The Influence of Spine Surgeons' Experience on the Classification and Intraobserver Reliability of the Novel AOSpine Thoracolumbar Spine Injury Classification System-An International Study

Percutaneous reduction of thoracolumbar fractures using monoaxial screws: Comparison of two instruments based on initial reduction and loss of reduction

Introduction

Percutaneous techniques for the surgical treatment of vertebral fractures are constantly progressing. There are different biomechanics involved.

Research question

Two percutaneous, monoaxial fixation systems with different reduction tools were analyzed in relation to their reduction capacity. Additionally, the impact of anterior fusion, fracture severity and bone quality on reduction and loss of reduction were examined.

Material and methods

117 cases were retrospectively included in the monocentric study. The subsample (N = 53) with complete data at follow-up times was used to analyze the influence of anterior fusion. The dependencies on fracture severity and bone quality were determined using Spearman and Pearson correlation.

Results

Both systems achieved equally good reduction (9° mean, 95%-CI: 8°-11°, p < 0.001). Anterior fused patients showed not significant (p = 0.057) less loss of reduction over time. Fracture severity had neither an influence on reduction or loss of reduction. Bone quality was positively correlated with greater amount of reduction and less loss of reduction. Early reduction within two days correlated with a greater amount of reduction (p = 0.006). Screw diameters and the patient's weight had no influence on loss of reduction. Complications occurred only in "V2" group.

Discussion and conclusion

Both systems are equivalent in reduction ability. The additional anterior fusion did not result in significantly lower reduction losses. The subsample being small, is a limitation. Good bone quality correlates with better initial reduction and less reduction loss. A preoperative bone density measurement can lead to optimization of surgical techniques.

The Surgical Algorithm for the AO Spine Sacral Injury Classification System

STUDY DESIGN

Global cross-sectional survey.

OBJECTIVE

To establish a surgical algorithm for sacral fractures based on the Arbeitsgemeinschaft für Osteosynthesefragen (AO) Spine Sacral Injury Classification System.

SUMMARY OF BACKGROUND DATA

Although the AO Spine Sacral Injury Classification has been validated across an international audience of surgeons, a consensus on a surgical algorithm for sacral fractures using the Sacral AO Spine Injury Score (Sacral AOSIS) has yet to be developed.

METHODS

A survey was sent to general orthopedic surgeons, orthopedic spine surgeons, and neurosurgeons across the five AO spine regions of the world. Descriptions of controversial sacral injuries based on different fracture subtypes were given, and surgeons were asked whether the patient should undergo operative or nonoperative management. The results of the survey were used to create a surgical algorithm based on each subtype's sacral AOSIS.

RESULTS

An international agreement of 70% was decided on by the AO Spine Knowledge Forum Trauma experts to indicate a recommendation of initial operative intervention. Using this, sacral fracture subtypes of AOSIS 5 or greater were considered operative, while those with AOSIS 4 or less were generally nonoperative. For subtypes with an AOSIS of 3 or 4, if the sacral fracture was associated with an anterior pelvic ring injury (M3 case-specific modifier), intervention should be left to the surgeons' discretion.

CONCLUSION

The AO Spine Sacral Injury Classification System offers a validated hierarchical system to approach sacral injuries. Through multispecialty and global surgeon input, a surgical algorithm was developed to determine appropriate operative indications for sacral trauma. Further validation is required, but this algorithm provides surgeons across the world with the basis for discussion and the development of standards of care and treatment.

Expert Opinion, Real-World Classification, and Decision-Making in Thoracolumbar Burst Fractures Without Neurologic Deficits?

STUDY DESIGN

Retrospective analysis of prospectively collected data.

OBJECTIVES

To compare decision-making between an expert panel and real-world spine surgeons in thoracolumbar burst fractures (TLBFs) without neurological deficits and analyze which factors influence surgical decision-making.

METHODS

This study is a sub-analysis of a prospective observational study in TL fractures. Twenty two experts were asked to review 183 CT scans and recommend treatment for each fracture. The expert recommendation was based on radiographic review.

RESULTS

Overall agreement between the expert panel and real-world surgeons regarding surgery was 63.2%. In 36.8% of cases, the expert panel recommended surgery that was not performed in real-world scenarios. Conversely, in cases where the expert panel recommended non-surgical treatment, only 38.6% received non-surgical treatment, while 61.4% underwent surgery. A separate analysis of A3 and A4 fractures revealed that expert panel recommended surgery for 30% of A3 injuries and 68% of A4 injuries. However, 61% of patients with both A3 and A4 fractures received surgery in the real world. Multivariate analysis demonstrated that a 1% increase in certainty of PLC injury led to a 4% increase in surgery recommendation among the expert panel, while a .2% increase in the likelihood of receiving surgery in the real world.

CONCLUSION

Surgical decision-making varied between the expert panel and real-world treating surgeons. Differences appear to be less evident in A3/A4 burst fractures making this specific group of fractures a real challenge independent of the level of expertise.

The AO Spine Thoracolumbar Injury Classification System and Treatment Algorithm in Decision Making for Thoracolumbar Burst Fractures Without Neurologic Deficit

STUDY DESIGN

Prospective Observational Study.

OBJECTIVE

To determine the alignment of the AO Spine Thoracolumbar Injury Classification system and treatment algorithm with contemporary surgical decision making.

METHODS

183 cases of thoracolumbar burst fractures were reviewed by 22 AO Spine Knowledge Forum Trauma experts. These experienced clinicians classified the fracture morphology, integrity of the posterior ligamentous complex and degree of comminution. Management recommendations were collected.

RESULTS

There was a statistically significant stepwise increase in rates of operative management with escalating category of injury (P < .001). An excellent correlation existed between recommended expert management and the actual treatment of each injury category: A0/A1/A2 (OR 1.09, 95% CI 0.70-1.69, P = .71), A3/4 (OR 1.62, 95% CI 0.98-2.66, P = .58) and B1/B2/C (1.00, 95% CI 0.87-1.14, P = .99). Thoracolumbar A4 fractures were more likely to be surgically stabilized than A3 fractures (68.2% vs 30.9%, P < .001). A modifier indicating indeterminate ligamentous injury increased the rate of operative management when comparing type B and C injuries to type A3/A4 injuries (OR 39.19, 95% CI 20.84-73.69, P < .01 vs OR 27.72, 95% CI 14.68-52.33, P < .01).

CONCLUSIONS

The AO Spine Thoracolumbar Injury Classification system introduces fracture morphology in a rational and hierarchical manner of escalating severity. Thoracolumbar A4 complete burst fractures were more likely to be operatively managed than A3 fractures. Flexion-distraction type B injuries and translational type C injuries were much more likely to have surgery recommended than type A fractures regardless of the M1 modifier. A suspected posterior ligamentous injury increased the likelihood of surgeons favoring surgical stabilization.

The Influence of Surgeon Experience and Subspeciality on the Reliability of the AO Spine Sacral Classification System

STUDY DESIGN

Cross-sectional survey.

OBJECTIVE

To determine the influence of surgeons' level of experience and subspeciality training on the reliability, reproducibility, and accuracy of sacral fracture classification using the Arbeitsgemeinschaft für Osteosynthesefragen Spine Sacral Classification System.

SUMMARY OF BACKGROUND DATA

A surgeons' level of experience or subspecialty may have a significant effect on the reliability and accuracy of sacral classification given various levels of comfort with imaging assessment required for accurate diagnosis and classification.

METHODS

High-resolution computerized tomography (CT) images from 26 cases were assessed on two separate occasions by 172 investigators representing a diverse array of surgical subspecialities (general orthopedics, neurosurgery, orthopedic spine, orthopedic trauma) and experience (<5, 5-10, 11-20, >20 yrs). Reliability and reproducibility were calculated with Cohen kappa coefficient (k) and gold standard classification agreement was determined for each fracture morphology and subtype and stratified by experience and subspeciality.

RESULTS

Respondents achieved an overall k = 0.87 for morphology and k = 0.77 for subtype classification, representing excellent and substantial intraobserver reproducibility, respectively. Respondents from all four practice experience groups demonstrated excellent interobserver reliability when classifying overall morphology (k = 0.842/0.850, Assessment 1/Assessment 2) and substantial interobserver reliability in overall subtype (k = 0.719/0.751) in both assessments. General orthopedists, neurosurgeons, and orthopedic spine surgeons exhibited excellent interobserver reliability in overall morphology classification and substantial interobserver reliability in overall subtype classification. Surgeons in each experience category and subspecialty correctly classified fracture morphology in over 90% of cases and fracture subtype in over 80% of cases according to the gold standard. Correct overall classification of fracture morphology (Assessment 1: P = 0.024, Assessment 2: P = 0.006) and subtype (P2 < 0.001) differed significantly by years of experience but not by subspecialty.

CONCLUSION

Overall, the Arbeitsgemeinschaft für Osteosynthesefragen spine sacral classification system appears to be universally applicable among surgeons of various subspecialties and levels of experience with acceptable reliability, reproducibility, and accuracy.Level of Evidence: 4.

Interrater and Intrarater Reliability of the Vertebral Bone Quality Score

BACKGROUND

Vertebral bone quality had a significant impact on postoperative outcomes in spinal fusion surgery. New magnetic resonance imaging-based measures, such as the Vertebral Bone Quality (VBQ) score, may allow for bone quality assessment without the radiation associated with conventional testing. In the present study, we sought to assess the intrarater and interrater reliability of VBQ scores calculated by medical professionals and trainees.

METHODS

Thirteen reviewers of various specialties and levels of training were recruited and asked to calculate VBQ scores for 30 patients at 2 time points separated by 2 months. Scored volumes were acquired from patients treated for both degenerative and oncologic indications. Intrarater and interrater agreement, quantified by intraclass correlation coefficient (ICC), was assessed using 2-way random effects modeling. Square-weight Cohen κ and Kendall Tau-b were used to determine whether raters assigned similar scores during both evaluations.

RESULTS

All raters showed moderate to excellent reliability for VBQ score (ICC 0.667-0.957; κ0.648-0.921) and excellent reliability for all constituent components used to calculate VBQ score (ICC all ≥0.97). Interrater reliability was also found to be good for VBQ score on both the first (ICC = 0.818) and second (ICC = 0.800) rounds of assessment; scores for the constituent component all had ICC values ≥0.97 for the constituent components.

CONCLUSIONS

The VBQ score appears to have both good intrarater and interrater reliability. In addition, there appeared to be no correlation between score reliability and level of training. External validation and further investigations of its ability to accurately model bone biomechanical properties are necessary.

Retrospective Evaluation of Thoracolumbar Injury Classification System and Thoracolumbar AO Spine Injury Scores for the Decision Treatment of Thoracolumbar Traumatic Fractures in 458 Consecutive Patients

BACKGROUND

Thoracolumbar Injury Classification System (TLICS) score and Thoracolumbar AO Spine Injury Score (TLAOSIS) are the scores preferred to classify and treat thoracolumbar fractures. Our study evaluates the reliability of both as guidelines for treatment.

METHODS

Single-center and retrospective case series of 458 patients. Clinical variables, radiology, and treatment were analyzed. We classified fractures according to the AO Spine Thoracolumbar System and retrospectively applied both scales in 2 groups (surgical and conservative). A concordance analysis and statistical measures comparing both were performed.

RESULTS

The patients were divided as follows: 257 patients (56.1%) in the conservative group and 201 patients (43.9%) in the surgical group. The concordance analysis between both scales was 89.7% (95% confidence interval, 86.5%-92.3%), and the Cohen kappa coefficient was 0.68 (95% confidence interval, 59%-76%). TLAOSIS had a higher tendency to classify patients in the gray zone (10.3% vs. 2.8%, P < 0.001), whereas TLICS had a more conservative nature (85.2% vs. 78.4%, P = 0.01). In the surgical group, the matching decision ratio was 29.9% for TLICS and 42.8% for TLAOSIS, but differences were found in TLICS being more conservative (70.1% vs. 57.2%, P = 0.01). In the conservative group, the matching decision ratio was 98.1% for both scales, being the main difference in the gray zone for TLAOSIS.

CONCLUSIONS

Both scales have a good concordance in general, with TLICS being more conservative overall. They had rather low coincidence when predicting surgery. Because TLAOSIS placed more patients in the gray zone, we think it might be slightly better for giving surgeons more license to decide a surgical approach on certain controversial types of fractures.

Is the AO spine thoracolumbar injury classification system reliable and practical? a systematic review

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.

Establishing the Injury Severity of Subaxial Cervical Spine Trauma: Validating the Hierarchical Nature of the AO Spine Subaxial Cervical Spine Injury Classification System

STUDY DESIGN

Global cross-sectional survey.

OBJECTIVE

The aim of this study was to validate the AO Spine Subaxial Cervical Spine Injury Classification by examining the perceived injury severity by surgeon across AO geographical regions and practice experience.

SUMMARY OF BACKGROUND DATA

Previous subaxial cervical spine injury classifications have been limited by subpar interobserver reliability and clinical applicability. In an attempt to create a universally validated scheme with prognostic value, AO Spine established a subaxial cervical spine injury classification involving four elements: injury morphology, facet injury involvement, neurologic status, and case-specific modifiers.

METHODS

A survey was sent to 272 AO Spine members across all geographic regions and with a variety of practice experience. Respondents graded the severity of each variable of the classification system on a scale from zero (low severity) to 100 (high severity). Primary outcome was to assess differences in perceived injury severity for each injury type over geographic regions and level of practice experience.

RESULTS

A total of 189 responses were received. Overall, the classification system exhibited a hierarchical progression in subtype injury severity scores. Only three subtypes showed a significant difference in injury severity score among geographic regions: F3 (floating lateral mass fracture, P = 0.04), N3 (incomplete spinal cord injury, P = 0.03), and M2 (critical disk herniation, P = 0.04). When stratified by surgeon experience, pairwise comparison showed only two morphological subtypes, B1 (bony posterior tension band injury, P = 0.02) and F2 (unstable facet fracture, P = 0.03), and one neurologic subtype (N3, P = 0.02) exhibited a significant difference in injury severity score.

CONCLUSION

The AO Spine Subaxial Cervical Spine Injury Classification System has shown to be reliable and suitable for proper patient management. The study shows this classification is substantially generalizable by geographic region and surgeon experience, and provides a consistent method of communication among physicians while covering the majority of subaxial cervical spine traumatic injuries.Level of Evidence: 4.

Assessment of the Accuracy of the AO Spine-TL Classification for Thoracolumbar Spine Fractures Using the AO Surgery Reference Mobile App

STUDY DESIGN

Cohort study.

OBJECTIVES

This study aimed to evaluate the accuracy of the AO Surgery Reference mobile app in the diagnosis of thoracolumbar fractures of the spine according to the AO TL classification, and to discuss the usefulness of this app in the teaching and training of the resident physicians in orthopedics and traumatology area.

METHODS

The 24 residents of Orthopedic and Traumatology program assessed 20 cases of thoracolumbar fractures selected from the hospital database on 2 different occasions, with a 30-day interval, and they classified these cases with and without using the AO Surgery Reference app. A group of spine experts previously established the gold standard and the answers were statistically compared, with the inter- and intraobserver reliability evaluated by the kappa index.

RESULTS

The use of the AO Surgery Reference app increased the classification success rate of the fracture morphology (from 53.4% to 72.5%), of the comorbidity modifier (from 61.4% to 77.9%) and of the neurological status modifier (from 55.1% to 72.9%). In addition, the mobile app raised the classification agreement and accuracy. The kappa index increased from 0.30 to 0.53 regarding the morphological classification of fractures.

CONCLUSIONS

The residents improved their ability to recognize and classify thoracolumbar spine fractures, which reinforces the importance of this tool in medical education and clinical practice.

Surgical Management of Thoracolumbar Burst Fractures: Surgical Decision-making Using the AOSpine Thoracolumbar Injury Classification Score and Thoracolumbar Injury Classification and Severity Score

The management of thoracolumbar burst fractures is controversial with no universally accepted treatment algorithm. Several classification and scoring systems have been developed to assist in surgical decision-making. The most widely accepted are the Thoracolumbar Injury Classification and Severity Score (TLICS) and AOSpine Thoracolumbar Injury Classification Score (TL AOSIS) with both systems designed to provide a simple objective scoring criteria to guide the surgical or nonsurgical management of complex injury patterns. When used in the evaluation and treatment of thoracolumbar burst fractures, both of these systems result in safe and consistent patient care. However, there are important differences between the 2 systems, specifically in the evaluation of the complete burst fractures (AOSIS A4) and patients with transient neurological deficits (AOSIS N1). In these circumstances, the AOSpine system may more accurately capture and characterize injury severity, providing the most refined guidance for optimal treatment. With respect to surgical approach, these systems provide a framework for decision-making based on patient neurology and the status of the posterior tension band. Here we propose an operative treatment algorithm based on these fracture characteristics as well as the level of injury.

Reliability and Clinical Usefulness of Current Classifications in Traumatic Thoracolumbar Fractures: A Systematic Review of the Literature

BACKGROUND

A validated classification remains the key to an appropriate treatment algorithm of traumatic thoracolumbar fractures. Considering the development of many classifications, it is remarkable that consensus about treatment is still lacking. We conducted a systematic review to investigate which classification can be used best for treatment decision making in thoracolumbar fractures.

METHODS

A comprehensive search was conducted using PubMed, Embase, CINAHL, and Cochrane using the following search terms: classification (mesh), spinal fractures (mesh), and corresponding synonyms. All hits were viewed by 2 independent researchers. Papers were included if analyzing the reliability (kappa values) and clinical usefulness (specificity or sensitivity of an algorithm) of currently most used classifications (Magerl/AO, thoracolumbar injury classification and severity score [TLICS] or thoracolumbar injury severity score, and the new AO spine).

RESULTS

Twenty articles are included. The presented kappa values indicate moderate to substantial agreement for all 3 classifications. Regarding the clinical usefulness, > 90% agreement between actual treatment and classification recommendation is reported for most fractures. However, it appears that over 50% of the patients with a stable burst fracture (TLICS 2, AO-A3/A4) in daily practice are operated, so in these cases treatment decision is not primarily based on classification.

CONCLUSION

AO, TLICS, and new AO spine classifications have acceptable accuracy (kappa > 0.4), but are limited in clinical usefulness since the treatment recommendation is not always implemented in clinical practice. Differences in treatment decision making arise from several causes, such as surgeon and patient preferences and prognostic factors that are not included in classifications yet. The recently validated thoracolumbar AO spine injury score seems promising for use in clinical practice, because of inclusion of patient-specific modifiers. Future research should prove its definite value in treatment decision making.

LEVEL OF EVIDENCE

2.

CLINICAL RELEVANCE

Without the appropriate treatment, the impact of traumatic thoracolumbar fractures can be devastating. Therefore it is important to achieve consensus in the treatment of thoracolumbar fractures.

Reliability and Validity of the AOSpine Thoracolumbar Injury Classification System: A Systematic Review

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.

Reliability and Agreement of Different Spine Fracture Classification Systems: An Independent Intraobserver and Interobserver Study

OBJECTIVE

Currently, no spinal classification system has achieved universal acceptance. Therefore, it is important to choose a reliable classification within clinical practice. The objective of this study was to determine and compare the intraobserver and interobserver agreement of the Load Sharing Classification (LSC), the Thoracolumbar Injury Classification System (TLICS), and the AOSpine Thoracolumbar Spine Injury Classification System.

METHODS

In this web-based intraobserver and interobserver study (www.spine.hostei.com), plain radiographs and computed tomographic scans of traumatic thoracolumbar fractures (T12-L2) were evaluated. By use of a questionnaire, fractures were classified according to the LSC, the TLICS, and the AOSpine classification. Data were analyzed with SPSS (Version 21, 76 Chicago, Illinois, USA). Intraobserver and interobserver agreement was determined by the Cohen κ. Statistical significance was defined as P < 0.05.

RESULTS

Data from 91 patients were classified twice by 7 board-certified spine surgeons. The intraobserver and interobserver reliability considering the LSC total score was noted as fair (intraobserver/interobserver reliability: κ = 0.26/0.22). Considering the resulting TLICS total score, a moderate intraobserver agreement (κ = 0.41) was noted, whereas the interobserver results presented only fair reliability (κ = 0.23). In contrast to the LSC and the TLICS, the AOSpine classification showed substantial agreement considering the fracture type (A;B;C) (intraobserver/interobserver reliability: κ = 0.71/0.61) and moderate agreement considering the fracture subtype (e.g., A0;A1;…;B1;…) (intraobserver/interobserver reliability: κ = 0.57/0.48).

CONCLUSION

In conclusion, the reliability of the AOSpine fracture classification is superior to the TLICS and the LSC. Therefore, this classification system could best be applied within clinical practice.

COMPARATIVE ANALYSIS OF TWO CLASSIFICATION SYSTEMS OF THORACOLUMBAR SPINE FRACTURES

ABSTRACT Objective: To evaluate the reproducibility and the interobserver coefficient of concordance between the AO/Magerl and AOSpine classifications for thoracolumbar spine fractures. Methods: Retrospective study of radiographic data analysis. Data were collected from 31 radiographic studies of patients with thoracolumbar spine fracture and distributed to a team involving spinal surgeons and residents. The fractures were classified according to the AO/Magerl and AOSpine classifications. Statistical analysis was performed using the Cohen Kappa test to assess the coefficient of concordance. Results: The Kappa value for interobserver concordance of AO/Magerl classification was κ = 0.70 and standard deviation was 0.16. For the AOSpine classification, we observed κ = 0.76, both with significance level α = 0.05 and P<0.001. Conclusions: We conclude that the interobserver concordance of the new AOSpine classification is similar to the AO/Magerl classification. This conclusion reinforces the reproducibility of the new AOSpine classification. Level of evidence: IV,Type of Study: Case series.

Assessment of variability in Turkish spine surgeons' trauma practices

OBJECTIVES

The aim of this study was to analyse the variability among Turkish spinal surgeons in the management of thoracolumbar fractures by carrying out a web survey.

METHODS

An invitation text and web-link of the survey were sent to the members of the Turkish Spine Society mail group. A fictitious spine trauma vignette, a 23 year-old male with a L1 burst fracture, was presented and 25 questions were asked to participants. Variability of answers in a given question was assessed with the Index of Qualitative Variation (IQV). Questions with high IQV values (>%80) were selected to evaluate the relation between participant factors (speciality, age, degree and experience level of the surgeon, type of the work centre and volume of the trauma patients).

RESULTS

Sixty-four (88%) among the 73 participating surgeons completed the survey. 45 (70%) of them were orthopaedic surgeons and 19 (30%) were neurosurgeons. 11 questions had very high variability (IQV ≥ 0.80), 5 had high variability (0.58-0.75) and 2 had low variability (IQV≤0.20). The question with the highest variability was related to the use of brace after surgery (IQV = 0.93). Following one was about the selection of fixation levels (IQV = 0.91). Neurosurgeons were more likely to use brace postoperatively and professors were less likely to perform decompression.

CONCLUSION

This survey shows that thoracolumbar spine trauma practice significantly varies among Turkish spine surgeons. Surgeons' characteristics affected some specific answers. Lack of enough knowledge about spine trauma care, fracture classifications and surgical techniques and/or ethical factors may be other reasons for this variability.

AOSpine Classification Systems (Subaxial, Thoracolumbar)

Numerous classification systems for subaxial and thoracolumbar spine injuries were proposed in the past with the attempt to facilitate communication between physicians. The AO-Magerl, thoracolumbar system, and Subaxial Cervical Spine Injury Classification systems are all well known, but did not achieve universal international adoption. A group of international experienced spine trauma surgeons were brought together by AOSpine with the goal to develop a comprehensive yet simple classification system for spinal trauma. This article is a synopsis of the proposed subaxial and thoracolumbar classification systems. In several studies, this classification system was developed using an iterative consensus process among the clinical experts in sufficient number and quality of DICOM images of real cases searching for meaningful and reproducible patterns. Both systems are based on 3 injury morphology types: compression injuries (A), tension band injuries (B), and translational injuries (C) with a total of 9 subgroups. In the subaxial cervical spine 4 additional subtypes for facet injuries exist. Patient-specific modifiers and neurologic status were also included to aid surgeons in therapeutic decision making. The proposed classification systems for subaxial and thoracolumbar injuries showed substantial intraobserver and interobserver reliability (κ = 0.64-0.85) for grading fracture type. Grading for the subtypes varied considerably due to the low frequency of certain injury subtypes among other reasons. In summary, the AOSpine thoracolumbar and subaxial cervical spine injury systems show substantial reliability, thus being valuable tools for clinical and research purposes.

Does the Spine Surgeon's Experience Affect Fracture Classification, Assessment of Stability, and Treatment Plan in Thoracolumbar Injuries?

STUDY DESIGN

Prospective survey-based study.

OBJECTIVES

The AO Spine thoracolumbar injury classification has been shown to have good reproducibility among clinicians. However, the influence of spine surgeons' clinical experience on fracture classification, stability assessment, and decision on management based on this classification has not been studied. Furthermore, the usefulness of varying imaging modalities including radiographs, computed tomography (CT) and magnetic resonance imaging (MRI) in the decision process was also studied.

METHODS

Forty-one spine surgeons from different regions, acquainted with the AOSpine classification system, were provided with 30 thoracolumbar fractures in a 3-step assessment: first radiographs, followed by CT and MRI. Surgeons classified the fracture, evaluated stability, chose management, and identified reasons for any changes. The surgeons were divided into 2 groups based on years of clinical experience as <10 years (n = 12) and >10 years (n = 29).

RESULTS

There were no significant differences between the 2 groups in correctly classifying A1, B2, and C type fractures. Surgeons with less experience had more correct diagnosis in classifying A3 (47.2% vs 38.5% in step 1, 73.6% vs 60.3% in step 2 and 77.8% vs 65.5% in step 3), A4 (16.7% vs 24.1% in step 1, 72.9% vs 57.8% in step 2 and 70.8% vs 56.0% in step3) and B1 injuries (31.9% vs 20.7% in step 1, 41.7% vs 36.8% in step 2 and 38.9% vs 33.9% in step 3). In the assessment of fracture stability and decision on treatment, the less and more experienced surgeons performed equally. The selection of a particular treatment plan varied in all subtypes except in A1 and C type injuries.

CONCLUSION

Surgeons' experience did not significantly affect overall fracture classification, evaluating stability and planning the treatment. Surgeons with less experience had a higher percentage of correct classification in A3 and A4 injuries. Despite variations between them in classification, the assessment of overall stability and management decisions were similar between the 2 groups.

Reliability and reproducibility analysis of the AOSpine thoracolumbar spine injury classification system by Chinese spinal surgeons

PURPOSE

The objective of this study was to analyze the interobserver reliability and intraobserver reproducibility of the new AOSpine thoracolumbar spine injury classification system in young Chinese orthopedic surgeons with different levels of experience in spinal trauma. Previous reports suggest that the new AOSpine thoracolumbar spine injury classification system demonstrates acceptable interobserver reliability and intraobserver reproducibility. However, there are few studies in Asia, especially in China.

METHODS

The AOSpine thoracolumbar spine injury classification system was applied to 109 patients with acute, traumatic thoracolumbar spinal injuries by two groups of spinal surgeons with different levels of clinical experience. The Kappa coefficient was used to determine interobserver reliability and intraobserver reproducibility.

RESULTS

The overall Kappa coefficient for all cases was 0.362, which represents fair reliability. The Kappa statistic was 0.385 for A-type injuries and 0.292 for B-type injuries, which represents fair reliability, and 0.552 for C-type injuries, which represents moderate reliability. The Kappa coefficient for intraobserver reproducibility was 0.442 for A-type injuries, 0.485 for B-type injuries, and 0.412 for C-type injuries. These values represent moderate reproducibility for all injury types. The raters in Group A provided significantly better interobserver reliability than Group B (P < 0.05). There were no between-group differences in intraobserver reproducibility.

CONCLUSIONS

This study suggests that the new AO spine injury classification system may be applied in day-to-day clinical practice in China following extensive training of healthcare providers. Further prospective studies in different healthcare providers and clinical settings are essential for validation of this classification system and to assess its utility.

Reliability assessment of AOSpine thoracolumbar spine injury classification system and Thoracolumbar Injury Classification and Severity Score (TLICS) for thoracolumbar spine injuries: results of a multicentre study

PURPOSE

The aim of this multicentre study was to determine whether the recently introduced AOSpine Classification and Injury Severity System has better interrater and intrarater reliability than the already existing Thoracolumbar Injury Classification and Severity Score (TLICS) for thoracolumbar spine injuries.

METHODS

Clinical and radiological data of 50 consecutive patients admitted at a single centre with a diagnosis of an acute traumatic thoracolumbar spine injury were distributed to eleven attending spine surgeons from six different institutions in the form of PowerPoint presentation, who classified them according to both classifications. After time span of 6 weeks, cases were randomly rearranged and sent again to same surgeons for re-classification. Interobserver and intraobserver reliability for each component of TLICS and new AOSpine classification were evaluated using Fleiss Kappa coefficient (k value) and Spearman rank order correlation.

RESULTS

Moderate interrater and intrarater reliability was seen for grading fracture type and integrity of posterior ligamentous complex (Fracture type: k = 0.43 ± 0.01 and 0.59 ± 0.16, respectively, PLC: k = 0.47 ± 0.01 and 0.55 ± 0.15, respectively), and fair to moderate reliability (k = 0.29 ± 0.01 interobserver and 0.44+/0.10 intraobserver, respectively) for total score according to TLICS. Moderate interrater (k = 0.59 ± 0.01) and substantial intrarater reliability (k = 0.68 ± 0.13) was seen for grading fracture type regardless of subtype according to AOSpine classification. Near perfect interrater and intrarater agreement was seen concerning neurological status for both the classification systems.

CONCLUSIONS

Recently proposed AOSpine classification has better reliability for identifying fracture morphology than the existing TLICS. Additional studies are clearly necessary concerning the application of these classification systems across multiple physicians at different level of training and trauma centers to evaluate not only their reliability and reproducibility, but also the other attributes, especially the clinical significance of a good classification system.