Thoracolumbar Injury Classification And Severity (TLICS) Score Calculator

How does this thoracolumbar injury classification and severity (TLICS) score calculator work?

This health tool allows physicians and surgeons to classify thoracolumbar spine injuries in order to devise clinical management. It was introduced in 2005 by the Spine Trauma Study Group.

There are three independent parameters assessed in the thoracolumbar injury classification and severity (TLICS) score calculator which predict spinal stability, future deformity and any progressive neurological consequences:

■ Injury Morphology;

■ Integrity of the Posterior Ligamentous Complex;

■ Neurologic status.

Compared to other spinal injury classifications, the TLICS does not focus on injury mechanism but on effects on the area and possible debilitating consequences. Classifications of fractures, be them thoracolumbar or lumbar fractures, are often complex and lead to a high inter-reader variability than TLICS.

Morphology

Looks at immediate stability as resulted from radiographs and CT and focuses on pattern of injury not on mechanism, although in some case, these two might match, this is not the rule:

■ Compression (1 point) – due to the axial force with flexion;

■ Burst (2 points) – resulting from compression with severe axial loading;

■ Translation/rotation (3 points) – caused by displacement in the horizontal plane;

■ Distraction (4 points) – due to displacement in the vertical plane.

Integrity of PLC (Posterior Ligamentous Complex)

Looks at long term stability as resulted from MRI investigation on the ligamentous structures. PLC’s role is to offer stability of the spinal column by acting as a tension band. Torn PLC rarely heals and the most common consequences are progressive kyphosis and collapse. Some of the characteristics in this case are:

■ Interspinous space widened;

■ Facet joints widened or dislocated;

■ Avulsion fractures or transverse fractures of spinous processes or articular facets;

■ Vertebral body translation.

Although MRI sometimes leads to overdiagnose of PLC injuries, most of the proven ones are an indication of surgery. The TLICS descriptors for this parameter and their assigned points are:

■ Intact (0 points);

■ Suspected (2 points);

■ Injured (3 points).

Neurological status

This is evaluated within the physical examination performed by a neurologist or by the spine surgeon:

■ Intact (0 points);

■ Nerve root (2 points);

■ Complete cord (2 points);

■ Incomplete cord (3 points);

■ Cauda equina (3 points).

TLICS score interpretation

Each parameter is scored with points ranging from 0 to 4 and the total score is between a minimum of 1 and a maximum of 10. The cut off value is considered at 4 points and the following recommendations are made:

■ 0 – 3: nonsurgical (treated non-operatively);

■ 4: surgeon decision (individual assessment);

■ >4: surgical (operative management).

In case there are several fractures involved, each needs to be scored independently and the highest score will count for the final TLICS result. Other present co-morbidities and injuries need to be taken in consideration as well.

References

1) Vaccaro AR, Lehman RA Jr, Hurlbert RJ, Anderson PA et al. (2005) A new classification of thoracolumbar injuries: the importance of injury morphology, the integrity of the posterior ligamentous complex, and neurologic status. Spine (Phila Pa 1976); 30(20):2325-33.

2) Joaquim AF, de Almeida Bastos DC, Jorge Torres HH, Patel AA. (2016) Thoracolumbar Injury Classification and Injury Severity Score System: A Literature Review of Its Safety. Global Spine J; 6(1):80-5.

3) Khurana B, Sheehan SE, Sodickson A, Bono CM, Harris MB. (2013) Traumatic Thoracolumbar Spine Injuries: What the Spine Surgeon Wants to Know RadioGraphics; 2031-2048.

4) Vaccaro AR, Rihn JA, Saravanja D, Anderson DG, Hilibrand AS et al. (2009) Injury of the posterior ligamentous complex of the thoracolumbar spine: a prospective evaluation of the diagnostic accuracy of magnetic resonance imaging. Spine (Phila Pa 1976); 34(23):E841-7.

5) Azhari S, Azimi P, Shahzadi S, Mohammadi HR, Khayat Kashani HR. (2016) Decision-Making Process in Patients with Thoracolumbar and Lumbar Burst Fractures with Thoracolumbar Injury Severity and Classification Score Less than Four. Asian Spine J; 10(1):136-42.