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The Thoracolumbar Injury Classification and Severity Score Appropriately Predicts Treatment in Children Aged 10 and
Tyler Metcalf1, Ambika E Paulson1, Katherine D Sborov1
1Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, TN.
Insights
The Thoracolumbar Injury Classification and Severity Score (TLICS) accurately predicts non-operative management for pediatric thoracolumbar fractures. However, its specificity for recommending surgery in younger children is limited, especially for flexion-distraction injuries.
Area of Science:
- Pediatric Orthopedics
- Spinal Trauma
- Clinical Decision Support Tools
Background:
- The Thoracolumbar Injury Classification and Severity Score (TLICS) is validated for adult thoracolumbar trauma.
- Its application in preadolescent children is uncertain due to developmental differences in spinal biomechanics.
- Existing pediatric studies often focus on older children with more mature spines.
Purpose of the Study:
- To evaluate the diagnostic accuracy of the TLICS in children aged 10 years and younger with thoracolumbar fractures.
- To determine if TLICS can reliably guide surgical versus non-surgical treatment decisions in this pediatric population.
Main Methods:
- Retrospective cohort study of 94 pediatric patients (≤10 years) with acute thoracolumbar fractures.
- Analysis of a single-center spine trauma registry from 2006-2020.
- Evaluation of TLICS accuracy using test characteristics and receiver-operator curve analysis, with TLICS <4 indicating non-operative and TLICS >4 indicating operative management.
Main Results:
- TLICS demonstrated high sensitivity (100%) and negative predictive value (100%) for non-operative management.
- Specificity for operative management was 89.2%, with 32.1% of patients with TLICS >4 treated non-operatively.
- Receiver operating characteristic analysis showed strong diagnostic ability (AUC: 0.97, F1-score: 0.86).
- Flexion-distraction injuries were noted in all cases deviating from TLICS-suggested treatment.
Conclusions:
- TLICS <4 is highly valid and specific for predicting non-operative treatment in young children with thoracolumbar fractures.
- TLICS >4 has limited specificity for surgical intervention necessity in this age group.
- Additional factors beyond TLICS may be required for optimal management of severe injuries in preadolescent patients.
Study Design:
A retrospective cohort study.
Objective:
This study aims to assess the validity of the Thoracolumbar Injury Classification and Severity Score (TLICS) in patients ≤10 years old.
Summary Of Background Data:
TLICS is a validated measure developed to help facilitate clinical decision-making regarding thoracolumbar spinal trauma in adults. Studies examining the utility of TLICS in children skew toward older pediatric patients, where the spine's biomechanical properties are more similar to adults. Due to differences in a preadolescent spine compared with a more mature, adolescent spine, it is unclear if TLICS can be applied to younger patients.
Methods:
A single-center spine trauma registry was queried for patients ≤10 with an acute, traumatic thoracolumbar fracture treated at a level-1 pediatric trauma center between 2006 and 2020. Test characteristics and receiver-operator curve were used to evaluate TLICS based on TLICS <4 recommedning nonsurgical treatment and TLICS >4 recommending surgery.
Results:
We identified 94 patients with traumatic thoracolumbar fractures (surgical=20; nonsurgical=74). Despite TLICS-suggested operative management in 28 patients with TLICS >4, nine (32.1%) were initially treated nonoperatively. All patients who deviated from TLICS-suggested treatment had flexion-distraction injuries (FDI). Sensitivity, specificity, positive predictive value, and negative predictive value were 100%, 89.2%, 70.4%, and 100%, respectively. The receiver operating characteristic curve demonstrated a strong diagnostic ability of TLICS in predicting the need for surgery (area under the curve: 0.97, F1-score: 0.86).
Conclusion:
TLICS score <4 showed strong validity and is highly specific in predicting non-operative management for patients ≤10 years old with thoracolumbar fractures. However, TLICS >4 has more limited specificity in indicating the necessity for surgical intervention, as many FDIs were successfully treated without surgery. Additional factors other than TLICS score may need to be considered for these more severe injuries to optimize management in this age group.
