Thoracolumbar Injury Classification And Severity Research Articles

Can conservative treatment be effective for thoracolumbar injuries patients with TLICS scores of 4 or 5? An analysis of initial radiological findings and clinical risk factors for treatment failure

BackgroundThis study aimed to assess the outcomes of conservative management in patients with thoracolumbar fractures classified with a Thoracolumbar Injury Classification and Severity (TLICS) score of 4 or 5, and to analyze initial imaging findings and clinical risk factors associated with treatment failure.MethodsIn this retrospective analysis, patients with thoracolumbar fractures and a TLICS score of 4 or 5, determined through MRI from January 2017 to December 2020, were included. Patients undergoing conservative treatment were categorized into two groups: Group 1 (treatment success) and Group 2 (treatment failure), based on initial and 6-month follow-up outcomes. Clinical data were compared between the two groups. Initial radiological assessments included three kyphosis measurements (Cobb angle, Gardner angle, and sagittal index [SI]), anterior and posterior wall height, and central canal compromise (CC). Additionally, risk factors contributing to treatment failure were analyzed.ResultsThe conservative treatment group comprised 84 patients (mean age, 60.25 ± 15.53; range 22–85; 42 men), with 57 in Group 1 and 27 in Group 2. Group 2 exhibited a higher proportion of women, older age, and lower bone mass density (p = 0.001–0.005). Initial imaging findings in Group 2 revealed significantly greater values for Cobb angle, SI, and CC (p = 0.001–0.045 or < 0.001; with cutoff values of 18.2, 12.8, and 7.8%, respectively), and lower anterior wall height (p = 0.001), demonstrating good to excellent interobserver agreement (0.72–0.99, p < 0.001). Furthermore, osteoporosis was identified as a significant risk factor (odds ratio = 5.64, p = 0.008).ConclusionAmong patients with TLICS scores of 4 or 5, those experiencing conservative treatment failure exhibited unfavorable initial radiological findings, a higher proportion of women, advanced age, and osteoporosis. Additionally, osteoporosis emerged as a significant risk factor for treatment failure.

Effectiveness of sagittal top compression reduction technique in treatment of thoracolumbar vertebral fractures

To investigate the effectiveness of sagittal top compression reduction technique in the treatment of thoracolumbar vertebral fractures. A retrospective analysis was conducted on the clinical data of 59 patients with thoracolumbar vertebral fractures who met the selection criteria and were admitted between November 2018 and January 2022. Among them, 34 patients were treated with sagittal top compression reduction technique (top pressure group), and 25 patients were treated with traditional reduction technique (traditional group). There was no significant difference in baseline data between the two groups ( P>0.05), including gender, age, fracture segment, cause of injury, AO classification of thoracolumbar vertebral fractures, thoracolumbar injury classification and severity (TLICS) score, American Spinal Injury Association (ASIA) grading, surgical approach, preoperative vertebral body index, height ratio of the anterior margin of injured vertebra, injured vertebra angle, segmental kyphosis angle, visual analogue scale (VAS) score, and Oswestry disability index (ODI). The operation time, intraoperative blood loss, and incidence of complications between the two groups were recorded and compared. After operation, VAS score and ODI were used to evaluate effectiveness, and X-ray and CT examinations were performed to measure imaging indicators such as vertebral body index, height ratio of the anterior margin of injured vertebra, injured vertebra angle, and segmental kyphosis angle. There was no significant difference in operation time and intraoperative blood loss between the two groups ( P>0.05). No complication such as dural sac, nerve root, or vascular injury was found during operation, and all incisions healed by first intention. Patients in both groups were followed up 6-48 months, with an average of 20.6 months. No loosening, breakage, or failure of internal fixation occurred during follow-up. The imaging indicators, VAS score, and ODI of the two groups significantly improved at 1 week and last follow-up when compared to preoperative ones ( P<0.05). At last follow-up, the VAS score and ODI further significantly improved when compared to 1 week after operation ( P<0.05). At 1 week after operation and last follow-up, the vertebral body index, segmental kyphosis angle, injured vertebra angle, and ODI in the top pressure group were significantly better than those in the traditional group ( P<0.05). There was no significant difference in VAS score and height ratio of the anterior margin of injured vertebra between the two groups at 1 week after operation ( P>0.05), but the two indicators in the top pressure group were significantly better than those in the traditional group at last follow-up ( P<0.05). The treatment of thoracolumbar vertebral fractures with sagittal top compression reduction technique can significantly improve the quality of vertebral reduction, and is superior to traditional reduction techniques in relieving pain and improving spinal function.

Evaluation of the Thoracolumbar Injury Classification and Severity (TLICS) Score Over a Two-Year Period at a Level One Trauma Center.

Introduction The use of the Thoracolumbar Injury Classification and Severity Score (TLICS) and other classification systems for guiding the management of traumatic spinal injuries remains controversial. TLICS is one of the few classifications that provides treatment recommendations.We sought to analyze intervention modality selection based on the TLICS scoring system. Methods A retrospective review of patients presenting with traumatic thoracolumbar fractures at a level 1 trauma center over a two-year period was performed. Primary endpoints for comparison analysis included visual analog scale (VAS) scores and Cobb angles during follow-up. Results There were 272 patients with thoracolumbar fractures, of whom 212 had TLICS of ≤3, six with TLICS of 4, and 54 with TLICS of ≥5. Of the 272 total patients, 59 were treated via surgery and 213 via non-surgical conservative methods. The VAS scores significantly decreased from presentation to last follow-up in both surgically treated and conservative groups (p<0.0001). This remained consistent in subgroup analyses of TLICS ≤ 3, TLICS = 4, and TLICS ≥ 5 (p<0.0001). Burst fractures treated conservatively had larger fracture Cobb angles versus those treated via surgery at the last follow-up, although this was not significantly associated (p=0.07). The only significant relationship with Cobb angles was in distraction fractures of the TLICS > 4 conservative group, who had significantly lower Cobb angles at the last follow-up than the TLICS > 4 surgical group (p<0.04). The "surgeon's choice" for TLICS = 4 was surgical intervention (4/6 patients, 66.7%). Conclusion Using the TLICS score, thoracolumbar injuries in a level 1 trauma center are more commonly TLICS ≤ 3. For patients with TLICS = 4, the surgeon's choice was most commonly surgical repair. VAS scores decreased over time from presentation between surgically and conservatively managed patients (as well as within-group analyses). The data concerning Cobb angles were more ambiguous, as larger Cobb angles in burst fractures treated conservatively did not show statistically significant differences with surgery.

Efficacy and Safety of Conservative Treatment Compared With Surgical Treatment for Thoracolumbar Fracture With Score 4 Thoracolumbar Injury Classification and Severity (TLICS): A Systematic Review and Meta-analysis.

This was a systematic review and meta-analysis. The clinical outcomes, radiologic outcome, and complications were compared between surgical treatment and conservative treatment of thoracolumbar fractures with a Thoracolumbar Injury Classification and Severity (TLICS) score of 4. The thoracolumbar fracture is the main reason leading to the spinal cord injury. Some studies suggested that the treatment of TLICS=4 is a "gray zone." Hence, the efficacy and safety of surgical treatment and conservative treatment of thoracolumbar fractures with scores 4 TLICS was still debated. A comprehensive search of PubMed, Embase, and the Cochrane Library, Chinese National Knowledge Infrastructure (CNKI), Chongqing VIP Database (VIP), and Wan Fang Database was performed up to October 2021. Relevant studies were identified using specific eligibility criteria and data was extracted and analyzed based on primary and secondary outcomes. A total of 10 studies involving 555 patients were included (3 randomized controlled trials and 7 retrospective studies). There was no significant difference of hospital time (standardized mean difference=0.24, 95% CI: -1.50 to 1.97, P =0.79) and Oswestry Disability Index (mean difference=2.97, 95% CI: -1.07 to 7.01, P =0.15) between surgery and nonsurgery. The length of returning to work was shorter in surgical treatment (standardized mean difference=1.27, 95% CI: 0.07-2.46, P =0.04). Visual Analog Scale in surgical treatment was lower at 1, 3, and 6 months (respectively, P <0.00001, P =0.003, and P =0.02). However, there existed no significant difference between surgical treatment and nonsurgical treatment at 12 and >24 months (respectively, P =0.18 and 0.17). Cobb angle was lower in surgical treatment at postoperative at 6, 12, and >24 months (respectively, P =0.005, P <0.00001, P =0.002, and P =0.0002). Finally, the surgical treatment had a lower incidence of complications (odds ratio=3.89, 95% CI: 1.90-7.94, P =0.0002). Current evidence recommended that surgical treatment is superior to conservative treatment of TLICS score of 4 at the early follow-up. Surgical treatment had lower Cobb angle, Visual Analog Scale scores, and complications compared with a nonsurgical TLICS score of 4. However, these findings needed to be verified further by multicenter, double-blind, and large-sample randomized controlled trials.

Early Surgical Treatment of Thoracolumbar Fractures With Thoracolumbar Injury Classification and Severity Scores Less Than 4.

Thoracolumbar fractures (TLFs) are the most common spinal fractures seen in patients with trauma. The Thoracolumbar Injury Classification and Severity (TLICS) classification system is commonly used to help clinicians make more consistent and objective decisions in assessing the indications for surgical intervention in patients with thoracolumbar fractures. Patients with TLICS scores <4 are treated conservatively, but a percentage of them will have failed conservative treatment and require surgery at a later date. All patients who received an orthopaedic consult between January 2016 and December 2020 were screened for inclusion and exclusion criteria. For patients meeting the study requirements, deidentified data were collected including demographics, diagnostics workup, and hospital course. Data analysis was conducted comparing length of stay, time between first consult and surgery, and time between surgery and discharge among each group. 1.4% of patients with a TLICS score <4 not treated surgically at initial hospital stay required surgery at a later date. Patients with a TLICS score <4 treated conservatively had a statistically significant shorter hospital stay compared with those treated surgically. However, when time between initial consult and surgery was factored into the total duration of hospital stay for those treated surgically, the duration was statistically equivalent to those treated nonsurgically. For patients with a TLICS score <4 with delayed mobilization after 3 days in the hospital or polytraumatic injuries, surgical stabilization at initial presentation can decrease the percentage of patients who fail conservative care and require delayed surgery. Patients treated surgically have a longer length of stay than those treated conservatively, but there is no difference in stay when time between consult and surgery was accounted for. In addition, initial surgery in patients with delayed mobilization can prevent long waits to surgery, while conservative measures are exhausted. Retrospective cohort study.

Thoracolumbar Injury Classification and Severity Score Is Predictive of Perioperative Adverse Events in Operatively Treated Thoracic and Lumbar Fractures.

A retrospective cohort study of patients with surgically treated thoracolumbar fractures. This study aimed to describe the incidence of adverse events (AEs) after surgical stabilization of thoracolumbar spine injuries and to identify predictive factors for the occurrence of AEs. Thoracolumbar spine fractures are frequently present in patients with blunt trauma and are associated with significant morbidity. AEs can occur due to the initial spinal injury or secondary to surgical treatment. There is a lack of emphasis in the literature on the AEs that can occur after operative management of thoracolumbar fractures. We performed a retrospective review of 199 patients with surgically treated thoracolumbar fractures operated between January 2007 and January 2018. The potential risk factors for the development of AEs as well as the development of common complications were evaluated by univariate analysis, and a multivariate logistic regression analysis was performed to identify independent risk factors predictive of the above. The overall rate of AEs was 46.7%; 83 patients (41.7%) had nonsurgical AEs, whereas 24 (12.1%) had surgical adverse events. The most common AEs were urinary tract infections in 43 patients (21.6%), and hospital-acquired pneumonia in 21 patients (10.6%). On multivariate logistic regression, a Thoracolumbar Injury Classification and Severity (TLICS) score of 8-10 (odds ratio [OR], 6.39; 95% confidence interval [CI], 2.33-17.51), the presence of polytrauma (OR, 2.64; 95% CI, 1.17-5.99), and undergoing open surgery (OR, 2.31; 95% CI, 1.09-4.88) were significant risk factors for AEs. The absence of neurological deficit was associated with a lower rate of AEs (OR, 0.47; 95% CI, 0.31-0.70). This study suggests the presence of polytrauma, preoperative American Spinal Injury Association score, and TLICS score are predictive of AEs in patients with surgically treated thoracolumbar fractures. The results might also suggest a role for minimally invasive surgical methods in reducing AEs in these patients.

Thoracolumbar Injury: The Thoracolumbar Injury Classification and Severity Scoring System or Modified Thoracolumbar Injury Classification and Severity?

To compare the Thoracolumbar Injury Classification and Severity (TLICS) scoring system with its modified (mTLICS) version based on their agreement with the surgeon's opinion regarding treatment for patients with thoracolumbar injuries. Moreover, the Posterior Ligamentous Complex health was compared between intraoperative examinations and magnetic resonance imaging (MRI) reports. MRI was obtained from 114 patients suffering thoracolumbar spinal trauma; the TLICS and mTLICS scores were measured. Approaches 1 and 2 were designed in both scoring systems based on assuming a total score of 4 as surgery and conservative management indication, respectively. Kappa was used to estimate the agreements between each approach and the surgeon's opinion on treatment. The receiver operating curve calculated the appropriate cut-off scores for the above systems over which surgical management was preferred. A P < 0.05 was considered significant. All the approaches showed moderate agreements with the surgeon's opinion on therapeutic management (TLICS: κapproach1=0.557, κapproach2=0.508; mTLICS: κapproach1=0.557, κapproach2=0.551; P < 0.001 for each κ). A score >3.5 best illustrated the indication for surgery in both systems. The radiology report agreed stronger with intraoperatively observed ligamentous health when suspicious cases on MRI were reported as injured (κTLICS= 0.830, κmTLICS= 0.704) rather than healthy (κTLICS= 0.620, κmTLICS= 0.620). The surgeon's treatment plan agreed moderately with suggestions of the TLICS and mTLICS systems; surgery was the preferred management for the patients with a score of 4. Moreover, radiologic suspicion of Posterior Ligamentous Complex injury seemed to indicate a damaged ligament rather than a healthy one.

Nonoperative Management in Intact Burst Fracture Patient With Thoracolumbar Injury Classification and Severity Score of 5: A Case Report

Thoracolumbar fractures are a common consequence of trauma, often a result of motor vehicle accidents or falls. Burst fractures are a morphology of thoracolumbar fracture in which compressive force causes retropulsion of the posterior elements of the vertebral body, potentially leading to neurological deficits. The Thoracolumbar Injury Classification and Severity (TLICS) score is a decision-making tool to help surgeons decide between nonoperative and operative management. For assigned scores of 4, management is at the discretion of the surgeon, and for scores ≥ 5, operative treatment is recommended. Burst fracture patients that are neurologically intact are given a score of 5 if there is a posterior ligamentous complex (PLC) injury and are recommended to undergo operative management. Here we present a neurologically intact patient with an L4 burst fracture with PLC injury that was managed conservatively and demonstrated successful clinical, functional, and radiographic recovery.

Reliability of the thoracolumbar injury classification and severity score compared with the McAfee classification among young neurosurgeons

Objective: The reliability of the thoracolumbar injury classification and severity (TLICS) score is well established; however, its reliability among young neurosurgeons in particular has not been investigated. This study was designed to identify intra- and inter-observer differences between the TLICS system and the McAfee classification among young neurosurgeons, with the goal of facilitating communication between physicians and treatment decision-making for patients with thoracolumbar injuries.Methods: Six young neurosurgeons reviewed thoracolumbar spinal fracture patients between January 2016 and October 2020 and analyzed thoracolumbar fractures according to the 2 classification systems. The intra- and inter-observer reliability of the TLICS and the McAfee scale was assessed with the Cohen and Fleiss kappa tests.Results: The intra-observer kappa value for the TLICS exhibited excellent reliability (κ=0.85) compared to the McAfee classification (κ=0.79). The inter-observer kappa values for each category of the TLICS were 0.69 (morphology), 0.93 (neurologic status), 0.74 (posterior ligamentous complex), and 0.72 (total score). The kappa value of the McAfee classification was lower (κ=0.52).Conclusion: The TLICS system showed higher reliability than the McAfee classification. The TLICS score showed more consistent results for thoracolumbar spinal fractures and may thus serve as a guideline for young neurosurgeons in treating patients with thoracolumbar fractures.

85. The neurology stability epidural compression assessment: a new score to establish the need for surgery in spinal metastases

85. The neurology stability epidural compression assessment: a new score to establish the need for surgery in spinal metastases

Load-Sharing Classification Score as Supplemental Grading System in the Decision-Making Process for Patients With Thoracolumbar Injury Classification and Severity 4.

Patients with Thoracolumbar Injury Classification and Severity (TLICS) score of 4 fall into a gray zone between surgical and conservative management. The integrity of posterior ligamentous complex (PLC) evaluated by magnetic resonance imaging (MRI) contributes to surgical decision-making. Load-sharing classification (LSC) may provide a modifier to further guide decision-making in these patients. To evaluate associations between LSC score and MRI acquisition, compromise of PLC on MRI, and surgical intervention in TLICS 4 patients. A cohort of 111 neurologically intact patients with isolated thoracolumbar burst fracture with TLICS 4 was evaluated. LSC score was determined based on degree of comminution (1-3), apposition (1-3), and kyphosis (1-3), total composite score of 3 to 9. Overall, 44 patients underwent MRI, 15 had PLC injury, and 32 (28.8%) underwent surgery. LSC score was higher in patients who had an MRI (median 6vs 3, P <.001) and patients who had surgery (median 7vs 4, P <.001). In univariate logistic regression, LSC score was associated with MRI acquisition (odds ratio [OR] 1.7; 1.32-2.12; P <.001), presence of PLC injury on MRI (OR 1.5; 1.2-2.0; P=.002) and, in multivariate logistic regression, undergoing surgical intervention (OR 3.7; 2.3-5.9; P <.001), independent of MRI or PLC injury. LSC score in neurologically intact patients with isolated thoracolumbar burst fracture with TLICS 4 was independently associated with operative intervention. The application of LSC may further guide decision-making in this patient group.

Surgical management of traumatic irreducible spondyloptosis of thoracolumbar junction

Introduction. The thoracolumbar junction is the most common location of traumatic spinal injuries. It accounts for 50-60% of all thoracic and lumbar spine injuries. Spondyloptosis is rather rare, but one of the most severe types of traumatic injury, that is characterized by a severe damage of spinal axis in one or more planes. Traumatic spondyloptosis is classified as reducible and irreducible, depending on the possibility of intraoperative restoration of the spinal axis without resection of the damaged vertebra. Objective. To determine the optimal surgical technique for traumatic irreducible spondyloptosis of thoracolumbar junction. Materials and methods. A retrospective analysis of the patients’ database treated at the Romodanov Neurosurgery Institute, Ukraine was performed over the past 4 years (2017 to 2020) to identify all cases with traumatic irreducible spondyloptosis of the thoracolumbar junction. Results. Treatment outcomes of five patients aged 18 to 52 years (mean age 31.2 years) were analyzed. The minimum period from the moment of injury to surgery was 14 days, the maximum was 3 months and 2 days (on average 42.2 days). At the time of admission all patients had a neurological deficit that corresponds to the functional class A on the American spine injury associatin ASIA scale of severity of spinal cord injury. The TLICS (Thoracolumbar injury classification and severity) score was 8 points. All the patients had the injury of lateral spondyloptosis: in three cases as an isolated displacement only in the coronal plane, in two – as a combined one - in the coronal and sagittal plane. Surgical intervention in all cases was performed from the posterior approach. As a body replacement system in 2 patients, a vertical cylindrical implant (Mesh) was used, in 3 patients - a telescopic body replacing implant. The method of bicortical implantation of pedicle screws was applied. The transpedicular system was strengthened by two cross links of the rod-to-rod type. In all cases the restoration of spinal axis was achieved in both the coronal and sagittal planes. Follow-up examinations were carried out 2, 6 and 12-18 months of the postoperative period. Regression of neurological disorders was registered in two patients, in one case to ASIA B, in the other to ASIA C. Conclusions. Isolated posterior approach has demonstrated high efficacy in the surgical management of traumatic irreducible spondyloptosis of the thoracolumbar junction both in restoring the axis of the spine and in ensuring the stability of fusion.

Early Experience with Percutaneous Transpedicular Screw Fixation for Thoracolumbar Fractures at a Tertiary Hospital in Pakistan.

Objective: To present our early experience with percutaneous transpedicular screw fixation for thoracolumbar fractures at a tertiary care hospital in Pakistan.&#x0D; Material &amp; Methods: A case series of 20 patients with thoracolumbar fractures, who met the inclusion and exclusion criteria were followed for up to six months to evaluate their functional status using the Oswestry Disability Index (ODI). Kendall’s tau, Spearman’s rho and Pearson correlations were conducted to draw useful conclusions.&#x0D; Results: 85% patients’ injury was reported from ‘fall from height’. 55% of the fracture was the dorsal-lumbar junction (T12-L1). Burst type morphology was reported in maximum number of patients (65%). 55% of patients were reported to be neurologically intact. ODI score’s mean percentage decreased from 40% to 23% during the first week to six months, indicates an improvement in the disabilities. A significant (p&lt;0.050) positive correlation was found between fracture morphology and ODI. All patients had an accurate screw trajectory postoperatively and no postoperative complications were documented. Neurology was stable for all patients at 1, 3 and 6 months.&#x0D; Conclusion: Percutaneous transpedicular screw fixation can be a viable approach for thoracolumbar burst fractures with intact posterior ligamentous complex in all types of thoracolumbar fractures, including type C and leads to an improvement the quality of life. Fracture morphology has a significantly positive correlation with a higher disability index score, with more severe fracture morphologies as per the Thoracolumbar Injury Classification and Severity (TLICS) score having a higher disability.

Therapeutic Effect of Teriparatide for Osteoporotic Thoracolumbar Burst Fracture in Elderly Female Patients.

ObjectiveTeriparatide is known as an effective anabolic agent not only for severe osteoporosis but also for bone healing and union. We explored the possibility of teriparatide as an alternative treatment option for osteoporotic thoracolumbar (TL) burst fracture. MethodsThis retrospective study enrolled 35 female patients with mean age of 73.77±6.71 years (61–88) diagnosed as osteoporotic TL burst fracture with ≥4 of thoracolumbar injury classification and severity (TLICS) score and no neurological deficits. All patients were treated by teriparatide only (12 of group A), teriparatide plus vertebroplasty (12 of group B), or surgical fixation with fusion (11 of group C), and followed up for 12 months. Radiological outcomes were evaluated using radiological parameters including kyphotic angle (KA), segmental vertebral kyphotic angle (SVKA), compression ratio (CR), and vertebral body height (anterior [AH], middle [MH], posterior [PH]). Functional outcomes were evaluated using visual analog scale (VAS) and Macnab classification (MC). ResultsThere were no statistical significant differences in age, bone mineral density (-3.36±0.73), and TLICS score (4.34±0.48) among the three groups (p>0.05). Teriparatide was administered during 8.63±2.32 months in group A and B. In 12-month radiological outcomes, there were significant restoration in SVKA, CR, AH, and MH of group B and KA, SVKA, CR, AH, and MH of group C compared to group A with no radiological changes (p<0.05). All groups showed similar significant improvements in 12-month functional outcomes, although group B and C showed a better 1-month VAS, 1-month MC, 3-month MC compared to group A (p<0.05). ConclusionNon-surgical treatment with teriparatide showed similar 12-month functional outcomes compared to surgical fixation with fusion. The additional vertebroplasty to teriparatide and surgical fixation with fusion were more helpful to improve short-term functional outcomes with structural restoration compared to teriparatide only.

Evaluation of outcome of posterior decompression and instrumented fusion in thoracolumbar fractures

&lt;p class="abstract"&gt;&lt;strong&gt;Background:&lt;/strong&gt; The fractures of the thoracolumbar junction are the most common injuries of the vertebral column. Fall from a height and road traffic accidents are the main causes of injury. The present study aims to evaluate the functional, neurological and radiological outcome of the posterior decompression and instrumented fusion in operated patients with thoracolumbar fractures.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Methods:&lt;/strong&gt; In this retrospective and prospective study, a cohort of 30 patients with thoracolumbar fractures, classified by thoracolumbar injury classification and severity (TLICS) scoring system, underwent posterior decompression and pedicle screw fixation from January 2013 to August 2018 were included. Patients were assessed functionally (ODI score), neurologically (MRC grading) and radiologically (kyphotic angle) preoperatively and at 6 weeks, 3 months, 6 months and 12 months post-operatively.&lt;strong&gt;&lt;/strong&gt;&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Results:&lt;/strong&gt; The mean ODI score improved from 87.40 pre-operatively to 13.33 at final follow-up (p value 0.001). The mean kyphotic angle decreased from 24.37 degrees preoperatively to 9.87 degrees postoperatively (p value 0.001) with mean loss of correction of 1.16 degrees at final follow-up. Hip flexors and knee extensors improved from a mean preoperative value of 2.60 to 4.83 at final follow-up (p value 0.001). Similarly, ankle dorsiflexors, long toe extensors and ankle plantar flexors improved from mean preoperative value of 2.53, 2.50 and 2.60 to 3.93, 3.80 and 4.73 at final follow-up, respectively (p value 0.001).&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Conclusions:&lt;/strong&gt; Posterior decompression and instrumented fusion is a safe and effective surgical option in patients with thoracolumbar fractures. TLICS scoring system has a prognostic value and helps in determining the prognosis in these patients.&lt;/p&gt;

Candidates for Percutaneous Screw Fixation Without Fusion in Thoracolumbar Fractures: A Retrospective Matched Cohort Study.

Study Design:Retrospective matched cohort study.Objectives:Identifying candidates for isolated percutaneous screw fixation (PSF) in thoracolumbar fractures based on Thoracolumbar Injury Classification and Severity (TLICS) score.Methods:Patients underwent PSF were split into 3 TLICS-score categories, then matched with groups having similar scores managed either non-operatively or via open screw fixation (OSF). Each category was assessed for corrective power and loss of correction by comparing initial and 1-year Cobb angles as well as Oswestry Disability Index and rates of fracture healing at 1 year.Results:A total of 102 patients (40 females) with age range 19 to 51 years, were admitted 1 to 25 hours following trauma. Each of TLISC categories consisted of matched treatment groups for comparison. In TLICS-3 fractures (2 treatment groups, n = 12 each), PSF showed similar outcomes but longer time to ambulation and length of stay (LOS) compared with nonoperative management. In TLICS-4 fractures (3 treatment groups, n = 18 each), PSF showed comparable corrective power and outcomes as OSF but was better in terms of operative time, blood loss, time to ambulation, LOS, and cosmesis. Despite higher LOS when compared with nonoperative cases, PSF showed superior radiologic and functional outcomes. In TLICS-5 fractures (2 treatment groups, n = 12 each), PSF showed shorter admissions and time to ambulation but lower corrective power, functional recovery, and tendency to lower healing rates.Conclusions:Isolated PSF is a valid choice in managing TLICS-4 thoracolumbar fractures; however, it did not surpass conventional methods in TLICS-3 or TLICS-5 fracture types. Further studies are needed before the generalization of findings.

Could Intermediate Screw in Thoracolumbar Fracture Fixation Save Motion Levels? Comparative Study between Long-Segment and Short-Segment with Intermediate Screw Fixation

Background Data: Thoracolumbar fractures are commonly managed by posterior pedicle screw fixation. Controversy about the number of levels involved in the fixation remains as the stability of the short-segment fixation remains questionable. Recently, it has been shown that application of intermediate screw in the fractured vertebra improves the biomechanical stability of the short-segment construct. Purpose: To compare the outcome of long-segment fixation (LSF) versus short-segment fixation with intermediate screws (SSFIS) in the management of the thoracolumbar burst fractures. Study Design: A prospective, nonrandomized clinical controlled trial. Patients and Methods: Fifty patients with thoracolumbar burst fracture (T11-L2) types A3 and A4 AOSpine classification with a Thoracolumbar Injury Classification and Severity (TLICS) scale of more than 4 were treated between 2009 and 2014 with posterior pedicle screw fixation. Patients were divided into two groups according to the number of instrumented levels. Group 1 included 25 patients treated with LSF (two levels above and two levels below the fractured level) while Group 2 included 25 patients treated by SSFIS (one level above and one level below with 2 intermediate screws in the fractured level). The patients were evaluated for local kyphotic angle (LKA) correction and maintenance, anterior vertebral body height (AVH) compression, and Visual Analogue Scale (VAS) for back pain and treatment related complications. Construct failure was defined as screw pullout or instrument breakage. Results: The two groups were similar with regard to age, sex, fractured levels, fracture type, TLICS score, preoperative local kyphotic angle, and anterior vertebral body height compression. Postoperative correction of the local vertebral compression assessed with LKA and AVH significantly improved in both groups compared to the preoperative degree. There was no significant difference in the two groups in early postoperative or follow-up regarding the degree of correction and its maintenance. No construct failure or major treatment related complication was encountered in both groups with significant reduction of VAS and ODI in both groups between early postoperative and late follow-up (13.5±2 months). Conclusion: Intermediate screw applied in the fractured level in management of thoracolumbar burst fracture improves the correction and maintenance of local kyphosis in short-segment fixation like long-segment construct with saving vertebral motion levels from being fixed. More randomized controlled and multicenter studies are needed to support these findings. (2019ESJ175)

Surgical Practice in Traumatic Spinal Fracture Treatment with Regard to the Subaxial Cervical Injury Classification and Severity and the Thoracolumbar Injury Classification and Severity Systems: A Review of 58 Patients at the University of Wisconsin

Spine surgeons at a Level 1 Trauma Center have observed a high incidence of spine and spinal cord injuries owing to falls from tree stands. These injuries have been retrospectively reviewed in the context of the Thoracolumbar Injury Classification and Severity (TLICS) and the Subaxial Cervical Injury Classification and Severity (SLICS) classification systems to assess inter-user reliability and validity. We hypothesize that the inter-rater reliability will be similar between neuroradiology and neurosurgery raters and validity of the scoring system will be maintained at our institution. The University of Wisconsin Hospital and Clinics' trauma database was reviewed for tree stand-related injuries from 1999 to 2013, with a focus on patients suffering from spine and spinal cord injuries. The TLICS and SLICS scores were then independently determined for these injuries by a neurosurgeon and a neuroradiologist. When cases were grouped by management recommendation (operative, equivocal, and nonoperative) reviewer agreement was 12/15 (80%) of SLICS and 38/52 (73%) of TLICS scores. Operative SLICS positive predictive value reached 100%, however, with a wide confidence interval. Conversely, the SLICS negative predictive value was poor at 54%-60%, with frequent operative treatment for patients assigned nonoperative scores. TLICS scores reached 77.8% and 93.3% positive predictive value per reviewer, whereas negative predictive values reached 93.9% and 89.2%, respectively. The TLICS and SLICS systems provide good-to-excellent inter-rater reliability. SLICS validity was poor, whereas TLICS was reasonable for nonoperative cases and moderate for operative cases. Systems such as the TLICS and the SLICS may be best applied in the educational setting to confirm the fracture morphology and presence or absence of ligamentous injury between surgeons and radiologists.

Non-Operatively Treated Thoracolumbar Burst Fracture with Posterior Ligamentous Complex Injury: Case Report and Consideration on the Limitation of Thoracolumbar Injury Classification and Severity (TLICS) Score

Fractures at the thoracolumbar region are commonly followed after major traumatic injuries, and up to 20% of these fractures are known to be burst fractures. Making surgical decisions for these patients are of great interest however there is no golden standard so far. Since the introduction of Thoracolumbar Injury Classification and Severity (TLICS) score in 2007, it has been widely used as a referential guideline for making surgical decisions in thoracolumbar fractures. However, there is still limitations in this system. In this clinical case report, we introduce a L1 burst fracture after motor vehicle injury, who was successfully treated conservatively even while she was graded as a TLICS 5 injury. A case report is presented as well as discussion on the limitations of this grading system.

Comparison of surgical or nonsurgical treatment outcomes in patients with thoracolumbar fracture with Score 4 of TLICS: A randomized, single-blind, and single-central clinical trial.

Background:Thoracolumbar fractures are among the most common types of damages caused to the spinal cord .Therefore, the aim of this study was the comparison of surgical or nonsurgical treatment outcomes in patients with thoracolumbar fracture with score 4 of the thoracolumbar injury classification and severity (TLICS)Methods:This study was clinical trial and double blind. Patients with thoracolumbar fracture with score 4 of TLICS entered at this research. We divided patients in 2 groups randomly (each group 25 patients) and then we followed patients for 1 year after start of treatment. We checked duration of bedridden and absence work, pain every 3 months for 1 year and radiography every 3 months for 1 year.Results:Pain in operative group was lower than nonoperative group (P = .02). Regional sagittal angles (RSA) in operative group was lower than nonoperative group in all time (P = .0001). Mean of time of return to work in operative group was lower than nonoperative group (P = .001).Conclusions:Pain and mean of time of return to work and RSA in operative group was lower than nonoperative group. The present data suggest the use of operative method in patients with thoracolumbar fracture with score 4 of TLICS.