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

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

BACKGROUND

This 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.

METHODS

In 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.

RESULTS

The 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).

CONCLUSION

Among 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.

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

STUDY DESIGN

This was a systematic review and meta-analysis.

OBJECTIVE

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.

SUMMARY OF BACKGROUND DATA

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.

MATERIALS AND METHODS

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.

RESULTS

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).

CONCLUSIONS

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.

Adult Trauma Patients With Thoracolumbar Injury Classification and Severity Score of 4: A Systematic Review

STUDY DESIGN

Systematic review.

OBJECTIVE

Evaluate characteristics of patients with thoracolumbar injury classification and severity (TLICS) score of 4 (To4) severity traumatic thoracolumbar injury.

SUMMARY OF BACKGROUND DATA

The TLICS score is used to predict the need for operative versus nonoperative management in adult patients with traumatic thoracolumbar injury. Ambiguity exists in its application and score categorization.

METHODS

A systematic review of the literature was performed. The databases of MEDLINE, Embase, Web of Science, and Cochrane Review were queried. Studies included adults with traumatic thoracolumbar injury with assigned TLICS score and description of management strategy.

RESULTS

A total of 16 studies met inclusion criteria representing 1911 adult patients with traumatic thoracolumbar injury. There were 503 (26.32%) patients with To4, of which 298 (59.24%) were operative. Studies focusing on the thoracolumbar junction and AO Type A fracture morphology had To4 patient incidences of 11.15% and 52.94%, respectively. Multiple studies describe better quality of life, pain scores, and radiographic outcomes in To4 who underwent operative treatment patients.

CONCLUSION

To4 injuries are more commonly AO Type A and located in the thoracolumbar junction in adult patients with traumatic thoracolumbar injury. Despite ambiguous recommendations regarding treatment provided by TLICS, outcomes favor operative intervention in this subset of traumatic thoracolumbar injury patients.

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

OBJECTIVE

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.

METHODS

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.

RESULTS

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).

CONCLUSIONS

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.

Predictors of hospital readmission within 30 days after surgery for thoracolumbar fractures: A mixed approach

BACKGROUND

Readmission followed by surgery to treat spinal fractures has a substantial impact on patient care costs and reflects a hospital's quality standards. This article analyzes the factors associated with hospital readmission followed by surgery to treat spinal fractures.

METHODS

This was a cross-sectional study with time-series analysis. For prediction analysis, we used Cox proportional hazards and machine-learning models, using data from the Healthcare Cost and Utilization Project, Inpatient Database from Florida (USA).

RESULTS

The sample comprised 215,999 patients, 8.8% of whom were readmitted within 30 days. The factors associated with a risk of readmission were male sex (1.1 [95% confidence interval 1.06-1.13]) and >60 years of age (1.74 [95% CI: 1.69-1.8]). Surgeons with a higher annual patient volume presented a lower risk of readmission (0.61 [95% CI: 0.59-0.63]) and hospitals with an annual volume >393 presented a lower risk (0.92 [95% CI: 0.89-0.95]).

CONCLUSION

Surgical procedures and other selected predictors and machine-learning models can be used to reduce 30-day readmissions after spinal surgery. Identification of patients at higher risk for readmission and complications is the first step to reducing unplanned readmissions.

How Should Patients with a Thoracolumbar Injury Classification and Severity Score of 4 Be Treated?

The thoracolumbar injury classification and severity score (TLICS) system help surgeons decide whether patients should undergo initial operative treatment or nonoperative treatment. However, the best treatment for patients with TLICS 4 fracture remains unknown. The aim of this study was to identify the risk factors for nonoperative treatment failure in patients with TLICS 4 fracture and establish treatment standards for TLICS 4 fractures. This study included 44 patients with TLICS 4 fracture who initially received nonoperative treatment. We divided these patients into two groups: the successful nonoperative treatment group included 18 patients, and the operative treatment group after nonoperative treatment failure included 26 patients. In multiple logistic regression analysis, spinal canal compromise (odd ratio = 1.316) and kyphotic angle (odd ratio = 1.416) were associated with nonoperative treatment failure in patients with TLICS 4 fracture. Other factors, including age, sex, BMI, initial VAS score, and loss of vertebral body height, were not significantly associated with nonoperative treatment failure in these patients. Spinal canal compromise and kyphotic angle were associated with nonoperative treatment failure in patients with TLICS 4 fracture. Therefore, we recommend the surgeon observe spinal canal compromise and kyphotic angle more carefully when deciding on the treatment of patients with TLICS 4 fracture.

Clinical efficacy and therapeutic value of delayed surgery in patients with symptomatic old thoracolumbar fractures

Background

To investigate the clinical efficacy and therapeutic value of posterior decompression reduction, bone grafting fusion, and internal fixation for treatment of symptomatic old thoracolumbar fractures.

Method

Retrospective analysis was conducted for 14 patients (9 men, 5 women; average age 40.1 years) with old thoracolumbar fractures who underwent posterior operation. American Spinal Injury Association (ASIA) scores were used to evaluate neurologic function. Vertebral body height, Cobb angle in the sagittal plane, spinal canal volume ratio (%) and bone graft fusion were analyzed by radiography and computed tomography on different follow-up times.

Results

Mean follow-up was 27.1 months (23–36 months). Of three patients with ASIA grade A, 2 had improved postoperative urination and defecation, although no classification change. Preoperative ASIA score for eight patients with incomplete injury was grade B; four patients recovered to grade C at final follow-up. Preoperative ASIA score was C in three patients, increased to D in two patients and returned to normal E in one patient. Preoperative results showed average injured vertebra height loss rate decreased from 50.4 to 8.9%; average Cobb angle on the sagittal plane recovered from 39.6 to 6.9°; and the average spinal canal volume ratio recovered from 33.8 to 5.9%. Bony fusion was achieved; local lumbago and leg pain were relieved to some extent. No patients exhibited loosening of the fracture treated by internal fixation, pseudoarthrosis, or other related serious complications.

Conclusion

Treatment of old thoracolumbar fractures by posterior decompression reduction, bone grafting fusion, and internal fixation can relieve spinal cord compression, improve neurologic function of some patients (ASIA grades B–C), effectively relieve pain, correct deformity, restore biomechanical stability, and significantly improve quality of life.

A modified MRI protocol for the increased detection of sacrococcygeal fractures in patients with thoracolumbar junction fractures

This study aimed to identify concurrent thoracolumbar junction (TLJ) and sacrococcygeal (SC) fractures using a modified MRI protocol and analyze the risk factors associated with tandem fractures. We retrospectively investigated patients with MRI-confirmed TLJ fractures from January 2017 to March 2020. Patients were divided into two study groups: study 1 with a modified MRI protocol and study 2 with a routine protocol. The modified protocol included an extended field of view of sagittal scans in L-spine MRI covering the full SC spine. In study 1, frequency of concurrent TLJ and SC fractures was investigated. And we analyzed risk factors and compared CT and MRI for detecting SC fractures. In study 2, co-occurrence of both fractures was investigated. A total of 176 and 399 patients with TLJ fractures were enrolled in study 1 and 2, then SC fractures were identified in 53 (30.14%) and 36 patients (9.02%), respectively. An axial loading trauma mechanism was a significant risk factor (Odds ratio 7.0, p < 0.001), and MRI was more sensitive than CT in detecting SC fractures (p < 0.002). Thus, a modified MRI protocol was useful to detect the high occurrence of SC fractures in TLJ fractures, which concurrent fractures increased by an axial loading mechanism.

Clinical relevance and validity of TLICS system for thoracolumbar spine injury

In order to enhance the reliability of the application to clinical practice of the TLICS classification, we retrospectively reviewed the patients with thoracolumbar spine injuries who underwent magnetic resonance imaging (MRI) and analyzed the validity of the TLICS classification and the necessity of MRI. We enrolled 328 patients with thoracolumbar spine injury who underwent MRI. All patients were classified into conservative and operative treatment groups. The TLICS score of each group was analyzed and the degree of consistent with the recommended treatment through the TLICS classification was examined. Of the total 328 patients, 138 patients were treated conservatively and 190 patients were treated by surgery. Of the 138 patients who underwent conservative treatment, 131 patients (94.9%) had a TLICS score of 4 points or less, and matched with the recommendation score for conservative treatment according to the TLICS classification (match rate 94.9%, 131/138). Of the 190 patients who underwent operative treatment, 160 patients (84.2%) had a TLICS score of 4 points or more (match rate 84.2%, 160/190). All of 30 mismatched patients with a TLICS score of 3 points or less (15.8%) had stable burst fracture without neurological deficit. We retrospectively reviewed the validity of the TLICS classification for the injuries of the thoracolumbar spine, based on MRI in a large group of patients. Treatment with TLICS classification showed high validity, especially in conservative group, and MRI should be an essential diagnostic tool for accurate evaluation of posterior ligamentous complex injury.

Assessment of load-sharing thoracolumbar injury: A modified scoring system

BACKGROUND

Many classification systems of thoracolumbar spinal fractures have been proposed to enhance treatment protocols, but none have achieved universal adoption.

AIM

To develop a new patient scoring system for cases with thoracolumbar injury classification and severity score (TLICS) = 4, namely the load-sharing thoracolumbar injury score (LSTLIS).

METHODS

Based on thoracolumbar injury classification and severity score, this study proposes the use of the established load-sharing classification (LSC) to develop an improved classification system (LSTLIS). To prove the reliability and reproducibility of LSTLIS, a retrospective analysis for patients with thoracolumbar vertebral fractures has been conducted.

RESULTS

A total of 102 cases were enrolled in the study. The scoring trend of LSTLIS is roughly similar as the LSC scoring, however, the average deviation based on the former method is relatively smaller than that of the latter. Thus, the robustness of the LSTLIS scoring method is better than that of LSC. LSTLIS can further classify patients with TLICS = 4, so as to assess more accurately this particular circumstance, and the majority of LSTLIS recommendations are consistent with actual clinical decisions.

CONCLUSION

LSTLIS is a scoring system that combines LSC and TLICS to compensate for the lack of appropriate inclusion of anterior and middle column compression fractures with TLICS. Following preliminary clinical verification, LSTLIS has greater feasibility and reliability value, is more practical in comprehensively assessing certain clinical circumstances, and has better accuracy with clinically significant guidelines.

Functional Outcome of Surgical versus Conservative Therapy in Patients with Traumatic Thoracolumbar Fractures and Thoracolumbar Injury Classification and Severity Score of 4; A Non-randomized Clinical Trial

OBJECTIVE

To compare the effectiveness of surgical intervention to conservative treatment in patients with thoracolumbar fracture and thoracolumbar injury classification and severity score (TLICS) of 4.

METHODS

Twenty-five patients with TLICS 4 were enrolled in this non-randomized clinical trial. Based on clinical symptoms and radiologic findings, patients were considered under surgical or conservative treatments. The JOA Back Pain Evaluation Questionnaire (JOABPEQ) was assessed at baseline and at 3, 6, 12 months after treatment. A 20-point improvement from the baseline JOABPEQ scores was considered as clinical success in both the conservative and surgery groups. Additionally, residual canal, angulations and height loss were determined in all patients.

RESULTS

Eight patients received conservative and 17 surgical treatment. Both study groups were comparable regarding the baseline characteristics. Both study demonstrated treatment success, regarding functional recovery when compared to baseline (p<0.001). However, those undergoing surgical intervention had significantly better JOABPEQ score (p<0.001) and higher residual canal (p=0.042) when compared to those receiving conservative therapy. The success rate of treatment was comparable between the two study groups in 6- (p=0.998) and 12-month (p=0.852) intervals; however, surgical therapy had significantly higher success arte in 3-month interval (p=0.031).

CONCLUSION

Our findings revealed that surgical treatment was preferred more in comparison to conservative treatment in patients with TLICS 4. Additionally, residual canal might be a modifying factor to decide the ideal therapeutic approach.