international agreement of 70% was reached for operative intervention recommendations.
Sacral AOSIS 5 or greater indicated operative management; 4 or less generally nonoperative.
AOSIS 3-4 with anterior pelvic ring injury (M3 modifier) allowed surgeon discretion.

Conclusions:

The AO Spine Sacral Injury Classification System provides a framework for sacral injuries.
A multispecialty, global surgeon input-driven algorithm for operative indications in sacral trauma was developed.
Further validation is needed, but the algorithm aids in developing standards of care.