Abstract
The most appropriate classification of traumatic thoracolumbar (TL) spine injuries remains controversial and current systems can be cumbersome and difficult to apply. No classification aids decision making in clinical management. Clinical spine trauma specialists from institutions around the world were canvassed with respect to information deemed pivotal in the communication of TL spine trauma and the clinical decision making process. Traditional injury patterns were reviewed and reconsidered in light of these essential characteristics. The reliability and validity of an earlier version of this system has been demonstrated.
The Thoracolumbar Injury Classification and Severity Score (TLICS) was devised based upon the three most important injury characteristics: 1) morphology of injury determined by radiographic appearance, 2) integrity of the posterior ligamentous complex, and 3) neurological status of the patient. These characteristics are largely independent of each other. A composite injury severity score can be calculated from these characteristics stratifying patients into surgical and non-surgical treatment groups. The three principal injury patterns are compression (including burst – 1 point each), translation/rotation (3 points) and distraction (4 points). Neurological status can be classified as a nerve root injury (1 point), a complete (ASIA A-2 points) or incomplete injury (3 points) to the spinal cord or conus, or injury of the cauda equina (3 points). Disruption of the posterior ligamentous complex and facet joint capsules results in instability. Disrupted posterior ligaments can be seen as subluxation or dislocation of a facet, interspinous widening, or MRI evidence of ligament discontinuity. Failure of the posterior ligamentous complex can be classified as indeterminate (2 points) or definitely disrupted (3points).
Coexisting clinical factors (qualifiers) may alter decision making by virtue of their effect on stability, general management or effect on healing. Metabolic disorders such as ankylosing spondylitis, DISH, osteoporosis and age may influence treatment. Injury characteristics such as excessive kyphosis, severe vertebral body collapse and sternal fracture may influence outcome and modify treatment. Treatment options might be influenced in patients with head injuries or polytrauma. The impact of these clinical qualifiers on patient care must be evaluated.
Once all the major variables have been assigned points, a total TLICS Score can be determined. Patients with 3 or less points are non-operative candidates while patients scoring 5 or more points should be considered for surgery. Clinical qualifiers may modify treatment. The morphology of the injury, neurological status, and integrity of the posterior ligamentous complex can help guide the management of TL injuries. Incomplete neurological injuries warrant anterior decompression if posterior realignment is ineffective in relieving neurological compromise. Distraction and translational injuries, and disruptions of the posterior ligamentous complex are managed optimally with an initial posterior approach for realignment and stabilization. Although there will always be limitations to any cataloging system, the TLICSS reflects accepted features cited in the literature important in predicting spinal stability, future deformity, and progressive neurological compromise. This classification system is intended to be easy to apply and to facilitate clinical decision making.
The abstracts were prepared by Assoc Prof Bruce McPhee. Correspondence should be addressed to him at the Division of Orthopaedics, The University of Queensland, Clinical Sciences Building, Royal Brisbane Hospital, Herston, Brisbane, 4029, Australia.
