J Neurosurg Spine 20:562–567, 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 Division of Neurosurgery, State University of Campinas (UNICAMP), Campinas, São Paulo, Brazil; and 2Department of Orthopaedics, Northwestern University, Chicago, Illinois 1
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 neurological 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 injuries. 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
Thoracolumbar Injury Classification and Severity Score (TLICS) is a new classification and injury severity score that identifies 3 critical injury categories and assigns a progressive score to guiding surgical decision making for thoracic or lumbar spinal trauma (TLST).11 The possible advantages over prior systems are the inclusion of the patient’s neurological status and an assessment of the integrity of the posterior ligamentous he
Abbreviations used in this paper: AIS = American Spinal Injury Association Impairment Scale; PLC = posterior ligamentous complex; TLICS = Thoracolumbar Injury Classification and Severity Score; TLST = thoracolumbar spinal trauma.
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complex (PLC) in the decision-making process. The injury 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 surgical treatment; and a score of 4 points remains an intermediate zone where either surgical or conservative treatment may be applied according to other variables, such as a patient’s comorbidities, body habitus, and patient or surgeon 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. J Neurosurg: Spine / Volume 20 / May 2014
Clinical evaluation of the TLICS system TABLE 1: The TLICS system* Variable
Points
injury morphology compression burst translation/rotation distraction neurological status intact nerve injury cord, conus medullaris incomplete complete cauda equina PLC integrity intact indeterminate† injured
1 +1 3 4 0 2 3 2 3 0 2 3
* As reported by Vaccaro et al.11 † For patients with suggested ligamentous injury on STIR imaging or T2-weighted MRI.
Given the potential benefits of this new system, assessment of the TLICS outside the institutions of Vaccaro and colleagues11 is needed. The purpose of this paper was to evaluate the validity and safety of the TLICS with regard to neurological status in a prospective, consecutive clinical series of patients treated based on the TLICS.
Methods
Between 2009 and 2012 we prospectively analyzed a consecutive series of patients treated for thoracic and lumbar spinal trauma (from T-1 to L-5) in a tertiary trauma center that is responsible for high-energy and complex trauma patients (State University of Campinas, Brazil). As part of our institutional protocols, a CT scan with reconstructions was obtained in all patients to evaluate the spine. Additionally, patients with burst fractures without neurological deficits underwent MRI to assess the integrity of the PLC. All patients were evaluated and treated by the same surgeon (A.F.J.), who was responsible for nonsurgical and surgical care and for assessing patients at follow-up. The TLICS system was prospectively applied to patients to aid in surgical decision making. Patients with a TLICS of 4 or more points underwent surgical treatment as soon as they were clinically stable. Those with a TLICS of less than 4 points underwent nonsurgical treatment comprising rigid brace for 8–12 weeks and early ambulation but with activity restrictions. Patients were allowed to cross over from one treatment arm to the other based on failure of the initial treatment, such as persistent pain, dysfunction, or spinal deformity, or for comorbidities that would preclude treatment. Clinical and radiological data were evaluated, clasJ Neurosurg: Spine / Volume 20 / May 2014
sifying the patient’s injury according to American Spinal Injury Association Impairment Scale (AIS) status and TLICS.5 Injuries were also classified as thoracic (T1–10), thoracolumbar (T11–L2), or lumbar (L3–5) spinal trauma. Demographic data including age and sex were recorded. Injury and treatment details were also recorded, including trauma etiology, treated fracture level (the most cranial when 2 consecutive vertebrae were involved), neurological status (pre- and posttreatment AIS classification), surgical approach, number of arthrodesis levels, and complications. The neurological status, based on the AIS grade, was the primary outcome measurement. Institutional ethics committee approval was obtained prior to the study. Our standard protocols for treatment included the following. Nonsurgical Management. An external lumbosacral or thoracolumbar orthosis, according to the level of injury, was prescribed for all patients who underwent nonsurgical treatment. Patients were mobilized immediately after application of the orthosis. The orthosis was used for 8–12 weeks with ambulation permitted but with other activities restricted. The orthosis was then discontinued and the patients were referred to a formal physical therapy program. Plain radiographs were obtained after 2 weeks, 1 month, 3 months, and 6 months of follow-up. Surgical Management. All surgically treated patients were treated through an open posterior approach with pedicular screw fixation, realignment, and arthrodesis with autologous bone graft. Patients with neurological deficits and concomitant neural compression also underwent a posterior and/or a transpedicular decompression when both ventral and dorsal decompression was needed. No external orthosis was used after surgery. Early physical rehabilitation was initialized after the procedure, and ambulation was allowed in patients who were neurologically capable of walking. All patients underwent immediate CT scanning to check instrumentation location, decompression, and fracture realignment after surgery. After hospital discharge, patients were seen in the outpatient clinics, and standard plain radiographs were obtained after 2 weeks, 1 month, 3 months, and 6 months of followup. Instrumentation status, fracture reduction, and spinal alignment were assessed.
Results
Sixty-five consecutive patients with TLST were treated during the period of this study. Thirty-seven patients were initially treated nonsurgically (with a TLICS of 3 or fewer points). Of these, 28 (76%) underwent follow-up at our institution. Thirteen patients (46%) had compression fractures and 15 (54%) had burst fractures. All nonsurgical patients were neurologically intact at baseline. Age ranged from 17 to 70 years (mean 44.5 years). Twentytwo patients (78.6%) were male and 6 (21.4%) were female. Fall from height was the main cause of trauma (17 patients, 61%), followed by automobile accidents (5 patients, 18%). Regarding injury level, 6 patients (21.4%) had thoracic fractures (T1–10), 18 (64.3%) had thoraco563
A. F. Joachim et al. lumbar fractures (T11–L2), and 4 (14.3%) had lumbar fractures (L3–5). 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 additional 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 neurological deficits (TLICS of 2 points) crossed over to surgical treatment. One of these patients underwent surgery after 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 narcotics. Both additionally have work-related litigation as a result of their injuries. Twenty-eight patients were initially surgically treated, 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 surgically 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 indeterminate 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 motorcycle (9 patients, 32%) and automobile (8 patients, 29%) accidents. Regarding injury level, 15 patients (54%) had thoracic fractures (T1–10), 11 (39%) had thoracolumbar fractures (T11–L2), and 2 (7%) had lumbar fractures (L3–5). 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 traumatic 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 neurological 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 patient 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 patient 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 patient was neurologically intact the day before and the day after surgery. He developed a fatal intracranial hypertension with brain swelling on the day after surgery. Despite a decompressive craniectomy, the patient died of intracranial 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. D–F: 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.
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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 showing 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 T5–7 and T9–10 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 preoperative pulmonary embolism (1 patient), severe atelectasis requiring continued mechanical ventilation for 3 days after surgery (1 patient), a postoperative ileus requiring 5 additional days in the hospital (1 patient), a preoperative sacral decubitus ulcer (1 patient), and severe heterotopic 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 neurological outcomes. In our series, 30 patients with thoracolumbar 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 patient 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 nonsurgical 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 deterioration 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 suppression 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 T1–3 fixation. The patient required wound debridement but was doing fairly well at 7 months after surgery.
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A. F. Joachim et al. TABLE 2: Patient distribution according to the AIS grade before surgery and after last follow-up* AIS Grade
Preop
Last Follow-Up
A B–D E total
12 7 11 30
12 5 13 30
* Includes the 2 patients who were neurologically intact and who underwent 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 treated based on the surgeon’s concerns of progressive deformity associated with severe fracture comminution. The TLICS does not uniquely consider the body height or the degree of comminution in burst fractures when determining injury severity or guiding treatment. Interestingly, in a recent case-control study of 46 patients, Radcliff et al. evaluated the association of local kyphosis (> 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 neurological injury and intact PLC. This study further supports the exclusion of these specific radiographic measurements 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, obtaining 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.1–3 Based on this premise, we interpret 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
revision surgery wound infection
2 4
CSF leak death
1 1
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Comment 2 cases required surgical debridement required revision surgery brain swelling after surgery
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 factors 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 ligamentous 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 costeffectiveness.6
Conclusions
The TLICS was safe in guiding us through the choice of surgical versus conservative management of thoracolumbar spine trauma with regard to neurological preservation. Our study is limited by its short follow-up, singlecenter 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 compromise. Surgically treated patients demonstrated no neurological deterioration. The treatment of burst fractures without deficits and the role of the MRI in the decisionmaking process requires further investigation. Disclosure The authors report no conflict of interest concerning the materials 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 preparation 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 methylprednisolone or naloxone in the treatment of acute spinal-cord injury. Results of the Second National Acute Spinal Cord Injury Study. N Engl J Med 322:1405–1411, 1990 2. Bracken MB, Shepard MJ, Holford TR, Leo-Summers L, Aldrich EF, Fazl M, et al: Administration of methylprednisolone 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 277:1597–1604, 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):S87–S98, 2001 4. Joaquim AF, Fernandes YB, Cavalcante RC, Fragoso RM, Honorato DC, Patel AP: Evaluation of the thoracolumbar injury classification system in thoracic and lumbar spinal trauma. Spine (Phila Pa 1976) 36:33–36, 2011
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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 neurological classification of spinal cord injury. J Spinal Cord Med 26 (Suppl 1):S50–S56, 2003 6. Patel AA, Vaccaro AR, Albert TJ, Hilibrand AS, Harrop JS, Anderson DG, et al: The adoption of a new classification system: time-dependent variation in interobserver reliability of the thoracolumbar injury severity score classification system. Spine (Phila Pa 1976) 32:E105–E110, 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) 37:1142–1150, 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 Spinal Disord Tech 19:477–482, 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) 31:2881–2890, 2006
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10. Vaccaro AR, Baron EM, Sanfilippo J, Jacoby S, Steuve J, Grossman E, et al: Reliability of a novel classification system for thoracolumbar injuries: the Thoracolumbar Injury Severity Score. Spine (Phila Pa 1976) 31 (11 Suppl):S62–S69, S104, 2006 11. Vaccaro AR, Lehman RA Jr, Hurlbert RJ, Anderson PA, Harris 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) 30:2325–2333, 2005 12. Wood K, Buttermann G, Mehbod A, Garvey T, Jhanjee R, Sechriest V: Operative compared with nonoperative treatment of a thoracolumbar burst fracture without neurological deficit. A prospective, randomized study. J Bone Joint Surg Am 85-A:773–781, 2003 (Erratum in J Bone Joint Surg Am 86A:1283, 2004) Manuscript submitted December 7, 2013. Accepted February 3, 3014. Please include this information when citing this paper: published online March 7, 2014; DOI: 10.3171/2014.2.SPINE121114. Address correspondence to: Andrei F. Joaquim, M.D., Ph.D., Rua Antônio Lapa 280, S 506, Cambuí, Campinas-SP 13025-240, Brazil. email: [email protected].
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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 Division of Neurosurgery, State University of Campinas (UNICAMP), Campinas, São Paulo, Brazil; and 2Department of Orthopaedics, Northwestern University, Chicago, Illinois 1
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 neurological 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 injuries. 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
Thoracolumbar Injury Classification and Severity Score (TLICS) is a new classification and injury severity score that identifies 3 critical injury categories and assigns a progressive score to guiding surgical decision making for thoracic or lumbar spinal trauma (TLST).11 The possible advantages over prior systems are the inclusion of the patient’s neurological status and an assessment of the integrity of the posterior ligamentous he
Abbreviations used in this paper: AIS = American Spinal Injury Association Impairment Scale; PLC = posterior ligamentous complex; TLICS = Thoracolumbar Injury Classification and Severity Score; TLST = thoracolumbar spinal trauma.
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complex (PLC) in the decision-making process. The injury 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 surgical treatment; and a score of 4 points remains an intermediate zone where either surgical or conservative treatment may be applied according to other variables, such as a patient’s comorbidities, body habitus, and patient or surgeon 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. J Neurosurg: Spine / Volume 20 / May 2014
Clinical evaluation of the TLICS system TABLE 1: The TLICS system* Variable
Points
injury morphology compression burst translation/rotation distraction neurological status intact nerve injury cord, conus medullaris incomplete complete cauda equina PLC integrity intact indeterminate† injured
1 +1 3 4 0 2 3 2 3 0 2 3
* As reported by Vaccaro et al.11 † For patients with suggested ligamentous injury on STIR imaging or T2-weighted MRI.
Given the potential benefits of this new system, assessment of the TLICS outside the institutions of Vaccaro and colleagues11 is needed. The purpose of this paper was to evaluate the validity and safety of the TLICS with regard to neurological status in a prospective, consecutive clinical series of patients treated based on the TLICS.
Methods
Between 2009 and 2012 we prospectively analyzed a consecutive series of patients treated for thoracic and lumbar spinal trauma (from T-1 to L-5) in a tertiary trauma center that is responsible for high-energy and complex trauma patients (State University of Campinas, Brazil). As part of our institutional protocols, a CT scan with reconstructions was obtained in all patients to evaluate the spine. Additionally, patients with burst fractures without neurological deficits underwent MRI to assess the integrity of the PLC. All patients were evaluated and treated by the same surgeon (A.F.J.), who was responsible for nonsurgical and surgical care and for assessing patients at follow-up. The TLICS system was prospectively applied to patients to aid in surgical decision making. Patients with a TLICS of 4 or more points underwent surgical treatment as soon as they were clinically stable. Those with a TLICS of less than 4 points underwent nonsurgical treatment comprising rigid brace for 8–12 weeks and early ambulation but with activity restrictions. Patients were allowed to cross over from one treatment arm to the other based on failure of the initial treatment, such as persistent pain, dysfunction, or spinal deformity, or for comorbidities that would preclude treatment. Clinical and radiological data were evaluated, clasJ Neurosurg: Spine / Volume 20 / May 2014
sifying the patient’s injury according to American Spinal Injury Association Impairment Scale (AIS) status and TLICS.5 Injuries were also classified as thoracic (T1–10), thoracolumbar (T11–L2), or lumbar (L3–5) spinal trauma. Demographic data including age and sex were recorded. Injury and treatment details were also recorded, including trauma etiology, treated fracture level (the most cranial when 2 consecutive vertebrae were involved), neurological status (pre- and posttreatment AIS classification), surgical approach, number of arthrodesis levels, and complications. The neurological status, based on the AIS grade, was the primary outcome measurement. Institutional ethics committee approval was obtained prior to the study. Our standard protocols for treatment included the following. Nonsurgical Management. An external lumbosacral or thoracolumbar orthosis, according to the level of injury, was prescribed for all patients who underwent nonsurgical treatment. Patients were mobilized immediately after application of the orthosis. The orthosis was used for 8–12 weeks with ambulation permitted but with other activities restricted. The orthosis was then discontinued and the patients were referred to a formal physical therapy program. Plain radiographs were obtained after 2 weeks, 1 month, 3 months, and 6 months of follow-up. Surgical Management. All surgically treated patients were treated through an open posterior approach with pedicular screw fixation, realignment, and arthrodesis with autologous bone graft. Patients with neurological deficits and concomitant neural compression also underwent a posterior and/or a transpedicular decompression when both ventral and dorsal decompression was needed. No external orthosis was used after surgery. Early physical rehabilitation was initialized after the procedure, and ambulation was allowed in patients who were neurologically capable of walking. All patients underwent immediate CT scanning to check instrumentation location, decompression, and fracture realignment after surgery. After hospital discharge, patients were seen in the outpatient clinics, and standard plain radiographs were obtained after 2 weeks, 1 month, 3 months, and 6 months of followup. Instrumentation status, fracture reduction, and spinal alignment were assessed.
Results
Sixty-five consecutive patients with TLST were treated during the period of this study. Thirty-seven patients were initially treated nonsurgically (with a TLICS of 3 or fewer points). Of these, 28 (76%) underwent follow-up at our institution. Thirteen patients (46%) had compression fractures and 15 (54%) had burst fractures. All nonsurgical patients were neurologically intact at baseline. Age ranged from 17 to 70 years (mean 44.5 years). Twentytwo patients (78.6%) were male and 6 (21.4%) were female. Fall from height was the main cause of trauma (17 patients, 61%), followed by automobile accidents (5 patients, 18%). Regarding injury level, 6 patients (21.4%) had thoracic fractures (T1–10), 18 (64.3%) had thoraco563
A. F. Joachim et al. lumbar fractures (T11–L2), and 4 (14.3%) had lumbar fractures (L3–5). 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 additional 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 neurological deficits (TLICS of 2 points) crossed over to surgical treatment. One of these patients underwent surgery after 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 narcotics. Both additionally have work-related litigation as a result of their injuries. Twenty-eight patients were initially surgically treated, 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 surgically 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 indeterminate 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 motorcycle (9 patients, 32%) and automobile (8 patients, 29%) accidents. Regarding injury level, 15 patients (54%) had thoracic fractures (T1–10), 11 (39%) had thoracolumbar fractures (T11–L2), and 2 (7%) had lumbar fractures (L3–5). 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 traumatic 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 neurological 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 patient 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 patient 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 patient was neurologically intact the day before and the day after surgery. He developed a fatal intracranial hypertension with brain swelling on the day after surgery. Despite a decompressive craniectomy, the patient died of intracranial 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. D–F: 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.
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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 showing 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 T5–7 and T9–10 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 preoperative pulmonary embolism (1 patient), severe atelectasis requiring continued mechanical ventilation for 3 days after surgery (1 patient), a postoperative ileus requiring 5 additional days in the hospital (1 patient), a preoperative sacral decubitus ulcer (1 patient), and severe heterotopic 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 neurological outcomes. In our series, 30 patients with thoracolumbar 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 patient 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 nonsurgical 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 deterioration 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 suppression 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 T1–3 fixation. The patient required wound debridement but was doing fairly well at 7 months after surgery.
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A. F. Joachim et al. TABLE 2: Patient distribution according to the AIS grade before surgery and after last follow-up* AIS Grade
Preop
Last Follow-Up
A B–D E total
12 7 11 30
12 5 13 30
* Includes the 2 patients who were neurologically intact and who underwent 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 treated based on the surgeon’s concerns of progressive deformity associated with severe fracture comminution. The TLICS does not uniquely consider the body height or the degree of comminution in burst fractures when determining injury severity or guiding treatment. Interestingly, in a recent case-control study of 46 patients, Radcliff et al. evaluated the association of local kyphosis (> 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 neurological injury and intact PLC. This study further supports the exclusion of these specific radiographic measurements 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, obtaining 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.1–3 Based on this premise, we interpret 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
revision surgery wound infection
2 4
CSF leak death
1 1
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Comment 2 cases required surgical debridement required revision surgery brain swelling after surgery
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 factors 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 ligamentous 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 costeffectiveness.6
Conclusions
The TLICS was safe in guiding us through the choice of surgical versus conservative management of thoracolumbar spine trauma with regard to neurological preservation. Our study is limited by its short follow-up, singlecenter 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 compromise. Surgically treated patients demonstrated no neurological deterioration. The treatment of burst fractures without deficits and the role of the MRI in the decisionmaking process requires further investigation. Disclosure The authors report no conflict of interest concerning the materials 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 preparation 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 methylprednisolone or naloxone in the treatment of acute spinal-cord injury. Results of the Second National Acute Spinal Cord Injury Study. N Engl J Med 322:1405–1411, 1990 2. Bracken MB, Shepard MJ, Holford TR, Leo-Summers L, Aldrich EF, Fazl M, et al: Administration of methylprednisolone 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 277:1597–1604, 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):S87–S98, 2001 4. Joaquim AF, Fernandes YB, Cavalcante RC, Fragoso RM, Honorato DC, Patel AP: Evaluation of the thoracolumbar injury classification system in thoracic and lumbar spinal trauma. Spine (Phila Pa 1976) 36:33–36, 2011
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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 neurological classification of spinal cord injury. J Spinal Cord Med 26 (Suppl 1):S50–S56, 2003 6. Patel AA, Vaccaro AR, Albert TJ, Hilibrand AS, Harrop JS, Anderson DG, et al: The adoption of a new classification system: time-dependent variation in interobserver reliability of the thoracolumbar injury severity score classification system. Spine (Phila Pa 1976) 32:E105–E110, 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) 37:1142–1150, 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 Spinal Disord Tech 19:477–482, 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) 31:2881–2890, 2006
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10. Vaccaro AR, Baron EM, Sanfilippo J, Jacoby S, Steuve J, Grossman E, et al: Reliability of a novel classification system for thoracolumbar injuries: the Thoracolumbar Injury Severity Score. Spine (Phila Pa 1976) 31 (11 Suppl):S62–S69, S104, 2006 11. Vaccaro AR, Lehman RA Jr, Hurlbert RJ, Anderson PA, Harris 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) 30:2325–2333, 2005 12. Wood K, Buttermann G, Mehbod A, Garvey T, Jhanjee R, Sechriest V: Operative compared with nonoperative treatment of a thoracolumbar burst fracture without neurological deficit. A prospective, randomized study. J Bone Joint Surg Am 85-A:773–781, 2003 (Erratum in J Bone Joint Surg Am 86A:1283, 2004) Manuscript submitted December 7, 2013. Accepted February 3, 3014. Please include this information when citing this paper: published online March 7, 2014; DOI: 10.3171/2014.2.SPINE121114. Address correspondence to: Andrei F. Joaquim, M.D., Ph.D., Rua Antônio Lapa 280, S 506, Cambuí, Campinas-SP 13025-240, Brazil. email: [email protected].
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