Clinical calculator
TLICS Calculator
Thoracolumbar Injury Classification and Severity Score
TLICS grades a thoracolumbar injury by adding three components — injury morphology scored 1 to 4, integrity of the posterior ligamentous complex scored 0 to 3, and neurological status scored 0 to 3 — giving a total from 1 to 10 in which 3 or less favours non-operative treatment, 4 is left to the surgeon’s discretion and 5 or more favours surgery.
What the TLICS score means
TLICS scores run from 1 to 10, where a lower score is better. The bands below are conventional reporting categories, not diagnostic cut-offs.
- Non-operative management1–3
The system’s own recommendation, not a rule. Patient factors, associated injuries and the quality of the imaging all bear on the decision.
- Surgeon’s discretion4–4
Deliberately indeterminate. A score of 4 says the system cannot decide, not that either option is equivalent for this patient.
- Operative management5–10
Published criteria and reliability
The published cut-offs that define this instrument, and the measured agreement between observers using it. Each is reported with the population it was derived in.
| Type | Value | Subscale | Population | Follow-up | Source |
|---|---|---|---|---|---|
| Criterion | Total 3 or less — non-operative management recommended | — | Adults with a thoracolumbar injury and no pathological fracture or ankylosing disorder | — | Vaccaro AR 2005 |
| Criterion | Total 4 — either operative or non-operative management, at the surgeon’s discretion | — | Adults with a thoracolumbar injury | — | Vaccaro AR 2005 |
| Criterion | Total 5 or more — operative management recommended | — | Adults with a thoracolumbar injury | — | Vaccaro AR 2005 |
| Criterion | Interobserver agreement is good for neurological status and morphology and weakest for the posterior ligamentous complex, which is the component that most often changes the recommendation | — | Spine surgeons applying TLICS to thoracolumbar injuries | — | Patel AA 2007 |
Criterion is a published cut-off, definition or performance figure belonging to a classification or decision rule — it is not a change score and should not be read as one.
How the score is calculated
Stated in full so the calculation can be independently checked, and reproduced by hand if needed.
Three components are scored and added. Injury morphology scores 1 for a compression injury, 2 for a burst injury, 3 for a translational or rotational injury and 4 for a distraction injury; where more than one pattern is present the highest applicable value is taken. Integrity of the posterior ligamentous complex scores 0 if intact, 2 if suspected or indeterminate and 3 if injured. Neurological status scores 0 if intact, 2 for a nerve root injury, 2 for a complete cord or conus injury, 3 for an incomplete cord or conus injury and 3 for cauda equina syndrome — the incomplete deficits scoring higher than the complete one because they are the injuries in which decompression may still recover function. The total runs from 1 to 10. A total of 3 or less favours non-operative management, 4 is left to the surgeon’s discretion, and 5 or more favours surgery. The score guides the decision to operate; it does not specify the approach, which is determined mainly by the neurological status and by whether the anterior column needs reconstruction.
Missing data
All three components must be assessed. Where the posterior ligamentous complex cannot be assessed, the system provides an explicit indeterminate value of 2 points rather than a blank — but that value is not a neutral placeholder, and because it is 2 of 10 points it can by itself move a patient across the operative threshold. Obtain the MRI where the decision turns on it.
Instrument profile
- Developer
- Alexander R. Vaccaro and the Spine Trauma Study Group
- Institution
- Thomas Jefferson University and the Rothman Institute, Philadelphia, United States
- First published
- 2005
- Custodian
- Superseded for descriptive purposes by the AOSpine thoracolumbar classification, which the same group published in 2013; TLICS remains widely used for the operative decision itself
- Items
- 3
- Response format
- Three clinician-assessed components, added
- Score range
- 1 to 10
- Direction
- Lower score = better
- Completion time
- About 2 minutes
- Age range
- Adults
- Regions
- Spine
- Conditions
- Thoracolumbar fracture, Burst fracture, Chance fracture, Spinal cord injury, Posterior ligamentous complex injury
- Procedures
- Posterior spinal instrumentation and fusion, Anterior corpectomy and reconstruction, Spinal decompression, Thoracolumbar bracing
- Observer agreement
- Intraobserver agreement is substantial for the total score across repeated readings by the same surgeon
- Validity
- Recommendations agree with actual treatment in the large majority of thoracolumbar injuries; disagreement clusters at a total of 4 and in burst fractures with an indeterminate posterior ligamentous complex, which is exactly where the system is designed to be indeterminate.
- Reliability
- Reliability is highest for neurological status, which is a clinical finding, and lowest for the posterior ligamentous complex, which depends on MRI interpretation — the component carrying up to 3 of the 10 points.
When to use the TLICS
Well suited to
- Deciding whether an adult thoracolumbar injury needs surgery, particularly a burst fracture in a neurologically intact patient.
- Structuring the discussion and the documentation around the three findings that actually drive the decision.
- Teaching and handover, where a single number conveys morphology, ligamentous integrity and neurology together.
Limitations and poor fits
- Pathological fractures, ankylosing spondylitis and diffuse idiopathic skeletal hyperostosis: in an ankylosed spine a morphologically minor injury is often a highly unstable three-column fracture, and the score will understate it badly.
- Children and adolescents, in whom the system was not developed or validated.
- Cervical injuries — the equivalent system for the subaxial cervical spine is the SLIC score.
- As a description of the fracture for research or registry purposes, where the AOSpine thoracolumbar classification is now the standard descriptive system.
- As a substitute for judgement at a total of 4, which the developers deliberately left undecided.
TLICS compared with other instruments
Instruments measuring a related construct, with the practical difference between them.
| Instrument | Items | Range | What it adds |
|---|---|---|---|
| AO/OTA | 3 | 1–3 | The AO/OTA classification gives every fracture an alphanumeric code in which the first digit is the bone, the second the segment and the letter the fracture type — extra-articular, partial articular or complete articular in an end segment, and simple, wedge or multifragmentary in a shaft — so that 32-A is a simple femoral shaft fracture and 43-C a complete articular pilon fracture. |
| Meyerding | — | 0–100 | The Meyerding classification grades spondylolisthesis by the percentage of anterior translation of one vertebral body over the one below, measured on a standing lateral radiograph, from grade I at 25% or less through to grade V, spondyloptosis, beyond 100%. |
| Canadian C-Spine Rule | 3 | 0–1 | The Canadian C-Spine Rule decides whether an alert, stable blunt trauma patient needs cervical spine radiography through three sequential steps — high-risk factors, low-risk factors, and the ability to actively rotate the neck 45 degrees each way — with a reported sensitivity of about 99% for clinically significant injury. |
| NEXUS | 5 | 0–1 | The NEXUS low-risk criteria allow the cervical spine to be cleared without imaging after blunt trauma when all five findings are absent — midline cervical tenderness, focal neurological deficit, altered alertness, intoxication and a distracting injury — with a reported sensitivity of about 99% for clinically significant injury. |
Copyright and permitted use
Published openly because it is the question every clinician and researcher asks before using an instrument, and almost nobody answers it.
A published classification and scoring method, described in full in the peer-reviewed literature and reproduced throughout the spine trauma literature without a licensing programme. No licence is required.
References
- Vaccaro AR, Lehman RA Jr, Hurlbert RJ, et al.. A new classification of thoracolumbar injuries: the importance of injury morphology, the integrity of the posterior ligamentous complex, and neurologic status. Spine. 2005.
- Patel AA, Vaccaro AR, Albert TJ, et al.. The adoption of a new classification system: time-dependent variation in interobserver reliability of the thoracolumbar injury severity score classification system. Spine. 2007.
- Vaccaro AR, Oner C, Kepler CK, et al.. AOSpine thoracolumbar spine injury classification system: fracture description, neurological status, and key modifiers. Spine. 2013.
Editorial status
This page has not yet been signed off by a named clinical reviewer. The scoring logic is stated in full above so it can be independently verified, and every threshold is traceable to its source. See our editorial methodology.