According to our research, the TLICS scoring system was in keeping with the clinical decision in all the patients who were treated conservatively. All 17 patients who were treated conservatively had had a TLICS score more than four. Only five of 18 patients (27.8%) underwent surgical intervention despite having a TLICS score > 4, this could be attributed to their neurological status, which was not included so TLICS score matched surgical treatment in 66.7% of patients. After inclusion of neurological status in TLICS score it accurately matched surgical treatment in 100% of patients, their TLICS score after neurological status inclusion ≥ 4.This was an advantage in our study to evaluate the high significance of utilizing injury morphology and PLC injury solely in decision-making. Thus using the TLICS scoring achieved sensitivity 77.2%, specificity 100%, positive predictive value 100, and negative predictive value 77.3.
This suggests that use of the TLICS may identify unstable injuries that would otherwise be missed and directs these situations towards surgical care. As a corollary, it suggests that the conservative treatment of unstable injuries (TLICS > 4) will likely fail due to kyphosis, deformity, and pain.
Our study matched with Pizones et al. [13] in a study included fifty-eight vertebral fractures (38 surgical, 20 conservative), of which 50% were males with average age of 40.4 years. He concluded that MR imaging accuracy in the diagnosis of traumatic PLC injuries had a total sensitivity and specificity of 91% and 100% respectively, with 100% accuracy in diagnosis of surgical fractures. Thus, MRI is a very useful tool in the evaluation of acute thoracolumbar fractures, as it allows a better visualization of the posterior complex integrity presenting extra data in comparison to the other conventional diagnostic tools. Pizones et al. [13] differ from our study that his study was a prospective study, data was analyzed before and after MRI examination, focusing on: diagnostic changes in classification, occult injuries and differences in treatment decision.
Our results also match with Wood et al. [2] in a study of 47 patients, demonstrated that surgical treatment of stable burst fractures (TLICS < 4) did not improve clinical outcomes and increased the risk of complications for the patient.
In a retrospective study done by Pneumaticos et al. [14] enrolling 58 patients with TL fractures (group A and B) treated conservatively and evaluated over a follow-up period of 28 months. He concluded that conservative treatment of cases with a TLICS score of 4 can be safely applied and is equally as valid to those scoring < 3.Thus, his results are in keeping with ours that TILCS scoring is effective in decision making in TL spine fractures without neurological deficits.
Yuksel et al. [15] in a retrospective analysis of 55 patients with TL burst fractures aimed to evaluate the reliability of recommendations in the surgical management of unstable TL burst fractures using both the TLICS and the AO System.He stated that all patients suffering from neurological deficits (18 patients) received a TLICS > 4. Patients with incomplete spinal cord injury (14) all received a TLICS score > 4, but according to AO system, eight of them received 4 points. None of the neurologically free patients (37) received < 4 points of TLICS yet 18 of them received 3 AO points, to whom AO recommends conservative treatment despite the fact that they had unstable burst fractures. He concluded that the TLICS recommendations are more reliable than those of AO especially in aiding the surgical decisions regarding the unstable thoracolumbar burst fractures without neurological deficit. These results are not matching our study that revealed that both TL AOSIS and TLICS are very close as regards their reliability for guiding treatment plans, yet TL AOSIS matched treatment decisions more than TLICS.
In another retrospective study by Dodwad et al. [16] that included 201 patients with thoracolumbar junction injuries revealed that the TLICS system agreed with the treatment plan at their institute in 98% of the time in conservatively managed patients and in 78% of the time in patients who underwent surgical intervention. This is in keeping with a study by An et al. [17] whose results revealed revealing that TLICS matched 87.27% patients without neurological deficit. This is also matching with our results as the TLICS matched treatment recommendation in 60 patients (85.7%).
Joaquim et al. [7] studied 49 patients prospectively treated surgically for thoracic and lumbar spine trauma The TLICS score range from 2 to 9 (average of 6.2). Forty-seven of 49 (96%) patients had a TLICS score greater than 4, suggesting surgical treatment, the TLICS score treatment recommendation matched surgical treatment in 47 of 49 patients (96%), the TLICS score (P < 0.0001), his values were comparable to our study could be attributed to near number of patients.
Our study showed that the two classification systems have an agreeable output in treatment recommendations and decision making for most patients with thoracolumbar spine injuries. It should be noted that in the group without neurological deficit all of patients received < 4 of TL AOSIS and also in TLICS score, all of them treated conservatively which was recommended by TLICS and TL AOSIS classification.
In our study, the TLICS matched the management plan in 60 patients (85.7%) while the TL AOSIS matched treatment recommendation in 62 patients (88.6%). TLICS score showed sensitivity 77.2% compared to 95% in TL AOSIS, specificity = 100% compared to 80%, positive predictive value = 100 compared to 86.4 in TL AOSIS, and negative predictive value = 77.3% compared to 92.3% in TL AOSIS. Our study matched with Pizones et al. [13] who reported that MR imaging efficiency in diagnosis of traumatic PLC injuries has achieved overall sensitivity and specificity of 91% and 100% respectively, with 100% accuracy in diagnosis of surgical fractures.
Our study is also in keeping with Joaquim et al. [6] that included 214 patients, 148 of them were treated conservatively (C) and 66 were surgically (S) treatedThe TLICS matched the management recommendation in 97.9% of patients who were treated conservatively. In another study by Joaquim et al. [7], the TLICS score treatment decision matched surgical treatment in 47 of 49 patients (96%).
If surgery was the choice for these cases it would due to the treating surgeon’s concerns for fracture comminution and the probability of progressive deformity, Some our cases had burst fracture with TLICS not matching the treatment plan while TL AOSIS matched (Figs. 5, 6). Those cases were treated surgically to decrease the probability for kyphosis deformity compared with conservative treatment. The TL AOSIS system differentiate between the rather benign incomplete burst fractures involving one end plate (typically treated conservatively), and the rather unstable complete burst fracture [18]
Also in a study done by An et al. [17] 110 patients were studied. The TL AOSIS matched the recommendations for the management of 108 patients (98.18%) while TLICS matched in 96 patients (87.27%). In patients who were neurologically free, according to the TL AOSIS system, 12 of 62 received more than 5 points, 12 received 4 or 5 points, and 38 received less than 4 points. On the contrarily, according to the TLICS system, 12 of 62 received five or more points, 50 received ≤ 3 points. The TL AOSIS matched the management plan of 60 patients (96.77%), while the TLICS matched management recommendation in 48 patients (77.42%). For the patients with neurological deficits when TL AOSIS system was applied, 36 of 48 received more than 5 points, and 12 received 4 or 5 points. While regarding the TLICS system, 22 received more than 4 points, and 26 received 4 points.
The neurological preservation is a vital goal in the acute management of patients, collectively; these records support the preliminary conservative management of stable burst fractures with the use of an external orthosis. The criteria for conversion to surgical treatment remain unclear, especially when we considered axial back pain as a potential cause of failure in the conservative treatment. Chronic pain is a complex subject in spinal trauma, not accessed in our study, which requires long-term follow-up and functional status questionnaires evaluation. Prospective application of the TLICS system, with consistently defined injuries, will better elucidate the potential differences between surgical and conservative treatment.
Our study has few limitations including by the relatively small number of patients as well as its retrospective nature and the limited clinical follow-up. We recommend more studies to be done in a prospective manner are important to assess the prognostic value of the classification scoring systems on patient outcomes.
However, it was difficult to prove the validity of the clinical consequences prospectively according to the TLICS classification because patients with high TLICS score that required surgical intervention could not be observed without surgery. Multi-institute studies are needed because of possibility of biases for treatment decisions within a single institute.