文献翻译-胸腰椎骨折-胸腰椎骨折分类进展

The evolution of thoracolumbar injury classification systems
胸腰椎骨折分类研究进展
Manish K. Sethi, MDa, Andrew J. Schoenfeld, MDb,*, Christopher M. Bono, MDb,
Mitchel B. Harris, MD, FACSba Harvard Combined Orthopaedic Program, Department of Orthopaedic Surgery, Brigham and Women’s Hospital, Boston, MA 02115, USA
bDepartment of Orthopaedic Surgery, Harvard Medical School, Brigham and Women’s Hospital, 75 Francis Street, Boston, MA 02115, USA
Received 20 September 2008; accepted 6 April 2009
Abstract
BACKGROUND CONTEXT: An ideal classification system for thoracolumbar (TL) spine fractures
should facilitate communication between treating physicians and guide treatment by means of
outlining the natural history of injuries. The classification scheme should also be comprehensive,
intuitive, and simple to implement. At the present time, no classification system fully meets these
criteria. In this review, the authors attempt to describe the evolution of TL fracture classification
systems from their inception to the present day.
背景：
理想的胸腰椎骨折分类系统应该能够简化骨折损伤病人病史方便脊柱外科医生交流并指导治疗。同时分类体系应该全面、直观、使用方便。目前，还没有一种分类方法能够达到以上标准，本文就胸腰椎骨折分类系统的进展过程进行阐述
。
PURPOSE: To review the evolution of TL injury classification schemes, particularly in regard to
the progression of thought on the importance of biomechanical stability, injury mechanism, and
neurologic status.
目的
对胸腰椎骨折分类方法的进展情况进行系统阐述，尤其是有关生物力学稳定性，损伤机制，神经损伤等在胸腰椎骨折分类方法中的重要性进行阐述
STUDY DESIGN: Review article.
研究设计
查阅相关文献资料

METHODS: The article reviews the salient classification systems that have addressed TL injuries
since Boehler’s first attempt in 1929. This progression culminates in the Thoracolumbar Injury Severity
Score/Thoracolumbar Injury Classification and Severity Score (TLISS/TLICS), a system
which incorporates features from earlier scales and represents the most comprehensive grading
scale to date.
方法
本文从1929年Boehler第一次对胸腰椎骨折分类开始，对有代表性的突出的胸腰椎骨折分类方法进行阐述，直到发展到今天的TLISS /TLICS（胸腰椎损伤严重性评分/胸腰椎骨折损伤分类及严重性评分），此方法是对早期分类方法的各种机制进行总结而形成的最全面的分类方法。


RESULTS: Each successive system played an important role in advancing contemporary understanding
of TL injuries. Most classifications were, however, based on a single individual’s, or a comparatively
small group’s, retrospective review of a case series. In most instances, these grading
systems were never validated or modified by their original developers, a shortcoming that prevented
their continued evolution. Despite the many advantages of the TLISS/TLICS system, more work in
terms of refining the classification and defining its validity remains to be performed.
结果
每一个成功分类方法都对当时胸腰椎骨折研究的发展起到重要的作用。然而大多数分类方法只是基于作者自己或者是相对少数医生对一部分胸腰椎骨折病人的形成的总结。大多数情况下，他们的分类方法对于后来者来说具有不可重复性，由于这方面的先天不足导致其分类方法不能得到持续发展。尽管TLISS /TLICS方法有许多的优点，但仍有许多的工作需要去使该分类方法更简练并具有更高的可信度
。
CONCLUSIONS: The classification of TL injuries has evolved significantly over the course of the
last 75 years. Most of these schemes were limited by their complexity, relevance, and/or poor
reliability. The TLISS classification system represents the most recent evolution as it combines
several important factors capable of guiding the management of TL injuries. Nonetheless, more
research regarding this rating scale remains to be performed.

结论
胸腰椎骨折分类方法在75年里已经取得了长足的发展，但大多数方法由于其复杂性，适应性、可靠性差限制了其实用性。TLISS /TLICS分类方法是结合许多重要因素而形成的最近的胸腰椎骨折分类方法。当然这个分类方法仍有许多工作需要完善
。
Keywords: Thoracolumbar fractures; Classification systems; Spine trauma; Rating scales; Interobserver reliability; Validity

Introduction
Despite the voluminous material available in the spineliterature regarding the evaluation and management of thoracolumbar(TL) spine fractures, a precise, comprehensive,and informative classification system has eluded spinesurgeons since Boehler first proposed his injury categories
in 1929. Classification systems are ideally applied to the clinical realm if they provide a uniformly accepted methodof describing an injury, while at the same time assisting thesurgeon in clinical decision making [1].
引言
尽管有关胸腰椎骨折诊断 、治疗的相关文献有许多，但自Boehler以来一直缺乏一个精确、全面、系统的胸腰椎骨折分类方法。完美的分类方法应该能提供临床范围内一致的标准，同时又能指导临床手术治疗
。
As such, an ideal classification system for TL spine fractures should follow this model, by facilitating effective communication between treating physicians and guiding their treatment by
means of evidence-based literature outlining the naturalhistory of the fracture. The classification scheme should also be comprehensive, intuitive, and simple to implement.Furthermore, an effective classification system should account for the biomechanics of TL injuries as the definition regarding stability of spinal fractures continues to elude us.
既然好的分类标准如此，胸腰椎骨折的分类方法那就需遵从这一标准，既有利于脊柱外科医生的交流又能指导其治疗。同时分类要全面，直观、易于实施。更重要的是，对于如何界定胸腰椎骨折的稳定性一直困扰着我们，一个好的分类标准应该能从生物力学方面给予解释In this review, the authors attempt to describe the evolution of TL fracture classification systems from their inception to the present day (Table 1). This review also provides special attention to the progression of thought regarding the importance of biomechanical stability, injury mechanism， and neurologic status in the classification of TL injuries
本文我们主要阐述了胸腰椎骨折分类的演进过程。（table1）同时对生物力学稳定性、损伤机制、神经损伤情况在胸腰椎骨折分类中重要性进行特别阐述。
Boehler
In the sentinel description of a TL fracture classification, Boehler combined anatomical descriptions of the fracture together with mechanism of injury [2]. He delineated five categories of TL injuries, including compression fractures, flexion-distraction injuries with anterior injury secondary to compression and posterior injury secondary to distraction, extension fractures with injury to the anterior and posterior longitudinal ligaments, shear fractures, and rotational injuries

Boehler分类方法
Boehler将胸腰椎解剖形态结构和损伤机制结合，第一次对胸腰椎骨折进行了分类。他把胸腰椎骨折分成五类，其中包括压缩骨折、屈曲-伸展骨折（包括椎前的压缩骨折和过伸引起的后部结构的损伤）、过伸性损伤（包括前后纵韧带的损伤）、剪切应力引起的骨折、旋转损伤引起的骨折。
Watson-Jones
In 1938, Watson-Jones added to Boehler’s work and proposed a modified classification system accounting for the concept of instability and its effect on the treatment of TL injuries
[3].Watson-Jones was the first to consider the integrity of the posterior ligamentous complex (PLC) as essential for spinal stability. Ultimately, his classification consisted of seven fracture types organized into three major patternsd simple wedge fractures, comminuted fractures, and fracture dislocations
.Watson-Jones stressed the concepts of anatomic reduction and radiographic alignment [3,4].
Watson-Jones分类法
1938年，Watson-Jones在总结Boehler分类方法的基础上提出了他对胸腰椎骨折的分类方法的修改意见，分类标准为骨折的稳定性和对骨折治疗的指导。Watson-Jones是第一个提出PLC（后韧带复合体）的完整性在脊柱的稳定性中起重要作用的人。他共将胸腰椎骨折分为三大类七种类型的骨折：简单的楔形骨折、粉碎性骨折、骨折脱位。Watson-Jones并着重提出了解剖复位和脊柱影像学序列等概念。

Nicoll
In 1949, Nicoll attempted to further define the concept of stability using an anatomical classification [5]. Contrary to his predecessors, Nicoll felt there were four specific structures involved in the mechanical stability of the spine- the vertebral body, the disc, the intervertebral joints,
and the interspinous ligament. In his view, the major determinant of stability was the integrity of the interspinous ligament. Nicoll reported on 166 TL fractures in coal miners and classified these injuries as anterior wedge fractures, lateral wedge fractures, fracture dislocations, and neural arch fractures
Nicoll分类法
1949年，Nicoll试图利用胸腰椎的解剖分类来对胸腰椎的稳定性作进一步的阐述，他认为脊柱的生物力学稳定性是由下面四种结构来决定的-椎体、间盘、椎间关节、棘间韧带，，他认为决定脊柱稳定性的最主要结构是棘间韧带，这种认识完全颠覆了前人的观点。Nicoll通过对166名煤矿工人的胸腰椎骨折病例总结后把胸腰椎骨折分类为：椎体前楔形骨折、椎体一侧的楔形骨折、骨折脱位、及椎弓骨折
。
Holdsworth
More than 25 years later, after reviewing 1,000 patients at Sheffield Hospital in England, Holdsworth expanded Nicoll’s system to the entire spine [6]. Moreover, he revolutionized the TL injury classification system with the introduction of the ‘‘column concept.’’ Holdsworth divided
the spine into two major columnsdthe anterior column, consisting of the vertebral body and intervertebral disc,and the posterior column, consisting of the facet joints and the PLC (interspinous ligament, supraspinous ligament, and ligamentum flavum) [7].
Holdsworth分类法
大约Nicoll分类法提出25年后，Holdsworth对谢菲尔德医院的1000名胸腰椎骨折患者进行了回顾性研究，并将Nicoll分类法扩大到全脊柱损伤的分类。进一步是他将胸腰椎骨折的分类中引入了‘柱’的概念，Holdsworth将每个节段分为前后两柱，前柱包括椎体及间盘，后柱包括横突关节、及PLC（含有棘间韧带、棘上韧带、黄韧带）。


Holdsworth elaborated on Nicoll’s theory of stability, which centered on the intact interspinous ligament, and maintained that the posterior column was also important for spinal stability. Holdsworth’s classification scheme included anterior compression fractures, fracture dislocations,
rotational fracture dislocations, extension injuries,shear injuries, and burst fractures. Holdsworth was the first to introduce the concept of a ‘‘burst fracture.’’ He reported that both burst and anterior compression fractures were inherently stable given that the posterior column was intact
Holdsworth对Nicoll的脊柱稳定理论进行了更精确的概述，他认为完整的椎间韧带和后柱的完整对其稳定性都起着重要的作用。Holdsworth分类包括：椎前压缩骨折、骨折脱位、旋转骨折脱位、过伸性损伤、剪切应力引起的骨折、爆裂骨折。Holdsworth第一个提出‘爆裂骨折’的概念，他认为爆裂骨折和椎前压缩骨折只要后柱结构完整应属于稳定性骨折。
Kelly and Whitesides
Although they based their views on a limited analysis of 11 cases,Kelly and Whitesides sought to refine Holdsworth’s classification scheme [8]. They preserved the concept of columns but redefined the anterior column as the solid vertebral body and the posterior column as the neural arch and posterior elements. In contrast to others, they proposed that burst fractures were inherently unstable [9]. This concept would be espoused by subsequent developers of classification schema, particularly Denis and McAfee
Kelly and Whitesides 分类法
Kelly and Whitesides 尽管只是复习了11例胸腰椎骨折病例，但还是总结出了Holdsworth’分类法的不足。他们保留了‘柱’的概念但对前后柱的进行了重新定义：前柱为椎体部分，后柱包括椎弓及后部的结构。同时他们认为爆裂骨折就是不稳定骨折，像Denis and McAfee等随后形成的胸腰椎骨折分类法中都延续了这样一种概念，但在当时的许多研究人员认为恰恰相反。
Denis
With the advent of computed tomography (CT) technology in the early 1980s, previous classification systems for TL fractures came under increased scrutiny. In 1983, after a review of 412 patients with TL injuries, including 53 with CT images, Denis modified the ‘‘column concept’’ originally proposed by Holdsworth. Additionally, he argued that spinal stability was based on three columns, rather than two
[10]. In his often-quoted study, the middle column was defined anatomically as ‘‘.the posterior half of the vertebral body, including the annulus fibrosus and the posterio rlongitudinal ligament.’’ The anterior column of Denis was formed by the anterior longitudinal ligament, the anterior annulus fibrosis, and the anterior part of the vertebral body. Denis’s posterior column consisted of all structures
posterior to the posterior longitudinal ligament including the osseous posterior elements and the PLC
Denis分类法
进入80年代以来随着CT技术的发展，对胸腰椎骨折有了更深的认识。Denis在1983年通过对412例胸腰椎骨折病例（其中53例进行了CT扫描成像）的观察后提出了新的脊柱稳定概念，他认为脊柱临床稳定性由三柱维持，而不是Denis提出的两柱。他从解剖学角度把三个柱解释为;前柱包括前纵韧带、前半部分椎体及间盘；中柱包括后半椎体及间盘、后纵韧带；后柱包括后纵韧带后的所有结构（含骨性结构及后部韧带复合体
）。
As opposed to previous classification schemes using the ‘‘column concept,’’ Denis argued that the middle column was the most important for structural stability. He classified spine fractures into four distinct groups based on this theory,including compression fractures sustained secondary
to the failure of the anterior column under compress Burst fractures were described as a failure of the anterior and middle columcompressions, resulting in fracture of the vertebral body under axial load. Seat belt injuries were sustained secondary to flexion-distraction forces and resulted in the failure of both the posterior and middle columns. Finally,fracture dislocations were defined as injuries resulting from failure of all three columns (Figs. 1–4) [10].

跟以往分类方法不同的是Denis提出中柱是维持脊柱稳定性的关键因素，他把脊柱骨折分为四种类型：1，由于前柱受压引起的压缩骨折、2，由于椎体受到垂直暴力，前中柱受压引起的爆裂骨折、3，由于受到屈曲伸展暴力中后柱受压引起的安全带骨折、4，由于暴力三柱受损伤引起的骨折脱位。The novel concept of the middle column is often attributed to Denis. Yet Decoulx and Rieunau had already proposed the middle column’s integral role in fracture stability by claiming ‘‘.the posterior vertebral wall is the mainstay to spinal stability [11].’’ Furthermore, Roy-Camille et al.
had defined the middle column before Denis, referring to it as the segment moyen [12]
脊柱中柱理论一般认为是Denis首先提出，其实Yet Decoulx 和 Rieunau早在Denis之前就提出“椎体后壁对维持脊柱稳定具有重要意义”的论断，这应该是更早的有关脊柱中柱的理论。此外Roy-Camille早于Denis对中柱的解释为脊柱节段的中间部分。

Despite the importance of the middle column championed by these surgeons, James et al. later refuted the biomechanical significance of the middle column in a laboratory investigation [13]. In this study, a cadaveric L1 burst fracture model was used to evaluate the contribution of Denis’ three columns to resisting flexion deforming forces. Results led the authors to conclude that the integrity of the posterior column was a far better indicator of burst fracture stability
尽管上述几位强调中柱对维持脊柱稳定的重要性，但仍有后人对此提出疑义。James等人利用尸体腰1骨折评价Denis的三柱理论的过程后认为后柱结构的完整性对维持脊柱稳定性较中柱更重要。Denis’ classic article was the first to highlight the importance of neurologic status. He did this through his concept of ‘‘degrees of instability.’’ This proposed scale maintained that mechanical and neurologic instability could be present simultaneously or separately. Denis referred to isolated mechanical instability as an injury of the first degree. Second-degree instability involved injuries with a neurologic component but no mechanical instability, whereas third degree injuries consisted of mechanical instability with neurologic compromise. In the authors’ view, this may be his greatest contribution to TL classification by identifying and highlighting the integral relationship between biomechanical stability and neurologic compromise
Denis分类法的经典处在于第一次明确了神经损伤在胸腰椎骨折分类的重要性，他认为有神经功能障碍的胸腰椎骨折就属于不稳定骨折，也就是说解剖学上脊柱序列的不稳定和神经功能损伤两者可以同时出现也可以单独出现。Denis把脊柱不稳分为三度：1度单纯的解剖序列的异常、2度问解剖序列正常但有神经功能的异常、3度为解剖序列和神经功能均不正常。应该说提出脊柱生物力学稳定性与神经功能稳定性并将两者结合应用于胸腰椎骨折的分类是Denis最大的贡献。
The Denis system was ultimately oversimplified to dictate that if two columns were injured, operative intervention was required. Long-term follow-up studies of burst fractures have demonstrated the successful nonoperative management of these two column injuries [14] and the classification system has been criticized for its inability to distinguish between stable and unstable burst fracture(Figs. 1 and 2) [1]. Additionally, the classification has been found to have poor interrater reliability [15].
Denis骨折分类法过分简化的认为涉及双柱的骨折均需行手术治疗。但长时间的随访研究表明：累及双柱的爆裂骨折经保守治疗的效果不错，同时其区别稳定和不稳定骨折的方法也遭到质疑，进而使分类法应用的可信度大大降低。
McAfee
McAfee et al. identified limitations of the Denis scale and expanded on it to better define the elusive property of instability [16]. McAfee’s classification system emphasized the PLC as the major factor in fracture stability. In this respect, his classification was largely indebted to the prior work of Boehler and Nicoll. After studying 100 TL injuries with CT sagittal reconstruction, McAfee proposed that the
mechanism of middle column failure could be determined and that this factor influenced injury stability. In an effort to simplify the Denis classification, McAfee combined Denis’ fracture categories with the mechanics of spine motion as proposed by White and Panjabi [17], and put forward a ‘‘simpler’’ classification with six categories [16].
McAfee分类法
McAfee等人认识到Denis分类法的局限性，并对如何界定不稳定型胸腰椎骨折较前做了很好的改观，他认为PLC对界定骨折的稳定性起着重要的作用。他的这种理念主要来源于Boehler 和Nicoll之前的工作。McAfee对100例胸腰椎骨折行CT三维重建观察后认为并不能确定造成脊柱中柱受损的因素的就是造成脊柱不稳的因素。McAfee在简化Denis分类法基础上结合White and Panjabi提出的脊柱运动模式把胸腰椎骨折分成6类型。


McAfee argued that there were three modes of failure of the middle column -axial compression, axial distraction, and translation. McAfee further maintained that both the degree of instability and the patient’s neurologic status hinged on the mode of failure. In turn, McAfee proposed that his classification system was capable of predicting neurologic deficits [16,18]. The McAfee modification of Denis’ classification has not been incorporated into general use and as such has not been tested for its reliability, nor has it been prospectively validated [1].
Mcafee认为中柱损伤有三种形式：轴性压缩暴力、轴性伸展暴力、旋转暴力。并仍将脊柱稳定程度和神经损伤程度作为分类标准。虽然Mcafee分类法有别于Denis分类法并称其分类能预测神经损伤的程度，但实际临床工作中很难将两者结合或无法对其可靠和有效性进行证实。
Ferguson and Allen
In 1984, Ferguson and Allen published an article in which they refuted the initial ‘‘column concept’’ advanced by Holdsworth and Denis [19]. They argued that the term ‘‘column’’ was semantically a poor choice, as the anatomy and biomechanics of the spine did not facilitate such an analogy. Instead, they proposed a classification scheme with anterior and posterior spinal ‘‘elements,’’ based on injury mechanism and patterns of failure. Ferguson and Allen addressed stability using specific criteria that included mechanism of injury,risk of progressive deformity, neurologic function, and patient functionality [19]. Their proposed TL injury classification system was an adaptation of their more widely accepted cervical injury classification that is a purely mechanistic classification. Those who found the mechanistic approach too unidirectional were equally hesitant to embrace the progressively
more severe stages of the classification
Ferguson and Allen分类法
1984年，Ferguson and Allen就对Holdsworth and Denis三柱理论发表论文质疑其三柱的概念是否合适，同时从解剖和生物力学角度分析了三柱理论的缺陷。他们根据脊椎骨折损伤的机制和损伤的形式提出分类要考虑多种因素例如：骨折椎体稳定程度决定于受损机制、有无继发性骨折畸形、神经功能状况及患者的整体状况。于是他们在业已广泛接受的颈椎损伤机制分类的条件下提出了胸腰椎骨折的分类方法。对于那些认为只以损伤机制进行分类太单一的人是不是又有些担心现在的分类是不是又变得越来越复杂了。


McCormack and Gaines
The introduction of pedicle screws revolutionized the treatment of TL trauma. With the advent of pedicle screw constructs, short-segment instrumentation became popular. Because of reports of high failure rates with these shortsegment constructs, McCormack, Karaikovic, and Gaines sought to
devise a scale capable of predicting the risk of implant failure [20]. These authors concluded that three
criteria were important in predicting posterior fixation failur-the degree of vertebral body comminution, apposition of fracture fragments, and the amount of sagittal plane deformity.
Each fracture was evaluated using McCormack’s criteria and scored on a point system from 1 to 3, with a higher number indicative of increased severity. Fractures with a total score greater than 7 had a high risk of short-segment fixation failure [1,20].
McCormack and Gaines分类法
椎弓根钉植入对胸腰椎骨折的治疗是***性的。随着椎弓根钉的出现，短节段固定变得越来越普及。McCormack Gaines and Karaikovic在观察到椎弓根钉植入存在很高的失败病例后认为需要制定评估植入物植入的条件。他们总结后认为下列三种情况下有植入物失败的风险：一是椎体骨折粉碎的程度、骨折块的位置、骨折畸形。每一种情况都可按照骨折严重程度给予1到3不等的分值，分值越高骨折越严重，总分大于7分的骨折有较高的植钉失败率。
This load-sharing classification was lauded for its simplicity and its attempt to assist in predicting outcome. However, the load-sharing classification was also criticized for its lack of consideration of neurologic status and ligamentous stability. In fact, it was more supportive evidence for the two-column theory rather than a new classification.Ultimately, because of its inability to uniformly describe injuries and assist in predicting outcome, the system of McCormack and Gaines does not meet the true criteria of a classification scheme
骨折受力分类法简单且有助于判断愈合，但对神经功能情况和韧带稳定性欠考虑。确切的说他不是一种新的分类法而是对两柱理论的有力补充。结果是McCormack and Gaines分类法不能成为一种真正的分类法。
AO/Magerl
The AO (Arbeitsgemeinschaft fur Osteosynthesenfragen) classification scheme was a culmination of 10 years of study at five institutions encompassing data from more than 1,445 TL injuries. The classification implemented AO concepts that had been originally applied to extremity fractures, basing injury categorization on a progressive scale of severity fromType A toTypeC[21]. Like Ferguson andAllen, the authors defined severity of injury by several factors including mechanical stability and risk of neurologic injury, Type A fractures consist of compression fractures (Figs. 1 and 2), TypeB fractures include distraction injuries (Fig. 4), and Type C fractures refer to rotationally unstable injuries or those with multidirectional instability (Fig. 3). Each of the three main fracture types is divided into three subtypes, which in turn are separated into three subgroups. Subgroups are divided into three subdivisions.
AO/Magerl分类法
AO分类法是五个研究机构汇集10年1445例胸腰椎骨折病例后总结而成。分类法继承了AO应用于四肢骨折的骨折分类原则，由轻到重分为ABC三种类型。如同Ferguson andAllen分类法，AO分类中也是按椎体稳定性和神经损伤程度对损伤严重度进行分级。ABCA型骨折指压缩骨折，B型骨折指牵张型骨折，C型骨折指旋转不稳定型骨折或多方向不稳骨折。每型骨折又分为3种亚型，每个亚型又分为三个组，每组下还有三个小组
。
The classification scheme is ultimately composed of 53 total patterns and was designed to identify injury severity,with A1 being the least severe and C3 the most severe [21]. In designing the AO classification, Magerl et al. abandoned the three-column concept of Denis and returned to the two-column theory of Holdsworth. They also sought to use and simplify the fracture mechanisms proposed by Ferguson and Allen. The AO classification attempted to design a comprehensive system in which every fracture fit within the classification. Nevertheless, beyond the most basic level of the classification, the system proved to be confusing and has demonstrated only moderate inter- and
intraobserver reliability [1,15,18]. Furthermore, the AO classification did not present a concrete
definition of stability nor did it include characterization of neurologic deficit. Instead, each fracture subtype was presumed to have some degree of intrinsic instability. Moreover,subsequent research has demonstrated little correlation between magnetic resonance imaging (MRI) findings of instability based on posterior ligamentous integrity and the AO classification [22,23]
AO分类按其损伤程度分为53种，其中A1损伤程度最轻、C3损伤程度最重。主要依据为Holdsworth的两柱原理而不是Denis的三柱理论。同时分类中也借鉴Ferguson及Allen提出的骨折损伤机制，试图设计成能够包含所有骨折分类的方法。然而，这又违背了分类设计的初衷，使AO分类法变得异常复杂且只能应用于不同研究可信度的比较。此外，AO分类中既不含骨折处稳定程度也不涉及神经损伤的程度，只是机械的把骨折按其不稳分为若干的亚型。随后的研究表明MRI显示不稳而后韧带结构完整与AO分类中的不稳定骨折无明显相关性。
The Thoracolumbar Injury Severity Score and Thoracolumbar Injury Classification and Severity System
胸腰椎骨折损伤严重度评分和胸腰椎骨折损伤严重度分类(TLISS分类法）

The Thoracolumbar Injury Severity Score (TLISS) classification, created by the Spine Trauma Study Group, was designed to truly identify, and objectify the factors that drive spine surgeons to perform surgery on TL injuries.Furthermore, this international group of spine surgeons tried to identify similarities in treatment algorithms felt to be directed by the injury characteristics of the TL injuries
[24]. As an injury severity scale, the TLISS sought to inform treatment and predict outcome. Additionally, it attempted to standardize the nomenclature used in previous classifications. Although technically a severity score, as a scheme that seeks to uniformly categorize injuries and inform treatment, the TLISS meets the criteria for a classification system.
TLISS（胸腰椎骨折损伤严重度评分）分类法是由脊柱创伤研究会创立的。它设计上真实可靠、对损伤情况客观描述、能够指导脊柱外科医生治疗。还有，该研究协会希望根据损伤特点就可以选择合适的治疗方法。作为评价损伤严重度的标准，TLISS 评分希望正确指导治疗并精确预测预后，同时统一前人不同分类的标准。尽管严重度分类专业性很强，TLISS分类法一直努力客观反映损伤情况并指导治疗，可以说其分类非常的标准和规范。
The TLISS is based on three major injury characteristics-mechanism of injury, integrity of the PLC, and neurologic status. The mechanism of injury and condition of the PLC are inferred from review of imaging studies including plain radiographs, CT, and/or MRI. Based on the severity scores within these three categories, a total score is calculated that can be used to guide treatment
TLISS分类法分类标准为;损伤机制、PLC的完整性、神经功能情况。平片、ct、mri等影像学资料可以反映其受伤机制及后纵韧带复合体的完整性，综合得分多少就可以指导治疗。
The mechanisms of injury in the TLISS system are identical to those proposed by the AO group (Figs. 1–4). Possible mechanisms include axial load compression injuries, translational/rotational injuries, and distraction injuries.One to 4 points are assigned to these mechanisms based on severity. Compression injuries receive 1 point, whereas burst fractures receive 2 points (Figs. 1 and 2). A compression fracture
with a coronal plane deformity of greater than 15 degrees is also assigned 2 points. Translational or rotational injuries, inherently more unstable than compression and burst fractures, are assigned 3 points (Fig. 3). Distraction injuries, consisting of osseous, ligamentous, or a combination of both components, are the most unstable injuries and receive 4 points (Fig. 4). In the TLISS system, if there are injuries at multiple levels only the most severe is included, but if multiple mechanisms of injury occur at a single
level, the score represents a summation of mechanisms
分类系统中主要以受损机制为主，受损机制有 垂直压缩暴力、旋转暴力或滑脱、伸展暴力，按受损严重度分为1到4分。压缩骨折为1分，而爆裂骨折为2分，压缩骨折合并脊柱大于15度的侧凸为2分，旋转暴力致骨折脱位，其稳定性要比压缩骨折及爆裂骨折差，为3分。伸展暴力可致多发骨折及韧带损伤，其稳定性最差，为4分。TLISS分类中，多发节段骨折时按最重节段算。如果是多种损伤机制集中于一个椎体节段时，得分为累加之和。
The TLISS system provides five categories for evaluating neurologic injury based on the severity of the deficit and the potential for recovery. Patients with an intact neurologic exam are assigned 0 points. Patients with a nerve root injury or complete spinal cord injury are allocated 2 points. Patients with an incomplete spinal cord injury or cauda equina syndrome are assigned 3 points secondary to the potential for these patients to benefit from surgical decompression.
根据神经功能障碍程度及其恢复程度TLISS分为五类，神经功能正常为0分，单一神经根障碍或者完全脊髓功能障碍为2分，不完全性脊髓功能障碍或有马尾综合症为3分，手术减压后患者神经功能恢复良。Another major component of the TLISS system includes the evaluation of the PLC. A disrupted PLC is determined by the clinical presence of a palpable gap between TL spinous processes and radiographically, by interspinous widening on imaging studies. The accuracy of MRI in predicting the integrity of the PLC has been nicely demonstrated in recently published clinical studies [2,25-27]. An
intact PLC is assigned 0 points, whereas confirmed ligamentous injury is assigned 3 points. If the condition of the PLC is indeterminate, 2 points are assigned
PLC在TLISS分类中也是一个主要因素，PLC断裂时可触及相邻棘突距离增宽，影像学上也有相应表现。MRI对PLC完整性的判断具有良好的表现。最近发表的相关临床研究也证实了这一点。PLC完整的为0分，损伤明确的为3分，不能确定其完整性的为2分。
The total score in the TLISS system evaluates the severity of the injury and helps guide decision making between operative versus nonoperative management. Patients with a score of 3 or less warrant consideration for nonoperative management, whereas patients with scores of 5 or greater have a greater likelihood to require stabilization with or without decompressive surgery. Patients with a total score
of 4 points fall into an intermediate category in which treatment is guided by the preferences of the surgeon [28,29]. The inter- and intrarater reliability of the TLISS scale have been demonstrated to range from fair to substantial (kvalues range from 0.24 to 0.724), with more recent investigations
documenting improved interrater reliability [30–32]. Additionally, Patel et al. have shown that the TLISS system can be reliably applied in the clinical setting resulting in reproducible classification of TL injuries by physicians with varying levels of experience [32].
TLISS评分所得与损伤的严重程度成正相关，并能指导手术还是非手术治疗，<3分建议保守治疗，>5分则需行内固定手术，术中可视实际情况进行减压，得分为4分时建议行手术治疗。TLISS分类法的可信度较高 ，可信区间值0.24-0.724。此外，从 各级临床医师应用此分类的效果来看具有可重复性，因此可以放心使用。
After a study by Harrop et al., the TLISS classification and its approach to injury mechanisms was slightly modified [31]. The modified algorithm, termed the Thoracolumbar Injury Classification and Severity Score (TLICS), no longer included summated scores for injury mechanism. Instead, the most severe injury mechanism was used alone, regardless of multiple mechanisms and/or different levels
of involvement. The addition of 1 point for coronal plane deformities was also eliminated [31].
后来Harrop等人对TLISS评分分类法及损伤机制评分法进行了轻微的改动，新的评分法命名为TLICS（胸腰椎骨折分类评分及严重度评分），即将原来损伤机制累加的评分制度改为单一由引起损伤最严重的损伤机制得分。
Although TLISS/TLICS remains the most comprehensive grading scale to date, more work in terms of refining the system and defining its validity remains to be performed [1]. One critique of the system can be that its validity has never been tested by a panel outside the Spine Trauma Study Group [1,30–32]. Additionally, the methodologies behind the grading scale remain to be clinically substantiated. For example, should distraction injuries, where injury occurs in only one plane, be deemed more unstable than multiplanar rotational injuries? Only long-term, prospective
studies can ultimately validate the grading scale and assess its reliability for predicting natural history over an extended period of time [

尽管TLISS/TLICS评分分类法现在仍是最广泛应用的分类标准，但还有更多的工作需要去做，如使分类变得更简练，可信度更高。有人批评其可信度高是因为没有非本组织外的专家对此评判过。
另外，分类方法的标准与否需临床实践的检验。例如，单一节段的过伸性损伤难道会比多节段旋转暴力骨折的稳定性更差？因此，只有较长时间的预期性研究才能最终对其评分分类法有更可信的评价。
Conclusions
The classification of TL spine fractures has evolved substantially over the course of the last 75 years. Initially, classification schemes were based on the concept of anatomic alignment and centered on radiographs, with the major modality of treatment being closed reduction and external immobilization. With the advent of new surgical technologies, classification systems continue to develop,ultimately embracing the importance of spinal columns and injury mechanism. Each successive system played an
important role in advancing contemporary understanding of TL injuries. Most classifications were, however, based on a single individual’s or a comparatively small group’s retrospective review of a case series [1]. In most instances, these grading systems were never validated or modified by
their original developers, a shortcoming that has prevented their continued evolution [1,15,32].
The TLISS classification system represents the most recent evolution of TL grading scales in that it clearly combines mechanism of injury, assessment of stability relevant to the PLC, and neurologic status into a system capable of guiding the management of TL injuries. Nonetheless, more research regarding this rating scale remains to be performed.
结论
TL骨折分类在历经的75年后已经发生了根本性的变化，最初的分类依据为解剖序列和影像学情况，对应的治疗方法主要为闭合复位及外固定。随着外科手术的出现，分类法也不断的向前发展，最后确定了脊柱分柱和受损机制在分类中的重要作用。但是，大多数的分类方法依据的病例数不多，因此其可信度差，易受后人影响，阻碍其继续发展。TLISS分类法是对TL骨折分类的最新总结，是将骨折损伤机制、LC的稳定性、神经损伤程度的有机结合，能够正确指导TL骨折的治疗。毫无疑问，还有更多的相关工作有待我们继续努力下去
。