Thoracolumbar Spine Trauma Classification.pdf

Thoracolumbar Spine TraumaClassification

Abstract

Thoracolumbar spine trauma is among the most commonmusculoskeletal injuries worldwide. However, there is littleconsensus on the adequate management of spine injury, in partbecause there is no widely accepted classification system. Severalsystems have been developed based on injury anatomy or inferredmechanisms of action, but they have demonstrated poor reliability,have yielded little prognostic information, and have not been widelyused. The Thoracolumbar Injury Classification and Severity Score(TLICS) was developed to address these limitations. The TLICSdefines injury based on three clinical characteristics: injurymorphology, integrity of the posterior ligamentous complex, andneurologic status of the patient. The severity score offersprognostic information and is helpful in medical decision making.Initial application of the TLICS has shown good to excellentreliability and validity. Additional evaluation of the TLICS is neededto prospectively define its clinical utility and identify potentiallimitations.

Spine fractures account for a largeportion of musculoskeletal inju-

ries worldwide. Approximately 75%to 90% of spinal fractures occur inthe thoracic and lumbar spine, withmost of these occurring at the thora-columbar junction (T10-L2).1-3 De-spite the high incidence of thora-columbar fractures, there is littleconsensus regarding injury classifica-tion and management.4 Treatmentvaries widely, from bracing to cir-cumferential fusion, based on geo-graphical, institutional, and surgeonpreferences rather than on scientificevidence. A principal reason for thisvariability lies in the lack of a widelyaccepted classification system. In theabsence of a common language withwhich to accurately define thora-columbar injuries, it is not surprisingthat optimal treatment remains elu-sive.

Ideally, a classification system isdescriptive and prognostic. The sys-tem must be easy to remember andapply in clinical practice, based on asimple algorithm with consistent ra-diographic and clinical characteris-tics. Additionally, the classificationshould provide information on theseverity and natural history of an in-jury pattern. Finally, by accountingfor injury prognosis, the classifica-tion should guide clinical decisionmaking. Such a system would be acritical tool for clinical outcomes re-search.

Historically, classification systemshave been based on retrospective re-views and the experience of individ-ual surgeons.5-7 These systems aretypically based on descriptions of an-atomic structures (eg, Denis three-column system), proposed mecha-nisms of injury (eg, Watson-Jones,

Alpesh A. Patel, MD

Alexander R. Vaccaro, MD, PhD

From the Department ofOrthopaedics, University of UtahSchool of Medicine, Salt Lake City,UT (Dr. Patel), and the Departmentof Orthopaedic Surgery, ThomasJefferson University, Philadelphia,PA (Dr. Vaccaro).

J Am Acad Orthop Surg 2010;18:63-71

Copyright 2010 by the AmericanAcademy of Orthopaedic Surgeons.

Review Article

February 2010, Vol 18, No 2 63

AO), or a combination thereof.5-8

Many systems are convoluted, withan impractical number of variables.Others are too simple, lacking suffi-cient detail to provide clinically rele-vant information.

Although these classification systemshave provided commonly used nomen-clature, none has gained widespread ac-ceptance. The lack of an accepted sys-tem has encouraged authors to definefurther systems, each hampered by thesame limitations as those of the exist-ing systems. The large number of sys-tems has led to increased confusion anddecreased agreement and accuracy inclassifying thoracolumbar trauma. TheThoracolumbar Injury Classificationand Severity Score (TLICS) was devel-oped to address the shortcomings ofprior systems and to offer an improvedmeans of classifying thoracolumbarspine trauma.

Historical ClassificationSystems

The historical sequence and clinicalbasis of thoracolumbar classificationsystems was described in excellentdetail by Mirza et al9 (Table 1).These systems are based on either de-scriptors of anatomic disruption orinferred mechanisms of injury.

Anatomic DisruptionWatson-Jones6 described the firstthoracolumbar injury classificationsystem in 1938. In a retrospective re-

view, he described three injury char-acteristics: simple wedge fracture,comminuted fracture, and fracture-dislocation. This system was the firstto use injury classification as aguide for medical decision making.Watson-Jones suggested different re-duction techniques for the manage-ment of wedge and comminutedfractures and surgical reduction forcertain fracture-dislocations.

Perhaps better known is the ana-tomic classification of Kelly andWhitesides,10 which was later modi-fied by Denis.7 In a review of 11 pa-tients, Kelly and Whitesides10 dividedthe spine into an anterior (ie, verte-bral body) column and a posterior(ie, neural arch) column. The authorsdescribed spinal instability as thepresence of disruption in both theanterior column and the posteriorcolumn. Although the authors de-scribed fracture patterns, it is the“column” concept that has persisted.In 1983, Denis7 refined this columnconcept of thoracolumbar trauma bydescribing a middle column consist-ing of the posterior vertebral body,posterior longitudinal ligament, andposterior anulus. Denis did not de-fine rigid parameters of stability andinstability. Rather, he stratified therisk of neurologic injury based ontwo-column involvement and modeof failure of the middle column. Al-though the fracture subtypes pro-posed by Denis7 provided little addi-tional information with regard to

classifying thoracolumbar injury, histhree-column description clearly dis-tinguishes compression fractures (an-terior column) from burst fractures(anterior column, middle column).

Neither of these anatomic classifi-cation systems accounts for the pa-tient’s neurologic status, addressesthe importance of the posterior liga-mentous structures, provides prog-nostic information, or guides clinicaldecision making. The Denis systemhas shown only fair to good interob-server reliability in separate investi-gations.16,17 Although these classifica-tions have provided nomenclaturefor thoracolumbar trauma, their lim-itations significantly impede theirclinical utility as reproducible tools.

MechanisticHoldsworth11 described the firstmechanistic classification system forspinal injuries based on his experi-ence with more than 1,000 patientswith spinal column and spinal cordinjuries. He categorized fracturesas simple wedge, dislocation, rota-tional fracture-dislocation, exten-sion, burst, and shear. This systemwas the first to emphasize the role ofthe posterior ligamentous complex(PLC) in determining spinal stability.Holdsworth11 also recommended sur-gical treatment of specific injury pat-terns (ie, pure dislocations) as well asof dislocations associated with neu-rologic injury. Although this systemoffers rudimentary treatment recom-

Dr. Patel or an immediate family member has received royalties from Amedica; is a member of a speakers’ bureau or has made paidpresentations on behalf of Stryker Spine, Amedica, and Medtronic; serves as a paid consultant to or is an employee of Amedica; andhas received research or institutional support from DePuy Spine. Dr. Vaccaro or an immediate family member serves as a boardmember, owner, officer, or committee member of the American Spinal Injury Association, the North American Spine Society, AO NorthAmerica, Computational Biodynamics, and Progressive Spinal Technology/Advanced Spinal Intellectual Properties; has receivedroyalties from Aesculap/B.Braun, Biomet, DePuy, Globus Medical, Lippincott, Elsevier, Medtronic Sofamor Danek, Stryker, Thieme, K2Spine, Stout Medical, and Progressive Spinal Technology/Applied Spinal Intellectual Properties; is a member of a speakers’ bureau orhas made paid presentations on behalf of Stryker, Medtronic Sofamor Danek, and DePuy Spine; serves as a paid consultant to or isan employee of Biomet, DePuy, Medtronic Sofamor Danek, Stryker, Vertiflex, and Osteotech; has received research or institutionalsupport from AO North America, DePuy, Medtronic Sofamor Danek, and Stryker; and has stock or stock options held in GlobusMedical, Disc Motion Technology, Vertebron, Progressive Spinal Technologies/Advanced Spinal Intellectual Properties, ComputationalBiodynamics, Stout Medical, Paradigm Spine, K2 Medical, Replication Medica, Spinology, Spine Medica, Orthovita, Vertiflex, SmallBone Technologies, NeuCore, Crosscurrent, Syndicom, In Vivo, Flagship Surgical, and Pearl Driver.

Thoracolumbar Spine Trauma Classification

64 Journal of the American Academy of Orthopaedic Surgeons

mendations, few data have been pub-lished to support its claims.9

Ferguson and Allen5 developedtheir classification based on a retro-spective review of spine radiographs.Similar to the subaxial cervicaltrauma system described by the sameauthors in 1982,18 the thoracolum-bar system defines injury patternsthrough inferred mechanisms of in-jury. Seven injury types and 12 injurysubtypes were defined. Injury typesinclude vertical compression, com-pression flexion, distraction flexion,lateral flexion, translation, torsionalflexion, and distractive extension.

The authors described a treatmentalgorithm based on this system aswell as on methods of spinal fixationavailable at that time: posterior dis-traction, posterior compression, seg-mental posterior fixation, and ante-rior fixation.19 Although this systemadded to the nomenclature of thora-columbar trauma, the number of in-jury patterns and subtypes makes itdifficult to use in the clinical setting.Additionally, very few data are avail-able on its reliability and validity.The Ferguson and Allen classifica-tion is fundamentally limited becauseit is based on an inferred injury

mechanism rather than on objectiveradiographic findings (ie, injury mor-phology).

The AO thoracolumbar system is amore recent mechanistic classifica-tion system described by Magerlet al.8 This system is based on theAO classification that had previouslybeen used for orthopaedic extremityinjuries. The AO/Magerl classifica-tion defines three major mechanismsof spinal injury—compression (A),distraction (B), and torsion (C)—toindicate increasing injury severity ac-cording to increasing grade of injury.Three groups exist within each type

Table 1

Data Supporting the Common Classification Schemes

StudyNo. of

SubjectsImagingModality

ClassificationVariables

No. of InjuryCategories

(Specific Types)Treatment or

Prognostic Value

Watson-Jones6 252 Rad Radiographic patterns 3 (7) Postural reduction withhyperextension for goodfunctional results

Chance12 3 Rad Radiographic patterns 1 100% healing rate withextension casting

Nicoll13 152 Rad Radiographic patterns 4 (7) Only unstable fractures needcast fixation

Holdsworth11 “A large number” Rad Radiographic patterns 6 Reversing the mechanism ofinjury can assist nonsurgi-cal reduction

Kelly andWhitesides10

11 Rad Two spinal columns 8 Surgery to restore theinvolved column

Denis7 412 Rad and CT Three spinal columns;three modes of failure*

5 (21)† Treatment is not related toinjury pattern

McAfee et al14 100 Rad and CT Three spinal columns;three modes of failure*

6 Mode of failure determinestreatment type

Ferguson andAllen5

Not listed Rad and CT Seven mechanisms ofinjury, with subtypesbased on severity

8 (12) Treatment is not related toinjury pattern

McCormacket al15

28 Rad and CT Comminution, fragmentapposition, kyphosiswith three severitygrades for each

9 Severe injury predicts failureof short-segment posteriorfixation with plates andscrews

Magerl et al8 1,445 Rad and CT Three injury types withthree groups per typeand additional sub-types

3 (53)† Higher injury grades implymore severe injury andhigher risk of neurologicdeficit

* Each column is assigned a presumed mode of failure based on radiography and CT findings. Each category is subdivided by radiographicpattern and injury severity.† Additional undefined terms such as “more severe” distinguish cases within specific injury types.Rad = plain radiographAdapted from Mirza SK, Mirza AJ, Chapman JR, Anderson PA: Classifications of thoracic and lumbar fractures: Rationale and supporting data.J Am Acad Orthop Surg 2002;10:364-377.

Alpesh A. Patel, MD, and Alexander R. Vaccaro, MD, PhD


of injury (eg, A1, A2, A3), and eachgroup is divided into three subgroups(eg, A1.1, A1.2, A1.3). Injury sever-ity is indicated by increasing valuesof injury classification. For example,type A injuries are less severe thantype C injuries, and type B1 injuriesare less severe than type B2 injuries.In addition to the aforementionedlimitations of inferred injury mecha-nisms, the AO system is a victim ofits comprehensiveness. The largenumber of subgroups lends a com-plexity that limits incorporation ofthe system into routine clinical prac-tice. This has also limited its reliabil-ity, as demonstrated independentlyby Wood et al16 and Oner et al.17

Blauth et al20 demonstrated only fairinterobserver reliability for the threemain AO categories (A, B, C; κ =0.33), with rapidly decreasing reli-ability with the inclusion of the AOsubtypes.

The mechanistic classification systemshave inherent limitations. They arebased on inferred mechanisms of injuryrather than on an objective descriptionof injury morphology.4 They do not

account for the neurologic status ofthe patient, a critical component inmedical decision making. Further-more, the comprehensive nature ofthese descriptors adds convolution,decreases reliability, and limits clini-cal and research utility. Finally, thesesystems are based on plain radio-graphs and early CT technology. Im-provements in imaging, such as high-resolution CT and MRI, are notreflected. Hampered by such limita-tions, these systems do not providesufficient data to guide current surgi-cal and nonsurgical decision making.

Thoracolumbar InjuryClassification andSeverity Score

Introduced by the Spine TraumaStudy Group in 2005, the TLICS wasdesigned to provide a clear, reliableclassification system that accountsfor many of the shortcomings ofprior systems.21 The TLICS is basedon an extensive review of the litera-ture as well as consensus opinion

from a multinational group of 40spinal trauma surgeons from 15trauma centers in the United States,Canada, Australia, Germany, Mex-ico, France, Sweden, India, and theNetherlands. The literature reviewidentified the limitations of previ-ously described classification systemsas well as the critical components ofmedical decision making in thora-columbar trauma. These findingswere then reviewed by all involvedsurgeons and, through consensusopinion, three major injury charac-teristics were defined: injury mor-phology, neurologic status, and in-tegrity of the PLC. Point values areassigned to each major categorybased on injury severity (Table 2).The sum of these points representsthe TLICS severity score, which maybe used to guide treatment.

Injury MorphologyInjury morphology is divided intothree subtypes, with increasing sever-ity: compression, rotation/transla-tion, and distraction. Although thesedescriptors share the nomenclatureof mechanistic systems, the TLICS isunique in that it defines objective ra-diographic findings for each injurymorphology.

Compression injuries are definedby a loss of height of the vertebralbody or disruption through the ver-tebral end plate. This includes tradi-tional compression (ie, anterior col-umn) and burst (ie, anterior column,middle column) fractures. Sagittaland coronal plane vertebral fracturesare difficult to classify using the col-umn descriptors.

Rotation/translation injury is iden-tified by horizontal displacement ofone thoracolumbar vertebral bodywith respect to another. It is typifiedby unilateral and bilateral disloca-tions and facet fracture-dislocations,as well as bilateral pedicle or parsfractures with vertebral subluxation.

Table 2

Thoracolumbar Injury Classification and Severity Score

Injury Characteristic Qualifier Points

Injury morphologyCompression — 1

Burst +1Rotation/translation — 3Distraction — 4

Neurologic statusIntact — 0Nerve root — 2Spinal cord, conus medullaris Incomplete 3

Complete 2Cauda equina — 3

Posterior ligamentous complex integrityIntact — 0Suspected/Indeterminate — 2Disrupted — 3

+ = 1 additional point given to the morphology



Distraction is identified by ana-tomic dissociation in the verticalaxis, such as a hyperextension injurythat causes disruption of the anteriorlongitudinal ligament, with subse-quent widening of the anterior diskspace. Fractures of the posterior ele-ments (ie, facet, lamina, spinous pro-cess) may also be present in distrac-tion injury. Severe thoracolumbarkyphotic deformities of the spine,caused by tensile failure of the poste-rior ligamentous structures, repre-sent another clinical example of thedistraction morphology.

Prior classification systems hadlimited utility in the setting of multi-ple concurrent injuries, whereas theTLICS accounts for this scenario intwo ways. First, in the presence ofmore than one injury morphology,the injury morphology with the high-est score is used. For example, anL1-2 flexion-distraction injury withan associated L2 burst fracturewould be described as an L1-2 dis-traction injury with an L2 burst frac-ture and scored accordingly, withpoints assigned only to the highest-valued injury—in this case, the dis-traction injury. Noncontiguous inju-ries (eg, T7 compression fracture, L1burst fracture) are classified andscored separately. However, thescores are not summated, and deci-sion making is based on the injurywith the highest score as well as onconfounding variables such as thepresence of noncontiguous injuries.

Neurologic StatusPatient neurologic status is one of themost influential components of medi-cal decision making. The TLICS isunique among thoracolumbar classifi-cation systems in including this status.Neurologic injury is a critical indicatorof the degree of spinal column injury (ie,spinal stability). Additionally, neuro-logic injury often warrants surgicaltreatment to prevent further neurologic

decline and to improve patient out-comes. Neurologic status is describedin increasing order of urgency: neuro-logically intact, nerve root injury, com-plete (motor and sensory) spinal cordor cauda equina injury, and incomplete(motor or sensory) spinal cord or caudaequina injury. In the American SpinalInjury Association classification, injurygrades B, C, and D are incomplete in-juries, whereas grade A represents acomplete spinal cord injury.22

Posterior LigamentousComplex IntegrityThe anatomic structures of the PLCinclude the supraspinous ligament,interspinous ligament, ligamentumflavum, and facet joint capsules. ThePLC plays a critical role in protectingthe spine and spinal cord against ex-cessive flexion, rotation, translation,and distraction.23,24 Once disrupted,the ligamentous structures demon-strate poor healing ability and gener-ally require surgical stabilization. Inthe TLICS, the integrity of the PLC iscategorized as intact, indeterminate,or disrupted. Assessment can bemade based on plain radiographs,CT scans, and magnetic resonanceimages.25 Disruption of the PLC istypically indicated by widening ofthe interspinous space or of the facetjoints, empty facet joints, facet perchor subluxation, and dislocation ofthe spine. When the evidence of dis-ruption is subtle, the integrity of theligaments is typically defined as ei-ther suspected or indeterminate. Insome cases, clinical examination maybe helpful in determining the statusof the PLC; an obvious gap betweenthe spinous processes is indicative ofPLC disruption. Additionally, magneticresonance images may reveal disruptionof the ligamentous structures on T1-weighted imaging or areas of high sig-nal intensity on short tau inversion re-covery images.26,27 Although they addto the clinical suspicion of PLC dis-

ruption, MRI findings have yet to bedefinitively correlated with intraop-erative findings.

Severity ScoreThe injury scores are totaled to pro-duce a management grade that is, inturn, used to guide treatment (Table3). A score >4 suggests the need forsurgical treatment because of signifi-cant instability, whereas a score <4suggests nonsurgical treatment. Apatient with a score of 4 may betreated either surgically or nonsurgi-cally. In the setting of multiple frac-tures, management is determinedbased on the injury with the greatestTLICS severity score. For noncontig-uous fractures, the severity score ofeach injury may be used to guide in-dependent treatment.

Validity, Reliability, andClinical Utility

The fundamental intent of the TLICSis to improve the management ofthoracolumbar injury through a re-producible and valid classificationsystem that is easy to learn and thatis readily applicable in clinical prac-tice. Vaccaro et al21 and Whanget al28 demonstrated good to excel-lent interobserver and intraobserverreliability with the TLICS. The au-thors reported Cohen unweightedkappa coefficients of 0.626, 0.477,and 0.455, and Spearman rank cor-relation values of 0.684, 0.616, and0.852 for TLICS injury morphology,PLC, and total severity score, respec-

Table 3

Thoracolumbar InjuryClassification System andSeverity Score Treatment Guide

Management Points

Nonsurgical <4Nonsurgical or surgical 4Surgical >4



tively. Good to excellent interob-server agreement was reported formanagement based on the TLICS re-sults.

The Denis and AO classificationshave not demonstrated results equiv-alent to those with the TLICS. Woodet al16 demonstrated average interob-server kappa coefficient of 0.606with the Denis system and 0.475with the AO system. With both sys-tems, as classification subtypes wereincluded (eg, AO A1, A2), kappa co-efficients decreased. Oner et al17 andBlauth et al20 demonstrated interraterkappa coefficients of 0.34 and 0.33,respectively, with the AO classifica-tion system, reporting decreasing re-liability when classification subtypesare included.

Validity of the TLICS was initiallydetermined by comparing TLICStreatment recommendations with ac-tual treatment administered in tworetrospective case series.21,28 Agree-ment (ie, validity) was achieved in95.4% of cases. Furthermore, 96.4%validity was observed in a prospec-tive series of thoracolumbar traumapatients at a single institution.29

Initial data are available on theclinical application of the TLICS.Raja Rampersaud et al30 examinedthe differences in application of theTLICS between orthopaedic sur-geons and neurosurgeons. Small dif-ferences between the groups werenoted, but the authors found anoverall agreement of 92% on injurymanagement. Ratliff et al31 demon-strated moderate to substantial inter-rater agreement (κ = 0.532 and κ =0.528) and intrarater agreement (κ =0.588 and κ = 0.658) based on over-all injury classification in theircomparison of US-based and non-US–based spine trauma surgeons, re-spectively. The authors reported sig-nificant agreement (74.2%) betweenUS and non-US surgeons regardinginjury management using the severityscore. Thus, the TLICS may help to

bridge the communication gap be-tween spine surgeons across subspe-cialties and national boundaries.

The TLICS system has been exam-ined in the educational setting aswell. Patel et al32 reported the pro-spective application of the system atone academic institution. The TLICSwas described to all members of thesurgical team, including residents,spine fellows, and attending staff,who then applied that knowledge inthe routine evaluation of a series ofinjured patients. This process was re-peated with a different group of resi-dents and fellows 7 months later.Statistically significant improvementsin interobserver reliability werenoted from the first assessment tothe second (P < 0.05). Cohen kappacoefficient total injury classificationand management scores improvedfrom 0.189 and 0.455 to 0.509 and0.724, respectively. The authors sug-gested that, given the turnover in res-idents and fellows, a learning curvecannot account for this improve-ment. Instead, they suggest that im-provements in reliability reflect inte-gration of the TLICS system into theclinical and educational environ-ments at the institution. The TLICSsystem may be readily applied toroutine clinical practice and may fa-cilitate resident and fellow educationon thoracolumbar trauma.

Case Examples

An 18-year-old woman presentedwith severe mid back pain followinga rollover motor vehicle collision.Patient assessment revealed a normalneurologic examination with a pal-pable, tender gap in the thoracolum-bar region. CT scans demonstrated aT11-12 fracture-dislocation with aChance fracture at T12 (Figure 1, Athrough C). A magnetic resonanceimage was suggestive of disruptionof the posterior ligamentous struc-tures (Figure 1, C).

In this patient, the TLICS scoringwas as follows: injury morphology(translation), 3 points; neurologicstatus (intact), 0 points; PLC (dis-rupted), 3 points. The total TLICSwas 6 points, which indicated theneed for surgical treatment. The pa-tient was treated with open reduc-tion and posterior spinal fusion (Fig-ure 1, D).

A 63-year-old man sustained a 15-foot fall at work and reported severeback pain. Assessment revealed anormal neurologic examination withno posterior tenderness, gap, or step-off. CT scans demonstrated an L2burst fracture with 50% canal occlu-sion (Figure 2, A and B). No interspi-nous splaying or focal kyphosis wasvisualized. MRI revealed no in-creased signal in the posterior liga-mentous structures (Figure 2, C).

Injury in this patient was scoredaccording to the TLICS as follows:injury morphology (compression,burst), 2 points; neurologic status(intact), 0 points; PLC (intact), 0points. The total severity score was 2points, which led to the decision totreat the patient nonsurgically. Ac-cordingly, the patient was prescribeda thoracolumbar orthosis and ambu-lated within 24 hours of injury. Thefracture had healed by 6 months af-ter injury, without subsequent dis-ability (Figure 2, D).

A 28-year-old man sustained a fallof 30 feet while skiing. He reportedsubsequent back pain as well subjec-tive weakness and numbness in thelegs. Examination revealed diffuseweakness (grade 2 to 3 out of 5) inall lower extremity muscle groups,diminished rectal tone with intactpinprick, and light touch sensation inthe perianal and lower extremity der-matomes. L2 burst fracture with>90% canal stenosis was demon-strated on CT scans (Figure 3, A andB). Focal kyphosis was visualized,and short tau inversion recoveryMRI (Figure 3, C) revealed slightly



increased signal in the posterior liga-mentous structures.

This patient scored 7 points, whichindicated the need for surgical treat-ment, as follows: injury morphology(compression, burst), 2 points; neuro-logic status (incomplete cord/caudaequina), 3 points; PLC (indeterminate),2 points. The patient was treated withcombined anterior and posterior de-compression and fusion (Figure 3, D).

Limitations

The TLICS system and severity scoreis intended for use in adults withtraumatic acute thoracolumbar inju-ries. It has not been investigated inother populations (eg, pediatric) andthus, cannot be directly applied toother thoracolumbar injuries. Thesystem cannot be applied to sympto-matic epidural hematoma, spinal

cord injury without radiographicabnormalities, posttraumatic defor-mity, iatrogenic spinal instability, orpathologic vertebral fractures associ-ated with tumor or infection. Theprinciples that guide surgical deci-sion making in the TLICS—spinalstability and neurologic injury—are,however, applicable to these clinicalscenarios.

Only limited information is avail-

A, Midsagittal reconstructed CT scan demonstrating T11-12 translation injury with anterior dislocation of T11 on T12 inan 18-year-old woman who presented with severe mid back pain following a rollover motor vehicle collision. B, Axial CTscan through the T11-12 level demonstrating T12 fracture and right-side facet dislocation. C, Midsagittal T2-weightedmagnetic resonance image suggestive of posterior ligamentous disruption through the T11-12 posterior interspace (ar-row). D, Lateral radiograph taken 12 months after open posterior reduction and instrumented fusion at T10-L2.

Figure 1

A, Midsagittal reconstructed CT scan revealing an L2 burst fracture without posterior interspinous widening, vertebraltranslation, or kyphosis in a 63-year-old man who fell from a height of 15 feet. B, Axial CT scan through the L2vertebral body demonstrating 50% canal occlusion. C, Midsagittal T2-weighted magnetic resonance imagedemonstrating no increased signal in the posterior ligamentous structures. D, Lateral radiograph taken 6 months afterinjury demonstrating stable alignment and fracture consolidation.

Figure 2



able on the clinical application ofTLICS. Many of the articles to date,including this one, have been au-thored by individuals involved in thecreation of the TLICS. It remains tobe seen whether similar reliabilityand validity can be reproduced byother investigators. Published appli-cation of the TLICS has primarilybeen retrospective. Prospective appli-cation, with a direct comparisonwith other classification systems, isneeded to clarify the relative and ab-solute efficacy of the TLICS.

Summary

The TLICS is a recent advancementin the management of thoracolumbarspine trauma. This system was de-signed to account for the limitationsof prior systems by being simple andreproducible, as well as useful inproviding prognostic informationand guiding medical decision mak-ing. The TLICS is the first system toincorporate the neurologic status ofthe patient, and it is the first thatwas intentionally designed to be

adaptable. In the future, MRI find-ings may be useful in better definingthe status of the PLC in the patientwith thoracolumbar trauma.

The TLICS has demonstrated reli-ability and clinical utility across sur-gical specialties and levels of surgicalexperience. The system has been in-tegrated into clinical and educationalsettings, and it is hoped that use ofthe TLICS will improve resident andfellow education. By providing acommon language and frameworkfor the assessment of thoracolumbartrauma, the TLICS may prove usefulin future clinical studies. Althoughthis system shows promise, much isunknown. Further investigation andprospective application of the TLICSare needed to define its clinical util-ity, predictive value, and validity.

References

Evidence-based Medicine: Levels ofevidence are described in the table ofcontents. In this article, no level Istudies are cited. Reference 2 is a level

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A, Midsagittal reconstructed CT scan demonstrating L2 burst fracture with slight posterior widening and kyphosis in a28-year-old man who sustained a 30-foot fall while skiing. B, Axial CT scan through the L2 vertebral bodydemonstrating 90% canal stenosis. C, Midsagittal short tau inversion recovery magnetic resonance imagedemonstrating canal stenosis as well as indeterminate signal change (arrow) within the posterior ligamentousstructures. D, Lateral radiograph taken 12 months after combined anterior and posterior decompression as well asfusion at L1-3.

Figure 3



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Thoracolumbar Spine Trauma Classification.pdf