Agreement and discordance between the modified thoracolumbar injury classification and severity score and the thoracolumbar AOSpine injury score in guiding surgical decision-making for thoracolumbar fractures: a comparative study.
TL;DR
For burst fractures with intervertebral disc involvement, mTLICS tends to recommend surgery more often, reflecting a difference in classification behaviour rather than a demonstrated clinical advantage, and mTLICS and TL AOSIS show substantial concordance as decision-support tools for thoracolumbar fractures.
Abstract
Purpose
To compare the agreement and the differences between the modified Thoracolumbar Injury Classification and Severity Score (mTLICS) system and the AO Thoracolumbar Spine Injury Score (TL AOSIS) in guiding surgical decision-making for thoracolumbar fractures.
Methods
The clinical and imaging data of 100 patients with thoracolumbar fractures admitted to our hospital between January 2021 and December 2023 were retrospectively analyzed. Two orthopedic surgeons, blinded to the patients' clinical outcomes, independently evaluated the cases using both scoring systems and provided treatment recommendations. Disagreements were resolved by a senior attending surgeon. Agreement between the two systems' treatment categories was quantified by weighted Cohen's κ with 95% confidence intervals from paired 3 × 3 cross-tabulations, and interobserver reliability was assessed before consensus adjudication.
Results
The two systems assigned the same treatment category in 86 of 100 patients (86.0%; unweighted κ = 0.773, 95% CI 0.666-0.881; linear-weighted κ = 0.820), with no significant asymmetry (McNemar-Bowker P = 0.160). Agreement was substantial in both the 57 neurologically intact patients (κ = 0.696) and the 43 patients with neurological impairment (κ = 0.619). Surgery was recommended by mTLICS versus TL AOSIS in 24.6% versus 19.2% of neurologically intact patients and in 90.7% versus 81.4% of those with neurological impairment. Interobserver reliability before consensus was substantial to high (linear-weighted κ = 0.88 for mTLICS and 0.75 for TL AOSIS). The two scoring systems showed substantial agreement in treatment recommendations. In burst fractures with intervertebral disc injury, mTLICS tended to assign cases to higher treatment categories than TL AOSIS, although these subgroup differences were not statistically significant.
Conclusion
mTLICS and TL AOSIS show substantial concordance as decision-support tools for thoracolumbar fractures. For burst fractures with intervertebral disc involvement, mTLICS tends to recommend surgery more often, reflecting a difference in classification behaviour rather than a demonstrated clinical advantage. Because no outcome data were analysed, whether this tendency improves patient outcomes remains to be determined.