Validation of the AO Spine CROST (Clinician Reported Outcome Spine Trauma) in the clinical setting.

PURPOSE: To evaluate feasibility, internal consistency, inter-rater reliability, and prospective validity of AO Spine CROST (Clinician Reported Outcome Spine Trauma) in the clinical setting. METHODS: Patients were included from four trauma centers. Two surgeons with substantial amount of experience in spine trauma care were included from each center. Two separate questionnaires were administered at baseline, 6-months and 1-year: one to surgeons (mainly CROST) and another to patients (AO Spine PROST-Patient Reported Outcome Spine Trauma). Descriptive statistics were used to analyze patient characteristics and feasibility, Cronbach's α for internal consistency. Inter-rater reliability through exact agreement, Kappa statistics and Intraclass Correlation Coefficient (ICC). Prospective analysis, and relationships between CROST and PROST were explored through descriptive statistics and Spearman correlations. RESULTS: In total, 92 patients were included. CROST showed excellent feasibility results. Internal consistency (α = 0.58-0.70) and reliability (ICC = 0.52 and 0.55) were moderate. Mean total scores between surgeons only differed 0.2-0.9 with exact agreement 48.9-57.6%. Exact agreement per CROST item showed good results (73.9-98.9%). Kappa statistics revealed moderate agreement for most CROST items. In the prospective analysis a trend was only seen when no concerns at all were expressed by the surgeon (CROST = 0), and moderate to strong positive Spearman correlations were found between CROST at baseline and the scores at follow-up (rs = 0.41-0.64). Comparing the CROST with PROST showed no specific association, nor any Spearman correlations (rs = -0.33-0.07). CONCLUSIONS: The AO Spine CROST showed moderate validity in a true clinical setting including patients from the daily clinical practice.

The changing landscape of spinal injuries: A narrative review.

In the past, spinal trauma was frequent in high- and middle-income regions of the world with high rates of automobility and was considered a "young men's disease." However, over the last 2 decades, both of these factors have changed dramatically. This has had important implications for our methods of diagnosis, treatment, and the organization of care.

The Diagnostic Process of Spinal Post-traumatic Deformity: An Expert Survey of 7 Cases, Consensus on Clinical Relevance Does Exist.

STUDY DESIGN: Survey of cases. OBJECTIVE: To evaluate the opinion of experts in the diagnostic process of clinically relevant Spinal Post-traumatic Deformity (SPTD). SUMMARY OF BACKGROUND DATA: SPTD is a potential complication of spine trauma that can cause decreased function and quality of life impairment. The question of when SPTD becomes clinically relevant is yet to be resolved. METHODS: The survey of 7 cases was sent to 31 experts. The case presentation was medical history, diagnostic assessment, evaluation of diagnostic assessment, diagnosis, and treatment options. Means, ranges, percentages of participants, and descriptive statistics were calculated. RESULTS: Seventeen spinal surgeons reviewed the presented cases. The items' fracture type and complaints were rated by the participants as more important, but no agreement existed on the items of medical history. In patients with possible SPTD in the cervical spine (C) area, participants requested a conventional radiograph (CR) (76%-83%), a flexion/extension CR (61%-71%), a computed tomography (CT)-scan (76%-89%), and a magnetic resonance (MR)-scan (89%-94%). In thoracolumbar spine (ThL) cases, full spine CR (89%-100%), CT scan (72%-94%), and MR scan (65%-94%) were requested most often. There was a consensus on 5 out of 7 cases with clinically relevant SPTD (82%-100%). When consensus existed on the diagnosis of SPTD, there was a consensus on the case being compensated or decompensated and being symptomatic or asymptomatic. CONCLUSIONS: There was strong agreement in 5 out of 7 cases on the presence of the diagnosis of clinically relevant SPTD. Among spine experts, there is a strong consensus to use CT scan and MR scan, a cervical CR for C-cases, and a full spine CR for ThL-cases. The lack of agreement on items of the medical history suggests that a Delphi study can help us reach a consensus on the essential items of clinically relevant SPTD. LEVEL OF EVIDENCE: Level V.

Spinal Post-traumatic Deformity: An International Expert Survey Among AO Spine Knowledge Forum Members.

STUDY DESIGN: Survey among spine experts. OBJECTIVE: To investigate the different views and opinions of clinically relevant spinal post-traumatic deformity (SPTD). SUMMARY OF BACKGROUND DATA: There is no clear definition of clinically relevant SPTD. This leads to a wide variation in characteristics used for diagnosis and treatment indications of SPTD. To understand the current concepts of SPTD a survey was conducted among spine trauma surgeons. METHODS: Members of the AO Spine Knowledge Forum Trauma participated in an online survey. The survey was divided in 4 domains: Demographics, criteria to define SPTD, risk factors, and management. The data were collected anonymously and analyzed using descriptive statistics, absolute, and relative frequencies. Consensus on dichotomous outcomes was set to 80% of agreement. RESULTS: Fifteen members with extensive experience in treatment of spinal trauma participated, representing the 5 AO Spine Regions. Back pain was the only criterion for definition of SPTD with complete agreement. Consensus (≥80%) was reached for kyphotic angulation outside normative ranges and impaired function. Eighty-seven percent and 100% agreed that a full-spine conventional radiograph was necessary in diagnosing and treating SPTD, respectively. The "missed B-type injury" was rated at most important by all but 1 participant. There was no agreement on other risk factors leading to clinically relevant SPTD. Concerning the management, all participants agreed that an asymptomatic patient should not undergo surgical treatment and that neurological deficit is an absolute surgical indication. For most of the participants the preferred surgical treatment of acute injury in all spine regions but the subaxial region is posterior fixation. CONCLUSION: Some consensus exists among leading experts in the field of spine trauma care concerning the definition, diagnosis, risk factors, and management of SPTD. This study acts as the foundation for a Delphi study among the global spine community.

AO Spine upper cervical injury classification system: a description and reliability study.

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.

Long-Term Reliability and Validity of the AO Spine PROST (Patient-Reported Outcome Spine Trauma).

STUDY DESIGN: Cross-sectional validation study. OBJECTIVE: The aim was to validate the AO Spine Patient-Reported Outcome Spine Trauma (PROST) at a minimum of 12 months posttrauma and to evaluate patient characteristics, types of spine fractures, and treatment strategies as determinants of AO Spine PROST scores. SUMMARY OF BACKGROUND DATA: The reliability and validity of the AO Spine PROST as a measure of health-related quality of life for more than 12 months after onset of spine trauma is unclear. MATERIALS AND METHODS: Patients with a traumatic spine injury were recruited from a level-1 trauma center. They were asked to complete the AO Spine PROST, EuroQoL 5D-5L (EQ-5D-5L), and either Oswestry disability index (ODI) or neck disability index (NDI) for concurrent validity. Internal consistency was assessed by calculating the Cronbach α and item-total correlation coefficients. Test-retest reliability was evaluated using intraclass correlation coefficients. Spearman correlation tests were performed for the AO Spine PROST in correlation with the EQ-5D-5L, and either ODI or NDI. Determinants for AO Spine PROST score were analyzed using multivariate regression models. RESULTS: A total of 175 patients participated in the cross-sectional arm and 49 in the test-retest arm of the study. Median duration of follow-up was 94.5 months. No floor or ceiling effects were seen. Internal consistency was excellent (α=0.98, item-total correlation coefficient: 0.73-0.91) as well as test-retest reliability (intraclass correlation coefficient=0.81). Satisfactory correlations were seen for the EQ-5D-5L (0.76; P <0.001), ODI (0.69; P <0.001), and NDI (0.68; P <0.001) with the AO Spine PROST. Multivariate linear regression models showed that having ≥1 comorbidities, duration of return to work within the range of 7 to 43 months and no return to work were significant independent determinants for a worse AO Spine PROST score. CONCLUSIONS: Very good long-term reliability and validity results were found for the AO Spine PROST.

Diagnostic accuracy of computed tomography angiography (CTA) for diagnosing blunt cerebrovascular injury in trauma patients: a systematic review and meta-analysis.

OBJECTIVES: Previous literature showed that the diagnostic accuracy of computed tomographic angiography (CTA) is not equally comparable with that of the rarely used golden standard of digital subtraction angiography (DSA) for detecting blunt cerebrovascular injuries (BCVI) in trauma patients. However, advances in CTA technology may prove CTA to become equally accurate. This study investigated the diagnostic accuracy of CTA in detecting BCVI in comparison with DSA in trauma patients. METHODS: An electronic database search was performed in PubMed, EMBASE, and Cochrane Library. Summary estimates of sensitivity, specificity, positive and negative likelihood, diagnostic odds ratio, and 95% confidence intervals were determined using a bivariate random-effects model. RESULTS: Of the 3293 studies identified, 9 met the inclusion criteria. Pooled sensitivity was 64% (95% CI, 53-74%) and specificity 95% (95% CI, 87-99%) The estimated positive likelihood ratio was 11.8 (95%, 5.6-24.9), with a negative likelihood ratio of 0.38 (95%, 0.30-0.49) and a diagnostic odds ratio of 31 (95%, 17-56). CONCLUSION: CTA has reasonable specificity but low sensitivity when compared to DSA in diagnosing any BCVI. An increase in channels to 64 slices did not yield better sensitivity. There is a risk for underdiagnosis of BCVI when only using DSA to confirm CTA-positive cases, especially in those patients with low-grade injuries. KEY POINTS: • Low sensitivity and high specificity were seen in identifying BCVI with CTA as compared to DSA. • Increased CTA detector channels (≤ 64) did not lead to higher sensitivity when detecting BCVI. • The use of CTA instead of DSA may lead to underdiagnosis and, consequently, undertreatment of BCVI.

Blunt cerebrovascular injury: incidence and long-term follow-up.

PURPOSE: Blunt cerebrovascular injuries (BCVI), which can result in ischemic stroke, are identified in 1-2% of all blunt trauma patients. Computed tomography angiography (CTA) scanning has improved and is the diagnostic modality of choice in BCVI suspected patients. Data about long-term functional outcomes and the incidence of ischemic stroke after BCVI are limited. The aim of this study was to determine BCVI incidence in relation to imaging modality improvements and to determine long-term functional outcomes. METHODS: All consecutive trauma patients from 2007 to 2016 with BCVI were identified from the level 1 trauma center prospective trauma database. Three periods were identified where CTA diagnostic modalities for trauma patients were improved. Long-term functional outcomes using the EuroQol six-dimensional (EQ-6D™) were determined. RESULTS: Seventy-one BCVI patients were identified among the 12.122 (0.59%) blunt trauma patients. In the first period BCVI incidence among the overall study cohort, polytrauma, basilar skull fracture and cervical trauma subgroups was found to be 0.3%, 0.9%, 1.2%, 4.6%, respectively, which more than doubled towards the third period (0.8, 2.4, 1.9 and 8.5% respectively). Ischemic stroke as a result of BCVI was found in 20 patients (28%). In-hospital stroke rate was lower in patients receiving antiplatelet therapy (p < 0.01). Six in-hospital deaths were BCVI related. Long-term follow-up (follow-up rate of 83%) demonstrated lower functional outcomes compared to Dutch reference populations (p < 0.01). Ischemic stroke was identified as a major cause of functional impairment at long-term follow-up. CONCLUSIONS: Improved CTA diagnostic modalities have increased BCVI incidence. Furthermore, BCVI patients reported significant functional impairment at long-term follow-up. Antiplatelet therapy showed a significant effect on in-hospital stroke rate reduction.

The Current Status of Spinal Posttraumatic Deformity: A Systematic Review.

STUDY DESIGN: Systematic Review. OBJECTIVE: To systematically analyze the definitions and descriptions in literature of "Spinal Posttraumatic Deformity" (SPTD) in order to support the development of a uniform and comprehensive definition of clinically relevant SPTD. METHODS: A literature search in 11 international databases was performed using "deformity" AND "posttraumatic" and its synonyms. When an original definition or a description of SPTD (Patient factors, Radiological outcomes, Patient Reported Outcome Measurements and Surgical indication) was present the article was included. The retrieved articles were assessed for methodological quality and the presented data was extracted. RESULTS: 46 articles met the inclusion criteria. "Symptomatic SPTD" was mentioned multiple times as an entity, however any description of "symptomatic SPTD" was not found. Pain was mentioned as a key factor in SPTD. Other patient related parameters were (progression of) neurological deficit, bone quality, age, comorbidities and functional disability. Various ways were used to determine the amount of deformity on radiographs. The amount of deformity ranged from not deviant for normal to >30°. Sagittal balance and spinopelvic parameters such as the Pelvic Incidence, Pelvic Tilt and Sacral Slope were taken into account and were used as surgical indicators and preoperative planning. The Visual Analog Scale for pain and the Oswestry Disability Index were used mostly to evaluate surgical intervention. CONCLUSION: A clear-cut definition or consensus is not available in the literature about clinically relevant SPTD. Our research acts as the basis for international efforts for the development of a definition of SPTD.

Development and reliability of the AOSpine CROST (Clinician Reported Outcome Spine Trauma): a tool to evaluate and predict outcomes from clinician's perspective.

PURPOSE: To report on the development of AOSpine CROST (Clinician Reported Outcome Spine Trauma) and results of an initial reliability study. METHODS: The AOSpine CROST was developed using an iterative approach of multiple cycles of development, review, and revision including an expert clinician panel. Subsequently, a reliability study was performed among an expert panel who were provided with 20 spine trauma cases, administered twice with 4-week interval. The results of the developmental process were analyzed using descriptive statistics, the reliability per parameter using Kappa statistics, inter-rater rater agreement using intraclass correlation coefficient (ICC), and internal consistency using Cronbach's α. RESULTS: The AOSpine CROST was developed and consisted of 10 parameters, 2 of which are only applicable for surgically treated patents ('Wound healing' and 'Implants'). A dichotomous scoring system ('yes' or 'no' response) was incorporated to express expected problems for the short term and long term. In the reliability study, 16 (84.2%) participated in the first round and 14 (73.7%) in the second. Intra-rater reliability was fair to good for both time points (κ = 0.40-0.80 and κ = 0.31-0.67). Results of inter-rater reliability were lower (κ = 0.18-0.60 and κ = 0.16-0.46). Inter-rater agreement for total scores showed moderate results (ICC = 0.52-0.60), and the internal consistency was acceptable (α = 0.76-0.82). CONCLUSIONS: The AOSpine CROST, an outcome tool for the surgeons, was developed using an iterative process. An initial reliability analysis showed fair to moderate results and acceptable internal consistency. Further clinical validation studies will be performed to further validate the tool.

A clinical comparative study on low versus medium viscosity polymethylmetacrylate bone cement in percutaneous vertebroplasty: viscosity associated with cement leakage.

STUDY DESIGN: Comparative, prospective follow-up study. OBJECTIVE: Comparison of outcome between patients treated with Percutaneous VertebroPlasty (PVP) using low and medium viscosity PolyMethylMetAcrylate (PMMA) bone cement. SUMMARY OF BACKGROUND DATA: Viscosity is the characterizing parameter of PMMA bone cement, currently the standard augmentation material in PVP, and influences interdigitation, cement distribution inside the vertebral body, injected volume and extravasation, thereby affecting the clinical outcome of PVP. Currently, low, medium, and high viscosity PMMA bone cements are used interchangeably. However, effect of viscosity on clinical outcome in patients with Osteoporotic Vertebral Compression Fractures (OVCFs) has not yet been explicit subject of investigation. METHODS: Follow-up was conducted using a 0 to 10 Pain Intensity Numerical Rating Scale (PI-NRS) and the Short Form 36 (SF-36) Quality of Life questionnaire before PVP and at 7 days (PI-NRS only), 1, 3, and 12 months after PVP. Injected cement volume, degree of interdigitation, and cement leakage were analyzed on direct postoperative computed tomography scanning. At 6 and 52 weeks and at suspicion, patients were analyzed for new fractures. RESULTS: A total of 30 consecutive patients received PVP using low viscosity PMMA bone cement (OsteoPal-V) for 62 OVCFs, followed by 34 patients who received PVP using medium viscosity PMMA bone cement (Disc-O-Tech) for 67 OVCFs. Results regarding PI-NRS and SF-36 were comparable between both groups. Postoperative comparison of injected cement volume, degree of interdigitation, proportion of bipedicular procedures, incidence of new vertebral fractures and complications revealed no differences between both groups. Viscosity was identified as a risk factor for the occurrence of cement leakage (yes/no, OR: 2.925, 95% confidence interval: [1.072-7.984], P = 0.036). CONCLUSION: No major differences in clinical outcome after PVP in OVCFs using low and medium viscosity PMMA bone cement were found. Viscosity of PMMA bone cement was identified as an independent predictor of cement leakage.