J Neurosurg Spine 10:201–206,

10:000–000, 2009

Thoracolumbar spine trauma classification: the

Thoracolumbar Injury Classification and
Severity Score system and case examples

Clinical article
Alpesh A. Patel, M.D.,1 Andrew Dailey, M.D., 2 Darrel S. Brodke, M.D.,1
Michael Daubs, M.D.,1 James Harrop, M.D., 3 Peter G. Whang, M.D., 5
Alexander R. Vaccaro, M.D., Ph.D., 4 and the Spine Trauma Study Group
Departments of 1Orthopaedic Surgery and 2Neurosurgery, University of Utah School of Medicine, Salt Lake
City, Utah; Departments of 3Neurosurgery and 4Orthopaedic Surgery, Thomas Jefferson University,
Philadelphia, Pennsylvania; and 5Department of Orthopaedic Surgery and Rehabilitation, Yale University,
New Haven, Connecticut

Object. The aim of this study was to review the Thoracolumbar Injury Classification and Severity Score (TLICS)
and to demonstrate its application through a series of spine trauma cases.
Methods. The Spine Trauma Study Group collaborated to create and report the TLICS system. The TLICS sys-
tem is reviewed and applied to 3 cases of thoracolumbar spine trauma.
Results. The TLICS system identifies 3 major injury characteristics to describe thoracolumbar spine injuries:
injury morphology, posterior ligamentous complex integrity, and neurological status. In addition, minor injury char-
acteristics such as injury level, confounding variables (such as ankylosing spondylitis), multiple injuries, and chest
wall injuries are also identified. Each major characteristic is assigned a numerical score, weighted by severity of
injury, which is then summated to yield the injury severity score. The TLICS system has demonstrated initial success
and its use is increasing. Limitations of the TLICS system exist and, in some instances, have yet to be addressed.
Despite these limitations, the severity score may provide a basis to judge spinal stability and the need for surgical
intervention.
Conclusions. By addressing both the posterior ligamentous integrity and the patient’s neurological status, the
TLICS system attempts to overcome the limitations of prior thoracolumbar classification systems. The TLICS system
has demonstrated both validity and reliability and has also been shown to be readily learned and incorporated into
clinical practice. (DOI: 10.3171/2008.12.SPINE08388)

Key Words      •      injury classification      •      injury severity score      •      spinal cord injury      •   
Thoracolumbar Injury Classification and Severity Score      •      thoracolumbar spine trauma

I
njuries to the thoracic and lumbar spine account for
> 50% of all spinal fractures and a large portion of
acute spinal cord injuries.7 Given this frequency and
the significant impact of these injuries, significant ad-
vancements have been made in the surgical treatment of
thoracolumbar trauma. Despite the invention and con-
tinued evolution of spinal instrumentation and surgical
techniques, medical decision-making in spine trauma re-
mains controversial. Fracture treatment can vary widely,
from bracing to invasive 360° fusions, based on geo-
graphical, institutional, or individual preferences with
little scientific basis.
Abbreviations used in this paper: AO = Arbeitsgemeinschaft für
Osteosynthesefragen; ASIA = American Spinal Injury Association;
PLC = posterior ligamentous complex; TLICS = Thoracolumbar
Injury Classification and Severity Score.
A number of classification systems have been devel-
oped in an attempt to better define thoracolumbar trauma
and aid treatment decision-making. These systems are
typically based on either anatomical structures (Denis
Three-Column System) or on proposed mechanisms
of injury (Ferguson and Allen, and the AO system).2,3,6
Overall, however, there is a paucity of strong data sup-
porting the use of any of these systems. Additionally,
there is currently no clear consensus regarding the opti-
mal system for characterizing thoracolumbar fractures.
An ideal system must be simple and reproducible based
on commonly identified clinical and radiographic param-
eters. Current systems are either excessively convoluted,
with an impractical number of variables, or are too sim-
ple, lacking sufficient detail to provide clinically relevant
information. These limitations have yielded classification
systems that are difficult to implement, have shown in-

J. Neurosurg.: Spine / Volume 10 / March 2009 201

 A. A. Patel et al.

sufficient validity and reproducibility, and have not been Table 1: Thoracolumbar injury classification and severity score
widely popular.1,6,8,16 scale
The TLICS has been described and validated to ad-
dress the shortcomings of the prior classification systems. Category Points
The purpose of this paper is to review the TLICS system injury morphology
and to demonstrate its clinical application using 3 cases
   compression 1
of thoracolumbar spine trauma.
     burst +1

Methods
The TLICS, introduced by the Spine Trauma Study
Group in 2005, was designed to provide a clear, reliable
classification system that accounts for many of the short-
comings of prior systems.14 The system has demonstrated
good to excellent inter- and intraobserver reliability and
has also been shown to be easily taught, learned, and in-
corporated into clinical practice.11,12,14,15 The TLICS sys-
tem assigns numerical values to each injury based on the
categories of morphology of injury, integrity of the PLC,
and neurological involvement (Table 1).
Injury Morphology
Compression injuries are defined by a visible loss of
height of the vertebral body or disruption through the ver-
tebral endplate. This category includes traditional com-
pression (anterior vertebral body) and burst (involvement
of the posterior vertebral wall) fractures as well as sagit-
tal or coronal plane fractures of the vertebrae.
The rotation/translation injury is defined by hori-
zontal displacement of one vertebral body with respect
to another (Fig. 1A). It is typified by unilateral and bilat-
eral dislocations, facet fracture dislocations, and bilateral
pedicle or pars fractures with vertebral subluxation (trau-
matic spondylolisthesis).
The distraction injury pattern is readily identified by
anatomical dissociation in the vertical axis. A represen-
tative example would be a hyperextension injury caus-
ing disruption of the anterior longitudinal ligament with
subsequent widening of the anterior disc space. Posterior
element fractures (facet, lamina, or spinous process) may
also be present. Thoracolumbar kyphotic deformities of
the spine, through a tensile failure of the posterior liga-
mentous restraints, represent another clinical example of
the distraction morphology.
If more than 1 injury morphology is present, then the
single injury morphology with the largest score is used.
For example, a T11–12 distraction injury with a T-12 burst
fracture would be classified as a distraction injury and
assigned 4 points (Table 1); scores for the burst fracture
morphology are not used. If multiple levels of involve-
ment are present, each injury can be assessed indepen-
dently. For example, an individual with a T-5 burst frac-
ture (2 points) and a T-9 compression fracture (1 point) is
assigned a different TLICS score for each injury.
Integrity of the PLC
The PLC includes the supraspinous ligament, inter­
spinous ligament, ligamentum flavum, and facet joint cap-
sules. The importance of this complex in protecting the
spine against excessive flexion, rotation, translation, and
   translational/rotational 3
   distraction 4
neurological status
   intact 0
   nerve root 2
   cord, conus medullaris
     incomplete 3
     complete 2
     cauda equina 3
PLC
   intact 0
   injury suspected/indeterminate 2
   injured 3
distraction has been well described.9,10 Furthermore, once
disrupted, the ligamentous structures have poor healing
ability and generally require surgical stabilization.
The integrity of the PLC is categorized as intact, in-
determinate, or disrupted. This assessment can be made
from plain radiographs, CT scans, and MR images.5 Dis-
ruption is typically indicated by splaying of the spinous
processes (widening of the interspinous space), widening
of the facet joints, empty facet joints, facet perch or sub-
luxation, or dislocation of the spine. Other measures of
posterior ligamentous disruption include vertebral body
translation or rotation.
When the evidence of disruption is subtle, the integ-
rity of the ligaments is labeled “indeterminate.” In some
cases, clinical examination may be helpful in determin-
ing the status of the PLC as an obvious gap between the
spinous processes indicates PLC disruption. Magnetic
resonance images may show areas of high signal intensity
on STIR or T2-weighted imaging, suggesting PLC injury.
However, MR imaging findings of the PLC have yet to
be reproducibly proven to correlate with anatomical dis-
ruption.4 Therefore, unless CT scans or plain radiographs
demonstrate clear disruption, MR imaging suggesting
PLC injury may be best classified as indeterminate.
Neurological Status
The neurological status of the patient is often the
most influential component of medical decision-making.
Additionally, it can be inferred that neurological injury
is a critical indicator of the degree of spinal column in-
jury. In addition, incomplete neurological injury in the
setting of neural compression is generally accepted as
an indication for surgical decompression. The neurologi-

202 J. Neurosurg.: Spine / Volume 10 / March 2009

Thoracolumbar injury classification system and severity score

Fig. 1.  Case 1. Images obtained in an 18-year-old female who sustained a fall of 10 ft off of a horse and presented with an
incomplete spinal cord injury (ASIA Grade B).  A: Lateral radiograph demonstrating a T10–11 dislocation.  B: Sagittal CT scan
demonstrating dislocation with associated fractures of the vertebral body and posterior elements.  C: Sagittal T2-weighted MR
image reveals compression on the spinal cord from the spinal deformity and disruption of the posterior ligamentous structures.

cal status is described in increasing order of urgency as:
neurologically intact, nerve root injury, complete (motor
and sensory) spinal cord injury, and incomplete (motor or
sensory) spinal cord or cauda equina injury. The incom-
plete spinal cord injuries are considered ASIA Grades B,
C, or D, while the complete injuries are considered ASIA
Grade A.
A numerical value is assigned for each injury subcat-
egory dependent on the severity of injury. These individu-
al scores are then summated to produce an injury severity
score, which is, in turn, used to guide treatment (Table
1). A score of ≥ 5 (Cases 1 and 3, below) suggests opera-
tive treatment of the patient due to significant instability,
whereas a score of ≤ 3 (Case 2) suggests nonoperative
treatment; a patient with a score of 4 may be treated either
operatively or conservatively. In the setting of multiple
fractures, the injury with the greatest TLICS score is used
to guide treatment.
Summary of Cases
sation in the perineal and perirectal region and the lower
extremities.
TLICS Classification: T10–11 translational injury
with a disrupted PLC and an incomplete spinal cord in-
jury.
TLICS Score: Injury Morphology (Translation) = 3
points; PLC (Disrupted) = 3 points; Neurological Status
(Incomplete) = 3 points; Total TLICS score = 9 points
(operative treatment).
Case 2
This patient (Fig. 2) was a 42-year-old male involved
in a high-speed motor vehicle collision who presented
with back pain but no neurological deficits.
TLICS Classification: T-12 burst fracture with an in-
tact PLC and normal neurological examination results.
TLICS Score: Injury Morphology (Burst) = 2 points;
PLC (Intact) = 0 points; Neurological Status (Intact) = 0
points; Total TLICS score = 2 points (nonoperative treat-
ment).

Three cases of thoracolumbar trauma are presented Case 3

to demonstrate use of the TLICS system and its ability to
guide surgical decision–making.
Case 1
This patient (Fig. 1) was an 18-year-old female who
sustained a fall from 10 ft after being thrown from a
horse. She presented with an incomplete spinal cord in-
jury (ASIA Grade B) with severe weakness in the lower
extremities but maintained light touch and pinprick sen-
This patient (Fig. 3) was a 23-year-old male who pre-
sented after a 25-ft fall with subsequent back pain and
lower-extremity weakness and numbness consistent with
an incomplete cauda equina injury.
TLICS Classification: L-2 burst fracture with inde-
terminate PLC injury and an incomplete cauda equina
injury.
TLICS Score: Injury Morphology (Burst) = 2 points;
PLC (Indeterminate/Suspected) = 2 points; Neurological

J. Neurosurg.: Spine / Volume 10 / March 2009 203


Fig. 2.  Case 2. Images obtained in a 42-year-old male involved in a high-speed motor vehicle collision who presented with
back pain but no neurological deficits.  A: Sagittal CT scan reveals a T-12 burst fracture with no kyphotic or translational defor-
mity.  B: Axial CT scan demonstrates T-12 fracture retropulsion and 20% canal stenosis.  C: Sagittal T2-weighted MR image
demonstrates intact posterior ligamentous structures with no increased signal intensity.
Status (Incomplete) = 3 points; Total TLICS Score = 7
points (operative treatment).
Discussion
Treatment of thoracolumbar spinal trauma is based
on a systematic evaluation of the clinical and radio-
graphic information available on the patient at the time
of assessment. Classification systems have been devel-
oped to help physicians categorize this information and
synthesize a treatment strategy. Prior systems have been
based on either injury to specific anatomical structures
(Denis Three-Column System) or proposed mechanisms
of injury (Ferguson and Allen, and the AO system).2,3,6
An inherent limitation of the latter system is that injuries
are classified by inferring unknown injury patterns rather
than by a description of known or presenting injury mor-
phology. Not surprisingly, significant interobserver vari-
ability has been noted with mechanistic classifications.13
Blauth et al.1 demonstrated only fair (κ = 0.33) interob-
server reliability of the AO system with 3 main categories
(A, B, and C); as injury subtypes were included, reliability
decreased significantly. Wood and colleagues16 and Oner
et al.8 independently demonstrated fair interobserver reli-
ability of the AO system and fair to good reliability of the
Denis classification system.
The TLICS system has been designed to address
these limitations. The TLICS system defines injuries
according to injury morphology, integrity of the PLC,
and neurological status of the patient. It is the first tho-
racolumbar system to use injury morphology combined
with the neurological status of the patient and the criti-
cal importance of the posterior ligamentous structures in
medical decision-making.
As such, the TLICS system has been designed to aid
204
A. A. Patel et al.
in medical decision-making by providing both diagnostic
and prognostic information with a weighted injury sever-
ity score. Stable injury patterns (TLICS < 4) may be treat-
ed nonoperatively with brace immobilization and active
patient mobilization. Unstable injury patterns (TLICS >
4) may be treated operatively with the guiding principles
of deformity correction, neurological decompression if
necessary, and spinal stabilization followed by active pa-
tient mobilization.
The TLICS system has shown good to excellent in-
tra- and interobserver reliability in a number of countries,
including with both orthopedic surgeons and neurosur-
geons, and throughout a spectrum of spine treatment
providers with varying levels of experience.11,12,14,15 The
TLICS system has been tested in the setting of an aca-
demic trauma center, verifying that physicians in training
(residents and fellows) can readily be taught and incorpo-
rate the TLICS system into patient care.11 Furthermore,
use of the TLICS has yielded > 90% agreement in the
management of thoracolumbar trauma across a number
of providers.14
Although the TLICS system has demonstrated suc-
cess, there are inherent limitations. To date, many of the
investigations into the TLICS system have been performed
by individuals involved with its development. Whereas
the system has demonstrated educational efficacy,11 a
broader application of the system across multiple physi-
cians and trauma centers may further validate or refute
the TLICS system. Additionally, a prospective application
of the TLICS system and severity score to the treatment
of spinal injuries is needed to define any improvements in
care and patient outcomes compared with conventional
systems. Lastly, there are certain injury patterns that may
be difficult to classify and score. The following case is an
example of the limitations of the TLICS system.
J. Neurosurg.: Spine / Volume 10 / March 2009
Thoracolumbar injury classification system and severity score

Fig. 3.  Case 3. Images obtained in a 23-year-old male who presented after a 25-ft fall out of a tree with resulting back pain
and an incomplete cauda equina injury.  A: Sagittal CT scan demonstrates an L-2 burst fracture.  B: Axial CT scan showing
the burst pattern at L-2 with 90% canal stenosis.  C: Sagittal T2-weighted MR image demonstrates compression of the cauda
equina and possible signal change in the PLC.

Fig. 4.  Images obtained in a 68-year-old male with ankylosing spondylitis who was involved in a ground-level fall and sub-
sequently presented with back pain and normal neurological examination results.  A: Sagittal CT scan demonstrates a T9–10
distraction injury with anterior, middle, and posterior column involvement (arrows).  B: Sagittal STIR MR image demonstrates an
increased signal at the level of the fracture but intact ligamentous structures.  C: Sagittal T2-weighted MR image demonstrates
no anatomical disruption of the PLC.

J. Neurosurg.: Spine / Volume 10 / March 2009 205


A 68-year-old male with ankylosing spondylitis pre-
sented with back pain and normal neurological examina-
tion results after a ground-level fall (Fig. 4). His TLICS
classification was a T9–10 distraction injury with an intact
PLC and normal neurological examination. His TLICS
score was: Injury Morphology (Distraction) = 4 points,
PLC (Intact) = 0 points, Neurological Status (Intact) =
0 points, and Total TLICS score = 4 points (operative or
nonoperative treatment). This case example demonstrates
a number of limitations. The patient’s bone injury is a
distraction injury, but the PLC is anatomically intact. Al-
though this patient’s fracture was not severe, others with
greater fracture displacement or angulation would be
classified using the same score. The TLICS system is not
sensitive enough to define these differences, but instead
includes ankylosing spondylitis and other confounding
factors as additional descriptors. Although this system al-
lows the ultimate treatment decision to be made by the
treating physician, the TLICS may not provide a common
language or suggest a standard treatment for this injury
pattern.
Conclusions
This paper has demonstrated the application of the
TLICS system, a significant improvement over current
classification systems because it incorporates major clini-
cal determinants for medical decision-making and prog-
nosis. Future prospective studies with the TLICS will
help to further define its role in the care of thoracolumbar
spine trauma.
Disclosure
This study was supported by the Spine Trauma Study Group
and funded by an educational/research grant from Medtronic
Sofamor Danek.
References
  1.  Blauth M, Bastian L, Knop C, Lange U, Tusch G: Inter-ob-
server reliability in the classification of thoraco-lumbar spinal
injuries. Orthopade 28:662–681, 1999
  2.  Denis F: The three-column spine and its significance in the
classification of acute thoracolumbar spinal injuries. Spine 8:
817–831, 1983
  3.  Ferguson RL, Allen BL Jr: A mechanistic classification of
thoracolumbar spine fractures. Clin Orthop Relat Res 189:
77–88, 1984
  4.  Lee HM, Kim HS, Kim DJ, Suk KS, Park JO, Kim NH: Reli-
ability of magnetic resonance imaging in detecting posterior
ligament complex injury in thoracolumbar spinal fractures.
Spine 25:2079–2084, 2000
206
A. A. Patel et al.
  5.  Lee JY, Vaccaro AR, Schweitzer KM, Lim MR, Baron EM,
Rampersaud R, et al: Assessment of injury to the thoracolum-
bar posterior ligamentous complex in the setting of normal-
appearing plain radiography. Spine J 7:422–427, 2007
  6.  Magerl F, Aebi M, Gertzbein SD, Harms J, Nazarian S: A
comprehensive classification of thoracic and lumbar injuries.
Eur Spine J 3:184–201, 1994
  7.  National SCI Statistical Center (US): Spinal Cord Injury
Facts & Figures at a Glance 2008. Birmingham, AL: The
National SCI Statistical Center, 2008 (http://www.spinalcord.
uab.edu/show.asp?durki=116979) [Accessed 15 December
2008]
  8.  Oner FC, Ramos LM, Simmermacher RK, Diekerhof CH,
Dhert WJ, Verbout AJ: Classification of thoracic and lumbar
spine fractures: problems of reproducibility. A study of 53 pa-
tients using CT and MRI. Eur Spine J 11:235–245, 2002
  9.  Oxland TR, Panjabi MM, Southern EP, Duranceau JS: An
anatomic basis for spinal instability: a porcine trauma model.
J Orthop Res 9:452–462, 1991
10.  Panjabi MM, White AA: Basic biomechanics of the spine.
Neurosurgery 7:76–93, 1980
11.  Patel AA, Vaccaro AR, Albert TJ, Hilibrand AS, Harrop JS,
Anderson DG, et al: The adoption of a new classification sys-
tem: time-dependent variation in interobserver reliability of
the thoracolumbar injury severity score classification system.
Spine 32:E105–E110, 2007
12.  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 Spi-
nal Disord Tech 19:477–482, 2006
13.  Schweitzer KM Jr, Vaccaro AR, Lee JY, Grauer JN: Confu-
sion regarding mechanisms of injury in the setting of thora-
columbar spinal trauma: a survey of The Spine Trauma Study
Group (STSG). J Spinal Disord Tech 19:528–530, 2006
14.  Vaccaro AR, Lehman RA Jr, Hulbert RJ, Anderson PA, Har-
ris 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 30:2325–2333, 2005
15.  Whang PG, Vaccaro AR, Poelstra KA, Patel AA, Anderson
DG, Albert TJ, et al: The influence of fracture mechanism and
morphology on the reliability and validity of two novel tho-
racolumbar injury classification systems. Spine 32:791–795,
2007
16.  Wood KB, Khanna G, Vaccaro AR, Arnold PM, Harris MB,
Mehbod AA: Assessment of two thoracolumbar fracture clas-
sification systems as used by multiple surgeons. J Bone Joint
Surg Am 87:1423–1429, 2005
Manuscript submitted July 10, 2008.
Accepted Decmber 11, 2008.
Address correspondence to: Alpesh A. Patel, M.D., Department
of Orthopaedic Surgery, University of Utah, Salt Lake City, Utah
84108. email: alpesh.patel@hsc.utah.edu.
J. Neurosurg.: Spine / Volume 10 / March 2009