The thoracolumbar injury severity score: a proposed treatment algorithm

Significant controversy exists regarding the optimal management of thoracolumbar injuries. This is in part due to the lack of understanding of the natural history of various injury subtypes and the absence of a universally accepted classification scheme that facilitates communication among care providers and assists in directing treatment. The Spine Trauma Study Group has developed an injury severity score based on three major variables: the mechanism of injury determined by radiographic appearance, the integrity of the posterior ligamentous complex, and the neurologic status of the patient. By systematically assigning specific point values within each category based on the severity of injury, a final severity score may be generated that can be used to help direct treatment. The goal of this work is to present a proposal of a detailed treatment algorithm to assist in the nonoperative or operative management of thoracolumbar injuries.

A detailed review of the world's spinal literature was performed to ascertain predictors of instability following thoracolumbar trauma. With use of known biomechanical and clinical outcome measures, an arbitrary assignment of point values to various injury descriptors was performed. The assessment of the validity of the severity score was compared retrospectively with a variety of selected cases representing the typical injury patterns under the three major injury groups: compression, translational/rotational, and distraction injuries.

The proposed treatment algorithm is an attempt to assist physicians using best-evidence medicine in managing thoracolumbar spinal injuries. The final point flow chart with graduated treatment recommendations is only preliminary and needs to be validated through prospective cohort analysis. In addition, the importance of the chosen variables determining spinal stability must also be verified.