THORACOLUMBAR INJURY

CLASSIFICATION HISTORY
Introduction
 Classificationof Thoracolumbar (TL) injuries 
evolved significantly within 75 years
 This article reviewed the salient classifications
 1st attempt by Boehler’s in 1929
 Culminates in Thoracolumbar Injury Severity Score
(TLISS)/Thoracolumbar Injury Classification and Severity
Score (TLICS)
Introduction
 Classification systems can be ideally applied if =
 provide a uniformly accepted method of describing an
injury,
 atthe same time assisting surgeon in clinical decision
making
 Classificationscheme should be comprehensive,
intuitive, and simple to implement
Anatomical Consideration

 The most common injury site for thoracic and

lumbar trauma
 TL Junction  predispose to Failure
 Transitional Zone
 Center of gravity
Classification Basis of Advantage Disadvantage
classification
Boehler Anatomic Simple Not validated
Easy to use Not predictive of
outcome
Descriptive only
Outdated
Watson-Jones morphologic-, Simple Not validated
focused on Easy to use Not predictive of
stability Can inform outcome
treatment Outdated
Nicoll Anatomic Simple Not validated
Morphologic Easy to use Not predictive of
outcome
Descriptive only
Outdated
Classification Basis of Advantage Disadvantage
classification
Kelly and Two-column Simple Not validated
Whitesides system Not predictive of
outcome
Solely based on 11
cases
Holdsworth Two-column Simple Not validated
system Can inform Not predictive of
treatment outcome
Outdated
Denis Three-column Simple Inability to
system Highlight distinguish between
Morphologic relationship stable and unstable
between fractures
neurologiv injury Poor interrater
and stability reliability
Classification Basis of Advantage Disadvantage
classification
McAfee et al Three-column Simple; Not incorporated in
system Predictive of general use;
instability and Not validated
neurologic
deficit
Ferguson and Mechanistic; Addresses Not validated;
Allen based on stability; Complex;
patterns of Comprehensive Not predictive of outcome
failure
McComack and Point system Simple; Intended to predict failure of
Gaines Predicts short segment fixation;
No consideration of
outcome neurologic status or stability;
Not validated;
Can’t uniformly describe
injuries
Classification Basis of Advantage Disadvantage
classification
AO/Magerl Morphologic Comprehensive; Complex
Defines injury severity Moderate reliability
& stability Does not define stability
Does not account for
neurologic injury

TLISS/TLICS Point system Comprehensive; Methodology behind

Defines stability; scale is insubstantial;
Predictive of Validity & ability to
outcome; predict outcome remain
Moderate reliability unproven
All validation studies
performed by Spine
Trauma Study Group
Boehler (1929)
 Combined anatomical descriptions of fracture + mechanism
of injury
 5 categories of TL injuries
 Compression fractures
 Flexion-distraction
injuries with anterior injury secondary to
compression and posterior injury secondary to distraction
 Extension fractures with injury to anterior and posterior longitudinal
ligaments
 Shear fractures
 Rotational injuries
Watson-Jones (1938)
 Proposed modified classification accounting the concept of
instability & its effect on TL injuries treatment
 THE FIRST to consider posterior ligamentous complex (PLC) 
essential in spinal stability
 Consist of seven fracture types; organized into 3 major patterns

Simple wedge fractures Comminuted fractures Fracture dislocations

 Emphasized the concept of anatomic reduction & radiographic

alignment
Nicoll (1949)
 Attempted to further define stability concept using anatomical
classification
 Four specific structures involved in spinal mechanical stability
Vertebral disc Intervertebral joint
Disc Interspinous ligament
 Major determinant of stability was integrity of interspinous ligament
 Reported on 166 TL fractures in coal miners  classified them as
Anterior wedge fractures Fracture dislocations
Lateral wedge fractures Neural arch fractures
Holdsworth (1970)
 Reviewing 1,000 patients @Sheffield Hospital, England  expanded Nicoll’s
 Revolutionized TL injury classification system with the introduction of “column
concept”
Anterior column (vertebral body & intervertebral disc)
2 1
Posterior column (facet joint & PLC)
 Elaborated Nicoll’s theory of stability
 centered on the intact interspinous ligament & maintain
the importance of posterior column
 Holdsworth classification system =

Anterior compression fractures Extension injuries

Fracture dislocations Shear injuries
Rotational fracture dislocations Burst fractures  the first to establish 
described as stable
Kelly and Whitesides (1968)
 Limited analysis of 11 cases
 Refine Holdworth’s
 Preserved concept of columns BUT redefine anterior
column as solid vertebral body & posterior column as
neural arch & posterior element
 Proposed that burst fracture were UNSTABLE (1977)
 Later on be espoused by Denis & McAfee
Denis (1983)
 In early 1980  CT scan was invented
 1983  reviewing 412 TL injuries patients, including 53 +CT image
 Denis modified Holdworth’s ‘column concept’
 Middle column was the most essential in structural stability  3
Column concept
 Classified spine fractures into 4 distinct groups
3 2 1

Compression fractures
Burst fractures
Seat belt injuries
Fractures dislocations
Compression fractures
Burst fractures
Seat belt injuries
Fractures dislocations
…Denis (1983)
 The FIRST to highlight NEUROLOGIC STATUS importance through the concept
of ‘degrees of instability’

1st degree instability  isolated mechanical instability

2nd degree  injuries with neurologic component but no mechanical instability

3rd degree  mechanical instability with neurologic compromise

 Identifying & highlighting the integral relationship between biomechanical

stability & neurologic compromise  Denis’ greatest contribution

 But criticized • Unable to distinguish stable & unstable burst fractures

McAfee (1983)
 McAfee et al identified Denis’ scale limitation and expanded it
 better define the elusive property of instability
 Emphasizing PLC as major factor in fracture stability
 Studied 100 TL injuries with CT sagittal reconstruction
 McAfee modification of Denis’ classification HAS NOT been
incorporated into genereal use
COLUMNS
Type Anterior Middle Posterior Mechanism
Wedge Compression Compression None None Forward Flexion
Stable Burst Compression Compression None Axial Compression
Unstable Burst Compression Compression Comp, Lat Flex, Rot Comp,Lat Flex, Rot
Flexion-Distraction Compression Tension Tension Anterior Fulcrum
Chance Tension Tension Tension Anterior Fulcrum
Translational Shear Shear Shear Shear
Ferguson and Allen (1984)
 Refuted initial “column concept” advanced by Holdsworth &
Denis
 “COLUMN”  semantically not fit as the anatomy &
biomechanics didn’t meet the analogy
 Proposed a classification system with anterior & posterior spinal
“elements” based on injury mechanism & pattern of failure
 Addressed stability using specific criteria =

Mechanism of injury Neurologic function

Risk of progressive deformity Patient functionality

McCormack and Gaines (1994)
 The introduction of pedicle screws revolutionized TL trauma
treatment  advent of pedicle screw construct  short-segmen
instrumentation became popular
 Important criteria in predicting posterior fixation failure

The degree of vertebral Apposition of fracture Amount of sagittal

body comminution fragments plane deformity
 Lack of consideration of neurologic status and ligamentous
stability
 Unable to uniformly describe injury & assist predicting outcome
McCormack and Gaines

 The load-sharing classification

 Important criteria in predicting posterior
fixation failure
 SCORING METHOD:
 6 points or less  successfully repaired from the
posterior approach with pedicle screw
implants.
 7 points or more  anterior approach with
vertebrectomy and strut grafting.
White and Punjabi

 Defined scoring criteria have been developed for the assessment of

clinical instability of spine fractures
AO/Magerl (1994)
 AO = Arbeitsgemeinschaft fur Osteosynthesenfragen  culmination of 10
years of study @ 5 institutions with > 1,445 TL injuries

Type A Type B Type C

Compression fractures Distraction fractures Rotational unstable injuries /
multidirectional instability
…AO/Magerl
 Each main fractures  divided into 3 subtypes  each into 3
subgroups  each into 3 subdivisions
 Ultimately composed of 53 total patterns  designed to identify injury
severity (A1 least, C3 most severe)
 Abandoning 3 column concept by Denis & returning to 2 column by
Holdsworth
 Simplify the fracture mechanism by Ferguson & Allen
 But this system proved to be confusing & demonstrated only
moderate inter-intraobserver reliability
 Did not present concrete definition of stability & neurologic deficit
Types Groups Subgroups Specificastions

A1.1
A1 impaction A1.3 A1.2.1, A1.2.2, A1.2.3
A1.3
A2.1
A compression A2 split A2.2
A2.3
A3.1 A3.1.1, A3.1.2, A3.1.3
A3 burst A3.2 A3.2.1, A3.2.2, A3.2.3
A3.3 A3.3.1, A3.3.2, A3.3.3

B1.1 B1.1.1, B1.1.2, B1.1.3

B1 post ligamentous B1.2 B1.2.1, B1.2.2, B1.2.3
B2.1
B distraction B2 post osseous B2.2 B2.2.1, B2.2.2
B2.3 B2.3.1, B2.3.2
B3.1 B3.1.1, B3.1.2
B3 anterior B3.2
B3.3

C1.1
C1 A with rotation C1.2 C1.2.1, C1.2.2, C1.2.3, C1.2.4
C2.1 C2.1.1, C2.1.2, C2.1.3, C2.1.4
B rotation C2 B with rotation C2.2 C2.2.1, C2.2.2, C2.2.3
C2.3 C2.3.1, C2.3.2, C2.3.3
C3 shear C3.1
C3.2
THORACOLUMBAR INJURY SEVERITY SCORE &
THORACOLUMBAR INJURY CLASSIFICATION AND
SEVERITY SYSTEM (2005)

 THORACOLUMBAR INJURY SEVERITY SCORE (TLISS)  created by Spine Trauma

Study Group  designed to identify, objectify factors that drive spine surgeons
to perform surgery on TL injuries
 Based on 3 major injury characteristic

Mechanism of injury Integrity of PLC Neurologic status

 Mechanism of injury & PLC condition  review of imaging study e.g plain
radiographs, CT, and/or MRI
 Total score is used to guide treatment
 TLISS
Score 3 / <  non
operative
management

4  intermediate
category in which
treatment is guided by
surgeons preference

5 / >  require
stabilization with /
without decompressive
surgery
TLICS

 After study by Harrop et al (2005)  TLISS slightly modified 

termed
 THORACOLUMBAR INJURY CLASSIFICATION & SEVERITY SCORE
(TLICS)
 No longer using summated score for injury mechanism  only
the most severe injury used regardless other level of
involvement
 Eliminating additional 1 point for coronal plate deformities
TLISS/TLICS
Present  the most
comprehensive
grading scale
 Based on the evaluation of three basic parameters:

1. Morphologic classification of the fracture

 Magerl classification modified by the AOSpine Classification

Group. For this evaluation radiograms and CT scans with multiplanar
reconstructions are essential.
2. Neurologic injury
3. Clinical modifiers
 The Role of Nonsurgical Versus Surgical Treatment
 Do not need surgical intervention
 relatively minor injuries like the AOSpine type A0 and A1 fractures
 Need surgical intervention :
 spinal cord injury or overt mechanical instability (AOSpine type B and C injuries)
 Topic of controversy  AOSpine type A burst (A3 or A4) fractures
without associated neurologic or posterior tension band injuries
(type B)

 potential benefit of surgical care relative to patient satisfaction, and

overall socio-economic burden >< improved outcomes and lower
morbidity with nonsurgical treatment