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Blixt S, Burmeister F, Mukka S, Bobinski L, Försth P, Westin O, Gerdhem P. Reliability of thoracolumbar burst fracture classification in the Swedish Fracture Register. BMC Musculoskelet Disord 2024; 25:281. [PMID: 38609938 PMCID: PMC11010401 DOI: 10.1186/s12891-024-07395-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Accepted: 03/28/2024] [Indexed: 04/14/2024] Open
Abstract
BACKGROUND The Swedish Fracture Register (SFR) is a national quality register for all types of fractures in Sweden. Spine fractures have been included since 2015 and are classified using a modified AOSpine classification. The aim of this study was to determine the accuracy of the classification of thoracolumbar burst fractures in the SFR. METHODS Assessments of medical images were conducted in 277 consecutive patients with a thoracolumbar burst fracture (T10-L3) identified in the SFR. Two independent reviewers classified the fractures according to the AOSpine classification, with a third reviewer resolving disagreement. The combined results of the reviewers were considered the gold standard. The intra- and inter-rater reliability of the reviewers was determined with Cohen's kappa and percent agreement. The SFR classification was compared with the gold standard using positive predictive values (PPV), Cohen's kappa and percent agreement. RESULTS The reliability between reviewers was high (Cohen's kappa 0.70-0.97). The PPV for correctly classifying burst fractures in the SFR was high irrespective of physician experience (76-89%), treatment (82% non-operative, 95% operative) and hospital type (83% county, 95% university). The inter-rater reliability of B-type injuries and the overall SFR classification compared with the gold standard was low (Cohen's kappa 0.16 and 0.17 respectively). CONCLUSIONS The SFR demonstrates a high PPV for accurately classifying burst fractures, regardless of physician experience, treatment and hospital type. However, the reliability of B-type injuries and overall classification in the SFR was found to be low. Future studies on burst fractures using SFR data where classification is important should include a review of medical images to verify the diagnosis.
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Affiliation(s)
- Simon Blixt
- Department of Orthopaedics and Hand surgery, Uppsala University Hospital, Uppsala, Sweden.
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden.
- Department of Clinical Science Intervention and Technology, Karolinska Institutet, Stockholm, Sweden.
| | - Fabian Burmeister
- Department of Surgical and Perioperative Sciences (Orthopaedics), Umeå University, Umeå, Sweden
| | - Sebastian Mukka
- Department of Surgical and Perioperative Sciences (Orthopaedics), Umeå University, Umeå, Sweden
| | - Lukas Bobinski
- Department of Surgical and Perioperative Sciences (Orthopaedics), Umeå University, Umeå, Sweden
| | - Peter Försth
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Olof Westin
- Department of Orthopaedics, Institute of Clinical Sciences at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Spine Surgery Unit, Orthopedic Clinic, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Paul Gerdhem
- Department of Orthopaedics and Hand surgery, Uppsala University Hospital, Uppsala, Sweden
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
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Pham TD, Hoang NT, Le TB, Ha TH, Nguyen TT. Computed Tomography Findings and Classification of Traumatic Lumbosacral Spine Injuries: Insights from the AOSpine Classification System. Orthop Res Rev 2024; 16:35-42. [PMID: 38292458 PMCID: PMC10826410 DOI: 10.2147/orr.s444675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2023] [Accepted: 01/16/2024] [Indexed: 02/01/2024] Open
Abstract
Purpose The main objective of this study was to provide a description and classification of lumbosacral spine injuries based on the new AOSpine classification system. Methods A cross-sectional study was conducted on 75 patients with lumbosacral spine trauma who were admitted to Hue University of Medicine and Pharmacy Hospital in Hue, Vietnam, between April 2021 and July 2022. All patients underwent lumbosacral computed tomography, and each injured vertebra was classified according to the AOSpine classification system. The frequency and percentage of subtypes of lumbosacral spine trauma were determined. Results The mean age of the patients was 50.6 ± 16.1 years, and the male-to-female ratio was 1.5:1. Falls and traffic accidents were found to be the main causes of injuries. Among the patients, 78.7% did not exhibit any neurological symptoms, while 1.3% experienced complete hemiplegia and 20% had incomplete hemiplegia. The most common fracture subtype was A3, accounting for 34.6% of cases. Conclusion This study provides valuable insights into the demographics, associated injuries, and classification of traumatic lumbosacral spine injuries based on the new AOSpine classification system. The study found that falls and motor vehicle accidents were the main causes of these injuries, with a higher proportion of male patients. The majority of injuries were classified as type A fractures, while type C fractures were the least common. Sacral fractures were relatively infrequent and often associated with pelvic ring fractures. These findings contribute to our understanding of lumbosacral spine trauma and can aid in the development of more effective treatment protocols.
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Affiliation(s)
- Thuy Dung Pham
- Department of Radiology, Binh Dinh General Hospital, Binh Dinh, Vietnam
| | - Ngoc Thanh Hoang
- Department of Radiology, Hue University of Medicine and Pharmacy, Hue University, Hue, Vietnam
| | - Trong Binh Le
- Department of Radiology, Hue University of Medicine and Pharmacy, Hue University, Hue, Vietnam
| | - Thi Hien Ha
- Department of Radiology, Hue University of Medicine and Pharmacy, Hue University, Hue, Vietnam
| | - Thanh Thao Nguyen
- Department of Radiology, Hue University of Medicine and Pharmacy, Hue University, Hue, Vietnam
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Aly MM, Al-Shoaibi AM, Aljuzair AH, Issa TZ, Vaccaro AR. A Proposal for a Standardized Imaging Algorithm to Improve the Accuracy and Reliability for the Diagnosis of Thoracolumbar Posterior Ligamentous Complex Injury in Computed Tomography and Magnetic Resonance Imaging. Global Spine J 2023; 13:873-896. [PMID: 36222735 DOI: 10.1177/21925682221129220] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
STUDY DESIGN Systematic Literature Review. OBJECTIVE To propose a systematic imaging algorithm for diagnosing posterior ligamentous complex (PLC) injury in computed tomography (CT) and magnetic resonance imaging (MRI) to improve the reliability of PLC assessment. METHODS A systematic review was conducted following PRISMA guidelines. The Scopus database was searched from its inception until July 21, 2022, for studies evaluating CT or MRI assessment of the PLC injury following thoracolumbar trauma. The studies extracted key findings, objectives, injury definitions, and radiographic modalities. RESULTS Twenty-three studies were included in this systematic review, encompassing 2021 patients. Five studies evaluated the accuracy of MRI in detecting thoracolumbar PLC injury using intraoperative findings as a reference. These studies indicate that black stripe discontinuity due to supraspinous or ligamentum flavum rupture is a more specific criterion of PLC injury than high-signal intensity. Thirteen papers evaluated the accuracy or reliability of CT in detecting thoracolumbar PLC injury using MRI or intraoperative findings as a reference. The overall accuracy rate of CT in detecting PLC injury was 68-90%. Two studies evaluate the accuracy of combined CT findings, showing that ≥2 CT findings are associated with a positive predictive value of 88-91 %. Vertebral translation, facet joint malalignment, spinous process fracture, horizontal laminar fracture, and interspinous widening were independent predictors of PLC injury. CONCLUSION We provided a comprehensive imaging algorithm for diagnosing PLC in CT and MRI based on available literature and our experience. The algorithm will potentially improve the accuracy and reliability of PLC assessment, however it needs multicentre prospective validation.
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Affiliation(s)
- Mohamed M Aly
- Department of Neurosurgery, Prince Mohammed Bin Abdulaziz Hospital, Riyadh, Saudi Arabia
- Department of Neurosurgery, Mansoura University, Mansoura, Egypt
| | - Abdulbaset M Al-Shoaibi
- Department of Diagnostic Radiology, Prince Mohammed Bin Abdulaziz Hospital, Riyadh, Saudi Arabia
| | - Ali H Aljuzair
- Department of Neurosurgery, Prince Mohammed Bin Abdulaziz Hospital, Riyadh, Saudi Arabia
| | - Tariq Ziad Issa
- Orthopaedic Surgery, 387400Rothman Orthopedic Institute, Philadelphia, PA, USA
| | - Alexander R Vaccaro
- Orthopaedic Surgery, 387400Rothman Orthopedic Institute, Philadelphia, PA, USA
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Aly MM, Al-Shoaibi AM, Abduraba Ali S, Almutairi HM, Kormi YH, Abdelaziz M, Eldawoody H. Which Morphological Features of Facet Diastasis Predict Thoracolumbar Posterior Ligamentous Complex Injury as Defined by Magnetic Resonance Imaging? World Neurosurg 2023; 171:e276-e285. [PMID: 36521759 DOI: 10.1016/j.wneu.2022.12.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Revised: 12/02/2022] [Accepted: 12/02/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND The association of various morphological features of facet diastasis with posterior ligamentous complex (PLC) injury has not been previously described. This study aims to determine the diagnostic value of facet diastasis subtypes for diagnosing thoracolumbar PLC injury. METHODS We retrospectively reviewed 337 consecutive patients with acute thoracolumbar fractures who had computed tomography (CT) and magnetic resonance imaging (MRI) within 10 days of injury. Three and 5 reviewers evaluated MRI and CT images, respectively. Facet diastasis was subclassified as follows: Dislocated, no articular surface apposition; subluxed, incomplete articular surface apposition; and facet fracture articular process fractures which may be displaced ≥2 mm or otherwise undisplaced, facet joint widening (FJW) ≥ 3 mm. We examined the diagnostic accuracy and the multivariate associations of facet diastasis subtypes with PLC injury in MRI. RESULTS Facet dislocation, subluxation, and displaced facet fracture yielded a high positive predictive value (PPV) for PLC injury (96%, 88%, and 94%, respectively). In contrast, undisplaced facet fracture and FJW yielded a moderate PPV for PLC injury (78%, and 45%, respectively). Facet dislocation, subluxation, and displaced facet fracture showed independent associations with PLC injury (adjusted odds ratio [AOR] = 38.4, 17.1, 13.4, respectively; P < 0.05). Undisplaced facet fracture and FJW were not associated with PLC injury (AOR = 3.9 [95% confidence interval, 0.49-38.4], P = 0.20) and (AOR = 1.94 [95% confidence interval, 0.48-7.13]; P = 0.20; P = 0.33), respectively. CONCLUSIONS Facet dislocation, subluxation, and displaced facet fracture, but not undisplaced facet fracture or FJW, were independently associated with PLC injury. Therefore, we propose to define facet diastasis as a surrogate marker of PLC injury in MRI based on these morphologies.
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Affiliation(s)
- Mohamed M Aly
- Department of Neurosurgery, Prince Mohammed Bin Abdulaziz Hospital, Riyadh, Saudi Arabia; Department of Neurosurgery, Mansoura University, Mansoura, Egypt.
| | - Abdulbaset M Al-Shoaibi
- Department of Diagnostic Radiology, Prince Mohammed Bin Abdulaziz Hospital, Riyadh, Saudi Arabia
| | - Saleh Abduraba Ali
- Department of Diagnostic Radiology, Prince Mohammed Bin Abdulaziz Hospital, Riyadh, Saudi Arabia
| | - Hatem Mashan Almutairi
- Department of Diagnostic Radiology, Prince Mohammed Bin Abdulaziz Hospital, Riyadh, Saudi Arabia
| | - Yahya H Kormi
- Department of Surgery, Division of Neurosurgery, Faculty of Medicine, Jazan University, Jazan, Saudi Arabia
| | | | - Hany Eldawoody
- Department of Neurosurgery, Prince Mohammed Bin Abdulaziz Hospital, Riyadh, Saudi Arabia; Department of Neurosurgery, Mansoura University, Mansoura, Egypt
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Hwang Z, Abdalla M, Ajayi B, Bernard J, Bishop T, Lui DF. Thoracolumbar spine trauma: a guide for the FRCS examination. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2022:10.1007/s00590-022-03430-9. [PMID: 36460810 PMCID: PMC10368559 DOI: 10.1007/s00590-022-03430-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Accepted: 11/09/2022] [Indexed: 06/17/2023]
Abstract
Thoracolumbar spine injuries are commonly seen in trauma settings and have a high risk of causing serious morbidity. There can be controversy when it comes to classifying thoracolumbar injuries within the spinal community, but there remains a need to classify, evaluate and manage thoracolumbar fractures. This article aims to provide a guide on classification of thoracolumbar spine injuries using the AO Spine Thoracolumbar Injury Classification System (AO TLICS).
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Affiliation(s)
- Z Hwang
- St. George's University of London, London, SW17 0RE, UK.
| | - M Abdalla
- St. George's University Hospitals NHS Foundation Trust, London, SW17 0QT, UK
| | - B Ajayi
- St. George's University Hospitals NHS Foundation Trust, London, SW17 0QT, UK
| | - J Bernard
- St. George's University Hospitals NHS Foundation Trust, London, SW17 0QT, UK
| | - T Bishop
- St. George's University Hospitals NHS Foundation Trust, London, SW17 0QT, UK
| | - D F Lui
- St. George's University Hospitals NHS Foundation Trust, London, SW17 0QT, UK
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Hwang Z, Houston J, Fragakis EM, Lupu C, Bernard J, Bishop T, Lui DF. Is the AO spine thoracolumbar injury classification system reliable and practical? a systematic review. Acta Orthop Belg 2021. [DOI: 10.52628/87.1.23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Controversy surrounding the classification of thoracolumbar injuries has given rise to various classification systems over the years, including the most recent AOSpine Thoracolumbar Injury Classification System (ATLICS). This systematic review aims to provide an up-to-date evaluation of the literature, including assessment of a further three studies not analysed in previous reviews. In doing so, this is the first systematic review to include the reliability among non-spine subspecialty professionals and to document the wide variety between reliability across studies, particularly with regard to sub-type classification. Relevant studies were found via a systematic search of PubMed, EBESCO, Cochrane and Web of Science. Data extraction and quality assessment were conducted in line with Cochrane Collaboration guidelines. Twelve articles assessing the reliability of ATLICS were included in this review. The overall inter-observer reliability varied from fair to substantial, but the three additional studies in this review, compared to previous reviews, presented on average only fair reliability. The greatest variation of results was seen in A1 and B3 subtypes. Least reliably classified on average was A4 subtype. This systematic review concludes that ATLICS is reliable for the majority of injuries, but the variability within subtypes suggests the need for further research in assessing the needs of users in order to increase familiarity with ATLICS or perhaps the necessity to include more subtype-specific criteria into the system. Further research is also recommended on the reliability of modifiers, neurological classification and the application of ATLICS in a paediatric context.
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Alan N, Donohue J, Ozpinar A, Agarwal N, Kanter AS, Okonkwo DO, Hamilton DK. Load-Sharing Classification Score as Supplemental Grading System in the Decision-Making Process for Patients With Thoracolumbar Injury Classification and Severity 4. Neurosurgery 2021; 89:428-434. [PMID: 34038938 DOI: 10.1093/neuros/nyab179] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Accepted: 03/30/2021] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Patients with Thoracolumbar Injury Classification and Severity (TLICS) score of 4 fall into a gray zone between surgical and conservative management. The integrity of posterior ligamentous complex (PLC) evaluated by magnetic resonance imaging (MRI) contributes to surgical decision-making. Load-sharing classification (LSC) may provide a modifier to further guide decision-making in these patients. OBJECTIVE To evaluate associations between LSC score and MRI acquisition, compromise of PLC on MRI, and surgical intervention in TLICS 4 patients. METHODS A cohort of 111 neurologically intact patients with isolated thoracolumbar burst fracture with TLICS 4 was evaluated. LSC score was determined based on degree of comminution (1-3), apposition (1-3), and kyphosis (1-3), total composite score of 3 to 9. RESULTS Overall, 44 patients underwent MRI, 15 had PLC injury, and 32 (28.8%) underwent surgery. LSC score was higher in patients who had an MRI (median 6 vs 3, P < .001) and patients who had surgery (median 7 vs 4, P < .001). In univariate logistic regression, LSC score was associated with MRI acquisition (odds ratio [OR] 1.7; 1.32-2.12; P < .001), presence of PLC injury on MRI (OR 1.5; 1.2-2.0; P = .002) and, in multivariate logistic regression, undergoing surgical intervention (OR 3.7; 2.3-5.9; P < .001), independent of MRI or PLC injury. CONCLUSION LSC score in neurologically intact patients with isolated thoracolumbar burst fracture with TLICS 4 was independently associated with operative intervention. The application of LSC may further guide decision-making in this patient group.
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Affiliation(s)
- Nima Alan
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Joseph Donohue
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Alp Ozpinar
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Nitin Agarwal
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Adam S Kanter
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - David O Okonkwo
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - D Kojo Hamilton
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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Maheswaran A, Aiyer SN, Farouk O, El-Sharkawi M, Park JB, O’Brien A, Oluwole I, Wang Y, Arruda ADO, Rajasekaran S. Assessment of Interobserver Variability for CT Scan-Based Evaluation of Posterior Ligament Complex Injury in Thoracolumbar Fractures: An International Multicenter Pilot Study. Global Spine J 2020; 10:118-129. [PMID: 32206510 PMCID: PMC7076588 DOI: 10.1177/2192568219839414] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
STUDY DESIGN A multicenter, pilot study, for radiological assessment of thoracolumbar spine fractures was performed with the participation of 7 centers in Africa, Europe, Asia, and South America as a part of the AO Foundation network. OBJECTIVES To determine the interobserver variability for computed tomography (CT) scan-based evaluation of posterior ligament complex (PLC) injury in thoracolumbar fractures. METHODS Forty-two observers including 1 principal investigator at each participating center performed variability assessment. Each center contributed toward a total of 91 patient images with A3 or A4 thoracolumbar burst fractures (T11-L2) with or without suspected PLC injury. Pathological fractures, multilevel injuries, obvious posterior bony element injury and translation/dislocation injuries were excluded. Ten patients were randomly selected and commonly reported CT parameters indicating PLC injury, including superior inferior endplate angle, vertebral body height loss, local kyphotic deformity, interspinous distance and interpedicular distance were assessed for variability. Observer values were compared with an experienced gold rater in spinal trauma. Analysis of variability was performed for all observers, between the principal investigators and also between observers participating in each center. RESULTS The studied parameters showed considerable variability in measurements among all observers and amongst all participating centers. The variability between the principal investigators was lower, but still substantial. The deviation of observer measurements from the gold rater were also significant for all CT parameters. CONCLUSIONS CT-based radiological parameters previously reported to be suggestive of PLC injury showed considerable variability and magnetic resonance imaging verification of a PLC injury in all doubtful cases is suggested.
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Affiliation(s)
| | | | | | | | - Jong-Beom Park
- The Uijeongbu St Mary’s Hospital, Uijeongbu-si, South-Korea
| | | | - Ige Oluwole
- The Ondo State Trauma and Surgical Centre, Ondo State, Nigeria
| | - Yue Wang
- The First Hospital of Zhejiang University, Hangzhou, China
| | | | - Shanmuganathan Rajasekaran
- Ganga Hospital, Coimbatore, Tamil Nadu, India,Shanmuganathan Rajasekaran, Department of Spine Surgery, Ganga Hospital, Mettupalayam Road, Coimbatore 641043, Tamil Nadu, India.
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Maeda FL, Formentin C, de Andrade EJ, Rodrigues PAS, Goyal DKC, Shroeder GD, Patel AA, Vaccaro AR, Joaquim AF. Reliability of the New AOSpine Classification System for Upper Cervical Traumatic Injuries. Neurosurgery 2020; 86:E263-E270. [PMID: 31642504 DOI: 10.1093/neuros/nyz464] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Accepted: 08/18/2019] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND The new AOSpine Upper Cervical Classification System (UCCS) was recently proposed by the AOSpine Knowledge Forum Trauma team to standardize the treatment of upper cervical traumatic injuries (UCI). In this context, evaluating its reliability is paramount prior to clinical use. OBJECTIVE To evaluate the reliability of the new AOSpine UCCS. METHODS A total of 32 patients with UCI treated either nonoperatively or with surgery by one of the authors were included in the study. Injuries were classified based on the new AO UCCS according to site and injury type using computed tomography scan images in 3 planes by 8 researchers at 2 different times, with a minimum interval of 4 wk between assessments. Intra- and interobserver reliability was assessed using the kappa index (K). Treatment options suggested by the evaluators were also assessed. RESULTS Intraobserver agreement for sites ranged from 0.830 to 0.999, 0.691 to 0.983 for types, and 0.679 to 0.982 for the recommended treatment. Interobserver analysis at the first assessment was 0.862 for injury sites, 0.660 for types, and 0.585 for the treatment, and at the second assessment, it was 0.883 for injury sites, 0.603 for types, and 0.580 for the treatment. These results correspond to a high level of agreement of answers for the site and type analysis and a moderate agreement for the recommended treatment. CONCLUSION This study reported an acceptable reproducibility of the new AO UCCS and safety in recommending the treatment. Further clinical studies with a larger patient sample, multicenter and international, are necessary to sustain the universal and homogeneity quality of the new AO UCCS.
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Affiliation(s)
- Fernando Luís Maeda
- Neurosurgery Division, Department of Neurology, University of Campinas (UNICAMP), Campinas, Brazil
| | - Cleiton Formentin
- Neurosurgery Division, Department of Neurology, University of Campinas (UNICAMP), Campinas, Brazil
| | - Erion Júnior de Andrade
- Neurosurgery Division, Department of Neurology, University of Campinas (UNICAMP), Campinas, Brazil
| | | | - Dhruv K C Goyal
- Spine Fellowship, Rothman Orthopaedic Institute, Philadelphia, Pennsylvania
| | - Gregory D Shroeder
- Neurosurgery Division, Department of Neurology, University of Campinas (UNICAMP), Campinas, Brazil.,Department of Orthopedic Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Alpesh A Patel
- Department of Orthopaedic Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois.,Department of Neurosurgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Alexander R Vaccaro
- Neurosurgery Division, Department of Neurology, University of Campinas (UNICAMP), Campinas, Brazil.,Department of Orthopaedic Surgery, The Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania
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10
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Alijanipour P, Greif D, Lebwohl NH, Gjolaj JP. Isolated multiple lumbar transverse process fractures with spinal instability: an uncommon yet serious association. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2019; 29:127-132. [PMID: 31407163 DOI: 10.1007/s00586-019-06105-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Revised: 06/22/2019] [Accepted: 08/07/2019] [Indexed: 10/26/2022]
Abstract
PURPOSE Isolated vertebral transverse process fractures of thoracolumbar spine without other vertebral injuries and neurological deficit are generally considered as minor injuries with no concern for associated spinal instability. This report describes a case of multiple lumbar transverse fractures associated with an unexpected yet clinically significant spinal instability. METHODS A young male presented with right flank pain following being pushed and trapped against the ground by a reversing truck. The neurological examination was normal, and computed tomography (CT) imaging revealed multiple fractures at right transverse processes from L1 to L5, a single left-sided transverse process fracture at L2 and subtle facet joint distraction without other spinal lesions or visceral injuries. The injury was initially deemed as stable requiring symptomatic treatment and in-patient observation. However, discharge upright X-rays taken in a brace showed marked subluxation of L2/L3 and L3/L4 levels. RESULTS Magnetic resonance imaging revealed significant discoligamentous injuries involving anterior and posterior longitudinal ligaments, annulus fibrosus as well as posterior ligamentous complex. The patient underwent posterior spinal instrumentation and fusion of L1 to L5. CONCLUSIONS This is the first case description of association of multisegmental lumbar transverse process fractures with notoriously unstable injuries of the major soft-tissue stabilizers of the spine presenting subtle changes on CT images. When a seemingly benign spinal injury is caused by high-energy trauma, careful scrutiny for associated instability is needed. In this case, the standing in-brace X-ray was able to avoid a misdiagnosis and potentially unfavourable outcome.
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Affiliation(s)
- Pouya Alijanipour
- Department of Orthopaedic Surgery, University of Miami, Coral Gables, USA. .,Department of Orthopaedic Surgery, University of Miami Hospital, 1120 NW 14TH ST Suite 1240, Miami, FL, 33136-2107, USA.
| | - Dylan Greif
- Department of Orthopaedic Surgery, University of Miami, Coral Gables, USA
| | - Nathan H Lebwohl
- Department of Orthopaedic Surgery, University of Miami, Coral Gables, USA
| | - Joseph P Gjolaj
- Department of Orthopaedic Surgery, University of Miami, Coral Gables, USA
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Kadom N, Palasis S, Pruthi S, Biffl WL, Booth TN, Desai NK, Falcone RA, Jones JY, Joseph MM, Kulkarni AV, Marin JR, Milla SS, Mirsky DM, Myseros JS, Reitman C, Robertson RL, Ryan ME, Saigal G, Schulz J, Soares BP, Tekes A, Trout AT, Whitehead MT, Karmazyn B. ACR Appropriateness Criteria® Suspected Spine Trauma-Child. J Am Coll Radiol 2019; 16:S286-S299. [DOI: 10.1016/j.jacr.2019.02.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Accepted: 02/07/2019] [Indexed: 12/29/2022]
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12
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Abedi A, Mokkink LB, Zadegan SA, Paholpak P, Tamai K, Wang JC, Buser Z. Reliability and Validity of the AOSpine Thoracolumbar Injury Classification System: A Systematic Review. Global Spine J 2019; 9:231-242. [PMID: 30984504 PMCID: PMC6448204 DOI: 10.1177/2192568218806847] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
STUDY DESIGN Systematic review. OBJECTIVES The AOSpine thoracolumbar injury classification system (ATLICS) is a relatively simple yet comprehensive classification of spine injuries introduced in 2013. This systematic review summarizes the evidence on measurement properties of this new classification, particularly the reliability and validity of the main morphologic injury types with and without inclusion of the subtypes. METHODS A literature search was performed using PubMed and Embase in September 2016. A revised version of the COSMIN checklist was used for evaluation of the quality of studies. Two independent reviewers performed all steps of the review. RESULTS Nine articles were included in the final review, all of which evaluated the reliability of the ATLICS and had a fair methodological quality. The reliability of the modifiers was unknown. Overall, the quality of evidence for reliability of the morphologic and neurologic classification sections was low. However, there was moderate evidence for poor interobserver reliability of the morphologic classification when all subtypes were included, and moderate evidence for good intraobserver reliability with exclusion of subtypes. The reliability of the morphologic classification was independent of the observer's experience and cultural background. CONCLUSIONS ATLICS represents the most current system for evaluation of thoracolumbar injuries. Based on this review, further studies with robust methodological quality are needed to evaluate the measurement properties of ATLICS. Shortcomings of the reliability studies are discussed.
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Affiliation(s)
- Aidin Abedi
- University of Southern California, Los Angeles, CA, USA
| | - Lidwine B. Mokkink
- VU University Medical Center, Amsterdam, the Netherlands,Amsterdam Public Health Research Institute, Amsterdam, the Netherlands
| | | | | | | | | | - Zorica Buser
- University of Southern California, Los Angeles, CA, USA,Zorica Buser, Department of Orthopaedic Surgery,
Keck School of Medicine, University of Southern California, Los Angeles, CA 90033, USA.
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Khurana B, Karim SM, Zampini JM, Jimale H, Cho CH, Harris MB, Sodickson AD, Bono CM. Is focused magnetic resonance imaging adequate for treatment decision making in acute traumatic thoracic and lumbar spine fractures seen on whole spine computed tomography? Spine J 2019; 19:403-410. [PMID: 30145370 DOI: 10.1016/j.spinee.2018.08.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Revised: 08/06/2018] [Accepted: 08/17/2018] [Indexed: 02/03/2023]
Abstract
PURPOSE To assess whether a focused magnetic resonance imaging (MRI) limited to the region of known acute traumatic thoracic or lumbar fracture(s) would miss any clinically significant injuries that would change patient management. STUDY DESIGN/SETTING A multicenter retrospective clinical study. PATIENT SAMPLE Adult patients with acute traumatic thoracic and/or lumbar spine fracture(s). OUTCOME MEASURES Pathology identified on MRI (ligamentous disruption, epidural hematoma, and cord contusion), outside of the focused zone, an alteration in patient management, including surgical and nonsurgical, as a result of the identified pathology outside the focused zone. METHODS Records were reviewed for all adult trauma patients who presented to the emergency department between 2008 and 2016 with one or more fracture(s) of the thoracic and/or lumbar spine identified on computed tomography (CT) and who underwent MRI of the entire thoracic and lumbar spine within 10 days. Exclusion criteria were patients with >4 fractured levels, pathologic fractures, isolated transverse, and/or spinous process fractures, prior vertebral augmentation, and prior thoracic or lumbar spine instrumentation. Patients with neurologic deficits or cervical spine fractures were also included. MRIs were reviewed independently by one spine surgeon and one musculoskeletal fellowship-trained emergency radiologist for posterior ligamentous complex (PLC) integrity, vertebral injury, epidural hematoma, and cord contusion. The surgeon also commented on the clinical significance of the pathology identified outside the focused zone. All cases in which pathology was identified outside of the focused zone (three levels above and below the fractures) were independently reviewed by a second spine surgeon to determine whether the pathology was clinically significant and would alter the treatment plan. RESULTS In total, 126 patients with 216 fractures identified on CT were included, with a median age of 49 years. There were 81 males (64%). Sixty-two (49%) patients had isolated thoracolumbar junction injuries and 36 (29%) had injuries limited to a single fractured level. Forty-seven (37%) patients were managed operatively. PLC injury was identified by both readers in 36 (29%) patients with a percent agreement of 96% and κ coefficient of 0.91 (95% CI 0.87-0.95). Both readers independently agreed that there was no pathology identified on the complete thoracic and lumbar spine MRIs outside the focused zone in 107 (85%) patients. Injury outside the focused zone was identified by at least one reader in 19 (15%) patients. None of the readers identified PLC injury, cord edema, or noncontiguous epidural hematoma outside the focused zone. Percent agreement for outside pathology between the two readers was 92% with a κ coefficient of 0.60 (95% CI 0.48-0.72). The two spine surgeons independently agreed that none of the identified pathology outside of the focused zone altered management. CONCLUSIONS A focused MRI protocol of three levels above and below known thoracolumbar spine fractures would have missed radiological abnormality in 15% of patients. However, the pathology, such as vertebral body edema not appreciated on CT, was not clinically significant and did not alter patient care. Based on these findings, the investigators conclude that a focused protocol would decrease the imaging time while providing the information of the injured segment with minimal risk of missing any clinically significant injuries.
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Affiliation(s)
- Bharti Khurana
- Department of Radiology, Brigham and Women's Hospital, 75 Francis St, Boston, MA 02115, USA.
| | - S Mohammed Karim
- Department of Orthopedics, Brigham and Women's Hospital, 75 Francis St, Boston, MA 02115, USA
| | - Jay M Zampini
- Department of Orthopedics, Brigham and Women's Hospital, 75 Francis St, Boston, MA 02115, USA
| | - Hamdi Jimale
- Department of Orthopedics, Brigham and Women's Hospital, 75 Francis St, Boston, MA 02115, USA
| | - Charles H Cho
- Department of Radiology, Brigham and Women's Hospital, 75 Francis St, Boston, MA 02115, USA
| | - Mitchel B Harris
- Department of Orthopedics, Massachusetts General Hospital, 55 Fruit St, Boston, MA 02114, USA
| | - Aaron D Sodickson
- Department of Radiology, Brigham and Women's Hospital, 75 Francis St, Boston, MA 02115, USA
| | - Christopher M Bono
- Department of Orthopedics, Brigham and Women's Hospital, 75 Francis St, Boston, MA 02115, USA
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Clifton W, Rahmathulla G. A Case of Delayed Paraplegia Following Missed Diagnosis on Computed Tomography. Cureus 2019; 11:e4151. [PMID: 31058034 PMCID: PMC6488344 DOI: 10.7759/cureus.4151] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
There are many proposed classification systems for traumatic thoracolumbar fractures (TLF). More recently published are the AO Spine Classification System and the Thoraco-Lumbar Injury Classification System (TLICS). There has been a paucity of high-level evidence to link these classification system subtypes with clinical outcomes and/or management strategies. Previously, post-traumatic burst fractures or two column injuries identified on computed tomography (CT) scan have been deemed stable injuries. The addition of magnetic resonance imaging (MRI) evaluation for concomitant ligamentous injuries in cases of incomplete burst fractures has been widely debated without high-level evidence. In this report, we present a case of an incomplete burst fracture at L1, AO-A3, which did not receive an MRI and presented with delayed paraplegia four weeks later.
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Jiang L, Zhang H, Chen H, Wu Q. Kyphotic Angle of the Motion Segment Most Accurately Predicts Injury to the Ligamentous Complex on Computed Tomography Scan of Thoracolumbar Fractures. World Neurosurg 2018; 118:e405-e413. [DOI: 10.1016/j.wneu.2018.06.202] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Revised: 06/22/2018] [Accepted: 06/23/2018] [Indexed: 01/17/2023]
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Korovessis P, Mpountogianni E, Syrimpeis V. Percutaneous pedicle screw fixation plus kyphoplasty for thoracolumbar fractures A2, A3 and B2. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2016; 26:1492-1498. [PMID: 27554351 DOI: 10.1007/s00586-016-4743-6] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Revised: 06/19/2016] [Accepted: 08/08/2016] [Indexed: 11/29/2022]
Abstract
DESIGN Retrospective cohort. PURPOSE The aim of this study is to evaluate the effectiveness of percutaneous short fixation (PSFx) plus kyphoplasty (BP) for thoracolumbar fractures. METHODS Thirty-six consecutive selected patients, aged 59 ± 17 years, with fresh single thoracolumbar A2, A3, and B2 AO-type fracture, received PSFx plus BP. The primary outcomes pain, and vertebral body deformity; and the secondary outcomes screw malposition, facet violation, PMMA leakage, adjacent segment degeneration (ASD) and loss of correction were evaluated. The f/up was 31 ± 7 months. RESULTS Pain and kyphosis decreased and vertebral body heights increased significantly postoperation. PMMA leakage occurred in five cases; 6 (4 %) screws were grades III malpositioned in relation to pedicle; facet violation occurred in 8 (5.5 %) facets; loss of kyphosis correction was 3.68°; ASD occurred in two cases; interfacet fusion in ten (28 %) patients; Three patients were reoperated for different reasons. CONCLUSIONS PSFx plus BP for thoracolumbar fractures reduces significantly spinal deformity and pain with few complications.
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Burst Fractures in the Thoracolumbar Junction: What Do We Know About Their Treatment? ARCHIVES OF NEUROSCIENCE 2016. [DOI: 10.5812/archneurosci.39949] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Chen JX, Goswami A, Xu DL, Xuan J, Jin HM, Xu HM, Zhou F, Wang YL, Wang XY. The radiologic assessment of posterior ligamentous complex injury in patients with thoracolumbar fracture. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2016; 26:1454-1462. [DOI: 10.1007/s00586-016-4687-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/29/2015] [Revised: 06/22/2016] [Accepted: 06/29/2016] [Indexed: 10/21/2022]
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Another diagnostic tool in thoracolumbar posterior ligament complex injury: interspinous distance ratio. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2016; 26:1447-1453. [DOI: 10.1007/s00586-016-4662-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/13/2015] [Revised: 05/30/2016] [Accepted: 06/15/2016] [Indexed: 10/21/2022]
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