Concordance and Variability in Thoracolumbar Injury Classification and Severity Score (TLICS)-guided Treatment Decision-making.

STUDY

DESIGN

Systematic review and pooled analysis.

OBJECTIVE

To evaluate the concordance between Thoracolumbar Injury Classification and Severity Score (TLICS) recommendations and actual treatment decisions in thoracolumbar trauma.

SUMMARY OF BACKGROUND DATA: TLICS is widely used to guide management of thoracolumbar fractures, recommending nonoperative treatment for scores ≤3 and operative intervention for scores ≥5. However, treatment variability may occur in cases with indeterminate scores, uncertainty in posterior ligamentous complex (PLC) integrity, or clinical modifiers not fully captured within the scoring framework.

METHODS

A systematic review of PubMed and Embase databases was performed. Studies reporting TLICS scores and corresponding treatment decisions were included. Pooled proportions were calculated for operative treatment in TLICS ≤3, nonoperative treatment in TLICS ≥5, operative treatment in TLICS =4, and delayed surgery following initial nonoperative management. Heterogeneity was assessed using I² statistic.

RESULTS

Fourteen studies encompassing 1,221 patients were included. Among patients with TLICS ≤3, 13.7% (95% CI: 8.7-20.9) underwent operative treatment. In TLICS ≥5 patients, 6.1% (95% CI: 3.2-11.3) were treated nonoperatively. Operative treatment in TLICS=4 occurred in 49.6% (95% CI: 37.6-61.6). Delayed surgery after initial nonoperative management occurred in 7.5% (95% CI: 2.9-18.2). Significant heterogeneity was observed across studies.

CONCLUSION

TLICS-based recommendations were concordant with treatment decisions in most low- and high-score thoracolumbar fractures. Observed treatment variability appeared to arise in predictable settings, including uncertainty in PLC assessment, borderline injury morphology, and patient-specific clinical modifiers. These findings support continued use of TLICS as a decision-support framework integrated with clinical judgment while identifying areas where future refinement of thoracolumbar trauma algorithms may be informed by evolving clinical practice.