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. 2026 Mar 6;18(4):733–744. doi: 10.1111/os.70280

The Integrated Nerve, Discoligamentous Complex, and Vertebra Scoring System for Thoracolumbar Junction (TLJ) Injury

Han Qiao 1,2, Guanhong Chen 1,2, Han Du 1,2, Xiaofei Cheng 1,2, Xiaojiang Sun 1,2, Hongfang Chen 1,2, Jianping Tian 3, Kai Zhang 1,2,✉, Changqing Zhao 1,2,✉, Jie Zhao 1,2
PMCID: PMC13056491  PMID: 41791837

ABSTRACT

Objectives

To avoid the confusion of mechanism, tissue, morphology, and injury severity that resulted from previous modified AO, the Thoracolumbar Injury Classification and Severity Score (TLICS), the Thoracolumbar AO Spine Injury Score (TL AOSIS), and Load Sharing Classification (LSC), the integrated scoring system is devised for thoracolumbar junction (TLJ) injury that can better assist clinical decision‐making strategy.

Methods

We reviewed the literature of TLJ classification and TLICS 4‐point treatment. Scoring and remedy strategies were proposed retrospectively. Patients included were validated with the change of Visual Analogue Scale (VAS) and Oswestry Disability Index (ODI) after surgical treatment retrospectively. The interobserver and intraobserver reliability was also evaluated.

Results

Nerve, discoligamentous complex (DLC), and vertebral bone that are three main spinal structures are weighted as 5, 4, and 3 points, respectively. If nerve injury ≥ 3 and/or bone + DLC injury ≥ 4, surgical treatment is recommended. If nerve injury = 2, delayed surgery may be needed after close observation of consistent pain. If nerve injury ≤ 1 or the bone + DLC score < 4, conservative treatment is recommended. When LSC ≥ 7, it may require vertebrectomy and anterior/middle column instrumentation. In ADLC = 2 of LSC ≤ 6, the removal of the injured disc and interbody fusion is needed, or only posterior fixation without intervertebral fusion. The consistency of the integrated system indicated substantial reliability.

Conclusion

This system showed substantial reliability and a desirable prognosis in TLJ patients. It could help differentiate injury morphology from severity and prevent the assignment of undue values to certain components, thereby providing a practicable decision‐making strategy for TLJ injured patients.

Keywords: classification, consistency reliability, thoracolumbar junction (TLJ), treatment guidance

The new scoring system for TLJ injury.

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1. Introduction

From the first thoracolumbar (TL) spine fracture classification by Boehler in 1929, almost two dozen thoracolumbar junction (TLJ) evaluation strategies have been proposed [1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15]. For instance, load sharing classification (LSC) assists in decision‐making strategies of anterior support for TLJ patients [16]. The modified AO (AO) system includes nearly all the morphologies of TLJ injury, and LSC and the Thoracolumbar Injury Classification and Severity Score (TLICS) guide certain treatment. However, LSC is limited to evaluating the degree of vertebral injury; the modified AO fails to evaluate nerve function and provides little guidance for treatment algorithms; and the TLICS confounds the mechanism, morphology, and severity of injuries, placing undue importance on PLC injuries, and ignoring anterior disc‐ligament complex (ADLC) evaluations. The vertebral body injury evaluation in the TLICS is not comprehensive either. Recently, the Thoracolumbar AO Spine Injury Score (TL AOSIS) system, which integrates the TLICS with modified AO classification, was introduced. It assigns greater values to injury morphology and nerve injuries, thus providing more reliable surgical recommendations than TLICS in complete burst fractures [17]. However, it does not evaluate PLC injury separately, which can lead to the potential post‐traumatic kyphosis. Collectively, current scoring systems failed to combine the advantages of morphology and spinal stability, which might result in deviatory surgical decisions or unnecessary secondary surgeries caused by insufficient anterior column support. This indicated that a more comprehensive integrated scoring system is essential to standardize the surgical strategies for the ensuring of long‐term surgical prognosis.

Herein, we aim to integrate the LSC, TLICS, and AO (modified AO) and TL AOSIS systems into one scoring system that will more accurately and comprehensively evaluate TLJ fracture injury, which highlights three scientific points as follows: (i) To develop an integrated TLJ injury scoring system that evaluates injury severity using three independent tissue elements (nerve, discoligamentous complex, and bone) and avoid defects among existing systems. (ii) To propose a practical, score‐based treatment framework for TLJ fractures, including operative indication thresholds and guidance on surgical strategy/approach selection. (iii) To assess the reproducibility of the new system by evaluating inter‐ and intraobserver reliability, and to provide preliminary clinical applicability based on our single‐center experience. We hope to differentiate injury morphology from the severity of injury and prevent the assignment of undue values to certain components, thereby providing a practicable decision‐making strategy to distinguish operative strategies in TLJ fracture patients.

2. Materials and Methods

2.1. Literature Review

We searched the MEDLINE, Pubmed, Embase, Web of Science, and Cochrane Review databases, which incorporated the following keywords: (“thoraco” OR “lumbar” OR “thoracolumbar”) AND (“burst” OR “injury” OR “fracture”) AND (“classification” OR “treatment guidance” OR “consistency reliability”) [18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29]. Relevant literature of TLJ injury, especially previous systems (TLICS, LSC, modified AO, and TL AOSIS systems) and TLICS 4‐point treatment [27, 30, 31] were studied, which highlighted the advantages and disadvantages of existing systems.

2.2. Establishment of New System

The three evaluation variables in TLICS (injury morphology, PLC integrity, and neurological status) were replaced by the primary TLJ spinal components (bone tissue, DLC, and nerve tissue) to evaluate injury severity. The TLICS deficiencies (assigning undue points to PLC and not evaluating the ADLC) were adjusted. LSC components of evaluating vertebral body injury were integrated, and an additional evaluation of ADLC injury was supplemented. The injury classification in the modified AO system, which reflected both hard and soft tissues, was also used. The importance of neurologic status in TL AOSIS was emphasized, together creating an integrated TLJ scoring system. Relative treatment strategies were proposed based on our single‐center experience, with an emphasis on the importance of nerve injury and the re‐evaluation of the poor prognosis of conservative treatment in TLICS‐4 patients [27, 30].

2.3. Clinical Validation

To verify its reliability, the radiological data of 32 patients of acute traumatic TLJ (T11‐L2) were distributed to eight spine surgeons. We excluded patients with other thoracic spine fractures (due to their four‐column structure from T1 to T10 [32]) or lower lumbar (L3/4/5) fractures (because of different lower spinal biomechanics [33, 34]). The assessments were independently performed 12 weeks apart in terms of data from three‐dimensional reconstructive spine CT (120 kV, 30 mA) and MRI (TR 2200 ms, TE 81 ms) in supine position [35], and the researchers were blinded to the subject information. Patients with ankylosing spondylitis (AS) and diffuse idiopathic skeletal hyperostosis (DISH) were excluded [36, 37]. Hounsfield values from spinal CT in nonfracture L1 or nearby L1 vertebrae were used to exclude possible severe osteoporotic fractures (< 80) [38, 39]. The baseline characteristics of these patients, along with the changes in the Visual Analogue Scale (VAS) and Oswestry Disability Index (ODI) after surgical treatment, were retrospectively reviewed and summarized in Table 1.

TABLE 1.

Patient characteristics who are receiving surgical treatment based on our new scoring system.

Patient ID Age Gender Follow‐up (years) Fractured vertebrae Pre‐OP VAS Post‐OP VAS Pre‐OP ODI Post‐OP ODI
No.1 52 Male 9 T11, T12 8 2 76 16
No.2 63 Female 9 T12, L1 8 4 76 40
No.3 29 Male 9 L2 7 1 60 10
No.4 47 Male 9 L1 8 1 70 10
No.5 58 Female 9 T12, L1 8 3 76 36
No.6 51 Female 9 T12 7 1 64 10
No.7 65 Female 9 L2 9 3 80 36
No.8 25 Male 9 T11, T12 7 1 64 16
No.9 45 Female 9 L1 6 1 56 10
No.10 58 Male 8 T12 8 1 70 16
No.11 47 Male 8 L1 8 1 70 10
No.12 60 Female 8 L2 8 2 76 16
No.13 59 Female 8 L1 8 3 76 24
No.14 46 Female 8 T12 8 1 76 16
No.15 62 Female 8 T12, L1 9 1 84 16
No.16 59 Female 8 T11 8 0 70 0
No.17 52 Male 7 T12 8 2 70 16
No.18 56 Male 7 L2 9 2 80 20
No.19 51 Male 7 T12 8 1 76 16
No.20 55 Female 7 T12 8 3 70 36
No.21 60 Female 7 T12 8 0 76 0
No.22 59 Male 6 L2 8 1 70 10
No.23 62 Female 5 T11 8 7 80 76
No.24 57 Female 5 T12, L1 8 0 64 0
No.25 20 Female 5 T12 8 0 70 0
No.26 55 Male 5 L1 7 2 60 20
No.27 50 Female 3 L2 7 1 64 16
No.28 33 Female 3 T12, L1 9 0 80 0
No.29 35 Female 3 T11, T12 8 2 80 24
No.30 47 Male 3 L2 8 2 76 16
No.31 65 Female 3 L1 7 1 64 10
No.32 49 Female 2 T11, T12 7 1 64 16
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Abbreviations: ODI, oswestry disability index; VAS, visual analogue score.

This study was approved by our hospital's institutional ethics board (SH9H‐2024‐T375‐1). Retrospective research of anonymized data was waived of patients' consent.

2.4. Statistical Analysis

SPSS 19.0 (SPSS Inc. Chicago, IL, USA) was used to calculate Fleiss' kappa (κ) coefficient to test the inter‐ and intraobserver reliability. Here, a κ value of 0.81 or more indicated almost perfect consistency, a κ value between 0.61 and 0.80 indicated substantial consistency, a κ value between 0.41 and 0.60 indicated moderate consistency, a κ value between 0.21 and 0.40 indicated fair consistency, and a κ value of 0.20 or less indicated poor consistency [40].

3. Results

3.1. Integrated TLJ Fracture Scoring for Graded Basic Spinal Unit Injuries

Of the articles reviewed, it depicted a wide range from spinal morphology description to comprehensive AO/TLICS classifications, which improved the standardized criteria of clinical treatments. It focused on the comparison between conservative treatment and surgery upon TLICS 4 patients, as well as the burst TLJ fracture without neurologic symptoms. More importantly, it hinted on us to balance the benefit and risk regarding conservation and surgery especially when neurologic deficits were devoid, leading to the need of refinement upon further treatment remedies.

Thereby, our scoring system assigns 5, 4, and 3 points to the most severe injuries to nerve tissue, discoligament, and vertebra, respectively (Table 2).

TABLE 2.

The new scoring system for TLJ injury.

Maximum scores Subvariables Criteria
Nerve tissue, 5 points No damage, 0 point
Transient neurological dysfunction, 1 point
Mono‐radicular pain, 2 points
Mono‐root paralyzes, 3 points
Suspected complete paralyzes, 4 points
Incomplete paralyzes/cauda equina syndrome, 5 points
DLC a , 4 points PLC Rupture of SL and IL, 1 point
Rupture of the LF and joint capsule, 1 point
ADLC Rupture of PLL and posterior annulus fibrosus, 1 point
Rupture of ALL and anterior annulus fibrosus, 1 point
Vertebra, 3 points Posterior elements Posterior elements injury except spinous process and transverse process, 1 point
Vertebral body b

LSC ≥ 7 and/or split involve posterior wall, 2 points

LSC ≤ 6 and/or split not involve posterior wall, 1 point
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Abbreviations: ADLC. anterior disc ligament complex; ALL, anterior longitudinal ligament; DLC, discoligament complex; IL, interspinous ligament; LSC, load sharing classification, LF, ligamentum flavum; PLC, posterior ligament complex; PLL, posterior longitudinal ligament; SL, supraspinous ligament.

a

1 point was assigned when simple intervertebral disc protrudes into the endplate.

b

Avulsion fractures of vertebral body were scored 0 point.

Incomplete spine cord injury (SCI)/cauda equina injury, suspected complete SCI, mono‐nerve root paralysis, mono‐radicular pain, transient nerve dysfunction, and lack of nerve injury are assigned 5, 4, 3, 2, 1, and 0 points, respectively.

Rupture of the anterior longitudinal ligament (ALL) and anterior annulus fibrosus, rupture of the posterior longitudinal ligament (PLL) and posterior annulus fibrosus, rupture of the ligamentum flavum (LF) and the facet joint capsule, and rupture of the supraspinous ligament (SL) and interspinous ligament (IL) each account for 1 point, for a maximum total of 4 points. The point scoring system assigns 1 point if the ALL and PLL are not ruptured and if only the nucleus pulposus has herniated into the vertebral body.

The maximum score for vertebral injury is 3 points. Specifically, 1 point is assigned if the posterior elements are injured (except for the spinous process and transverse process injuries). Injury to the vertebral body can be further assessed by LSC scores in detail. Herein, 1 point is given if LSC ≤ 6, and 2 points are given if LSC ≥ 7. For those vertebral body injuries that could not be assessed by LSC, including horizontal, sagittal, and coronal splits, 2 points are given if these splits involved the posterior wall of the vertebral body, and 1 point is given if the posterior wall of the vertebral body failed to be involved. Avulsion fractures of the vertebral body are scored as 0 points.

The theoretical maximum score of the integrated system is 12 points. The assessment of disc ligament injury adopts the following criteria: discontinuity of the black line representing the ALL, PLL, LF, SL, or IL on T1 or T2 fat‐suppressed MR images is used as the diagnostic criterion for ligament rupture; translation exceeding 3.5 mm, or Type C injury in the modified AO classification, such as rotation and distraction injury, is a definitive indirect sign of complete rupture of the disc ligament; widening of the spinous process gap greater than 2 mm from the adjacent spinous process gap is a definitive indirect sign of SL rupture. MR imaging reveals a high signal in the interspinous ligament on T2 images, or any images showing mild separation of the articular joints without discontinuity of the black line representing the ALL, PLL, LF, SL, and IL on T1 or T2 fat‐suppressed images; these patients are not diagnosed as ligamentum ruptures. Furthermore, to potentially improve the detection rate of this sign on MRI, it is recommended that (1) using thin slice (e.g., 1 mm) MRI sequences in the sagittal plane to improve the readability of black line continuity on MRI; (2) using three‐dimensional MRI reconstruction imaging of spine. Representative scores of patients with TLJ injuries are shown in Figures 1, 2, 3, 4, 5. Specifically, Figures 1 and 2 illustrate low‐grade TLJ injuries with preserved neurologic function, for which the integrated scoring system supports conservative management. Figure 3 indicates the integrated framework supports posterior stabilization while no anterior structural augmentation given a low LSC. Figures 4 and 5 exemplify high‐grade cauda equina injuries requiring surgical intervention, with the integrated system further indicates spinal stability reconstruction.

FIGURE 1.

FIGURE 1

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(A) Lateral X ray, (B) CT reconstruction, and (C) sagittal MRI images of a TLJ patient with neurologically intact. Modified AO was subtype A1; TLICS score was 1 point; TL AOSIS was type A1; LSC was 3 points. Based on our integrated scoring system for TLJ, the nerve tissue was intact (0 point), no PLC injury (0 point), L1/2 nucleus pulposus protruded into anterior L2 superior endplate with no ALL/PLL injury (1 point), intact posterior bony element (0 point) and vertebral body LSC ≤ 6 (1 point). The total score was 2 points. Conservative treatment was therefore recommended.

FIGURE 2.

FIGURE 2

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(A) Lateral X ray, (B) CT reconstruction and (C) sagittal MRI images of a TLJ patient with no spinal cord injury. This patient was subtype A2 of modified AO; TLICS score was 1 point; TL AOSIS was type A2 (2 points); LSC was 3 points. Our integrated scoring system showed that the nerve tissue was well (0 point), intact PLC (0 point) and T12/L1 nucleus pulposus protruded into middle L1 superior endplate with no ALL/PLL injury (1 point). LSC ≤ 6 and split not involved posterior wall (1 point). The total score was 2 points. Conservative treatment was thereby recommended.

FIGURE 3.

FIGURE 3

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Images of (A) X ray, (B) CT, and (C) MRI of a TLJ patient with mono‐radicular leg pain which alleviated significantly after 3 days observation. This patient was subtype L1‐A4 of modified AO (white arrow in C showed the high signal of T12/L1 LF whereas SL and IL failed to exhibit high signal, therefore the PLC injury could not be confirmed); TLICS score was 4 points (burst fracture 2 points + indetermined PLC injury 2 points = 4 points), but transient nerve injury could not be scored by TLICS, therefore conservation treatment might be suggested simply according to TLICS system. Type A4N1 injury of TL AOSIS (Type A4 5 points + N1 1 point = 6 points), thus surgical treatment should be recommended according to the algorithm. The LSC was 6 points, hence anterior bulk support between T12/L2 intraoperatively was dispensable. Our integrated scoring system showed the transient nerve tissue injury (1 point), and ADLC injury showed with T12/L1 nucleus pulposus protruded into posterior L1 superior endplate with no ALL/PLL injury (1 point as red arrow indicated), PLC with LF injury (white arrow) and facet capsule (green arrow) injury (1 point). Posterior elements were fractured (1 point), vertebrae LSC = 6 but split fracture (yellow arrow) involved posterior wall (2 points). Since bone (3 points) + DLC (2 points) injury ≥ 4, a posterior surgery was performed with spinal reduction, fixation without laminectomy decompression, and anterior vertebrectomy with bulk support was dispensable because LSC< 7 (D).

FIGURE 4.

FIGURE 4

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Images of (A) CT, (B) MRI of a TLJ patient with cauda equina syndrome. This patient was subtype L1/2‐B2 (L2‐A4) of modified AO and TLICS score was 9 points (translation injury 3 points + PLC injury 3 points + cauda equina injury 3 points = 9 points). Type B2N3 fracture of TL AOSIS (10 points) and LSC was 9 points. Our integrated scoring system showed the nerve tissue injury (5 points), DLC injury (4 points). Posterior elements were fractured (1 point) and vertebrae LSC > 7 (2 points). The total points were 12 points. Surgical operation was recommended despite TLICS, TL AOSIS or our scoring system. Based on LSC scoring, however, merely our integrated system suggested whether anterior bulk support was required. She received a one‐stage posterior pedicle screws fixation and anterior L2 vertebrectomy with iliac bone support and instrumentation (C, D).

FIGURE 5.

FIGURE 5

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Images of (A) X ray, (B) CT, and (C) MRI of a TLJ patient with cauda equina syndrome. This patient was type L1/2‐C2 of modified AO; TLICS was 9 points (translation injury 3 points + injured PLC 3 points + cauda equina injury 3 points = 9 points). Type CN3 fracture of TLAOSIS (12 points) and LSC was 3 points. Our integrated scoring system showed the cauda equina injury (5 points), ruptured DLC (4 points), posterior element fracture (1 point) and vertebrae LSC < 7 (1 point). The overall points were 11 points. Surgical treatment was performed for this patient via posterior approach to achieve decompression, reduction, pedicle screw fixation and inter‐transverse process fusion (D).

3.2. Determination of the Margin of the Most Severe Injury

Notably, when assessing damage to vertebrae and their connecting tissues, it is essential to determine the boundary that can be regarded as a single injury, encompassing the most severely damaged vertebra and its superior/inferior DLC. Multilevel patterns are classified as noncontiguous or contiguous: in noncontiguous injuries, the score is defined by the most severe scored injury unit, whereas contiguous injuries are aggregated and evaluated as one injury unit. This can be the ADLC on the cranial side and the posterior ligament complex (PLC) on the caudal side of the injured vertebra, or vice versa, but not both the ADLC and the PLC on both the cranial and caudal sides, which are scored simultaneously. For example, in traumatic spondylolisthesis involving the pars interarticularis, damaged DLC encompasses the PLC on the cranial side and the ADLC on the caudal side of the injured vertebra, which can be considered a single injury. Additionally, for modified AO Type B2 injuries, scores should be given for the superior ADLC and the caudal PLC of the injured vertebrae. In the case of an A4 injury type in the modified AO, which may simultaneously affect both the superior and inferior intervertebral discs, only one of these discs can be scored for injury; otherwise, the theoretical maximum total score would exceed 12 points.

3.3. Treatment Algorithm Recommendations Using New Integrated Score

If the degree of nerve injury ≥ 3 and/or the degree of bone + DLC injury ≥ 4, surgical treatment is recommended. In the case of nerve injury = 2, delayed surgery may be needed after close observation of consistent pain. If nerve injury ≤ 1 or the bone + DLC score < 4, conservative treatment is recommended.

An LSC ≥ 7 may require vertebrectomy and anterior and middle column reconstruction with a bulk bone graft or artificial vertebrae. Additionally, in ADLC = 2 of LSC ≤ 6, the removal of the injured disc and subsequent interbody fusion is needed [41, 42], or only posterior fixation without intervertebral fusion [43]. Although early studies have indicated that fusion is not necessary for an injured DLC despite fixation alone, some studies have shown that residual damaged intervertebral discs can still cause delayed symptoms of low back pain due to instability [44, 45, 46].

The surgical approach is determined by the injury level of TLJ. For vertebrectomy, a posterior approach was recommended at the T11 and T12 levels to avoid entering the thoracic cavity, and resection of the thoracic nerve roots barely affects motor function. In the L1 and L2 segments, an anterior approach is more advisable to avoid damaging the posterior nerve roots because the L1 and L2 nerve roots play vital roles in the regulation of the motor functions in the lower extremities. For intervertebral fusion, a posterior approach is recommended for the L1 and L2 segments.

3.4. Clinical Validation

A total of 32 patients were included (Table 1) with a mean age of 51.0 ± 11.6 years old and a mean follow‐up duration of 6.7 ± 2.3 years. Specifically, 12 patients were male and 20 were female. Fractures involved T11 (n = 6), T12 (n = 17), L1 (n = 11), and L2 (n = 7), with nine multi‐level cases. Postoperatively, VAS values improved from 7.8 ± 0.7 to 1.6 ± 1.4, and ODI values improved from 71.5 ± 7.1 to 17.4 ± 15.0. The evaluation consistency of different tissue injuries via the new system indicated that there is substantial interobserver and intraobserver reliability of bone tissue and DLC damage (bone tissue: κ = 0.71 ± 0.33 and κ = 0.60 ± 0.27; DLC: κ = 0.85 ± 0.33 and κ = 0.64 ± 0.30). The neurological function state was clearly recorded in the medical history, so the observer did not need this information and could not perform a neurological examination on the patients retrospectively. The total evaluation score also has substantial reliability (κ = 0.74 ± 0.17).

4. Discussion

4.1. The Need for a New Scoring System due to Existing Limitations

The LSC, AO (modified AO), TLICS, and TL AOSIS present important milestones in the evolution of TLJ injury classification. However, TLICS considers only the PLC and does not evaluate the structural continuity of the anterior or mid‐column. Translation/rotation and extension injuries primarily involve the intervertebral disc and ligaments, which could lead to the overestimation of PLC injury. TLICS separately scores the injury morphology and PLC injury, which is assigned to patients with PLC injury twice. For example, distraction injuries that completely transverse through the intervertebral disc ligament are rated as 4 points. The PLC injury is a clear rupture, which is rated as 3 points. This results in repeated scoring, as exemplified by a PLC injury score of 7 points in total. Additionally, TL AOSIS does not provide detailed imaging methodology, which cannot distinguish between radicular pain/radicular paralysis, and fails to recommend whether anterior bulk support is needed while only providing surgical thresholds. Hence, we propose evaluating the severity of these three tissues separately to avoid confusion upon the injury shape and severity, thereby restricting excess values to certain tissue.

4.2. Rationale for Point Assignment in the New Scoring System

4.2.1. Maximal Point Values for Tissues

Among the previously proposed classifications for TLJ injuries, the LSC, TLICS, and TL AOSIS are semiquantitative scoring systems. The adoption of 10 points for TLICS and 12 points for TL AOSIS may implicitly align with the decimal and duodecimal systems commonly used in human life, with the former supposedly stemming from humans' use of ten fingers for counting, and the latter from the observation that the moon revolves around the earth approximately twelve times a year. Our system involves three variables corresponding to the three basic types of spinal tissues. If the relative importance of these three tissues is equal, a total score of 12 can be evenly divided into 4 points, whereas using a 10‐point system would result in decimal numbers when divided into three equal parts. If, however, the relative importance of these tissues varies, dividing 12 points into 5, 4, and 3 points seems more reasonable than dividing 10 points into 5, 3, 2 or 4, 3, or 3 points. Furthermore, the distributions of 5, 4, and 3 points out of 12 can be more easily assigned to subvariables. Therefore, our new integrated scoring system follows the 12‐point system of TL AOSIS.

Undoubtedly, the evaluation of TLJ injuries primarily emphasizes whether neurological deficits are present and determines the necessity of decompression surgery. Immediate surgery is recommended for nerve injury, so its score weight should be 5 points. Repair of DLC is more difficult than bone tissue, and back pain is often caused by DLC injury. Vertebral wedge deformities following fracture recovery are asymptomatic in most cases. Thus, DLC is assigned 4 points, and bone tissue is assigned 3 points.

4.2.2. Scores Based on Variable Importance

In terms of the importance of different neural tissues, the spinal cord/cauda equina is considered more critical than nerve roots. Incomplete spinal cord and cauda equina injuries require the most urgent surgical decompression; hence, they are assigned the highest score of 5 points. Notably, even in cases of obvious translation or distraction injuries, the diagnosis of complete spinal cord injury should be made with extreme caution unless MRI clearly reveals a complete disruption of spinal cord continuity. This is because during the acute phase of spinal injury, differentiating between spinal shock and complete spinal cord injury can be challenging, as the latter may inadvertently reduce the urgency of decompression surgery, potentially allowing reversible incomplete spinal cord injuries in a state of spinal shock to progress into irreversible complete spinal cord injuries. Therefore, patients who appear to have complete spinal cord injuries are considered to have suspected complete spinal cord injuries and are assigned a score of 4 points. Herein, the suspected complete SCI are defined as spinal ASIA‐A injury without clear rupture of spinal cord continuity, in which both sensation and movement below the plane of spinal cord injury disappear. TL AOSIS assigns 2 points for persistent radicular symptoms, but there are varying degrees of severity in radicular symptoms. For example, radicular symptoms caused by lumbar disc herniation may necessitate urgent surgery in cases of foot drop due to nerve root paralysis, whereas simple radicular pain without sensory or motor abnormalities can be managed conservatively. Therefore, we assign 3 points for radicular paralysis and 2 points for simple radicular pain. Transient neurological deficits are given 1 point, indicating that the neural tissue has been irritated and may experience recurrent neurological symptoms due to mechanical instability. Normal neurological function is scored 0 points. Our scoring principles of neural injury severity is consistent with TLICS, with a more refined allocation of points.

It is shown that TLICS assigns undue points to PLC, which may be based on the acknowledgement that PLC, ALL, and PLL play important roles in spinal stability [47]. Some researchers believe that the tension of the ALL helps reduce fracture and serve as the third fixation point in three‐point fixation [48], whereas the ligament tension of the PLL contributes to the reduction and maintenance of fracture fragments during posterior internal fixation [49, 50]. ALL/PLL injuries eliminate the indirect reduction effect, resulting in poor contact between the fractured bone fragments. This could retard bone union and facilitate the progression of spinal deformity and back pain. Therefore, our evaluation system uses the 4‐point method for the anteroposterior diameter to evaluate different degrees of intervertebral ligamentous injury. It also differentiates the degree of severity of simple supraspinous and interspinous ligament injuries from that of PLC injuries.

The discontinuity of the black line representing the ALL, PLL, LF, and SSL on T1 or T2 fat‐suppressed images is used as the diagnostic criterion for ligamentous ruptures. Signs of rotation, separation, or translation, indicative of subtype C in the modified AO classification, were all indirect signs of a complete rupture of the intervertebral DLC and were therefore assigned 4 points. In contrast, in TLICS, distraction injury morphology, which is assigned 4 points, already includes PLC rupture. However, PLC injury is also separately assigned 3 points again. Thus, the TLICS places undue point weights on PLC injuries, which could be avoided in our evaluation system.

For bone tissue, the vertebral bone is given a maximum of 2 points, and the posterior elements are given 1 point, which fits Denis' three‐column theory [2]. This finding is also in accordance with the biomechanical evidence that the anterior and middle columns collectively afford 2/3 of the axial load of the spine, and the posterior column experiences the remaining 1/3 weight. According to LSC, the LSC ≥ 7 suggests that anterior and middle column support are needed; otherwise, failure of the posterior short‐segment pedicle screw fixation can occur easily.

Hence, when evaluating the degree of vertebral body injury, an LSC ≤ 6 is considered 1 point for vertebral injury, and an LSC ≥ 7 is considered 2 points. Because LSC cannot evaluate coronal, sagittal, or transverse fractures of the vertebral body, any fractures involving the posterior wall are assigned 2 points, and 1 point is assigned if the fracture does not involve the posterior wall. The posterior element injuries included pedicles, articular joints, and lamina are assigned 1 point. Transverse and spinous process fractures are assigned 0 points. It should be noted that in the case of modified AO type B1 injury, the SL, PLL, and ALL that certainly rupture trans‐vertebral level, rather than trans‐disc level, should be scored separately. Therefore, the vertebra score was 3 points (1 point for posterior elements + 2 points for the vertebral body), and at least the ALL or PLL was injured by 1 point, leading to an overall minimum of 4 points (3 points + 1 point) that required surgical surgery.

We selected patients according to the modified AO classification and used this new system for points verification. Reliability results found that our new system had substantial inter‐ and intra‐observer reliability for TLJ injury evaluation, indicating the possible potential in evaluating the severity of TLJ injury for broader clinical use.

4.3. New System Aids in the Formation of Treatment Strategy

Both TLICS and TL AOSIS have threshold values for whether surgery is recommended based on the Delphi method. However, they fail to emphasize the importance of decompression surgery for neurological injuries, whereas the LSC overlooks the significance of neurological factors in guiding surgical decisions. For example, a traumatic TLJ epidural hematoma caused by minor trauma, despite the absence of any ligament or bone tissue injury, may require decompression surgery if severe compression of the nerves occurs [51]. Hence, we agree that if neurological involvement is present, the injury is deemed unstable, thus necessitating surgical intervention [30]. Therefore, our system assigns 5 points to neurological factors and further subdivides TL AOSIS radicular injury into radicular pain and radicular paralysis. Our treatment principles are referred to the therapeutic principles of lumbar degenerative diseases, as radicular paralysis requires surgery more urgently than radicular pain. In such cases, if the neurological score = 2, close observation is recommended, whereas if the score ≥ 3, early surgery is needed.

There are few reports of TLICS 4 points with associated neurological injuries; therefore, we believe that such cases involve mainly bone and discoligament injuries. However, a previous study revealed that spinal canal compression and kyphotic angle were also risk factors for the failure of conservative treatment in TLICS‐4 patients without neurologic deficits [52]. It was also demonstrated that patients with TLICS 4 points had better clinical outcomes when surgery was performed [27]. Therefore, if nerve injury ≥ 3 and/or bone + DLC injury ≥ 4, surgical treatment is recommended. In the case of nerve injury = 2, delayed surgery may be needed after close observation of consistent pain. If nerve injury ≤ 1 or the bone + DLC score < 4, conservative treatment is recommended.

The importance of PLC integrity has been well recognized in posttraumatic deformities; however, little attention has been given to ADLC. We improve the evaluation of ADLC injuries in ALL/PLL based on the possible effects of ADLC on spinal stability and posttraumatic deformity. However, some studies have reported the opposite results [53]. This could be explained by the fact that type A fractures rarely require surgical operation, which seems to contradict single‐level fixation against the A1 fractures previously reported. Nonetheless, studies have reported the necessity of a surgical approach in the treatment of A1 fractures via short segment fixation [54, 55]. Therefore, it is possible to improve the surgical threshold, which also demands high‐level evidence in the future.

4.4. New Scoring System Guides Surgical Approach Selection

Before the introduction of TLICS, the selection of these surgical procedures primarily depended on the experience of the surgeon. Although TLICS provides surgical indications and recommends surgical approach options, it does not comprehensively evaluate all three primary spinal components (bone, DLC, and nerve). Some researchers have used the TLICS and LSC in combination to guide treatment strategies for TL fractures. However, the combination still cannot account for every one of the injury subtypes introduced by the modified AO classification when treatment strategies are considered.

When the LSC score ≥ 7, vertebrectomy with decompression and anterior and middle column reconstruction with a bulk bone graft or artificial vertebrae may be needed. Additionally, in ADLC = 2 of LSC ≤ 6, the removal of the injured disc and subsequent interbody fusion are needed, and some researchers even perform posterior fixation without intervertebral fusion [42, 56, 57]. Latest research showed that TL burst‐split fracture (A4 type fracture) could be treated effectively via the posterior reduction, instrumentation, and anterior fusion, which promoted the bone union, deformity correction, and movement ability [58]. Some authors have reported that the posterior approach also results in good restoration and good clinical outcomes when LSC ≥ 7, even with 2‐level posterior fixation selectively for TL burst trauma patients [59], possibly because the integrity of the ALL/PLL is good for restoration and maintenance. However, most researchers tend to use the anterior approach in patients with comminuted vertebral body fractures and severe separations [60]. In addition, the need for an anterior approach is determined by the level of the injured segment. Except for L1 and L2 vertebrectomy, all surgeries can be completed through a posterior approach without an additional anterior approach.

4.5. Strengths and Limitations

Our integrated scoring system avoids repetitive scoring and imbalanced weighting compared with existing scoring systems. By decomposing spinal structures into three independent variables, it effectively addresses inherent shortages of existing classifications. Besides, with more refined neurological assessment, it improves the precision of clinical decision‐making regarding TLJ fracture, which has substantial inter‐ and intraobserver reliability that could provide preliminary clinical applicability for future translation. The limitations are as follows. This was a single‐center study based mainly on literature reviews and our single institution's experience. The reliability and efficacy of our proposed system require long‐term, multicenter validation with a larger group of selected TLJ patients. The subjective weighting scheme of our system also requires more sensitivity/specificity analysis. Also, the superiority of new classification over previous clinical guidance (like TL AOSIS) should be based on prospective, high‐level clinical research. Therefore, a randomized control trial (RCT) study comparing these systems would be performed in the future.

4.6. Prospects, Feasibility and Clinical Promotion

By classifying spinal tissues into nerve, DLC, and bone as independent elements, the new system may improve the consistency of decision‐making for TLJ fractures. It may also reduce repetitions among variable scores and facilitate TLJ fracture treatments. In addition, our new system showed substantial inter‐ and intraobserver reliability, suggesting acceptable reproducibility in clinical application. However, this study is single‐centered and retrospective, and a broader application requires multicentered, prospective validation. Therefore, a more standardized protocol, as well as systematic training and high‐evidenced studies are still needed before a wider adoption.

5. Conclusions

Our integrated scoring system avoids confounding the properties of the involved tissues, injury mechanisms, injury morphologies, and severity of the injuries, and classifies the relative importance of nerve, DLC, and bone tissue in TLJ injuries. This technique refines the evaluation of vertebral body burst fractures and increases the importance of evaluating the ADLC with respect to spine stability. In addition, our system provides an algorithm for surgical indications based on a point threshold and selection of a surgical approach. Such a system integrates the LSC, TLICS, and AO (modified AO) and TL AOSIS systems into one scoring system that would more accurately and comprehensively evaluate TLJ injuries reliably. We hope to help differentiate injury morphology from the severity of injury and prevent the assignment of undue point values to certain components, thereby providing a practicable decision‐making strategy to distinguish between operation and nonoperation in TLJ injured patients.

Author Contributions

The study was designed by Changqing Zhao. Data was collected by Han Qiao and Guanhong Chen. The manuscript was prepared by Han Qiao, Han Du, and Kai Zhang. Xiaofei Cheng, Xiaojiang Sun, Hongfang Chen, Jianping Tian, and Jie Zhao contributed to the data analysis and careful revision of the article. All authors read and consented to the final version of the manuscript.

Funding

This study was funded by Shanghai Orthopedic Digital Medicine Research Center (KYQY2023285).

Conflicts of Interest

The authors declare no conflicts of interest.

Acknowledgments

The authors have nothing to report.

Contributor Information

Kai Zhang, Email: orth_kai@163.com.

Changqing Zhao, Email: zhaocq9hospital@163.com.

Data Availability Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Data Availability Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.

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