TLICS Thoracolumbar Injury Classification and Severity score

{
  "categories": [
    {
      "outcome_code": "<=3",
      "total_points": "0_to_3",
      "original_guidance": "nonoperative_candidate"
    },
    {
      "outcome_code": "4",
      "total_points": "exactly_4",
      "original_guidance": "operative_or_nonoperative_candidate"
    },
    {
      "outcome_code": ">=5",
      "total_points": "5_or_more",
      "original_guidance": "operative_candidate"
    }
  ],
  "applicability": {
    "use_for": "Acute traumatic injuries of the thoracolumbar spine in skeletally mature patients when morphology, PLC status and a reliable neurologic examination can be integrated.",
    "scoring_unit": "the_most_severely_involved_thoracolumbar_level_for_the_patient_level_treatment_score",
    "multilevel_rule": "Describe every injured level, but follow the original TLICS method by scoring the most severely involved level rather than summing contiguous or noncontiguous levels.",
    "required_inputs": [
      "CT_defined_injury_morphology",
      "posterior_ligamentous_complex_status",
      "documented_clinical_neurologic_examination",
      "level_or_levels",
      "patient_and_injury_modifiers"
    ],
    "outside_scope": [
      "subaxial_cervical_injury",
      "nontraumatic_collapse",
      "pathologic_fracture_without_trauma_framework",
      "pediatric_growth_plate_injury",
      "imaging_only_inference_of_neurologic_status",
      "automatic_treatment_selection"
    ]
  },
  "component_scoring": {
    "morphology_choose_highest_only": [
      {
        "finding": "compression",
        "points": 1
      },
      {
        "finding": "burst",
        "points": 2,
        "construction": "compression_1_plus_burst_modifier_1"
      },
      {
        "finding": "translation_or_rotation",
        "points": 3
      },
      {
        "finding": "distraction",
        "points": 4
      }
    ],
    "posterior_ligamentous_complex": [
      {
        "state": "intact",
        "points": 0
      },
      {
        "state": "suspected_or_indeterminate",
        "points": 2
      },
      {
        "state": "injured",
        "points": 3
      }
    ],
    "neurologic_status_from_exam": [
      {
        "state": "intact",
        "points": 0
      },
      {
        "state": "nerve_root_injury",
        "points": 2
      },
      {
        "state": "complete_spinal_cord_or_conus_medullaris_injury",
        "points": 2
      },
      {
        "state": "incomplete_spinal_cord_or_conus_medullaris_injury",
        "points": 3
      },
      {
        "state": "cauda_equina_syndrome",
        "points": 3
      }
    ],
    "forbidden_modifier": "Do not add a persistent or ongoing cord-compression point. That modifier belongs to the subaxial cervical SLIC framework, not original TLICS."
  },
  "morphology_assignment": {
    "highest_only_rule": "At a scored level, use the single highest applicable morphology value; do not add compression, burst, translation and distraction as separate points.",
    "compression_versus_burst": "A burst morphology is the 2-point compression category with posterior-wall involvement or retropulsion; record canal compromise separately.",
    "translation_rotation": "Horizontal displacement or rotation indicates translation or rotation morphology; distinguish true injury from positioning or chronic deformity.",
    "distraction": "Separation through anterior or posterior tension structures is distraction; confirm acute morphology and do not infer it from one equivocal sign.",
    "uncertain_rule": "If morphology is genuinely unresolved, preserve alternatives and a score range instead of upgrading an equivocal sign to a definite high-point category."
  },
  "PLC_assessment": {
    "structures": [
      "supraspinous_ligament",
      "interspinous_ligament",
      "ligamentum_flavum",
      "facet_joint_capsules"
    ],
    "CT_findings_to_report": [
      "facet_joint_widening_or_dislocation",
      "interspinous_widening",
      "spinous_process_or_transverse_process_avulsion",
      "translation",
      "posterior_tension_band_disruption"
    ],
    "MRI_role": "Consider MRI when disco-ligamentous or cord status remains uncertain and the result may change care; MRI signal alone can overcall PLC injury and must be integrated with CT morphology and clinical findings.",
    "reliability_boundary": "PLC integrity is the least reproducible TLICS component. Use suspected or indeterminate when evidence is incomplete rather than forcing intact or injured."
  },
  "neurologic_gate": {
    "source": "The neurologic component comes from the documented clinical examination, not CT or MRI appearance.",
    "unavailable_exam": "When sedation, intubation, spinal shock, severe brain injury or another barrier prevents a reliable examination, final TLICS is not calculable; return a conditional range and the missing exam.",
    "imaging_boundary": "Cord signal abnormality, compression or canal stenosis must be reported but cannot silently assign complete, incomplete, root or cauda-equina clinical points."
  },
  "calculation_and_assignment_algorithm": [
    "Identify and describe every acute thoracolumbar injured level.",
    "At each candidate level, assign only the highest morphology value.",
    "Assign PLC points as intact 0, suspected or indeterminate 2, or injured 3.",
    "Assign neurologic points from the reliable clinical examination only.",
    "For the patient-level original TLICS, use the most severely involved level and sum morphology plus PLC plus neurologic points.",
    "Map totals 3 or less, exactly 4, and 5 or more to the original guidance bands while retaining the exact total and components."
  ],
  "risk_interpretation": {
    "structural_meaning": "Increasing totals reflect more disruptive morphology, greater concern for PLC failure and/or neurologic injury within the score's treatment-guidance construct.",
    "no_calibrated_prognosis": "No band supplies a validated individual probability of paralysis, neurologic recovery, mortality, nonunion, late kyphosis or treatment failure.",
    "no_outcome_inference": "The same total can arise from clinically different component combinations; always expose the components and actual neurologic state."
  },
  "management_boundary": {
    "original_thresholds": "A total of 3 or less supports nonoperative treatment, 4 allows either operative or nonoperative treatment, and 5 or more supports operative treatment.",
    "guidance_not_command": "These thresholds are decision support, not absolute orders. Urgent neurologic or mechanical findings and patient-specific constraints can override a score-band default.",
    "modifiers_outside_score": [
      "polytrauma_and_other_life_threats",
      "open_injury_or_wound_over_surgical_site",
      "progressive_neurologic_deficit",
      "excessive_kyphosis",
      "ankylosing_spondylitis_or_DISH",
      "osteoporosis",
      "comorbidities_and_anesthetic_risk",
      "soft_tissue_condition",
      "patient_goals_and_local_expertise"
    ]
  },
  "system_collision_boundary": {
    "SLIC_or_SLICS": "Subaxial cervical SLIC uses related axes and may add ongoing-cord-compression points; do not import that modifier or cervical thresholds into TLICS.",
    "AO_Spine_thoracolumbar": "AO Spine is a separate morphology and modifier classification. Record it separately and never convert A, B or C directly into a TLICS total.",
    "Denis_three_column": "Denis column involvement is not a TLICS point table and cannot replace PLC assessment."
  },
  "agent_output_contract": [
    "Return examination reliability, neurologic findings and any reason the neurologic component cannot be scored.",
    "Return every injured level, then identify the single level used for the original patient-level score.",
    "Return morphology evidence, highest morphology points, PLC evidence and certainty, clinical neurologic category and points.",
    "Return the exact arithmetic total, band and conditional range when any component is unresolved.",
    "Keep canal compromise, cord signal, kyphosis, open injury, modifiers, prognosis and final treatment decision as separate fields.",
    "Never add the cervical ongoing-cord-compression modifier or present the band as a probability."
  ],
  "missing_input_behavior": [
    "If the clinical neurologic examination is unavailable, return TLICS_not_final with the morphology-plus-PLC subtotal and conditional totals; do not infer points from MRI.",
    "If PLC is uncertain, use the published indeterminate value of 2 and state the evidence and whether MRI could change management.",
    "If morphology is unresolved between categories, return a bounded score range and the decisive missing feature.",
    "If multiple levels are present, report all and do not sum their totals.",
    "If only a total is supplied, do not infer its morphology, PLC status, neurologic injury, prognosis or mandatory treatment."
  ],
  "supporting_sources": [
    {
      "role": "original_classification",
      "citation": "Vaccaro et al. Spine. 2005;30:2325-2333",
      "doi": "10.1097/01.brs.0000182986.43345.cb"
    },
    {
      "role": "operational_paradigm",
      "citation": "Lee et al. J Orthop Sci. 2005;10:671-675",
      "doi": "10.1007/s00776-005-0956-y",
      "pmcid": "PMC2779435"
    },
    {
      "role": "PLC_and_validation_limitations",
      "citation": "Jiménez-Almonte et al. Clin Orthop Relat Res. 2018",
      "doi": "10.1007/s11999.0000000000000088",
      "pmcid": "PMC6263590"
    },
    {
      "role": "current_imaging_context",
      "citation": "Bajamal et al. Neurospine. 2021;18:884-894",
      "doi": "10.14245/ns.2142650.325",
      "pmcid": "PMC8752700"
    }
  ],
  "source_locator": "Vaccaro et al. Spine 2005, DOI 10.1097/01.brs.0000182986.43345.cb, Tables 1-4 and treatment algorithm; Lee et al. 2005, PMC2779435, score components, thresholds and caveats; Jiménez-Almonte et al. 2018, PMC6263590, PLC reliability and limitations; Bajamal et al. 2021, PMC8752700, CT/MRI and contemporary classification context."
}