TLICS- Thoracolumbar Injury Classification and Severity Score

Thoracolumbar injury classification and severity score or TLICS  is a scoring system for thoracolumbar fractures which classifies and provides guidance to the treatment as well.

TLICS is based on three major categories

• Morphology of the injury
• Integrity of the posterior ligamentous complex
• Neurologic status of the patient.

Denis classification of spinal injuries which is based on the three column concept emphasized that that mechanical instability and progressive neurologic deterioration could occur separately or together. It is the most popular classification but it fails to provide useful treatment guidance.

For example, not all two column injuries would require surgery but the simplification of Denis classification has been widely accepted so. But studies have shown repeatedly that conservative treatment works well for some two column injuries.

Moreover, the Denis’ classification is not clear on how ligamentous injuries can be identified.  These, if present could lead to progressive instability. These patients require surgical intervention to prevent progressive deformity or progressive neurologic deficit. These patients may be missed.

These can be identified with MRI and TLICS incorporates its use quite well.

Thoracolumbar injury classification and severity score or TLICS

The thoracolumbar injury classification and severity score  or TCLICS)  is based on three major categories

• Morphology of the injury
• Integrity of the posterior ligamentous complex
• Neurologic status of the patient.

The morphology of injury and the integrity of the posterior ligamentous complex are both defined by the appearance of the injury on imaging studies. Neurologic status is determined clinically.

Each category is given a score depending on the severity.

The total score is calculated by addition of scores from individual categories.

Based on the severity of these categories, specific points are allocated, and the sum of the points defines the possible treatment alternatives. Higher total points indicate a more severe injury, and those injuries are more likely to benefit from surgical intervention based on the opinions of the Spine Trauma Study Group.

Morphology of injury

The three major morphologic subcategories are

• Compression injuries
• Burst Fractures
• Translational/rotational injuries
•  Distraction injuries

If there are injuries at multiple levels, only the more severe morphology is counted. If multiple primary morphologies are involved at a single level, only the most severe is counted.

Compression fractures [score 1]are most common thoracolumbar injuries and result from an axial loading of the spine transferred to the anterior vertebral body. This results in wedge deformity of the vertebral body because of the collapse of the anterior vertebral body while the posterior vertebral body remains intact.

Compression fracture get a score of 1

The burst fracture [score 2]is more severe injury and in this, the axial load is transferred to both the anterior and posterior vertebral walls resulting in disruption of anterior and posterior cortex.

Score 2 is assigned to these fractures

Translational/rotational injuries [score 3] occur from violent torsional, shear forces, or both and often cause significant ligament injury. or osseous damage. These injuries are frequently unstable and a score of 3 is assigned to these injuries.

Distraction injuries [score 4] are the severest form of injury to the spine and occur due to spine failing under tensile forces.

Score assigned is 4.

For proper scoring, the injury should be well identified.

Neurologic injury

There are five categories of neurologic injury

• Intact – score is zero
• Nerve root injury- 1
• Complete spinal cord injury -2
• Incomplete spinal cord injury – 3
• Cauda equina syndrome- 4

One of the surprising element is assigning a lesser score to complete spinal injury whereas incomplete spinal injuries like cauda equina syndrome are assigned the higher score.

This is because of the therapeautic significance of scoring. Surgery has greater relative value in incomplete injury and patients with a higher score are the candidate for surgery in this scheme of scoring.

Posterior ligamentous complex

Injury to the posterior ligamentous complex is seen in three categories.

• Intact – Zero point
  • The absence of a palpable gap between spinous processes
  • No interspinous widening on plain x-ray or CT
  • Absence of posterior ligamentous hyperintensity on fat-suppressed MRI images [T2-weighted ]
•  Indeterminate disruption of the posterior ligamentous complex – 2 points
• Definite disruption – 3 points.

Total Score and Its Applicaton

The total score is calculated by adding points in all the major categories.

• Score less than 3
  • Nonoperative
• Score of 4
  • Indistinct category
  • Either nonoperative or operative treatment
• 5 or more Score
  • Surgery

Use of TLICS

The TLICS can serve as a guide to help determine possible treatment options.

However other factors important for decision making, like medical co-morbidities, other injuries, skin condition of the intended incision site, the preexisting bony disorders like ankylosing spondylitis, DISH etc. may also affect treatment decisions.

References

• Lee JY, Vaccaro AR, Lim MR, et al. Thoracolumbar injury classification and severity score: a new paradigm for the treatment of thoracolumbar spine trauma. J Orthop Sci. 2005;10(6):671-5.
• Blauth M, Bastian L, Knop C, Lange U, Tusch G. Inter-observer reliability in the classification of thoraco-lumbar spinal injuries. Orthopade. 1999;28:662–81. doi: 10.1007/s001320050397.