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Lambrechts MJ, Schroeder GD, Karamian BA, Canseco JA, Oner C, Vialle E, Rajasekaran S, Hazenbiller O, Dvorak MR, Benneker LM, Kandziora F, Schnake K, Kepler CK, Vaccaro AR. Development of Online Technique for International Validation of the AO Spine Subaxial Injury Classification System. Global Spine J 2024; 14:177-186. [PMID: 35475400 PMCID: PMC10676157 DOI: 10.1177/21925682221098967] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
STUDY DESIGN Global cross-sectional survey. OBJECTIVE To develop and refine the techniques for web-based international validation of fracture classification systems. METHODS A live webinar was organized in 2018 for validation of the AO Spine Subaxial Injury Classification System, consisting of 35 unique computed tomography (CT) scans and key images with subaxial spine injuries. Interobserver reliability and intraobserver reproducibility was calculated for injury morphology, subtype, and facet injury according to the classification system. Based on the experiences from this webinar and incorporating rater feedback, adjustments were made in the organization and techniques used and in 2020 a repeat validation webinar was performed, evaluating images of 41 unique subaxial spine injuries. RESULTS In the 2018 session, the AO Spine Subaxial Injury Classification System demonstrated fair interobserver reliability for fracture subtype (κ = 0.35) and moderate reliability for fracture morphology and facet injury (κ=0.45, 0.43, respectively). However, in 2020, the interobserver reliability for fracture morphology (κ = 0.87) and fracture subtype (κ = 0.80) was excellent, while facet injury was substantial (κ = 0.74). Intraobserver reproducibility for injury morphology (κ =0.49) and injury subtype/facet injury were moderate (κ = 0.42) in 2018. In 2020, fracture morphology and subtype reproducibility were excellent (κ =0.85, 0.88, respectively) while reproducibility for facet injuries was substantial (κ = 0.76). CONCLUSION With optimized webinar-based validation techniques, the AO Spine Subaxial Injury Classification System demonstrated vast improvements in intraobserver reproducibility and interobserver reliability. Stringent fracture classification methodology is integral in obtaining accurate classification results.
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Affiliation(s)
| | | | - Brian A. Karamian
- Rothman Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - Jose A. Canseco
- Rothman Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - Cumhur Oner
- Department of Orthopedic Surgery, University Medical Center, University of Utrecht, Utrecht, Netherlands
| | - Emiliano Vialle
- Spine Surgery Group, Department of Orthopaedics, Cajuru University Hospital, Catholic University of Parana, Curitaba, Brazil
| | | | | | - Marcel R. Dvorak
- Division of Spine, University of British Columbia, Vancouver, BC, Canada
| | - Lorin M. Benneker
- Department of Orthopaedic Surgery, Inselspital, University of Bern, Bern, Switzerland
| | | | - Klaus Schnake
- Center for Spinal and Scoliosis Surgery, Malteser Waldkrankenhaus St. Marien, Erlangen, Germany
| | | | | | - AO Spine Subaxial Classification Group Members
- Rothman Institute at Thomas Jefferson University, Philadelphia, PA, USA
- Department of Orthopedic Surgery, University Medical Center, University of Utrecht, Utrecht, Netherlands
- Spine Surgery Group, Department of Orthopaedics, Cajuru University Hospital, Catholic University of Parana, Curitaba, Brazil
- Department of Orthopedics and Spine Surgery, Ganga Hospital, Coimbatore, India
- Research Department, AO Spine, AO Foundation, Davos, Switzerland
- Division of Spine, University of British Columbia, Vancouver, BC, Canada
- Department of Orthopaedic Surgery, Inselspital, University of Bern, Bern, Switzerland
- Unfallklinik Frankfurt am Main, Frankfurt, Germany
- Center for Spinal and Scoliosis Surgery, Malteser Waldkrankenhaus St. Marien, Erlangen, Germany
- Department of Orthopedics and Traumatology, Paracelsus Private Medical University Nuremberg, Nuremberg, Germany
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Karamian BA, Schroeder GD, Lambrechts MJ, Canseco JA, Vialle EN, Rajasekaran S, Benneker LM, Dvorak MR, Kandziora F, Oner C, Schnake K, Kepler CK, Vaccaro AR. The Influence of Regional Differences on the Reliability of the AO Spine Sacral Injury Classification System. Global Spine J 2023; 13:2025-2032. [PMID: 35000410 PMCID: PMC10556908 DOI: 10.1177/21925682211068419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
STUDY DESIGN Global cross-sectional survey. OBJECTIVE To explore the influence of geographic region on the AO Spine Sacral Classification System. METHODS A total of 158 AO Spine and AO Trauma members from 6 AO world regions (Africa, Asia, Europe, Latin and South America, Middle East, and North America) participated in a live webinar to assess the reliability, reproducibility, and accuracy of classifying sacral fractures using the AO Spine Sacral Classification System. This evaluation was performed with 26 cases presented in randomized order on 2 occasions 3 weeks apart. RESULTS A total of 8320 case assessments were performed. All regions demonstrated excellent intraobserver reproducibility for fracture morphology. Respondents from Europe (k = .80) and North America (k = .86) achieved excellent reproducibility for fracture subtype while respondents from all other regions displayed substantial reproducibility. All regions demonstrated at minimum substantial interobserver reliability for fracture morphology and subtype. Each region demonstrated >90% accuracy in classifying fracture morphology and >80% accuracy in fracture subtype compared to the gold standard. Type C morphology (p2 = .0000) and A3 (p1 = .0280), B2 (p1 = .0015), C0 (p1 = .0085), and C2 (p1 =.0016, p2 =.0000) subtypes showed significant regional disparity in classification accuracy (p1 = Assessment 1, p2 = Assessment 2). Respondents from Asia (except in A3) and the combined group of North, Latin, and South America had accuracy percentages below the combined mean, whereas respondents from Europe consistently scored above the mean. CONCLUSIONS In a global validation study of the AO Spine Sacral Classification System, substantial reliability of both fracture morphology and subtype classification was found across all geographic regions.
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Affiliation(s)
- Brian A. Karamian
- Rothman Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | | | | | - Jose A. Canseco
- Rothman Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - AO Spine Sacral Classification Group Members
- Rothman Institute at Thomas Jefferson University, Philadelphia, PA, USA
- Spine Surgery Group, Department of Orthopaedics, Cajuru University Hospital, Catholic University of Parana, Curitaba, Brazil
- Department of Orthopedics and Spine Surgery, Ganga Hospital, Coimbatore, India
- Department of Orthopaedic Surgery, Inselspital, University of Bern, Bern, Switzerland
- Division of Spine, University of British Columbia
- Unfallklinik Frankfurt am Main, Frankfurt, Germany
- Department of Orthopedic Surgery, University Medical Center, University of Utrecht, Utrecht, Netherlands
- Center for Spinal Surgery, Schön Klinik Nürnberg Fürth, Fürth, Germany
| | - Emiliano N. Vialle
- Spine Surgery Group, Department of Orthopaedics, Cajuru University Hospital, Catholic University of Parana, Curitaba, Brazil
| | | | - Lorin M. Benneker
- Department of Orthopaedic Surgery, Inselspital, University of Bern, Bern, Switzerland
| | | | | | - Cumhur Oner
- Department of Orthopedic Surgery, University Medical Center, University of Utrecht, Utrecht, Netherlands
| | - Klaus Schnake
- Center for Spinal Surgery, Schön Klinik Nürnberg Fürth, Fürth, Germany
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Karamian BA, Schroeder GD, Lambrechts MJ, Canseco JA, Oner C, Vialle E, Rajasekaran S, Dvorak MR, Benneker LM, Kandziora F, Schnake K, Kepler CK, Vaccaro AR. An international validation of the AO spine subaxial injury classification system. Eur Spine J 2023; 32:46-54. [PMID: 36449081 DOI: 10.1007/s00586-022-07467-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Revised: 09/09/2022] [Accepted: 11/11/2022] [Indexed: 12/02/2022]
Abstract
PURPOSE To validate the AO Spine Subaxial Injury Classification System with participants of various experience levels, subspecialties, and geographic regions. METHODS A live webinar was organized in 2020 for validation of the AO Spine Subaxial Injury Classification System. The validation consisted of 41 unique subaxial cervical spine injuries with associated computed tomography scans and key images. Intraobserver reproducibility and interobserver reliability of the AO Spine Subaxial Injury Classification System were calculated for injury morphology, injury subtype, and facet injury. The reliability and reproducibility of the classification system were categorized as slight (ƙ = 0-0.20), fair (ƙ = 0.21-0.40), moderate (ƙ = 0.41-0.60), substantial (ƙ = 0.61-0.80), or excellent (ƙ = > 0.80) as determined by the Landis and Koch classification. RESULTS A total of 203 AO Spine members participated in the AO Spine Subaxial Injury Classification System validation. The percent of participants accurately classifying each injury was over 90% for fracture morphology and fracture subtype on both assessments. The interobserver reliability for fracture morphology was excellent (ƙ = 0.87), while fracture subtype (ƙ = 0.80) and facet injury were substantial (ƙ = 0.74). The intraobserver reproducibility for fracture morphology and subtype were excellent (ƙ = 0.85, 0.88, respectively), while reproducibility for facet injuries was substantial (ƙ = 0.76). CONCLUSION The AO Spine Subaxial Injury Classification System demonstrated excellent interobserver reliability and intraobserver reproducibility for fracture morphology, substantial reliability and reproducibility for facet injuries, and excellent reproducibility with substantial reliability for injury subtype.
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Affiliation(s)
- Brian A Karamian
- Rothman Institute at Thomas Jefferson University, 925 Chestnut St, 5th Floor, Philadelphia, PA, 19107, USA
| | - Gregory D Schroeder
- Rothman Institute at Thomas Jefferson University, 925 Chestnut St, 5th Floor, Philadelphia, PA, 19107, USA
| | - Mark J Lambrechts
- Rothman Institute at Thomas Jefferson University, 925 Chestnut St, 5th Floor, Philadelphia, PA, 19107, USA.
| | - Jose A Canseco
- Rothman Institute at Thomas Jefferson University, 925 Chestnut St, 5th Floor, Philadelphia, PA, 19107, USA
| | - Cumhur Oner
- Department of Orthopedic Surgery, University Medical Center, University of Utrecht, Utrecht, Netherlands
| | - Emiliano Vialle
- Spine Surgery Group, Department of Orthopaedics, Cajuru University Hospital, Catholic University of Parana, Curitaba, Brazil
| | | | - Marcel R Dvorak
- Division of Spine, University of British Columbia, Vancouver, Canada
| | - Lorin M Benneker
- Department of Orthopaedic Surgery, Inselspital, University of Bern, Bern, Switzerland
| | | | - Klaus Schnake
- Center for Spinal Surgery, Schön Klinik Nürnberg Fürth, Fürth, Germany
| | - Christopher K Kepler
- Rothman Institute at Thomas Jefferson University, 925 Chestnut St, 5th Floor, Philadelphia, PA, 19107, USA
| | - Alexander R Vaccaro
- Rothman Institute at Thomas Jefferson University, 925 Chestnut St, 5th Floor, Philadelphia, PA, 19107, USA
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Vaccaro AR, Lambrechts MJ, Karamian BA, Canseco JA, Oner C, Vialle E, Rajasekaran S, Dvorak MR, Benneker LM, Kandziora F, El-Sharkawi M, Tee JW, Bransford R, Joaquim AF, Muijs SPJ, Holas M, Takahata M, Hamouda WO, Kanna RM, Schnake K, Kepler CK, Schroeder GD. AO Spine upper cervical injury classification system: a description and reliability study. Spine J 2022; 22:2042-2049. [PMID: 35964830 DOI: 10.1016/j.spinee.2022.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Revised: 07/20/2022] [Accepted: 08/04/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Prior upper cervical spine injury classification systems have focused on injuries to the craniocervical junction (CCJ), atlas, and dens independently. However, no previous system has classified upper cervical spine injuries using a comprehensive system incorporating all injuries from the occiput to the C2-3 joint. PURPOSE To (1) determine the accuracy of experts at correctly classifying upper cervical spine injuries based on the recently proposed AO Spine Upper Cervical Injury Classification System (2) to determine their interobserver reliability and (3) identify the intraobserver reproducibility of the experts. STUDY DESIGN/SETTING International Multi-Center Survey. PATIENT SAMPLE A survey of international spine surgeons on 29 unique upper cervical spine injuries. OUTCOME MEASURES Classification accuracy, interobserver reliability, intraobserver reproducibility. METHODS Thirteen international AO Spine Knowledge Forum Trauma members participated in two live webinar-based classifications of 29 upper cervical spine injuries presented in random order, four weeks apart. Percent agreement with the gold-standard and kappa coefficients (ƙ) were calculated to determine the interobserver reliability and intraobserver reproducibility. RESULTS Raters demonstrated 80.8% and 82.7% accuracy with identification of the injury classification (combined location and type) on the first and second assessment, respectively. Injury classification intraobserver reproducibility was excellent (mean, [range] ƙ=0.82 [0.58-1.00]). Excellent interobserver reliability was found for injury location (ƙ = 0.922 and ƙ=0.912) on both assessments, while injury type was substantial (ƙ=0.689 and 0.699) on both assessments. This correlated to a substantial overall interobserver reliability (ƙ=0.729 and 0.732). CONCLUSIONS Early phase validation demonstrated classification of upper cervical spine injuries using the AO Spine Upper Cervical Injury Classification System to be accurate, reliable, and reproducible. Greater than 80% accuracy was detected for injury classification. The intraobserver reproducibility was excellent, while the interobserver reliability was substantial.
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Affiliation(s)
| | - Mark J Lambrechts
- Rothman Institute at Thomas Jefferson University, Philadelphia, PA, USA.
| | - Brian A Karamian
- Rothman Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - Jose A Canseco
- Rothman Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - Cumhur Oner
- Department of Orthopedic Surgery, University Medical Center, University of Utrecht, Utrecht, Netherlands
| | - Emiliano Vialle
- Spine Surgery Group, Department of Orthopaedics, Cajuru University Hospital, Catholic University of Parana, Curitaba, Brazil
| | | | - Marcel R Dvorak
- Division of Spine, University of British Columbia, BC, Canada
| | - Lorin M Benneker
- Department of Orthopaedic Surgery, Inselspital, University of Bern, Bern, Switzerland
| | | | | | - Jin Wee Tee
- Department of Neurosurgery, The Alfred, Melbourne, VIC, Australia
| | - Richard Bransford
- Department of Orthopaedic Surgery, University of Washington, Harborview Medical Center, Seattle, WAS, USA
| | - Andrei F Joaquim
- Department of Neurology, Neurosurgery Division, State University of Campinas, Campinas, SP, Brazil
| | - Sander P J Muijs
- Department of Orthopedic Surgery, University Medical Center, University of Utrecht, Utrecht, Netherlands
| | - Martin Holas
- Klinika Úrazovej Chirurgie SZU FNsP F.D.Roosevelta, Banská Bystrica, Slovakia
| | - Masahiko Takahata
- Department of Orthopaedic Surgery, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Waeel O Hamouda
- Department of Neurosurgery, Cairo University Medical School and Teaching Hospitals, Cairo, Egypt
| | - Rishi M Kanna
- Department of Orthopedics and Spine Surgery, Ganga Hospital, Coimbatore, India
| | - Klaus Schnake
- Center for Spinal and Scoliosis Surgery, Malteser Waldkrankenhaus St. Marien, Erlangen, Germany; Department of Orthopedics and Traumatology, Paracelsus Private Medical University Nuremberg, Nuremberg, Germany
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