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A New Classification of Thoracolumbar Injuries: The Importance of Injury Morphology, the Integrity of the Posterior Ligamentous Complex, and Neurologic Status

Vaccaro, Alexander R., MD*; Lehman, Ronald A. Jr, MD; Hurlbert, R John, MD, PhD; Anderson, Paul A., MD§; Harris, Mitchel, MD; Hedlund, Rune, MD; Harrop, James, MD#; Dvorak, Marcel, MD**; Wood, Kirkham, MD††; Fehlings, Michael G., MD, PhD‡‡; Fisher, Charles, MD, MHSc**; Zeiller, Steven C., MD*; Anderson, D Greg, MD*; Bono, Christopher M., MD§§; Stock, Gordon H., MD*; Brown, Andrew K., MD*; Kuklo, Timothy, MD; Öner, F C., MD, PhD∥∥

doi: 10.1097/01.brs.0000182986.43345.cb
Epidemiology
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SDC

Study Design. A new proposed classification system for thoracolumbar (TL) spine injuries, including injury severity assessment, designed to assist in clinical management.

Objective. To devise a practical, yet comprehensive, classification system for TL injuries that assists in clinical decision-making in terms of the need for operative versus nonoperative care and surgical treatment approach in unstable injury patterns.

Summary of Background Data. The most appropriate classification of traumatic TL spine injuries remains controversial. Systems currently in use can be cumbersome and difficult to apply. None of the published classification schemata is constructed to aid with decisions in clinical management.

Methods. Clinical spine trauma specialists from a variety of institutions around the world were canvassed with respect to information they 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. An initial validation process to determine the reliability and validity of an earlier version of this system was also undertaken.

Results. A new classification system called the Thoracolumbar Injury Classification and Severity Score (TLICS) was devised based on three injury characteristics: 1) morphology of injury determined by radiographic appearance, 2) integrity of the posterior ligamentous complex, and 3) neurologic status of the patient. A composite injury severity score was calculated from these characteristics stratifying patients into surgical and nonsurgical treatment groups. Finally, a methodology was developed to determine the optimum operative approach for surgical injury patterns.

Conclusions. Although there will always be limitations to any cataloging system, the TLICS reflects accepted features cited in the literature important in predicting spinal stability, future deformity, and progressive neurologic compromise. This classification system is intended to be easy to apply and to facilitate clinical decision-making as a practical alternative to cumbersome classification systems already in use. The TLICS may improve communication between spine trauma physicians and the education of residents and fellows. Further studies are underway to determine the reliability and validity of this tool.

A new thoracolumbar trauma classification system is described called the Thoracolumbar Injury Classification and Severity Score (TLICS). It is composed of three main components: 1) morphology of injury according to radiographic features, 2) integrity of the posterior ligamentous complex, and 3) neurologic status of the patient. This new classification scheme accounts for predictors of spinal stability, future deformity, and progressive neurologic compromise, thereby facilitating clinical decision making.

From the *Department of Orthopaedic Surgery, Thomas Jefferson University, Philadelphia, PA; †Department of Orthopaedics Surgery and Rehabilitation, Walter Reed Army Medical Center, Washington, DC; ‡University of Calgary Spine Program and Department of Clinical Neurosciences, Foothills Hospital and Medical Centre, Calgary, Alberta, Canada; §Department of Orthopaedic Surgery and Rehabilitation, University of Wisconsin, Madison, WI; ∥Orthopaedic Trauma, Brigham and Women’s Hospital, Boston, MA; ¶Orthopaedic Surgery, Karolinska Institute, Haddinge University Hospital, Stockholm, Sweden; #Department of Neurosurgery, Thomas Jefferson University, Philadelphia, PA; **Division of Spine, Department of Orthopaedics, University of British Columbia, Vancouver, British Columbia, Canada; ††Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA; ‡‡Department of Neurosurgery, University of Toronto, University Health Network, Toronto, Ontario, Canada; §§Department of Orthopaedic Surgery, Boston University Medical Center, Boston, MA; and ∥∥Department of Orthopedics, University Hospital Utrecht, Utrecht, The Netherlands.

Acknowledgment date: October 19, 2004. First revision date: November 11, 2004. Second revision date: December 7, 2004. Acceptance date: December 17, 2004.

Supported by the Spine Trauma Study Group and funded by an educational/research grant from Medtronic Sofamor Danek.

The manuscript submitted does not contain information about medical device(s)/drug(s).

Corporate/Industry funds were received in support of this work. No benefits in any form have been or will be received from a commercial party related directly or indirectly to the subject of this manuscript.

The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the United States Army or the Department of Defense. One author is an employee of the United States government. This work was prepared as part of his official duties and as such, there is no copyright to be transferred.

Address correspondence and reprint requests to Alexander R. Vaccaro, MD, Rothman Institute, 925 Chestnut Street, 5th Floor, Philadelphia, PA 19107-4216; E-mail: alexvaccaro3@aol.com

© 2005 Lippincott Williams & Wilkins, Inc.