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Thoracolumbar Spine Trauma are present in 7% of blunt trauma patients, most of them are due to road traffic accidents. A comprehensive, easy to apply, with sufficient reliability and validity, algorithm should be established to determine the degree of injury and to decide on the appropriate treatment plan.
The system should have good interrater (between different physicians) and intrarater (the physician and himself over time) reliability, along with high validity to measure what it is set to measure (spinal instability and the need for surgery). Cohen’s kappa value and spearman’s correlation coefficient are the two most agreed upon parameters to measure a tool’s reliability. As any other screening tool the validity of the classification system is determined by comparing it to the gold standard of treatment and comparing conformity between the system’s recommendations and the actual treatment received by the patient.
Denis’s classification system, which represents the most popular in use currently, has good inter- and intraobserver reliability, with a kappa coefficient of 0.6. However, oversimplification of the injury mechanism by the Denis’ system, may lead to incorrectly treating potentially unstable injuries nonoperatively or stable fractures with unnecessary surgery. On the contrary as the classification system becomes more comprehensive, the inter- and intraobserver reliability becomes poor. For example, the AO classification of thoracolumbar fractures, which is a comprehensive categorization of more than 50 types of fracture, has poor inter- and intraobserver reliability.
The Thoracolumbar Injury Classification and Severity (TLICS) score represents the best collaboratively developed tool to date that addresses thoracolumbar spine trauma. It is the first classification to incorporate patient’s neurological status and the first to take all pivotal factors of spinal stability into account while assessing the patient; fine tuning the balance between a simple yet holistic tool to assess thoracolumbar spine trauma.
This study aims at collecting all available evidence regarding the TLICS score and representing it orderly and objectively to better get an idea of the system and its modification and its usefulness. Seven studies with ten data sets were included and revealed an interrater reliability (assessed by generalized kappa coefficient) of 0.45 ±0.17 for injury morphology/mechanism, 0.91 ±0.03 for neurologic status, 0.42 ±0.13 for posterior ligamentous complex status, 0.36 ±0.14 for TLICS/TLISS total, and 0.59 ±0.10 for treatment recommendation. Respective results using the Spearman correlation were 0.52 ±0.18, 0.95 ±0.05, 0.57 ±0.13, 0.75 ±0.10, and 0.64 ±0.20. The Intrarater kappa coefficients were 0.53 ±0.14 for injury morphology/mechanism, 0.89 ±0.07 for neurologic status, 0.53 ±0.15 for posterior ligamentous complex status, 0.46 ±0.16 for TLICS/TLISS total, and 0.61 ±0.02 for treatment recommendation. Respective results using the Spearman correlation were 0.63 ±0.08, 0.90 ±0.03, 0.64 ±0.10, 0.77 ±0.03, and 0.60 ±0.02. The percent of correct treatment recommendation by the score and the treatment actually received by the patients was 94.4% ±1.5, with sensitivity of 0.91 ±0.06, specificity of 0.94 ±0.01, PPV of 0.94 ±0.01, NPV of 0.93 ±0.02.
Tabulation and presentation of the available data reflects that the TLICS score has good reliability and validity and it compares favorably to other contemporary and old thoracolumbar fracture classification systems.