What is the evaluation and management process for spinal conditions to determine the appropriate listing or classification?

Spine Listing: Evaluation and Classification of Spinal Conditions

For thoracolumbar spine trauma, use either the Thoracolumbar Injury Classification and Severity Score (TLICS/TLISS) or the AO Spine Thoracolumbar Spine Injury Classification System, as both demonstrate validated reliability and guide treatment decisions based on injury morphology, neurological status, and ligamentous integrity. 1

Classification Systems by Spinal Region

Thoracolumbar Spine Trauma

Modern validated classification systems:

• TLICS/TLISS assigns points based on three components: injury morphology, posterior ligamentous complex integrity, and neurological status 1

  • Score ≥5 points indicates surgical intervention
  • Score ≤3 points suggests conservative management
  • Scores 2-4 require individualized assessment 1

• AO Spine Thoracolumbar Classification uses hierarchical morphological patterns 1:

  • Type A: compression injuries (axial loading)
  • Type B: distraction injuries (anterior/posterior element disruption)
  • Type C: translational injuries (rotation with displacement)
  • Neurological grading: N0 (intact) through N4 (complete injury) 1

• Load Sharing Classification (LSC) specifically guides burst fracture treatment 1:

  • Evaluates three CT characteristics: comminution, fragment apposition, and kyphotic deformity
  • Score 7-9 points: requires anterior and posterior fixation
  • Score >6 points: posterior short-segment fixation alone may suffice 1

Key limitation: Insufficient evidence exists to prove that using any classification system improves clinical outcomes compared to not using one, though both TLICS and AO Spine demonstrate good inter- and intraobserver reliability 1

Cervical Spine Injuries

The Subaxial Injury Classification System (SLICS) uses three weighted categories 2:

• Injury Morphology (compression, distraction, translation)
• Discoligamentous Complex (DLC) Integrity (intact, indeterminate, disrupted)
• Neurological Status (intact, nerve root injury, incomplete/complete cord injury)

Treatment algorithm:

• Score ≥5: surgical intervention indicated
• Score <4: conservative management appropriate
• Intraclass correlation coefficients: 0.49-0.90 for different components 2

AO Spine Cervical Classification provides morphological description 2:

• Type A, B, C hierarchical system based on CT imaging
• Separate neurological grading (N0-N4) not integrated into treatment algorithm
• Superior morphological detail but lacks validated treatment protocols 2

Critical distinction: SLICS requires MRI assessment when discoligamentous injury is suspected, as this directly affects the severity score and surgical decision-making 2

Degenerative Conditions

Clinical and Radiographic Degenerative Spondylolisthesis (CARDS) Classification 3:

Four radiographic subtypes:

• Type A: Advanced disc collapse without kyphosis (16% prevalence)
• Type B: Disc partially preserved with translation ≤5mm (37% prevalence)
• Type C: Disc partially preserved with translation >5mm (33% prevalence)
• Type D: Kyphotic alignment (14% prevalence)

Leg pain modifiers:

• 0: No leg pain
• 1: Unilateral leg pain
• 2: Bilateral leg pain

Reliability: Kappa 0.82 (interobserver) and 0.83 (intraobserver), representing near-perfect agreement 3

Imaging Approach by Clinical Scenario

Acute Myelopathy (Non-Traumatic)

MRI without and with contrast of the symptomatic spine region is the primary imaging modality 1:

• Evaluates for extrinsic cord compression (most common: degenerative disease, disc herniation, epidural abscess/hematoma)
• Detects intrinsic cord pathology (ischemia, inflammation, demyelination)
• May require imaging entire spine even with localized symptoms 1

CT myelography serves as alternative when MRI contraindicated 1

Suspected Spine Trauma with Ankylosis

Multiplanar CT is mandatory for fracture exclusion in ankylosed spines 1:

• Patients with ankylosis have high incidence of unstable fractures from minor trauma
• Radiography has poor sensitivity for fracture detection
• MRI without contrast added if neurological symptoms present (evaluates cord, nerve roots, ligaments) 1

Chronic Back Pain with Suspected Radiculopathy

MRI is preferred when imaging indicated 4:

• Visualizes soft tissues, nerve root compression, and inflammation without ionizing radiation
• Indicated for: rapidly progressive neurologic deficits, motor deficits at multiple levels, cauda equina syndrome features 4

Clinical assessment precedes imaging:

• Straight-leg-raise: 91% sensitivity, 26% specificity for herniated disc
• Crossed straight-leg-raise: 88% specificity, 29% sensitivity 4

Common Pitfalls

Avoid over-reliance on radiographic findings alone - psychosocial factors are stronger predictors of low back pain outcomes than physical examination or pain severity 4

In ankylosed spines, maintain high clinical suspicion - fractures occur from seemingly minor trauma and are frequently unstable with high neurological injury rates 1

TLICS scores 2-4 remain controversial - prospective validation lacking for optimal treatment of stable burst fractures in this range 1

Classification systems require proper training - reliability depends on understanding the specific definitions and imaging requirements of each system 1