You are on page 1of 9

Review Article

Thoracolumbar Spine Trauma


Thoracolumbar spine trauma is among the most common
Alpesh A. Patel, MD
musculoskeletal injuries worldwide. However, there is little
Alexander R. Vaccaro, MD, PhD consensus on the adequate management of spine injury, in part
because there is no widely accepted classification system. Several
systems have been developed based on injury anatomy or inferred
mechanisms of action, but they have demonstrated poor reliability,
have yielded little prognostic information, and have not been widely
used. The Thoracolumbar Injury Classification and Severity Score
(TLICS) was developed to address these limitations. The TLICS
defines injury based on three clinical characteristics: injury
morphology, integrity of the posterior ligamentous complex, and
neurologic status of the patient. The severity score offers
prognostic information and is helpful in medical decision making.
Initial application of the TLICS has shown good to excellent
reliability and validity. Additional evaluation of the TLICS is needed
to prospectively define its clinical utility and identify potential

S pine fractures account for a large

portion of musculoskeletal inju-
ries worldwide. Approximately 75%
Ideally, a classification system is
descriptive and prognostic. The sys-
tem must be easy to remember and
to 90% of spinal fractures occur in apply in clinical practice, based on a
the thoracic and lumbar spine, with simple algorithm with consistent ra-
most of these occurring at the thora- diographic and clinical characteris-
columbar junction (T10-L2).1-3 De- tics. Additionally, the classification
spite the high incidence of thora- should provide information on the
columbar fractures, there is little severity and natural history of an in-
consensus regarding injury classifica- jury pattern. Finally, by accounting
tion and management.4 Treatment for injury prognosis, the classifica-
varies widely, from bracing to cir- tion should guide clinical decision
From the Department of
cumferential fusion, based on geo- making. Such a system would be a
Orthopaedics, University of Utah graphical, institutional, and surgeon critical tool for clinical outcomes re-
School of Medicine, Salt Lake City, preferences rather than on scientific search.
UT (Dr. Patel), and the Department evidence. A principal reason for this Historically, classification systems
of Orthopaedic Surgery, Thomas
Jefferson University, Philadelphia, variability lies in the lack of a widely have been based on retrospective re-
PA (Dr. Vaccaro). accepted classification system. In the views and the experience of individ-
J Am Acad Orthop Surg 2010;18:
absence of a common language with ual surgeons.5-7 These systems are
63-71 which to accurately define thora- typically based on descriptions of an-
Copyright 2010 by the American
columbar injuries, it is not surprising atomic structures (eg, Denis three-
Academy of Orthopaedic Surgeons. that optimal treatment remains elu- column system), proposed mecha-
sive. nisms of injury (eg, Watson-Jones,

February 2010, Vol 18, No 2 63

Thoracolumbar Spine Trauma Classification

AO), or a combination thereof.5-8 view, he described three injury char- classifying thoracolumbar injury, his
Many systems are convoluted, with acteristics: simple wedge fracture, three-column description clearly dis-
an impractical number of variables. comminuted fracture, and fracture- tinguishes compression fractures (an-
Others are too simple, lacking suffi- dislocation. This system was the first terior column) from burst fractures
cient detail to provide clinically rele- to use injury classification as a (anterior column, middle column).
vant information. guide for medical decision making. Neither of these anatomic classifi-
Although these classification systems Watson-Jones suggested different re- cation systems accounts for the pa-
have provided commonly used nomen- duction techniques for the manage- tient’s neurologic status, addresses
clature, none has gained widespread ac- ment of wedge and comminuted the importance of the posterior liga-
ceptance. The lack of an accepted sys- fractures and surgical reduction for mentous structures, provides prog-
tem has encouraged authors to define certain fracture-dislocations. nostic information, or guides clinical
further systems, each hampered by the Perhaps better known is the ana- decision making. The Denis system
same limitations as those of the exist-
tomic classification of Kelly and has shown only fair to good interob-
ing systems. The large number of sys-
Whitesides,10 which was later modi- server reliability in separate investi-
tems has led to increased confusion and
fied by Denis.7 In a review of 11 pa- gations.16,17 Although these classifica-
decreased agreement and accuracy in
tients, Kelly and Whitesides10 divided tions have provided nomenclature
classifying thoracolumbar trauma. The
the spine into an anterior (ie, verte- for thoracolumbar trauma, their lim-
Thoracolumbar Injury Classification
bral body) column and a posterior itations significantly impede their
and Severity Score (TLICS) was devel-
(ie, neural arch) column. The authors clinical utility as reproducible tools.
oped to address the shortcomings of
prior systems and to offer an improved described spinal instability as the
means of classifying thoracolumbar presence of disruption in both the Mechanistic
spine trauma. anterior column and the posterior Holdsworth11 described the first
column. Although the authors de- mechanistic classification system for
scribed fracture patterns, it is the spinal injuries based on his experi-
Historical Classification “column” concept that has persisted. ence with more than 1,000 patients
Systems In 1983, Denis7 refined this column with spinal column and spinal cord
concept of thoracolumbar trauma by injuries. He categorized fractures
The historical sequence and clinical describing a middle column consist- as simple wedge, dislocation, rota-
basis of thoracolumbar classification ing of the posterior vertebral body, tional fracture-dislocation, exten-
systems was described in excellent posterior longitudinal ligament, and sion, burst, and shear. This system
detail by Mirza et al9 (Table 1). posterior anulus. Denis did not de- was the first to emphasize the role of
These systems are based on either de- fine rigid parameters of stability and the posterior ligamentous complex
scriptors of anatomic disruption or instability. Rather, he stratified the (PLC) in determining spinal stability.
inferred mechanisms of injury. risk of neurologic injury based on Holdsworth11 also recommended sur-
two-column involvement and mode gical treatment of specific injury pat-
Anatomic Disruption of failure of the middle column. Al- terns (ie, pure dislocations) as well as
Watson-Jones6 described the first though the fracture subtypes pro- of dislocations associated with neu-
thoracolumbar injury classification posed by Denis7 provided little addi- rologic injury. Although this system
system in 1938. In a retrospective re- tional information with regard to offers 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 paid
presentations on behalf of Stryker Spine, Amedica, and Medtronic; serves as a paid consultant to or is an employee of Amedica; and
has received research or institutional support from DePuy Spine. Dr. Vaccaro or an immediate family member serves as a board
member, owner, officer, or committee member of the American Spinal Injury Association, the North American Spine Society, AO North
America, Computational Biodynamics, and Progressive Spinal Technology/Advanced Spinal Intellectual Properties; has received
royalties from Aesculap/B.Braun, Biomet, DePuy, Globus Medical, Lippincott, Elsevier, Medtronic Sofamor Danek, Stryker, Thieme, K2
Spine, Stout Medical, and Progressive Spinal Technology/Applied Spinal Intellectual Properties; is a member of a speakers’ bureau or
has made paid presentations on behalf of Stryker, Medtronic Sofamor Danek, and DePuy Spine; serves as a paid consultant to or is
an employee of Biomet, DePuy, Medtronic Sofamor Danek, Stryker, Vertiflex, and Osteotech; has received research or institutional
support from AO North America, DePuy, Medtronic Sofamor Danek, and Stryker; and has stock or stock options held in Globus
Medical, Disc Motion Technology, Vertebron, Progressive Spinal Technologies/Advanced Spinal Intellectual Properties, Computational
Biodynamics, Stout Medical, Paradigm Spine, K2 Medical, Replication Medica, Spinology, Spine Medica, Orthovita, Vertiflex, Small
Bone Technologies, NeuCore, Crosscurrent, Syndicom, In Vivo, Flagship Surgical, and Pearl Driver.

64 Journal of the American Academy of Orthopaedic Surgeons

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

Table 1
Data Supporting the Common Classification Schemes
No. of Injury
No. of Imaging Classification Categories Treatment or
Study Subjects Modality Variables (Specific Types) Prognostic Value

Watson-Jones6 252 Rad Radiographic patterns 3 (7) Postural reduction with

hyperextension for good
functional results
Chance12 3 Rad Radiographic patterns 1 100% healing rate with
extension casting
Nicoll13 152 Rad Radiographic patterns 4 (7) Only unstable fractures need
cast fixation
Holdsworth11 “A large number” Rad Radiographic patterns 6 Reversing the mechanism of
injury can assist nonsurgi-
cal reduction
Kelly and 11 Rad Two spinal columns 8 Surgery to restore the
Whitesides10 involved column
Denis7 412 Rad and CT Three spinal columns; 5 (21)† Treatment is not related to
three modes of failure* injury pattern
McAfee et al14 100 Rad and CT Three spinal columns; 6 Mode of failure determines
three modes of failure* treatment type
Ferguson and Not listed Rad and CT Seven mechanisms of 8 (12) Treatment is not related to
Allen5 injury, with subtypes injury pattern
based on severity
McCormack 28 Rad and CT Comminution, fragment 9 Severe injury predicts failure
et al15 apposition, kyphosis of short-segment posterior
with three severity fixation with plates and
grades for each screws
Magerl et al8 1,445 Rad and CT Three injury types with 3 (53)† Higher injury grades imply
three groups per type more severe injury and
and additional sub- higher risk of neurologic
types deficit

* Each column is assigned a presumed mode of failure based on radiography and CT findings. Each category is subdivided by radiographic
pattern and injury severity.

Additional undefined terms such as “more severe” distinguish cases within specific injury types.
Rad = plain radiograph
Adapted 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.

mendations, few data have been pub- The authors described a treatment mechanism rather than on objective
lished to support its claims.9 algorithm based on this system as radiographic findings (ie, injury mor-
Ferguson and Allen5 developed well as on methods of spinal fixation phology).
their classification based on a retro- available at that time: posterior dis- The AO thoracolumbar system is a
spective review of spine radiographs. traction, posterior compression, seg- more recent mechanistic classifica-
Similar to the subaxial cervical mental posterior fixation, and ante- tion system described by Magerl
trauma system described by the same rior fixation.19 Although this system et al.8 This system is based on the
authors in 1982,18 the thoracolum- added to the nomenclature of thora- AO classification that had previously
bar system defines injury patterns columbar trauma, the number of in- been used for orthopaedic extremity
through inferred mechanisms of in- jury patterns and subtypes makes it injuries. The AO/Magerl classifica-
jury. Seven injury types and 12 injury difficult to use in the clinical setting. tion defines three major mechanisms
subtypes were defined. Injury types Additionally, very few data are avail- of spinal injury—compression (A),
include vertical compression, com- able on its reliability and validity. distraction (B), and torsion (C)—to
pression flexion, distraction flexion, The Ferguson and Allen classifica- indicate increasing injury severity ac-
lateral flexion, translation, torsional tion is fundamentally limited because cording to increasing grade of injury.
flexion, and distractive extension. it is based on an inferred injury Three groups exist within each type

February 2010, Vol 18, No 2 65

Thoracolumbar Spine Trauma Classification

Table 2 from a multinational group of 40

spinal trauma surgeons from 15
Thoracolumbar Injury Classification and Severity Score
trauma centers in the United States,
Injury Characteristic Qualifier Points Canada, Australia, Germany, Mex-
Injury morphology ico, France, Sweden, India, and the
Compression — 1 Netherlands. The literature review
Burst +1 identified the limitations of previ-
Rotation/translation — 3 ously described classification systems
Distraction — 4 as well as the critical components of
Neurologic status medical decision making in thora-
Intact — 0 columbar trauma. These findings
Nerve root — 2 were then reviewed by all involved
Spinal cord, conus medullaris Incomplete 3 surgeons and, through consensus
Complete 2 opinion, three major injury charac-
Cauda equina — 3 teristics were defined: injury mor-
Posterior ligamentous complex integrity phology, neurologic status, and in-
Intact — 0 tegrity of the PLC. Point values are
Suspected/Indeterminate — 2 assigned to each major category
Disrupted — 3 based on injury severity (Table 2).
The sum of these points represents
+ = 1 additional point given to the morphology
the TLICS severity score, which may
be used to guide treatment.
of injury (eg, A1, A2, A3), and each account for the neurologic status of
group is divided into three subgroups the patient, a critical component in Injury Morphology
(eg, A1.1, A1.2, A1.3). Injury sever- medical decision making. Further- Injury morphology is divided into
ity is indicated by increasing values more, the comprehensive nature of three subtypes, with increasing sever-
of injury classification. For example, these descriptors adds convolution, ity: compression, rotation/transla-
type A injuries are less severe than decreases reliability, and limits clini- tion, and distraction. Although these
type C injuries, and type B1 injuries cal and research utility. Finally, these descriptors share the nomenclature
are less severe than type B2 injuries. systems are based on plain radio- of mechanistic systems, the TLICS is
In addition to the aforementioned graphs and early CT technology. Im- unique in that it defines objective ra-
limitations of inferred injury mecha- diographic findings for each injury
provements in imaging, such as high-
nisms, the AO system is a victim of morphology.
resolution CT and MRI, are not
its comprehensiveness. The large Compression injuries are defined
reflected. Hampered by such limita-
number of subgroups lends a com- by a loss of height of the vertebral
tions, these systems do not provide
plexity that limits incorporation of body or disruption through the ver-
sufficient data to guide current surgi-
the system into routine clinical prac- tebral end plate. This includes tradi-
cal and nonsurgical decision making.
tice. This has also limited its reliabil- tional compression (ie, anterior col-
ity, as demonstrated independently umn) and burst (ie, anterior column,
by Wood et al16 and Oner et al.17 Thoracolumbar Injury middle column) fractures. Sagittal
Blauth et al20 demonstrated only fair Classification and and coronal plane vertebral fractures
interobserver reliability for the three Severity Score are difficult to classify using the col-
main AO categories (A, B, C; κ = umn descriptors.
0.33), with rapidly decreasing reli- Introduced by the Spine Trauma Rotation/translation injury is iden-
ability with the inclusion of the AO Study Group in 2005, the TLICS was tified by horizontal displacement of
subtypes. designed to provide a clear, reliable one thoracolumbar vertebral body
The mechanistic classification systems classification system that accounts with respect to another. It is typified
have inherent limitations. They are for many of the shortcomings of by unilateral and bilateral disloca-
based on inferred mechanisms of injury prior systems.21 The TLICS is based tions and facet fracture-dislocations,
rather than on an objective description on an extensive review of the litera- as well as bilateral pedicle or pars
of injury morphology.4 They do not ture as well as consensus opinion fractures with vertebral subluxation.

66 Journal of the American Academy of Orthopaedic Surgeons

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

Distraction is identified by ana- decline and to improve patient out- Table 3

tomic dissociation in the vertical comes. Neurologic status is described
Thoracolumbar Injury
axis, such as a hyperextension injury in increasing order of urgency: neuro- Classification System and
that causes disruption of the anterior logically intact, nerve root injury, com- Severity Score Treatment Guide
longitudinal ligament, with subse- plete (motor and sensory) spinal cord Management Points
quent widening of the anterior disk or cauda equina injury, and incomplete
space. Fractures of the posterior ele- (motor or sensory) spinal cord or cauda Nonsurgical <4
ments (ie, facet, lamina, spinous pro- equina injury. In the American Spinal Nonsurgical or surgical 4
cess) may also be present in distrac- Injury Association classification, injury Surgical >4
tion injury. Severe thoracolumbar grades B, C, and D are incomplete in-
kyphotic deformities of the spine, juries, whereas grade A represents a
caused by tensile failure of the poste- complete spinal cord injury.22 ruption, MRI findings have yet to be
rior ligamentous structures, repre- definitively correlated with intraop-
sent another clinical example of the Posterior Ligamentous erative findings.
distraction morphology. Complex Integrity
Prior classification systems had Severity Score
The anatomic structures of the PLC
limited utility in the setting of multi- include the supraspinous ligament, The injury scores are totaled to pro-
ple concurrent injuries, whereas the duce a management grade that is, in
interspinous ligament, ligamentum
TLICS accounts for this scenario in turn, used to guide treatment (Table
flavum, and facet joint capsules. The
two ways. First, in the presence of 3). A score >4 suggests the need for
PLC plays a critical role in protecting
more than one injury morphology, surgical treatment because of signifi-
the spine and spinal cord against ex-
the injury morphology with the high- cant instability, whereas a score <4
cessive flexion, rotation, translation,
est score is used. For example, an suggests nonsurgical treatment. A
and distraction.23,24 Once disrupted,
L1-2 flexion-distraction injury with patient with a score of 4 may be
the ligamentous structures demon-
an associated L2 burst fracture treated either surgically or nonsurgi-
strate poor healing ability and gener-
would be described as an L1-2 dis- cally. In the setting of multiple frac-
ally require surgical stabilization. In
traction injury with an L2 burst frac- tures, management is determined
the TLICS, the integrity of the PLC is
ture and scored accordingly, with based on the injury with the greatest
categorized as intact, indeterminate,
points assigned only to the highest- TLICS severity score. For noncontig-
or disrupted. Assessment can be
valued injury—in this case, the dis- uous fractures, the severity score of
made based on plain radiographs,
traction injury. Noncontiguous inju- each injury may be used to guide in-
CT scans, and magnetic resonance
ries (eg, T7 compression fracture, L1 dependent treatment.
images.25 Disruption of the PLC is
burst fracture) are classified and typically indicated by widening of
scored separately. However, the the interspinous space or of the facet
Validity, Reliability, and
scores are not summated, and deci- joints, empty facet joints, facet perch Clinical Utility
sion making is based on the injury or subluxation, and dislocation of The fundamental intent of the TLICS
with the highest score as well as on the spine. When the evidence of dis- is to improve the management of
confounding variables such as the ruption is subtle, the integrity of the thoracolumbar injury through a re-
presence of noncontiguous injuries. ligaments is typically defined as ei- producible and valid classification
ther suspected or indeterminate. In system that is easy to learn and that
Neurologic Status some cases, clinical examination may is readily applicable in clinical prac-
Patient neurologic status is one of the be helpful in determining the status tice. Vaccaro et al21 and Whang
most influential components of medi- of the PLC; an obvious gap between et al28 demonstrated good to excel-
cal decision making. The TLICS is the spinous processes is indicative of lent interobserver and intraobserver
unique among thoracolumbar classifi- PLC disruption. Additionally, magnetic reliability with the TLICS. The au-
cation systems in including this status. resonance images may reveal disruption thors reported Cohen unweighted
Neurologic injury is a critical indicator of the ligamentous structures on T1- kappa coefficients of 0.626, 0.477,
of the degree of spinal column injury (ie, weighted imaging or areas of high sig- and 0.455, and Spearman rank cor-
spinal stability). Additionally, neuro- nal intensity on short tau inversion re- relation values of 0.684, 0.616, and
logic injury often warrants surgical covery images.26,27 Although they add 0.852 for TLICS injury morphology,
treatment to prevent further neurologic to the clinical suspicion of PLC dis- PLC, and total severity score, respec-

February 2010, Vol 18, No 2 67

Thoracolumbar Spine Trauma Classification

tively. Good to excellent interob- bridge the communication gap be- In this patient, the TLICS scoring
server agreement was reported for tween spine surgeons across subspe- was as follows: injury morphology
management based on the TLICS re- cialties and national boundaries. (translation), 3 points; neurologic
sults. The TLICS system has been exam- status (intact), 0 points; PLC (dis-
The Denis and AO classifications ined in the educational setting as rupted), 3 points. The total TLICS
have not demonstrated results equiv- well. Patel et al32 reported the pro- was 6 points, which indicated the
alent to those with the TLICS. Wood spective application of the system at need for surgical treatment. The pa-
et al16 demonstrated average interob- one academic institution. The TLICS tient was treated with open reduc-
server kappa coefficient of 0.606 was described to all members of the tion and posterior spinal fusion (Fig-
with the Denis system and 0.475 surgical team, including residents, ure 1, D).
with the AO system. With both sys- A 63-year-old man sustained a 15-
spine fellows, and attending staff,
tems, as classification subtypes were foot fall at work and reported severe
who then applied that knowledge in
included (eg, AO A1, A2), kappa co- back pain. Assessment revealed a
the routine evaluation of a series of
efficients decreased. Oner et al17 and normal neurologic examination with
injured patients. This process was re-
Blauth et al20 demonstrated interrater no posterior tenderness, gap, or step-
peated with a different group of resi-
kappa coefficients of 0.34 and 0.33, off. CT scans demonstrated an L2
dents and fellows 7 months later.
respectively, with the AO classifica- burst fracture with 50% canal occlu-
Statistically significant improvements
tion system, reporting decreasing re- sion (Figure 2, A and B). No interspi-
in interobserver reliability were
liability when classification subtypes nous splaying or focal kyphosis was
noted from the first assessment to
are included. visualized. MRI revealed no in-
the second (P < 0.05). Cohen kappa
Validity of the TLICS was initially creased signal in the posterior liga-
coefficient total injury classification
determined by comparing TLICS mentous structures (Figure 2, C).
and management scores improved
treatment recommendations with ac- Injury in this patient was scored
from 0.189 and 0.455 to 0.509 and
tual treatment administered in two according to the TLICS as follows:
0.724, respectively. The authors sug-
retrospective case series.21,28 Agree- injury morphology (compression,
gested that, given the turnover in res-
ment (ie, validity) was achieved in burst), 2 points; neurologic status
idents and fellows, a learning curve
95.4% of cases. Furthermore, 96.4% (intact), 0 points; PLC (intact), 0
cannot account for this improve-
validity was observed in a prospec- points. The total severity score was 2
ment. Instead, they suggest that im-
tive series of thoracolumbar trauma points, which led to the decision to
provements in reliability reflect inte-
patients at a single institution.29 treat the patient nonsurgically. Ac-
gration of the TLICS system into the
Initial data are available on the cordingly, the patient was prescribed
clinical and educational environ-
clinical application of the TLICS. a thoracolumbar orthosis and ambu-
ments at the institution. The TLICS
Raja Rampersaud et al30 examined lated within 24 hours of injury. The
system may be readily applied to
the differences in application of the fracture had healed by 6 months af-
routine clinical practice and may fa-
TLICS between orthopaedic sur- ter injury, without subsequent dis-
cilitate resident and fellow education
geons and neurosurgeons. Small dif- ability (Figure 2, D).
on thoracolumbar trauma.
ferences between the groups were A 28-year-old man sustained a fall
noted, but the authors found an of 30 feet while skiing. He reported
Case Examples
overall agreement of 92% on injury subsequent back pain as well subjec-
management. Ratliff et al31 demon- An 18-year-old woman presented tive weakness and numbness in the
strated moderate to substantial inter- with severe mid back pain following legs. Examination revealed diffuse
rater agreement (κ = 0.532 and κ = a rollover motor vehicle collision. weakness (grade 2 to 3 out of 5) in
0.528) and intrarater agreement (κ = Patient assessment revealed a normal all lower extremity muscle groups,
0.588 and κ = 0.658) based on over- neurologic examination with a pal- diminished rectal tone with intact
all injury classification in their pable, tender gap in the thoracolum- pinprick, and light touch sensation in
comparison of US-based and non- bar region. CT scans demonstrated a the perianal and lower extremity der-
US–based spine trauma surgeons, re- T11-12 fracture-dislocation with a matomes. L2 burst fracture with
spectively. The authors reported sig- Chance fracture at T12 (Figure 1, A >90% canal stenosis was demon-
nificant agreement (74.2%) between through C). A magnetic resonance strated on CT scans (Figure 3, A and
US and non-US surgeons regarding image was suggestive of disruption B). Focal kyphosis was visualized,
injury management using the severity of the posterior ligamentous struc- and short tau inversion recovery
score. Thus, the TLICS may help to tures (Figure 1, C). MRI (Figure 3, C) revealed slightly

68 Journal of the American Academy of Orthopaedic Surgeons

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

Figure 1

A, Midsagittal reconstructed CT scan demonstrating T11-12 translation injury with anterior dislocation of T11 on T12 in
an 18-year-old woman who presented with severe mid back pain following a rollover motor vehicle collision. B, Axial CT
scan through the T11-12 level demonstrating T12 fracture and right-side facet dislocation. C, Midsagittal T2-weighted
magnetic 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 2

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

increased signal in the posterior liga- Limitations cord injury without radiographic
mentous structures. abnormalities, posttraumatic defor-
This patient scored 7 points, which The TLICS system and severity score mity, iatrogenic spinal instability, or
indicated the need for surgical treat- is intended for use in adults with pathologic vertebral fractures associ-
ment, as follows: injury morphology traumatic acute thoracolumbar inju- ated with tumor or infection. The
(compression, burst), 2 points; neuro- ries. It has not been investigated in principles that guide surgical deci-
logic status (incomplete cord/cauda other populations (eg, pediatric) and sion making in the TLICS—spinal
equina), 3 points; PLC (indeterminate), thus, cannot be directly applied to stability and neurologic injury—are,
2 points. The patient was treated with other thoracolumbar injuries. The however, applicable to these clinical
combined anterior and posterior de- system cannot be applied to sympto- scenarios.
compression and fusion (Figure 3, D). matic epidural hematoma, spinal Only limited information is avail-

February 2010, Vol 18, No 2 69

Thoracolumbar Spine Trauma Classification

Figure 3

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

able on the clinical application of adaptable. In the future, MRI find- II study. References 11 and 25 are
TLICS. Many of the articles to date, ings may be useful in better defining level III studies. The remainder are
including this one, have been au- the status of the PLC in the patient level IV and V studies.
thored by individuals involved in the with thoracolumbar trauma. Citation numbers printed in bold type
creation of the TLICS. It remains to The TLICS has demonstrated reli- indicate references published within
be seen whether similar reliability ability and clinical utility across sur- the past 5 years.
and validity can be reproduced by gical specialties and levels of surgical
other investigators. Published appli- 1. Hu R, Mustard CA, Burns C:
experience. The system has been in- Epidemiology of incident spinal fracture
cation of the TLICS has primarily tegrated into clinical and educational in a complete population. Spine (Phila
been retrospective. Prospective appli- settings, and it is hoped that use of Pa 1976) 1996;21:492-499.
cation, with a direct comparison
the TLICS will improve resident and 2. Wood K, Buttermann G, Mehbod A,
with other classification systems, is et al: Operative compared with
fellow education. By providing a nonoperative treatment of a
needed to clarify the relative and ab-
common language and framework thoracolumbar burst fracture without
solute efficacy of the TLICS. neurological deficit: A prospective,
for the assessment of thoracolumbar randomized study. J Bone Joint Surg Am
trauma, the TLICS may prove useful 2003;85:773-781.

Summary in future clinical studies. Although 3. Gertzbein SD: Scoliosis Research Society.
this system shows promise, much is Multicenter spine fracture study. Spine
(Phila Pa 1976) 1992;17:528-540.
The TLICS is a recent advancement unknown. Further investigation and
in the management of thoracolumbar 4. Schweitzer KM Jr, Vaccaro AR, Lee JY,
prospective application of the TLICS Grauer JN; Spine Trauma Study Group:
spine trauma. This system was de- are needed to define its clinical util- Confusion regarding mechanisms of
signed to account for the limitations ity, predictive value, and validity. injury in the setting of thoracolumbar
spinal trauma: A survey of The Spine
of prior systems by being simple and Trauma Study Group (STSG). J Spinal
reproducible, as well as useful in Disord Tech 2006;19:528-530.
providing prognostic information References 5. Ferguson RL, Allen BL Jr: A mechanistic
and guiding medical decision mak- classification of thoracolumbar spine
Evidence-based Medicine: Levels of fractures. Clin Orthop Relat Res 1984;
ing. The TLICS is the first system to 189:77-88.
incorporate the neurologic status of evidence are described in the table of
6. Watson-Jones R: The results of postural
the patient, and it is the first that contents. In this article, no level I reduction of fractures of the spine.
was intentionally designed to be studies are cited. Reference 2 is a level J Bone Joint Surg Am 1938;20:567-586.

70 Journal of the American Academy of Orthopaedic Surgeons

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

7. Denis F: The three column spine and its 17. Oner FC, Ramos LM, Simmermacher 26. Lee HM, Kim HS, Kim DJ, Suk KS, Park
significance in the classification of acute RK, et al: Classification of thoracic and JO, Kim NH: Reliability of magnetic
thoracolumbar spinal injuries. Spine lumbar spine fractures: Problems of resonance imaging in detecting posterior
(Phila Pa 1976) 1983;8:817-831. reproducibility. A study of 53 patients ligament complex injury in
using CT and MRI. Eur Spine J 2002;11: thoracolumbar spinal fractures. Spine
8. Magerl F, Aebi M, Gertzbein SD, Harms 235-245. (Phila Pa 1976) 2000;25:2079-2084.
J, Nazarian S: A comprehensive
classification of thoracic and lumbar 18. Allen BL Jr, Ferguson RL, Lehmann TR, 27. Vaccaro AR, Lee JY, Schweitzer KM Jr,
injuries. Eur Spine J 1994;3:184-201. O’Brien RP: A mechanistic classification et al; Spine Trauma Study Group:
of closed, indirect fractures and Assessment of injury to the posterior
9. Mirza SK, Mirza AJ, Chapman JR, dislocations of the lower cervical spine. ligamentous complex in thoracolumbar
Anderson PA: Classifications of thoracic Spine (Phila Pa 1976) 1982;7:1-27. spine trauma. Spine J 2006;6:524-528.
and lumbar fractures: Rationale and
supporting data. J Am Acad Orthop 19. Ferguson RL, Allen BL Jr: An algorithm 28. Whang PG, Vaccaro AR, Poelstra KA,
Surg 2002;10:364-377. for the treatment of unstable et al: The influence of fracture
thoracolumbar fractures. Orthop Clin mechanism and morphology on the
10. Kelly RP, Whitesides TE Jr: Treatment of North Am 1986;17:105-112. reliability and validity of two novel
lumbodorsal fracture-dislocations. Ann thoracolumbar injury classification
Surg 1968;167:705-717. 20. Blauth M, Bastian L, Knop C, Lange U, systems. Spine (Phila Pa 1976) 2007;32:
Tusch G: Inter-observer reliability in the 791-795.
11. Holdsworth F: Fractures, dislocations, classification of thoraco-lumbar spinal
and fracture-dislocations of the spine. injuries [German]. Orthopade 1999;28: 29. Vaccaro AR, Zeiller SC, Hulbert RJ,
J Bone Joint Surg Am 1970;52:1534- 662-681. et al: The thoracolumbar injury severity
1551. score: A proposed treatment algorithm.
21. Vaccaro AR, Lehman RA Jr, Hurlbert J Spinal Disord Tech 2005;18:209-215.
12. Chance GQ: Note on a type of flexion RJ, et al: A new classification of
fracture of the spine. Br J Radiol 1948; thoracolumbar injuries: The importance 30. Raja Rampersaud Y, Fisher C, Wilsey J,
21:452-453. of injury morphology, the integrity of the et al: Agreement between orthopedic
13. Nicoll EA: Fractures of the dorso-lumbar posterior ligamentous complex, and surgeons and neurosurgeons regarding a
spine. J Bone Joint Surg Br 1949;31:376- neurologic status. Spine (Phila Pa 1976) new algorithm for the treatment of
394. 2005;30:2325-2333. thoracolumbar injuries: A multicenter
reliability study. J Spinal Disord Tech
14. McAfee PC, Yuan HA, Fredrickson BE, 22. American Spinal Injury Association: 2006;19:477-482.
Lubicky JP: The value of computed Standards for Neurological and
tomography in thoracolumbar fractures: Functional Classification of Spinal Cord 31. Ratliff J, Anand N, Vaccaro AR, et al;
An analysis of one hundred consecutive Injury. Chicago, IL, American Spinal Trauma Study Group Spine: Regional
cases and a new classification. J Bone Injury Association, 1992. variability in use of a novel assessment of
Joint Surg Am 1983;65:461-473. thoracolumbar spine fractures: United
23. Panjabi MM, White AA III: Basic States versus international surgeons.
15. McCormack T, Karaikovic E, Gaines biomechanics of the spine. Neurosurgery World J Emerg Surg 2007;2:24.
RW: The load sharing classification of 1980;7:76-93.
spine fractures. Spine (Phila Pa 1976) 32. Patel AA, Vaccaro AR, Albert TJ, et al:
24. Oxland TR, Panjabi MM, Southern EP, The adoption of a new classification
1994;19:1741-1744. Duranceau JS: An anatomic basis for system: Time-dependent variation in
16. Wood KB, Khanna G, Vaccaro AR, spinal instability: A porcine trauma interobserver reliability of the
Arnold PM, Harris MB, Mehbod AA: model. J Orthop Res 1991;9:452-462. thoracolumbar injury severity score
Assessment of two thoracolumbar 25. Lee JY, Vaccaro AR, Schweitzer KM Jr, classification system. Spine (Phila Pa
fracture classification systems as used by et al: Assessment of injury to the 1976) 2007;32:E105-E110.
multiple surgeons. J Bone Joint Surg Am thoracolumbar posterior ligamentous
2005;87:1423-1429. complex in the setting of normal-
appearing plain radiography. Spine J

February 2010, Vol 18, No 2 71