2. Definition of instability
White and Panjabi –
“Clinical instability is defined as a loss in the ability of the spine under
physiologic loads to maintain relationships between vertebrae in such a
way that there is neither damage nor subsequent irritation to the
spinal cord or nerve roots. In addition there is no development of
incapacitating deformity or pain due to structural changes. ”
3. Evaluation of the Thoracolumbar Injury Classification System in
Thoracic and Lumbar Spinal Trauma
Andrei F. Joaquim, MD,* Yvens B. Fernandes, PhD, MD,*† Rodrigo A. C. Cavalcante, MD,‡ Rodrigo M. Fragoso, MD,† Donizeti C.
Honorato, MD, PhD,§ and Alpesh A. Patel, MD¶
A New Classification of Thoracolumbar Injuries The
Importance of Injury Morphology, the Integrity of the
Posterior Ligamentous Complex, and Neurologic Status
Alexander R. Vaccaro, MD,* Ronald A. Lehman, Jr., MD,† R. John Hurlbert, MD, PhD,‡ Paul A. Anderson, MD,§ Mitchel
Harris, MD, Rune Hedlund, MD,¶ James Harrop, MD,# Marcel Dvorak, MD,** Kirkham Wood, MD,†† Michael G. Fehlings,
MD, PhD,‡‡ Charles Fisher, MD, MHSc,** Steven C. Zeiller, MD,* D. Greg Anderson, MD,* Christopher M. Bono, MD,§§
4. Problems with Denis classification
• Not detailed enough to account for all fracture types.
• No prognostic information
• Doesn’t account for the neurologic status and, therefore, does not
adequately guide surgical decision making
5. AO attempt
• AO tried correcting it but has 50 subtypes
• Low inter and intraobserver agreement due to the complexity
• Doesn’t account for the patients neurologic status
6. TLICS CLASSIFICATION
• Vaccaro et al proposed a new classification system based on 3 major
descriptive categories :-
1. Morphology
2. Integrity of posterior ligamentous complex (PLC)
3. Neurological status
7. When there are several fractures, each level has to be scored separately. The level with the highest TLICS
score will determine the type of treatment.
8. Morphology
Compression Translation/Rotation Distraction
Axial compression/ axial burst Translation/rotation Flexion distraction
Flexion compression, flexion burst,
flexion compression or burst with
distraction of posterior elements
Unilateral or bilateral facet
dislocation
flexion distraction compression or
burst
Lateral compression Translation/rotation compression
or burst
Extension distraction
Lateral burst Unilateral or bilateral facet
dislocation compression or burs
9.
10. Integrity of PLC
• PLC consists of Supraspinous ligament, interspinous
ligament, ligament flavum and facet joint capsule
• Together known as ‘tension band’ of spinal column
• A torn PLC has a tendency not to heal and can lead
to progressive kyphosis and collapse.
11. CT features of PLC pathology are:
•Widening of the interspinous space.
•Avulsion fractures or transverse fractures of
spinous processes or articular facets.
•Widening or dislocation of facet joints.
•Vertebral body translation or rotation.
When the PLC is definitely injured on CT, it can
already be scored as 3.
MRI features of PLC pathology are:
•Definite: 3 points
Loss of normal low signal intensity of the
ligamenta flava or supraspinous ligaments on
T1 and T2.
•Indeterminate: 2 points
Edema without clear rupture; high signal
intensity of the interspinous ligaments or along
the facet joints on T2 SPIR or STIR.
MRI has a tendency to overdiagnose PLC
injury (4).
12. Neurological status
• The incomplete spinal cord injuries are
considered American Spinal Injury
Association (ASIA) B, C, and D
• The complete injuries are considered
ASIA A.
13. TLICS guiding surgical approach
1) An incomplete neurologic injury generally requires an anterior
procedure if neural compression from the anterior spinal elements is
present following attempts at postural or open reduction
2) PLC disruption generally requires a posterior procedure and
3) A combined incomplete neurologic injury and PLC disruption generally
requires a combined anterior and posterior procedure.
14. Qualifiers
• Local - extreme kyphosis or collapse, lateral fracture angulation, open
fractures, overlying burns, multiple adjacent rib fractures, or inability
to brace.
• Comorbidities can also influence treatment such as a sternum
fracture, severe closed head injury, limb amputation, and multisystem
trauma.
• Systemic considerations also play a role in clinical decision-making
such as rheumatoid arthritis, ankylosing spondylitis, osteoporosis,
obesity, patient age, and even general health.
