J Neurosurg Spine 20:562567, 2014

AANS, 2014

Clinical results of patients with thoracolumbar spine trauma

treated according to the Thoracolumbar Injury Classification
and Severity Score

Clinical article

Andrei F. Joaquim, M.D., Ph.D.,1 Enrico Ghizoni, M.D., Ph.D.,1

Helder Tedeschi, M.D., Ph.D.,1 Ulysses Caus Batista, M.D.,1 and Alpesh A. Patel, M.D. 2
1
Division of Neurosurgery, State University of Campinas (UNICAMP), Campinas, So Paulo, Brazil;
and 2Department of Orthopaedics, Northwestern University, Chicago, Illinois

Object. The Thoracolumbar Injury Classification and Severity Score (TLICS) was developed to improve injury
classification and guide surgical decision making, yet validation remains necessary. This study evaluates the neuro-
logical outcome of patients with thoracolumbar spine trauma (TLST) treated according to the TLICS.
Methods. The TLICS was prospectively applied to a consecutive series of patients treated for TLST between
2009 and 2012. Patients with a TLICS of 4 points or more were surgically treated, whereas patients with a TLICS of
3 points or fewer were conservatively managed. The primary outcome was the American Spinal Injury Association
Impairment Scale (AIS).
Results. A total of 65 patients were treated. In 37 patients, the TLICS was 3 points or fewer and the patients were
treated nonsurgically (Group 1). The remaining 28 patients with a TLICS of 4 or more points underwent surgical
treatment (Group 2). In Group 1, 28 patients underwent some follow-up at the authors institution; all of these patients
were neurologically intact with compression or burst fractures (TLICS of 1 or 2 points; median 2). The average age
in this group was 44.5 years, and follow-up ranged from 1 to 36 months (mean 6.7 months, median 3 months). Two
patients (both with a TLICS of 2 points) underwent late surgery for axial back pain and mild focal kyphosis, without
significant clinical improvement. In Group 2, follow-up ranged from 1 to 18 months (mean 4.4 months, median 3
months) and the TLICS ranged from 4 to 10 points (median 7 points). In this group, preoperatively, 9 (32%) patients
had AIS Grade E injuries, 6 (21%) had AIS Grade C, 1 (4%) had AIS Grade B, and 12 (43%) had AIS Grade A inju-
ries. At the final follow-up, the AIS grade was E in 11 patients (39%), D in 5 (18%), and A in 12 (43%). No patient
had neurological worsening during the follow-up.
Conclusions. The TLICS can be used to guide treatment that is safe with regard to the neurological status of
patients treated for TLST.
(http://thejns.org/doi/abs/10.3171/2014.2.SPINE121114)

Key Words spinal cord injury thoracolumbar spine classification

spine trauma spine fracture

T
he Thoracolumbar Injury Classification and Sever-
ity Score (TLICS) is a new classification and injury
severity score that identifies 3 critical injury cat-
egories and assigns a progressive score to guiding surgi-
cal decision making for thoracic or lumbar spinal trauma
(TLST).11 The possible advantages over prior systems are
the inclusion of the patients neurological status and an
assessment of the integrity of the posterior ligamentous
Abbreviations used in this paper: AIS = American Spinal Injury
Association Impairment Scale; PLC = posterior ligamentous com-
plex; TLICS = Thoracolumbar Injury Classification and Severity
Score; TLST = thoracolumbar spinal trauma.
complex (PLC) in the decision-making process. The inju-
ry severity score is calculated by summing the individual
scores. Nonoperative treatment is suggested when 3 or
fewer points are obtained; 5 or more points indicate surgi-
cal treatment; and a score of 4 points remains an interme-
diate zone where either surgical or conservative treatment
may be applied according to other variables, such as a
patients comorbidities, body habitus, and patient or sur-
geon preference (Table 1).11
Although reliability and validity of the system have
been suggested, especially when compared with other
thoracolumbar classification systems,6,8,10 the efficacy and
safety of the TLICS in a prospective clinical context has
not yet been published.

562 J Neurosurg: Spine / Volume 20 / May 2014

Clinical evaluation of the TLICS system
TABLE 1: The TLICS system* sifying the patients injury according to American Spinal
Injury Association Impairment Scale (AIS) status and
Variable Points TLICS.5 Injuries were also classified as thoracic (T110),
injury morphology thoracolumbar (T11L2), or lumbar (L35) spinal trau-
ma. Demographic data including age and sex were re-
compression 1 corded. Injury and treatment details were also recorded,
burst +1 including trauma etiology, treated fracture level (the most
translation/rotation 3 cranial when 2 consecutive vertebrae were involved),
distraction 4 neurological status (pre- and posttreatment AIS classifi-
neurological status cation), surgical approach, number of arthrodesis levels,
intact 0 and complications. The neurological status, based on the
AIS grade, was the primary outcome measurement. Insti-
nerve injury 2
tutional ethics committee approval was obtained prior to
cord, conus medullaris the study.
incomplete 3 Our standard protocols for treatment included the
complete 2 following.
cauda equina 3 Nonsurgical Management. An external lumbosacral
PLC integrity or thoracolumbar orthosis, according to the level of in-
intact 0 jury, was prescribed for all patients who underwent non-
indeterminate 2 surgical treatment. Patients were mobilized immediately
injured 3 after application of the orthosis. The orthosis was used
for 812 weeks with ambulation permitted but with other
* As reported by Vaccaro et al.11 activities restricted. The orthosis was then discontin-
For patients with suggested ligamentous injury on STIR imaging or ued and the patients were referred to a formal physical
T2-weighted MRI. therapy program. Plain radiographs were obtained after
2 weeks, 1 month, 3 months, and 6 months of follow-up.
Given the potential benefits of this new system, as- Surgical Management. All surgically treated patients
sessment of the TLICS outside the institutions of Vaccaro were treated through an open posterior approach with pe-
and colleagues11 is needed. The purpose of this paper was dicular screw fixation, realignment, and arthrodesis with
to evaluate the validity and safety of the TLICS with re- autologous bone graft. Patients with neurological deficits
gard to neurological status in a prospective, consecutive and concomitant neural compression also underwent a
clinical series of patients treated based on the TLICS. posterior and/or a transpedicular decompression when
both ventral and dorsal decompression was needed. No
external orthosis was used after surgery. Early physical
Methods rehabilitation was initialized after the procedure, and am-
Between 2009 and 2012 we prospectively analyzed bulation was allowed in patients who were neurologically
a consecutive series of patients treated for thoracic and capable of walking. All patients underwent immediate
lumbar spinal trauma (from T-1 to L-5) in a tertiary trau- CT scanning to check instrumentation location, decom-
ma center that is responsible for high-energy and complex pression, and fracture realignment after surgery. After
trauma patients (State University of Campinas, Brazil). hospital discharge, patients were seen in the outpatient
As part of our institutional protocols, a CT scan with re- clinics, and standard plain radiographs were obtained af-
constructions was obtained in all patients to evaluate the ter 2 weeks, 1 month, 3 months, and 6 months of follow-
spine. Additionally, patients with burst fractures without up. Instrumentation status, fracture reduction, and spinal
neurological deficits underwent MRI to assess the integ- alignment were assessed.
rity of the PLC.
All patients were evaluated and treated by the same Results
surgeon (A.F.J.), who was responsible for nonsurgical and
surgical care and for assessing patients at follow-up. The Sixty-five consecutive patients with TLST were treat-
TLICS system was prospectively applied to patients to ed during the period of this study. Thirty-seven patients
aid in surgical decision making. Patients with a TLICS were initially treated nonsurgically (with a TLICS of 3 or
of 4 or more points underwent surgical treatment as soon fewer points). Of these, 28 (76%) underwent follow-up at
as they were clinically stable. Those with a TLICS of less our institution. Thirteen patients (46%) had compression
than 4 points underwent nonsurgical treatment compris- fractures and 15 (54%) had burst fractures. All nonsurgi-
ing rigid brace for 812 weeks and early ambulation but cal patients were neurologically intact at baseline. Age
with activity restrictions. Patients were allowed to cross ranged from 17 to 70 years (mean 44.5 years). Twenty-
over from one treatment arm to the other based on failure two patients (78.6%) were male and 6 (21.4%) were fe-
of the initial treatment, such as persistent pain, dysfunc- male. Fall from height was the main cause of trauma
tion, or spinal deformity, or for comorbidities that would (17 patients, 61%), followed by automobile accidents (5
preclude treatment. patients, 18%). Regarding injury level, 6 patients (21.4%)
Clinical and radiological data were evaluated, clas- had thoracic fractures (T110), 18 (64.3%) had thoraco-

J Neurosurg: Spine / Volume 20 / May 2014 563

 A. F. Joachim et al.

lumbar fractures (T11L2), and 4 (14.3%) had lumbar
fractures (L35). Figure 1 illustrates a conservatively
treated patient.
Of the nonsurgically treated patients, the TLICS
ranged from 1 to 2 points (median 2 points, mean 1.5
points). Six patients with burst fractures underwent ad-
ditional MRI. All of these patients were considered to
have a normal PLC status. Follow-up ranged from 1 to 36
months (mean 6.7 months, median 3 months). No patient
had a loss of neurological function during nonsurgical
care. Two patients with burst fractures without neurologi-
cal deficits (TLICS of 2 points) crossed over to surgical
treatment. One of these patients underwent surgery af-
ter 3 months of conservative treatment due to refractory
axial back pain. The other patient underwent surgery 1
year after injury for progressive kyphosis and a persistent
complaint of local back pain (Fig. 2). Both reported only
mild to moderate improvement, reporting only partial
relief of their back pain with continued use of oral nar-
cotics. Both additionally have work-related litigation as a
result of their injuries.
Twenty-eight patients were initially surgically treat-
ed, all of whom had a TLICS of 4 or more points. The
TLICS ranged from 4 to 10 points (mean 7 points, median
7 points). Fracture classification morphology included 9
burst fractures (32%), 9 distractive injuries (32%), and 10
rotational injuries (36%). All 19 distractive and rotational
injuries had a concomitant PLC injury.
Four patients had a TLICS of 4 points and were sur-
gically treated; all had burst fractures. These fractures
are summarized as follows: 1) a T-10 fracture without
PLC injury and complete neurological deficit (AIS Grade
A), 2) an L-1 fracture without PLC injury and a nerve root
injury (AIS Grade E), 3) a T-4 fracture and an indeter-
minate PLC injury (diastasis of the facet joints) without
neurological deficits (AIS Grade E), and 4) a T-2 fracture
and MRI-suspected disruption of the PLC (Fig. 3).
In the surgical group, age ranged from 15 to 65 years
(mean 33 years). Ten patients (36%) were female and 18
(64%) were male. Fall from height was the main cause of
spinal cord injury (10 patients, 36%), followed by motor-
cycle (9 patients, 32%) and automobile (8 patients, 29%)
accidents. Regarding injury level, 15 patients (54%) had
thoracic fractures (T110), 11 (39%) had thoracolumbar
fractures (T11L2), and 2 (7%) had lumbar fractures
(L35). Follow-up ranged from 1 to 18 months (mean 4.4
months, median 3 months). One patient had an early death
(Case 22) during the same hospital admission of a trau-
matic brain injury.
The preoperative neurological status included 9
(32%) patients with AIS Grade E injuries, 6 (21%) with
AIS Grade C, 1 (4%) with AIS Grade B, and 12 (43%)
with AIS Grade A injuries. No patient experienced neu-
rological worsening during the follow-up. Postoperative
neurological status was AIS Grade E in 11 patients (39%),
Grade D in 5 (18%), and Grade A in 12 patinets (43%)
(Table 2).
Complications directly related to surgery included
2 patients with pedicle screw revision for asymptomatic
misplacement and 4 patients with wound infections, 2 of
whom required revision surgery for debridement without
instrumentation removal or revision (Table 3). One pa-
tient required a second surgical treatment for a persistent
CSF leak associated with a traumatic durotomy that was
identified and treated during the primary procedure. In
all, 5 patients underwent 2 surgical procedures. One pa-
tient died on postoperative Day 4 due to a severe cerebral
edema associated with a frontal lobe contusion. Surgery
was performed 9 days after the head injury, and the pa-
tient was neurologically intact the day before and the day
after surgery. He developed a fatal intracranial hyperten-
sion with brain swelling on the day after surgery. Despite
a decompressive craniectomy, the patient died of intracra-
nial hypertension.

Fig. 1. This woman fell from a height and sustained an L-1 fracture. She was neurologically intact.A: Lateral radiograph
showing an L-1 fracture with loss of anterior vertebral body height. B and C: Axial CT scans showing a burst fracture of the
vertebral body and a laminar fracture. The TLICS was 2 points morphology + 0 points for PLC + 0 for neurological status, giving
a total of 2 points. She was treated with a brace for 6 weeks with good clinical outcome. DF: Coronal (D) and axial (E and F)
CT scans obtained 6 months after injury showing a bone bridge between T-12 and L-1, vertebral body consolidation, and canal
clearance. G: Final lateral radiograph showing no local kyphosis or deformity.

564 J Neurosurg: Spine / Volume 20 / May 2014

Clinical evaluation of the TLICS system

Fig. 2. This 30-year-old man fell from the height of 7 ft. He was neurologically intact. A: Anteroposterior radiograph show-
ing T-8 collapse. B: Sagittal T2-weighted MR image showing no canal compression or suspect PLC injury. The patient was
treated conservatively for 12 weeks with a brace but developed significant back pain and focal kyphosis. C: Sagittal CT scan
reconstruction obtained 1 year after injury, just before we decided to perform surgery because of severe local pain. D and
E: The patient underwent posterior T57 and T910 instrumentation and fusion as seen on lateral (D) and anteroposterior (E)
postoperative radiographs. The patient reported only transitory back pain improvement after surgery, maintaining back pain.

Perioperative medical complications included a pre-
operative pulmonary embolism (1 patient), severe atel-
ectasis requiring continued mechanical ventilation for 3
days after surgery (1 patient), a postoperative ileus requir-
ing 5 additional days in the hospital (1 patient), a preop-
erative sacral decubitus ulcer (1 patient), and severe het-
erotopic ossification in the knees and hip in 1 patient with
complete thoracic spinal cord injury.
Discussion
This is the first paper to prospectively use the TLICS
to guide surgical and nonsurgical care in the treatment of
a consecutive series of patients with thoracolumbar spine
trauma. This study provides evidence that the prospective
clinical application of the TLICS system can safely guide
surgeons toward surgical and nonsurgical care with low
complication rates, low crossover rates, and safe neuro-
logical outcomes. In our series, 30 patients with thoraco-
lumbar spine trauma were ultimately surgically treated.
Twenty-eight had a TLICS of 4 or more points and were
primarily treated surgically. None of these patients had
neurological worsening during follow-up. Two patients
who were initially treated conservatively had late surgery,
both with a TLICS of 2 points, for axial back pain and
mild worsening of the segmental kyphosis. Neither pa-
tient had significant clinical improvement after surgery.
The ideal treatment of burst fractures in intact patients
is controversial.9,12 At our institution, we have treated all
patients with burst fractures without neurological deficits
conservatively, similar to the TLICS recommendations,
as neurological deterioration is rare and treatment can be
successful. Two of 37 patients initially treated with non-
surgical management in this study required late surgery.
This represents 5.4% of the patients with a TLICS of 3 or
lower. However, neither patient had neurological deteriora-
tion during the follow-up, attesting to the fact the TLICS
can be applied prospectively with both efficacy and safety.
Moreover, late surgery did not improve these 2 patients
outcomes, attesting the uncertainty of the treatment of
burst fractures without neurological deficits. Joaquim et al.

Fig. 3. This 42-year-old man was involved in an automobile accident. He had a normal neurological examination and mild
cervical pain. A: Sagittal CT scan showing a T-2 burst fracture with normal congruence of the facet joints. B: Axial CT scan
showing no canal compression. C: Sagittal T2-weighted MR image showing no cord compression. D: Sagittal MRI with sup-
pression of fat signal suggesting PLC injury (arrow). The TLICS was 2 points (burst) + 2 points for suspected PLC disruption +
0 points for neurological status, giving a total of 4 points. E: Surgery was performed with T13 fixation. The patient required
wound debridement but was doing fairly well at 7 months after surgery.

J Neurosurg: Spine / Volume 20 / May 2014 565


TABLE 2: Patient distribution according to the AIS grade before
surgery and after last follow-up*
AIS Grade Preop Last Follow-Up
A 12 12
BD 7 5
E 11 13
total 30 30
* Includes the 2 patients who were neurologically intact and who un-
derwent surgery later for refractory pain.
performed a retrospective evaluation of 49 cases of TLST
treated surgically and classified according to the TLICS.
They reported that only 2 patients had a TLICS lower than
4 points.4 These 2 patients also had a TLICS of 2 points
(burst fracture without neurological injury) and were treat-
ed based on the surgeons concerns of progressive defor-
mity associated with severe fracture comminution. The
TLICS does not uniquely consider the body height or the
degree of comminution in burst fractures when determin-
ing injury severity or guiding treatment.
Interestingly, in a recent case-control study of 46 pa-
tients, Radcliff et al. evaluated the association of local ky-
phosis (> 20) and vertebral body collapse (> 50%) with
PLC injury in burst fractures.7 They concluded that there
was not a correlation between kyphosis or vertebral body
collapse with PLC injury. These radiographic parameters
(comminution, body height, and canal compromise) did
not correlate to clinical outcomes in patients without neu-
rological injury and intact PLC. This study further sup-
ports the exclusion of these specific radiographic mea-
surements from the TLICS system.
Our follow-up was relatively short, varying from 1
to 36 months (mean 6.7 months, median 3 months) in the
conservative group and from 1 to 18 months (mean 4.4
months, median 3 months) in the surgically treated group.
Our hospital system, as a regional tertiary center, usually
returns stable patients to regional hospitals or outpatient
facilities. These patients are referred back only if there is
a change in neurological status or if there are concerns
regarding complications of fracture healing. As such, ob-
taining a greater percentage of patients with long-term
follow-up is a limitation of our health system and, hence,
of our study. Furthermore, it has been reported that most
of the neurological improvement occurs in the first 6
months after trauma.13 Based on this premise, we inter-
pret our study to demonstrate that prospective utilization
of the TLICS system is safe with regard to neurological
TABLE 3: Complications related directly to the surgical
procedure
Surgical Complication No. of Patients Comment
revision surgery 2
wound infection 4 2 cases required surgical
debridement
CSF leak 1 required revision surgery
death 1 brain swelling after surgery
566
A. F. Joachim et al.
outcomes; no patient worsened after treatment and all 7
patients with incomplete deficits had some improvement.
Another important point raised in our series is that
all patients with distractive and rotational injuries had a
PLC injury. A PLC evaluation is one of the 3 main fac-
tors considered in the decision-making process of the
TLICS. However, the PLC evaluation is more important
when classifying a compression or a burst fracture, as
most distractive and rotational injuries have posterior lig-
amentous disruption. Although our protocol for MRI use
presents the potential benefits of using an MRI in select
patients with burst fractures, additional clinical studies
are needed to determine specificity, sensitivity, and cost-
effectiveness.6
Conclusions
The TLICS was safe in guiding us through the choice
of surgical versus conservative management of thoraco-
lumbar spine trauma with regard to neurological preser-
vation. Our study is limited by its short follow-up, single-
center nature, and lack of assessment of functional status
other than neurological status. Patients with compression
and burst fractures without neurological deficits can be
treated nonsurgically without late neurological compro-
mise. Surgically treated patients demonstrated no neu-
rological deterioration. The treatment of burst fractures
without deficits and the role of the MRI in the decision-
making process requires further investigation.
Disclosure
The authors report no conflict of interest concerning the mate-
rials or methods used in this study or the findings specified in this
paper. Dr. Patel reports that he owns stock in Amedica, Cytonics,
and Nocimed and that he is a consultant for Amedica, Biomet,
Stryker Spine, Zimmer, and GE Healthcare.
Author contributions to the study and manuscript prepara-
tion include the following. Conception and design: Joaquim, Patel.
Acquisition of data: Joaquim, Tedeschi, Batista. Analysis and
interpretation of data: Joaquim, Ghizoni, Tedeschi, Patel. Drafting
the article: all authors. Critically revising the article: all authors.
Reviewed submitted version of manuscript: all authors. Approved
the final version of the manuscript on behalf of all authors: Joaquim.
References
1. Bracken MB, Shepard MJ, Collins WF, Holford TR, Young
W, Baskin DS, et al: A randomized, controlled trial of methyl-
prednisolone or naloxone in the treatment of acute spinal-cord
injury. Results of the Second National Acute Spinal Cord In-
jury Study. N Engl J Med 322:14051411, 1990
2. Bracken MB, Shepard MJ, Holford TR, Leo-Summers L, Al-
drich EF, Fazl M, et al: Administration of methylpredniso-
lone for 24 or 48 hours or tirilazad mesylate for 48 hours in
the treatment of acute spinal cord injury. Results of the Third
National Acute Spinal Cord Injury Randomized Controlled
Trial. JAMA 277:15971604, 1997
3. Geisler FH, Coleman WP, Grieco G, Poonian D: The Sygen
multicenter acute spinal cord injury study. Spine (Phila Pa
1976) 26 (24 Suppl):S87S98, 2001
4. Joaquim AF, Fernandes YB, Cavalcante RC, Fragoso RM,
Honorato DC, Patel AP: Evaluation of the thoracolumbar in-
jury classification system in thoracic and lumbar spinal trau-
ma. Spine (Phila Pa 1976) 36:3336, 2011
J Neurosurg: Spine / Volume 20 / May 2014
Clinical evaluation of the TLICS system
5. Marino RJ, Barros T, Biering-Sorensen F, Burns SP, Donovan
WH, Graves DE, et al: International standards for neurologi-
cal classification of spinal cord injury. J Spinal Cord Med 26
(Suppl 1):S50S56, 2003
6. Patel AA, Vaccaro AR, Albert TJ, Hilibrand AS, Harrop JS,
Anderson DG, et al: The adoption of a new classification sys-
tem: time-dependent variation in interobserver reliability of
the thoracolumbar injury severity score classification system.
Spine (Phila Pa 1976) 32:E105E110, 2007
7. Radcliff K, Su BW, Kepler CK, Rubin T, Shimer AL, Rihn JA,
et al: Correlation of posterior ligamentous complex injury and
neurological injury to loss of vertebral body height, kyphosis,
and canal compromise. Spine (Phila Pa 1976) 37:11421150,
2012
8. Raja Rampersaud Y, Fisher C, Wilsey J, Arnold P, Anand N,
Bono CM, et al: Agreement between orthopedic surgeons and
neurosurgeons regarding a new algorithm for the treatment of
thoracolumbar injuries: a multicenter reliability study. J Spi-
nal Disord Tech 19:477482, 2006
9. Siebenga J, Leferink VJM, Segers MJM, Elzinga MJ, Bakker
FC, Haarman HJ, et al: Treatment of traumatic thoracolumbar
spine fractures: a multicenter prospective randomized study of
operative versus nonsurgical treatment. Spine (Phila Pa 1976)
31:28812890, 2006
J Neurosurg: Spine / Volume 20 / May 2014
10. Vaccaro AR, Baron EM, Sanfilippo J, Jacoby S, Steuve J, Gross-
man E, et al: Reliability of a novel classification system for tho-
racolumbar injuries: the Thoracolumbar Injury Severity Score.
Spine (Phila Pa 1976) 31 (11 Suppl):S62S69, S104, 2006
11. Vaccaro AR, Lehman RA Jr, Hurlbert RJ, Anderson PA, Har-
ris M, Hedlund R, 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) 30:23252333, 2005
12. Wood K, Buttermann G, Mehbod A, Garvey T, Jhanjee R, Se-
chriest V: Operative compared with nonoperative treatment
of a thoracolumbar burst fracture without neurological defi-
cit. A prospective, randomized study. J Bone Joint Surg Am
85-A:773781, 2003 (Erratum in J Bone Joint Surg Am 86-
A:1283, 2004)
Manuscript submitted December 7, 2013.
Accepted February 3, 3014.
Please include this information when citing this paper: pub-
lished online March 7, 2014; DOI: 10.3171/2014.2.SPINE121114.
Address correspondence to: Andrei F. Joaquim, M.D., Ph.D., Rua
Antnio Lapa 280, S 506, Cambu, Campinas-SP 13025-240, Brazil.
email: andjoaquim@yahoo.com.
567