Thoracolumbar Injury Classification And Severity (TLICS) Score

TLICS explained

This score was created by the Spine Trauma Study Group for use in patients with thoracolumbar spine injuries.

It evaluates the severity of spinal injury and whether surgery is necessary based on three independent parameters which predict spinal stability, future deformity and any progressive neurological consequences.

The three predictors and their answer choices are described below.

1. Morphology

This item evaluates the pattern of the injury rather than the mechanism (in some cases these might match but it is not a rule) and assesses immediate stability as resulted from radiographs and computed tomography.

■ Compression (1 point) – usually the result of 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.

2. Integrity of PLC (Posterior Ligamentous Complex)

This item evaluates long term stability as resulted from the MRI investigation of the ligamentous structures.

■ Intact (0 points);

■ Suspected (2 points);

■ Injured (3 points).

Because of their support role for the spinal column (tension band), torn PLCs tend to lead to progressive kyphosis and collapse.

■ Interspinous space widened;

■ Facet joints widened or dislocated;

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

■ Vertebral body translation.

The PLC is composed of the supraspinous ligaments, interspinous ligaments, articular facet capsules, and ligamenta flava.

MRI investigations tend to over diagnose PLC injuries, however, proven cases require surgery.

3. Neurological status

This item is assessed through a physical examination performed by a neurologist or by the spine surgeon. The neurological status characteristics are the following:

■ Intact (0 points);

■ Nerve root (2 points);

■ Complete cord (2 points);

■ Incomplete cord (3 points);

■ Cauda equina (3 points).

Other spinal injury classification focus on the injury mechanism in order to predict outcome whilst TLICS evaluates the effects of the injury and possible consequences.

Score interpretation

Each of the three clinical predictors is scored on a scale from 0 (or 1 for morphology) to 4. The total score varies from 1 to 10, with a cut off point for surgery recommendation set at 4 points.

In case there is more than one fracture, each are evaluated individually and the highest score amongst them is considered as final.

The following table summarises the recommendations for each score category:

It is important that present co-morbidities and other injuries are taken into account as well when deciding non-operative or operative management.

About the study

In 2005, Vaccaro et al. proposed a new classification system for thoracolumbar spine injuries that could help support the choice between operative versus nonoperative care in unstable injury patterns.

The three aspects that were taken into account during the study and which remained in the TLICS are:

1) morphology of injury determined by radiographic appearance;

2) integrity of the posterior ligamentous complex;

3) neurologic status of the patient.

A composite injury severity score is calculated and stratifies patients into surgical and nonsurgical treatment groups, thus facilitating clinical decision making and potentially improving inter-rater agreement between spine trauma physicians.

Original source

Vaccaro AR, Lehman RA Jr, Hurlbert RJ, Anderson PA et al. 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). 2005; 30(20):2325-33.

Other references

1. Patel AA, Vaccaro AR, Albert TJ, Hilibrand AS, Harrop JS, Anderson DG, Sharan A, Whang PG, Poelstra KA, Arnold P, Dimar J, Madrazo I, Hegde S. The adoption of a new classification system: time-dependent variation in interobserver reliability of the thoracolumbar injury severity score classification system. Spine (Phila Pa 1976). 2007; 32(3):E105-10.

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

3. Vaccaro AR, Rihn JA, Saravanja D, Anderson DG, Hilibrand AS et al. 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). 2009; 34(23):E841-7.

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