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Low Lumbar Fractures: Does Thoracolumbar Injury Classification and Severity Score Work?

Moore, Timothy A. MD*; Bransford, Richard J. MD; France, John C. MD; Anderson, James MD§; Steinmetz, Michael P. MD§; Lubelski, Daniel MSIII; Anderson, Paul A. MD

doi: 10.1097/BRS.0000000000000415
Clinical Case Series

Study Design. Case series.

Objective. To investigate if the thoracolumbar injury classification and severity score (TLICS) system is effective in evaluating low lumbar injuries.

Summary of Background Data. The TLICS classification has been used by spine traumatologists since its introduction in 2006. The classification is predictable and consistent when dealing with thoracolumbar injuries. It is not known if the classification is effective in dealing with low lumbar injuries that tend to behave differently than thoracolumbar injuries. TLICS is yet to be clinically validated. There are no reports of its use for low lumbar injuries alone.

Methods. For this case series, 20 low lumbar injuries were graded using the TLICS system by 15 fellowship-trained orthopedic spine and neurosurgeons. Interobserver reliability was graded using κ values. The reviewers were also asked 4 clinical questions regarding diagnosis and treatment of these injuries.

Results. When using the TLICS system for low lumbar injuries, there was “fair” reliability among the reviewers. Concerning the final TLICS score, there was 28% agreement with a κ of 0.245. Concerning fracture morphology, there was 58% agreement with a κ value of 0.394. When evaluating the posterior ligamentous complex, there was 56% agreement with a κ value of 0.328. The reviewers did agree consistently on determining the patient's neurological status. The data showed 94% agreement with a κ of 0.818. When looking at L3 injuries by themselves, the reliability of TLICS improved significantly.

Conclusion. The authors think that there are factors involved in treating low lumbar injuries that are not inclusive to the TLICS system. Overall, there was only “fair” reliability for low lumbar injuries. The maintenance of lordosis and global sagittal alignment is paramount when dealing with low lumbar injuries and not considered in TLICS. L3 injuries tend to behave like thoracolumbar injuries but there is a wide variation in classification between L4–L5 and thoracolumbar injuries.

Level of Evidence: 4

The authors present reliability data by using the thoracolumbar injury classification and severity score system in evaluating low lumbar injuries exclusively. Many investigators think that low lumbar injuries behave differently than thoracolumbar injuries and there are other factors to be considered when treating these injuries.

*Departments of Orthopaedic Surgery and Neurosciences, MetroHealth Medical Center, Cleveland, OH

Department of Orthopaedic Surgery, Harborview Medical Center, Seattle, WA

Department of Orthopaedic Surgery, West Virginia University, Morgantown, WV

§Department of Neurosciences, MetroHealth Medical Center, Cleveland, OH

Lerner School of Medicine, Cleveland, OH; and

Department of Orthopaedic Surgery and Rehabilitation, University of Wisconsin, Madison, WI.

Address correspondence and reprint requests to Timothy A. Moore, MD, Departments of Orthopaedic Surgery and Neurosciences, MetroHealth Medical Center H910C, 2500 MetroHealth Drive, Cleveland, OH 44109; E-mail:

Acknowledgment date: February 9, 2014. Revision date: April 8, 2014. Acceptance date: April 25, 2014.

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

No funds were received in support of this work.

Relevant financial activities outside the submitted work: consultancy, grants/grants pending, payment for lectures, payment for development of educational presentations, stock/stock options, royalties, and other.

© 2014 by Lippincott Williams & Wilkins