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.
STUDY DESIGN: Systematic review and pooled analysis.
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