Congress of Neurological Surgeons Systematic Review and Evidence-Based Guidelines on the Evaluation and Treatment of Patients With Thoracolumbar Spine Trauma: Radiological Evaluation

Canadian Association of Radiologists Trauma Diagnostic Imaging Referral Guideline

The Canadian Association of Radiologists (CAR) Trauma Expert Panel consists of adult and pediatric emergency and trauma radiologists, emergency physicians, a family physician, a patient advisor, and an epidemiologist/guideline methodologist. After developing a list of 21 clinical/diagnostic scenarios, a systematic rapid scoping review was undertaken to identify systematically produced referral guidelines that provide recommendations for 1 or more of these clinical/diagnostic scenarios. Recommendations from 49 guidelines and contextualization criteria in the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) for guidelines framework were used to develop 50 recommendation statements across the 21 scenarios related to the evaluation of traumatic injuries. This guideline presents the methods of development and the recommendations for head, face, neck, spine, hip/pelvis, arms, legs, superficial soft tissue injury foreign body, chest, abdomen, and non-accidental trauma.

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/ .

Thoracic and Lumbar Spine Injury: Evidence-Based Diagnosis, Management, and Outcomes

BACKGROUND

Traumatic thoracolumbar spine injuries are associated with significant morbidity and mortality. Targeted for non-spine specialist trauma surgeons, this systematic scoping review aimed to examine literature for up-to-date evidence on presentation, management, and outcomes of thoracolumbar spine injuries in adult trauma patients.

METHODS

This review was reported using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist. We searched four bibliographic databases: PubMed, EMBASE, Web of Science, and the Cochrane Library. Eligible studies included experimental, observational, and evidence-synthesis articles evaluating patients with thoracic, lumbar, or thoracolumbar spine injury, published in English between January 1, 2010 and January 31, 2021. Studies which focused on animals, cadavers, cohorts with N <30, and pediatric cohorts (age <18 years old), as well as case studies, abstracts, and commentaries were excluded.

RESULTS

A total of 2501 studies were screened, of which 326 unique studies were fully text reviewed and twelve aspects of injury management were identified and discussed: injury patterns, determination of injury status and imaging options, considerations in management, and patient quality of life. We found: (1) imaging is a necessary diagnostic tool, (2) no consensus exists for preferred injury characterization scoring systems, (3) operative management should be considered for unstable fractures, decompression, and deformity, and (4) certain patients experience significant burden following injury.

DISCUSSION

In this systematic scoping review, we present the most up-to-date information regarding the management of traumatic thoracolumbar spine injuries. This allows non-specialist trauma surgeons to become more familiar with thoracolumbar spine injuries in trauma patients and provides a framework for their management.

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.

How Often Would MRI Change the Thoracolumbar Fracture Classification or Decision-Making Compared to CT Alone?

STUDY DESIGN

retrospective study of consecutive patients.

OBJECTIVE

to analyze the frequency of change in Thoracolumbar fractures (TLFs) classification or decision-making after MRI compared by CT alone.

METHODS

A retrospective review of 244 consecutive patients with acute TLFs (T1-L5) presented to a single level 1 trauma center between 2014 and 2021. Three and 4 reviewers independently classified all fractures according to AOSpine and AOSpine injury severity score (TLAOSIS) by CT then MRI, respectively. Posterior ligamentous complex Injury (PLC) was diagnosed on CT and MRI by ≥ 2 positive CT findings and Black stripe discontinuity.

RESULTS

MRI changed AO classification in 25/244 patients (10.2%, P < .0001) due to an 8.2% upgrade from type A to type B and a 2% downgrade from type B to type A. The addition of MRI changed TL AOSIS among the 3 treatment recommendation groups in 35/244 (19.7%, 95% CI [14.9%-25.2%]. The best predictor of upgrade from type A to type B and downgrade from type B to type A was a single positive CT finding and the presence of only 2 CT signs as opposed to ≥3 signs, respectively (P < .0001 P = .03, respectively). Thoracic fractures showed a significantly higher reclassification rate than thoracolumbar and low lumbar (20% vs 10% and 0%, respectively, P = .07).

CONCLUSION

using appropriate CT/MRI criteria for PLC injury, MRI changed the AOSpine classification by 10% and TLAOSIS based treatment by 19.7%. The best predictors of fracture reclassification by MRI were the number of positive CT findings and fracture level.

Injury patterns of the spine following blunt trauma: A per-segment analysis of spinal structures and their detection rates in CT and MRI

Rationale and objectives

To provide a detailed analysis of injury patterns of the spine following blunt trauma and establish the role of supplementary MRI by evaluating discrepancies in the detection rates of damaged structures in CT and MRI.

Method

216 patients with blunt trauma to the spine who underwent CT followed by supplementary MRI were included in this study. Two board-certified radiologists blinded to clinical symptoms and injury mechanisms independently interpreted all acquired CT and MRI images. The interpretation was performed using a dedicated catalogue of typical findings associated with spinal trauma and assessed for spinal stability using the AO classification systems.

Results

Lesions to structures associated with spinal instability were present in 31.0% in the cervical spine, 12.3% in the thoracic spine, and 29.9% in the lumbar spine. In all spinal segments, MRI provided additional information regarding potentially unstable injuries. Novel information derived from supplementary MRI changed clinical management in 3.6% of patients with injury to the cervical spine. No change in clinical management resulted from novel information on the thoracolumbar spine. Patients with injuries to the vertebral body, intervertebral disc, or spinous process were significantly more likely to benefit from supplementary MRI.

Conclusion

In patients that sustained blunt spinal trauma, supplementary MRI of the cervical spine should routinely be performed to detect injuries that require surgical treatment, whereas CT is the superior imaging modality for the detection of unstable injuries in the thoracolumbar spine.

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.

Is magnetic resonance imaging needed for decision making diagnosis and treatment of thoracic and lumbar vertebral fractures?

PURPOSE

The radiological examination including plain radiography, CT and MRI are critical to assess the severity of the instability, to diagnose the fracture type and to select the appropriate treatment strategy for the thoracic and lumbar vertebral fractures. The aim of this prospective observational study was to investigate the effect of magnetic resonance imaging (MRI) on decision making for the diagnosis and treatment of acute thoracic and lumbar vertebral fractures.

METHODS

Consecutive 180 patients with acute thoracic and/or lumbar vertebral fractures were included in the study. The fracture pattern was evaluated by using initial radiographs, computed tomography (CT) and MRI within 24 h of trauma. Fractures were classified according to AO classification before and after MRI. TLICS classification was also used to decide treatment plan. MRI findings were compared to surgical findings in the surgically treated patients.

RESULTS

A significant moderate agreement was found between Xray + CT and post-MRI classifications for all fracture types (Kappa = 0.511; p < 0.001). In 101 patients with new findings on MRI, a significant moderate correlation was observed between Xray + CT and post-MRI classifications in the fracture re-classification (Kappa = 0.441, p < 0.001). There was a significant change in the treatment plan of patients with new findings on MRI according to Xray + CT (p < 0.0001). After MRI evaluation, the treatment plan changed in favor of surgery in 33.9% of patients who were scheduled for conservative treatment according to Xray + CT (p < 0.0001).

CONCLUSION

Since MRI assessment of acute thoracic and/or lumbar injuries has led to a remarkable treatment change decision that confirms intraoperative findings of the patients who were decided to undergo surgery, MRI should be obtained in thoracic and lumbar vertebral fractures, regardless of the CT and plain radiographic findings.

LEVEL OF EVIDENCE

Level II, prospective observational study.

Thoracic and lumbar spine trauma classification systems fail to predict post-traumatic kyphotic deformity

Background

Post-traumatic kyphosis of the thoracic and lumbar spine can lead to pain and decreased function. MRI has been advocated to assess ligament integrity and risk of kyphosis.

Methods

All thoracic and lumbar spine MRI performed for evaluation of trauma over a 3-year period at a single institution were reviewed. Patients were included if there was an MRI showing a vertebral body fracture and follow-up radiographs. Two observers retrospectively reviewed all radiographs, CT and MRI scans, and classified injuries based on the Denis, TLICS, AO and load sharing classification systems. Change in kyphosis between injury and follow-up studies was measured. The initial radiology reports made at time of patient injury were compared to the retrospective interpretations.

Results

There were 67 separate injuries in 62 patients. Kyphosis measuring ≥ 10° developed despite an intact PLC in 6/14 nonoperative cases, and 3/7 surgically treated cases; when PLC was partially injured, it developed in 6/10 cases (8 treated nonoperatively, 2 treated operatively. Thirty injuries had complete disruption of PLC by MRI, 24 treated with fusion. Kyphosis ≥ 10° developed in 3/6 treated nonoperatively, and 8/24 treated with fusion. Development of kyphosis was independent of degree of vertebral body comminution. It developed equally in patients with Grade 2 and Grade 3 Denis injuries. It developed in patients with intact PLC when multiple vertebrae were involved and/or there was compressive injury to anterior longitudinal ligament (ALL). There was high interobserver variability in assessment of severity of ligamentous injury on MRI.

Conclusions

Classification systems of thoracic and lumbar spine injury and integrity of the PLC failed to predict the risk of development of post-traumatic kyphotic deformity.

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

OBJECTIVE

This bibliometric review of literature on posterior ligamentous complex (PLC) injury in thoracolumbar (TL) trauma aims to guide future research.

METHODS

We conducted a keyword-based search from January 2000 to September 2021 using the Scopus database. Relevant publications were analyzed for the year of publication, authorship, publishing journals, institution and country of origin, subject matter, and article type. In addition, content analysis of clinical articles was performed, analyzing for sample size, study design (retrospective vs. prospective), single vs. multicenter, and level of evidence.

RESULTS

262 publications have been published in 61 journals by 537 authors, 162 institutions, and 29 countries. Thomas Jefferson University, the University of Calgary, and the University of Toronto have the largest number of publications related to PLC injury. The United States, Canada, and China were the most frequent contributors in terms of the number of publications. Spine was the most prolific and top-cited Journal, while Vaccaro A.R. was the most prolific author. The most cited publication was the Thoracolumbar Injury Classification and Severity Score (TLICS) classification by Vaccaro et al. in 2005. Most of the publications have been case studies, with diagnostic accuracy being the most frequently discussed topic. The sample size for a large portion of the case series was less than 50. The majority of case series were retrospective studies conducted at a single center.

CONCLUSION

Our review provides an extensive list of the most historically significant spinal imaging articles, acknowledging the key contributions made to the advancement of this research area.

Traumatic low lumbar fractures: How often MRI changes the fracture classification or clinical decision-making compared to CT alone?

PURPOSE

To determine the impact of magnetic resonance imaging (MRI) on fracture classification for low lumbar fractures (LLFs) compared to CT alone.

METHODS

This study was a retrospective review of 41 consecutive patients with LLFs who underwent CT and MRI within 10 days of injury. Three reviewers classified all fractures according to AOSpine Classification and the Thoracolumbar Injury Classification (TLISS). Posterior ligamentous complex (PLC) injury in MRI was defined by black stripe discontinuity and in CT by the presence of: vertebral body translation, facet joint malalignment, horizontal laminar or spinous process fracture, and interspinous widening. The proportion of patients with AO type A/B/C and with TLISS < 5 and ≥ 5 was compared between CT and MRI. We examined the overall accuracy and individual CT findings for PLC injury.

RESULTS

AO classification using CT was: AO type A in 26 patients (61%), type B in 7 patients (17%), and type C in 8 patients (22%). Seventeen patients (41%) had a TLISS ≥ 5 while 24 (59%) had TLISS < 5. The addition of MRI after CT changed the AO classification in only 2 patients (4.9%, 95% CI (0.6-16.5%) due to upgrade of type A to type B or vice versa, but did not change TLISS from < 5 to ≥ 5 [p< 0.0001; 95% CI (0.59, 0.77)].

CONCLUSIONS

CT was highly accurate (95%) for diagnosis of PLC injury in LLFs. Addition of MRI after CT did not change the AO classification or TLISS, compared to CT alone, thus suggesting limited additional value of MRI for PLC assessment or fracture classification.

Analysis of the Combined Computed Tomography Findings Improves the Accuracy of Computed Tomography for Detecting Posterior Ligamentous Complex Injury of the Thoracolumbar Spine as Defined by Magnetic Resonance Imaging

OBJECTIVE

To determine the diagnostic accuracy of combined computed tomography (CT) findings for detecting posterior ligamentous complex (PLC) injury in thoracolumbar fractures using magnetic resonance imaging as a reference.

METHODS

A retrospective review of 263 consecutive patients with thoracolumbar fractures who underwent CT and magnetic resonance imaging within 10 days of injury. Two reviewers evaluated CT for the following findings: facet joint malalignment, facet joint widening, horizontal laminar fracture, spinous process fracture, and interspinous widening. We examined the independent association of CT findings with PLC injury before combining the CT findings to calculate the diagnostic accuracy: sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV), and positive and negative likelihood ratios. PLC injury was defined by black stripe discontinuity caused by supraspinous or ligamentum flavum rupture.

RESULTS

Facet joint malalignment, spinous process fracture, horizontal laminar fracture, and interspinous widening were independently associated with PLC injury (adjusted odds ratio range, 4.4e17.4). A single positive CT finding yielded a PPV of 31% and NPV of 66% for PLC injury. Two or more CT findings yielded a PPV of 91% for PLC injury. A negative CT for all the 4 CT sings had a 94% NPV for PLC injury.

CONCLUSIONS

Two or more CT findings provided the best combination to confirm PLC injury; thus, this combination could be used as a criterion for injured PLC. A single CT finding lacks sufficient predictive value to confirm or rule out PLC injury. A negative CT for the 4 CT findings provided the highest sensitivity for PLC injuries.

Achieving Value in Spine Surgery: 10 Major Cost Contributors

STUDY DESIGN

Narrative Review.

OBJECTIVES

The increasing cost of healthcare overall and for spine surgery, coupled with the growing burden of spine-related disease and rising demand have necessitated a shift in practice standards with a new emphasis on value-based care. Despite multiple attempts to reconcile the discrepancy between national recommendations for appropriate use and the patterns of use employed in clinical practice, resources continue to be overused-often in the absence of any demonstrable clinical benefit. The following discussion illustrates 10 areas for further research and quality improvement.

METHODS

We present a narrative review of the literature regarding 10 features in spine surgery which are characterized by substantial disproportionate costs and minimal-if any-clear benefit. Discussion items were generated from a service-wide poll; topics mentioned with great frequency or emphasis were considered. Items are not listed in hierarchical order, nor is the list comprehensive.

RESULTS

We describe the cost and clinical data for the following 10 items: Over-referral, Over-imaging & Overdiagnosis; Advanced Imaging for Low Back Pain; Advanced imaging for C-Spine Clearance; Advanced Imaging for Other Spinal Trauma; Neuromonitoring for Cervical Spine; Neuromonitoring for Lumbar Spine/Single-Level Surgery; Bracing & Spinal Orthotics; Biologics; Robotic Assistance; Unnecessary perioperative testing.

CONCLUSIONS

In the pursuit of value in spine surgery we must define what quality is, and what costs we are willing to pay for each theoretical unit of quality. We illustrate 10 areas for future research and quality improvement initiatives, which are at present overpriced and underbeneficial.

Extracellular Vesicles: Novel Roles in Neurological Disorders

Exosomes are small extracellular vesicles (EVs) secreted by almost all cells, which have been recognized as a novel platform for intercellular communication in the central nervous system (CNS). Exosomes are capable of transferring proteins, nucleic acids, lipids, and metabolites between neurons and glial cells, contributing to CNS development and maintenance of homeostasis. Evidence shows that exosomes originating from CNS cells act as suppressors or promoters in the initiation and progression of neurological disorders. Moreover, these exosomes have been shown to transfer molecules associated with diseases through the blood-brain barrier (BBB) and thus can be detected in blood. This unique feature enables exosomes to act as potential diagnostic biomarkers for neurological disorders. In addition, a substantial number of researches have indicated that exosomes derived from mesenchymal stem cells (MSCs) have repair effects on neurological disorders. Herein, we briefly introduce the roles of exosomes under physiological and pathological conditions. In particular, novel roles of exosomes as potential diagnostic biomarkers and therapeutic tools for neurological disorders are highlighted.

Early Management of Spinal Cord Injury: WFNS Spine Committee Recommendations

Scientific knowledge today is being generated more rapidly than we can assimilate thus requiring continuous review of gold-standards for diagnosis and treatment of specific pathologies. The aim of this paper is to provide an update on the best early management of spinal cord injury (SCI), in order to produce acceptable worldwide recommendations to standardize clinical practice as much as possible.The WFNS Spine Committee voted recommendations regarding management of SCI based on literature review of the last 10 years. The committee stated 9 recommendations on 3 main topics: (1) clinical assessment and classification of SCI; (2) emergency care and early management; (3) cardiopulmonary management. American Spinal Injury Association impairment scale, Spinal Cord Independence Measure, and International Spinal Cord Injury Basic Pain Data Set are considered the most useful and feasible in emergency evaluation and follow-up in case of SCI. Magnetic resonance imaging is the most indicated examination to evaluate patients with symptomatic SCI. In early phase, correction of hypotension (systolic blood pressure < 90 mmHg), and bradycardia are strongly recommended. Surgical decompression should be performed as soon as possible with the ideal surgical time being within 8 hours for both complete and incomplete lesions.