Applicability of thoracolumbar injury classification and severity score to criteria of korean health insurance review and assessment service in treatment decision of thoracolumbar injury

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: κ_approach1 = 0.557, κ_approach2 =0.508; mTLICS: κ_approach1 = 0.557, κ_approach2 = 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 (κ_TLICS = 0.830, κ_mTLICS = 0.704) rather than healthy (κ_TLICS = 0.620, κ_mTLICS = 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.

A Comparison of Thoracolumbar Injury Classification in Spine Trauma Patients Among Neurosurgeons in East Africa Versus North America

Background In January 2021, we published findings evaluating the validity of thoracolumbar injury classification and biomechanical approach in the clinical outcome of operative and non-operative treatments. A notable result in our study was patients with unstable burst fractures received an Arbeitsgemeinschaft für Osteosynthesefragen System (AO) score that recommended conservative treatment compared to a Thoracolumbar Injury Classification and Severity Scale (TLICS) score that recommended surgical intervention. We designed a survey to determine reported differences in thoracolumbar injury classification, including the percentage of thoracolumbar spine fractures, type of classification system(s) used, use of classification system by board-certified neurosurgeons and neurosurgical residents, reliance on classification system to guide management, use of MRI in the evaluation of the posterior ligamentous complex, and readmission rate < 90 days at treating facilities. This study aims to determine which areas of neurosurgical practice in spine trauma patients differ among surgeons in North America and East Africa, including Ethiopia, Kenya, and Sudan. Multiple classification systems have been proposed to describe thoracolumbar spine injuries. We hypothesized that there would be marked variability in the classification systems used to evaluate thoracolumbar spine injury among neurosurgeons in North America and East Africa. Methods The survey consisted of seven questions and was sent to 440 neurosurgeons practicing on the continents of North America and East Africa. Results A total of 67 surgeons responded, 50 from North America and 17 from East Africa, including Ethiopia, Kenya, and Sudan. A significant percentage of African respondents reported a higher thoracolumbar spine fracture rate than respondents in North America (53% and 30%, respectively). Regarding the classification system used, 65% of surgeons in East Africa reported using TLICS, whereas 62% of surgeons in North America reported using Denis 3-column classification. For patients with spine trauma, surgeons in East Africa and North America reported a similar percentage of readmission <90 days (47% and 52%, respectively). Conclusion Our findings vary in spine trauma classification for American and East African patients and still highlight crucial areas for improvement due to patient load, education, and resource accessibility.

The Effect of Thoracolumbar Injury Classification in the Clinical Outcome of Operative and Non-Operative Treatments

This review assesses the validity of a biomechanical approach using finite element analysis in the Thoracolumbar Injury Classification and Severity Score System (TLICS) by addressing the “gray zone” decision discrepancy of thoracolumbar spinal injuries. A systematic review was performed using the keywords “Thoracolumbar Injury Classification” AND “finite element analysis of the spinal column” to evaluate the validity of the TLICS and finite element analysis of the thoracolumbar spinal column. Results were classified according to the main conclusions and level of evidence. Thirteen articles are included. Four of the articles evaluated the TLICS in comparison to other classification systems of thoracolumbar spinal injuries. A notable finding is that the TLICS had inconsistencies with other classification systems in the treatment of burst fractures without neurological deficits. One article evaluated the TLICS with the inclusion of magnetic resonance imaging (MRI) in the evaluation, which decreased the agreement between the suggested and actual treatment. Among the three finite element analysis studies, limited data have been published on the posterior ligamentous complex (PLC) status when an injury is suspected or indeterminate. The TLICS has been a reliable classification system in the management of single-column fractures and three-column injuries treated with surgical stabilization. Special attention to enhancing the TLICS classification system by eliminating the “gray zone” of a TLICS score of 4 is essential. Biomedical computational modeling evaluating the PLC status of indeterminate or injury suspected is needed to enhance the current TLICS system and to clarify the decision discrepancy in the “gray zone.”

Congress of Neurological Surgeons Systematic Review and Evidence-Based Guidelines on the Evaluation and Treatment of Patients With Thoracolumbar Spine Trauma: Classification of Injury

QUESTION 1

Are there classification systems for fractures of the thoracolumbar spine that have been shown to be internally valid and reliable (ie, do these instruments provide consistent information between different care providers)?

RECOMMENDATION 1

A classification scheme that uses readily available clinical data (eg, computed tomography scans with or without magnetic resonance imaging) to convey injury morphology, such as Thoracolumbar Injury Classification and Severity Scale or the AO Spine Thoracolumbar Spine Injury Classification System, should be used to improve characterization of traumatic thoracolumbar injuries and communication among treating physicians. Strength of Recommendation: Grade B.

QUESTION 2

In treating patients with thoracolumbar fractures, does employing a formally tested classification system for treatment decision-making affect clinical outcomes?

RECOMMENDATION 2

There is insufficient evidence to recommend a universal classification system or severity score that will readily guide treatment of all injury types and thereby affect outcomes. Strength of Recommendation: Grade Insufficient The full version of the guideline can be reviewed at: https://www.cns.org/guideline-chapters/congress-neurological-surgeons-systematic-review-evidence-based-guidelines/chapter_2.

Single-Stage Posterior Subtotal Corpectomy and Circumferential Reconstruction for the Treatment of Unstable Thoracolumbar Burst Fractures

Objective

To illustrate the technique of single-stage posterior subtotal corpectomy and circumferential reconstruction for the treatment of unstable thoracolumbar burst fractures and to evaluate the radiographical and clinical outcomes of patients treated using this technique.

Methods

16 consecutive patients with unstable thoracolumbar burst fractures were treated with single-stage posterior subtotal corpectomy and circumferential reconstruction. The mean patient age was 54.8 years. The mean follower up period was 25 months. Five patients suffered from T12 fractures, 10 from L1, 1 from L2. The segmental kyphosis, neurologic status, visual analogue scale for back pain was evaluated before surgery and at follow up.

Results

The segmental kyphotic angle improved from 18.5 degrees before surgery to -9.2 degrees at the last follow up. The mean correction angle was 28.9 degrees. The mean surgical time was 255 minutes, and a mean intraoperative blood loss was 1073 mL. Intraoperative complications included two dural tears, and a superficial wound infection. There were no other severe complications. The mean visual analog scale of back pain decreased from a mean value of 6.6 to 2 at the last follow up.

Conclusion

The single-stage posterior subtotal corpectomy and circumferential reconstruction achieved satisfactory kyphosis correction with direct visualization of the circumferentially decompressed spinal cord, as well as good fusion with less blood loss and complications. It is a safe and reliable surgical treatment option for unstable thoracolumbar burst fractures.