Injury of the thoracolumbar posterior ligamentous complex : a bibliometric literature review

How frequently MRI modifies thoracolumbar fractures' classification or decision-making? A systematic review and meta-analysis

PURPOSE

To provide the first meta-analysis of the impact of magnetic resonance imaging (MRI) on thoracolumbar fractures (TLFs) classification and decision-making.

METHODS

A systematic review was conducted following PRISMA guidelines. We searched PubMed, Scopus, Cochrane, and Web of Science from inception to June 30, 2023 for studies evaluating the change in TLFs classification and treatment decisions after MRI. The studies extracted key findings, objectives, and patient population. A meta-analysis was performed for the pooled frequency of change in AO fracture classification or treatment decisions from surgical to conservative or vice versa after MRI.

RESULTS

This meta-analysis included four studies comprising 554 patients. The pooled frequency of change in TLFs classification was 17% (95% CI 9-31%), and treatment decision was 22% (95% CI 11-40%). An upgrade from type A to type B was reported in 15.7% (95% CI 7.2-30.6%), and downgrading type B to type A in 1.2% (95% CI 0.17-8.3%). A change from conservative to surgery recommendation of 17% (95% CI 5.0-43%) was higher than a change from surgery to conservative 2% (95% CI 1-34%).

CONCLUSIONS

MRI can significantly change the thoracolumbar classification and decision-making, primarily due to upgrading type A to type B fractures and changing from conservative to surgery, respectively. These findings suggest that MRI could change decision-making sufficiently to justify its use for TLFs. Type A subtypes, indeterminate PLC status, and spine regions might help to predict a change in TLFs' classification. However, more studies are needed to confirm the association of these variables with changes in treatment decisions to set the indications of MRI in neurologically intact patients with TLFs. An interactive version of our analysis can be accessed from here: https://databoard.shinyapps.io/mri_spine/ .

Towards a standardized reporting of the impact of magnetic resonance imaging on the decision-making of thoracolumbar fractures without neurological deficit: Conceptual framework and proposed methodology

Introduction

A recent meta-analysis showed that only four prior studies have shown that magnetic resonance imaging (MRI) can change the fracture classification in 17% and treatment decisions in 22% of cases. However, previous studies showed a wide methodological variability regarding the study population, the definition of posterior ligamentous complex (PLC) injury, and outcome measures.

Research question

How can we standardize the reporting of the impact of MRI for neurologically intact patients with thoracolumbar fractures?

Material and methods

All available literature regarding the impact of MRI on thoracolumbar fracture classification or decision-making were reviewed. Estimating the impact of MRI on the TLFs' classification is an exercise of analyzing the CTs' accuracy for PLC injury against MRI as a ''Gold standard''and should follow standardized checklists such as the Standards for the Reporting of Diagnostic Accuracy Studies. Additionally, specific issues related to TLFs should be addressed.

Results

A standardized approach for reporting the impact of MRI in neurologically intact TLF patients was proposed. Regarding patient selection, restricting the inclusion of neurologically intact patients with A- and B-injuries is crucial. Image interpretation should be standardized regarding imaging protocol and appropriate criteria for PLC injury. The impact of MRI can be measured by either the rate of change in fracture classification or treatment decisions; the cons and pros of each measure is thoroughly discussed.

Discussion and conclusion

We proposed a structured methodology for examining the impact of MRI on neurologically intact patients with TLFs, focusing on appropriate patient selection, standardizing image analysis, and clinically relevant outcome measures.

The Influence of Comminution and Posterior Ligamentous Complex Integrity on Treatment Decision Making in Thoracolumbar Burst Fractures Without Neurologic Deficit?

STUDY DESIGN

A prospective study.

OBJECTIVE

to evaluate the impact of vertebral body comminution and Posterior Ligamentous Complex (PLC) integrity on the treatment recommendations of thoracolumbar fractures among an expert panel of 22 spine surgeons.

METHODS

A review of 183 prospectively collected thoracolumbar burst fracture computed tomography (CT) scans by an expert panel of 22 trauma spine surgeons to assess vertebral body comminution and PLC integrity. This study is a sub-study of a prospective observational study of thoracolumbar burst fractures (Spine TL A3/A4). Each expert was asked to grade the degree of comminution and certainty about the PLC disruption from 0 to 100, with 0 representing the intact vertebral body or intact PLC and 100 representing complete comminution or complete PLC disruption, respectively.

RESULTS

≥45% comminution had a 74% chance of having surgery recommended, while <25% comminution had an 86.3% chance of non-surgical treatment. A comminution from 25 to 45% had a 57% chance of non-surgical management. ≥55% PLC injury certainity had a 97% chance of having surgery, and ≥45-55% PLC injury certainty had a 65%. <20% PLC injury had a 64% chance of having non-operative treatment. A 20 to 45% PLC injury certainity had a 56% chance of non-surgical management. There was fair inter-rater agreement on the degree of comminution (ICC .57 [95% CI 0.52-.63]) and the PLC integrity (ICC .42 [95% CI 0.37-.48]).

CONCLUSION

The study concludes that vetebral comminution and PLC integrity are major dterminant in decision making of thoracolumbar fractures without neurological deficit. However, more objective, reliable, and accurate methods of assessment of these variables are warranted.

Worldwide Research Trends on Transvenous Embolization of Brain Arteriovenous Malformations: A Bibliometric and Visualized Study

BACKGROUND

Transvenous embolization (TVE) of brain arteriovenous malformations (bAVMs) is an emerging endovascular technique that has shown high cure rates in selected cases. The rationale of our study was to determine authorship and worldwide institutional trends and contributions to the knowledge in this topic.

METHODS

Web of Science database was used. A total of 63 articles were included based on predefined inclusion criteria, which were manually reviewed. The bibliometric analysis involved the use of quantitative bibliometric indicators and network analysis with co-authorship and co-occurrence of terms, which were performed using the bibliometrix package in R and VOSviewer, respectively.

RESULTS

The first article was published in 2010, with the largest number of articles published in 2022 (10 articles). The average number of citations per document was 11.38, and the annual growth rate was 14.35%. The top 10 authors with the most scientific production on TVE of bAVMs were from France, and the most cited study was published by Iosif C in 2015, followed by Consoli A in 2013, and Chen CJ in 2018. Journal of Neurointerventional Surgery was the journal with the most articles published. The most commonly used keywords were dural arteriovenous fistula, Onyx, vascular disorders, and neurological surgery around 2016, and intervention around 2021.

CONCLUSIONS

TVE of bAVMs is an emerging technique. Our search identified some scientific articles, without randomized clinical trials, but many case series from single institutions. French and German institutions are the pioneers in the field, and further research is required in specialized endovascular centers.

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

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.

Which Morphological Features of Facet Diastasis Predict Thoracolumbar Posterior Ligamentous Complex Injury as Defined by Magnetic Resonance Imaging?

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.