Surgeons Solve the Dilemma of Classifying Thoracolumbar Spinal Fractures

Surgeons faced with decisions about treatment for thoracolumbar spinal fractures are really challenged by the lack of one simple, adaptable, easy-to-remember classification system. Currently there are at least eight different systems described and in use. In this article, a new valid and reliable system is introduced that can be used in the clinic.

Let’s step back a minute and define and describe what we are talking about — first, what’s a thoracolumbar fracture and second what’s a classification system? Thoracolumbar refers to the spot in the spine where the thoracic vertebrae end (T12) and the lumbar vertebrae begin (L1). That point (T12-L1) is called the thoracolumbar junction. Fractures affecting one level above (T11) and one level below (L2) are also included in this category.

Classification systems help surgeons identify the location and severity of the fracture. Some classification systems also include the mechanism of injury (how it happened). That information is what they use to determine the most appropriate treatment for each patient.

A good system should be prognostic — in other words, give some idea of the outcomes (how bad is it, can the patient recover). And it should be all the things we’ve said so far: easy to remember, easy to use, easy to reproduce (any surgeon can use it and get the same results), and provide prognostic value. Not only that, but the system should not include unnecessary information because that just creates confusion in the decision-making process.

To add another twist to the challenge, these kinds of fractures can be described based on the injury pattern. And there can be subtypes for each injury. How and what is done in surgery to treat these injuries depends on understanding what needs to be done to stabilize each specific injury type.

To give you an idea of the wide range of classification descriptions already out there, here’s a partial list of fracture categories: wedge, dislocation, rotational fracture-dislocation, extension, burst, shear, vertical compression, compression flexion, distraction flexion, torsional, translation, and so on — you get the idea.

The complexity of a system that can place the fracture in a category and assign a subtype is just too cumbersome for clinical use. Can a simple system be possible? With eight different systems already proposed, it doesn’t seem so. But this new system called the Thoracolumbar Injury Classification and Severity Score (TLICS) may just fit the bill.

In the TLICS system, points are given for three basic characteristics of the injury: type of injury, neurologic status, and condition of the ligament. For example, a simple compression fracture would be assigned one point. A burst compression fracture would get an additional point for a subtotal of two points. If the X-ray or other imaging studies show a rotation or translation of the segment, that’s another three points. Four points are added to the subtotal if the fracture has separated and the two ends of the fracture have moved apart.

Values ranging from zero to three are given based on morphology (type of injury: compression, burst) neurologic status (spinal cord or nerve root involvement), and ligament integrity (intact, torn). The condition of thse soft tissues is important because they can create additional problems if not treated. For example, a distracted fracture with jagged edges increases the risk for nerve damage. A partially or fully torn ligament puts the patient at risk for instability.

The authors provide a table with columns outlining each of the injury characteristics and points for easy assessment and calculation. The points are all totaled and the final value (indicating severity) guides treatment. Less than four points suggests a nonsurgical approach to treatment is possible. More than four points requires surgery. Patients with zero to four points fall in the middle: they could be candidates for surgical or nonsurgical treatment. In those middle-of-the-road patients, the surgeon must evaluate all factors before making the final treatment decision.

To help surgeons see the value of the TLICS system, the authors made up another table comparing and contrasting the other commonly used classification schemes. They show who the author of each study was, how many patients it was tested on, and the main classification variables used (e.g., X-ray patterns, mechanism of injury, location of injury, clinical deformities present). A final column in the table describes treatment or prognostic value for each of the eight systems. They also provide several case examples to show surgeons how the TLICS system works.

The ability to share data that can be compared from one study to another is another great advantage to the TLICS. But the authors warn this new classification system does have some limits in how it can be used. It is only intended to be used with adults who have traumatic injuries that lead to fractures. Fractures caused by tumors or infection or that occur without a known cause cannot be assessed using the TLICS system until the tool has been tested and validated on those types of injuries.

In summary, the value of a single system that all surgeons can use to classify thoracolumbar spinal fractures is obvious. The Thoracolumbar Injury Classification and Severity Score (TLICS) will help surgeons share one system, use the same words to describe the injury, and come out with the same results predicting the optimal treatment approach.