Age / Sex : 46 / F

Age / Sex : 46/F

Chief complaint :

Back pain after TA (several hours ago)

No neurologic deficit

1) What is your impression?

Two weeks later, you can see the final diagnosis with a brief discussion of this case.

* Send Application Answers to In Sook Lee, MD (lis@pusan.ac.kr)

Courtesy : Kim Su Jin, SNUBH (Seoul National University Bundang Hospital)

flexion distraction injury

Discussion

Findings:

- Injury Morphology: flexion distraction injury.

     : T12, posterior 1/3 VB fracture, Lt. pedicle fracture, lamina fracture, and spinous process fracture

- Posterior ligament complex injury

     : ligamentum flavum tear, suspicious

      supraspinous ligament tear

- Cord injury: unremarkable.

- Central canal compromise: unremarkable.

- Others: T12 and L1 anterior 2/3 VB, subtle bone marrow edema, suggestive of contusion

other traumatic lesion: extensive soft tissue swelling, back area.

Differential Diagnosis: (-)

Diagnosis: flexion distraction injury – TLICS injury Morphology 4 + PCL injury 3 + neurologic deficit 0

Discussion:

The Thoracolumbar Injury Classification and Severity Score is a more recent attempt to place thoracolumbar spine trauma into a more comprehensive clinical context. The TLICS system identifies 3 major injury characteristics including injury morphology, posterior ligamentous complex integrity, and neurological status.

Injury Morphology

Compression injuries are defined by a visible loss of height of the vertebral body or disruption through the vertebral endplate. This category includes traditional compression (anterior vertebral body) and burst (involvement of the posterior vertebral wall) fractures as well as sagittal or coronal plane fractures of the vertebrae.

The rotation/translation injury is defined by horizontal displacement of one vertebral body with respect to another. It is typified by unilateral and bilateral dislocations, facet fracture dislocations, and bilateral pedicle or pars fractures with vertebral subluxation (traumatic spondylolisthesis).

The distraction injury pattern is readily identified by anatomical dissociation in the vertical axis. A representative example would be a hyperextension injury causing 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 ligamentous 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.

Integrity of the PLC

The PLC includes the supraspinous ligament, interspinous ligament, ligamentum flavum, and facet joint capsules. The importance of this complex in protecting the

spine against excessive flexion, rotation, translation, and distraction has been well described. Furthermore, once disrupted, the ligamentous structures have poor healing ability and generally require surgical stabilization. The integrity of the PLC is categorized as intact, indeterminate, or disrupted. This assessment can be made

from plain radiographs, CT scans, and MR images. Disruption 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 subluxation, or dislocation of the spine. Other measures of posterior ligamentous disruption include vertebral body translation or rotation.

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 injury. In addition, incomplete neurological injury in the setting of neural compression is generally accepted as

an indication for surgical decompression. The neurological status is described in increasing order of urgency as: neurologically intact, nerve root injury, complete (motorand sensory) spinal cord injury, and incomplete (motor or sensory) spinal cord or cauda equina injury.

A numerical value is assigned for each injury subcategory dependent on the severity of injury. These individual scores are then summated to produce an injury severity score, which is, in turn, used to guide treatment (Table 1). A score of ≥ 5 suggests operative treatment of the patient due to significant instability, whereas a score of ≤ 3 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.

References:

Thoracolumbar spine trauma classification: the Thoracolumbar Injury Classification and Severity Score system and case examples. J Neurosurg Spine 10:201–206, 2009

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