Simplified Universal Grading of Lumbar Spine MRI Degenerative Findings: Inter-Reader Agreement of Non-Radiologist Spine Experts.

OBJECTIVE: 1) To describe a simplified multidisciplinary grading system for the most clinically relevant lumbar spine degenerative changes. 2) To measure the inter-reader variability among non-radiologist spine experts in their use of the classification system for interpretation of a consecutive series of lumbar spine magnetic resonance imaging (MRI) examinations. METHODS: ATS multidisciplinary and collaborative standardized grading of spinal stenosis, foraminal stenosis, lateral recess stenosis, and facet arthropathy was developed. Our institution's picture archiving and communication system was searched for 50 consecutive patients who underwent non-contrast MRI of the lumbar spine for chronic back pain, radiculopathy, or symptoms of spinal stenosis. Three fellowship-trained spine subspecialists from neurosurgery, orthopedic surgery, and physiatry interpreted the 50 exams using the classification at the L4-L5 and L5-S1 levels. Inter-reader agreement was assessed with Cohen's kappa coefficient. RESULTS: For spinal stenosis, the readers demonstrated substantial agreement (κ = 0.702). For foraminal stenosis and facet arthropathy, the three readers demonstrated moderate agreement (κ = 0.544, and 0.557, respectively). For lateral recess stenosis, there was fair agreement (κ = 0.323). CONCLUSIONS: A simplified universal grading system of lumbar spine MRI degenerative findings is newly described. Use of this multidisciplinary grading system in the assessment of clinically relevant degenerative changes revealed moderate to substantial agreement among non-radiologist spine physicians. This standardized grading system could serve as a foundation for interdisciplinary communication.

Relationship between size of disc and early postoperative outcomes after lumbar discectomy.

BACKGROUND: Previous studies suggest that patients with larger disc herniations (greater than 6 mm) will have better outcomes following discectomy. This has not been validated in a large series of patients. PURPOSE: We sought to empirically evaluate this relationship in a series of patients who had data collected prospectively as part of a randomized trial. METHODS: This retrospective review included 63 consecutive adult patients who underwent a single-level, primary lumbar discectomy. Outcomes were VAS for leg and back pain and the modified oswestry disability index (MODI). Statistical tests were used to compare patients using different cutoffs of preoperative disc diameters and disc volume removed. Regression analysis was performed to determine if there was a relationship between outcomes and the measured parameters. RESULTS: While patients who achieved substantial clinical benefit (SCB) for MODI had larger disc diameters, this relationship was not found for leg or back pain for any of the measured parameters. Using 5, 6, 7, or 8 mm as a cutoff for disc diameter demonstrated no differences. Regression analysis did not demonstrate a significant relationship between disc volume removed and final MODI scores. CONCLUSION: While patients with larger disc herniations on average might have a greater likelihood of superior clinical outcomes, the previously suggested "6 mm rule" was not supported.

Comprehensive Grading System of Inflammatory Features of the Lumbar Facet Joints on Magnetic Resonance Imaging.

STUDY DESIGN: Retrospective. OBJECTIVE: We aimed to describe a magnetic resonance imaging (MRI)-based grading system of inflammatory features of the lumbar facet joints using an atlas and assess its reliability. SUMMARY OF BACKGROUND DATA: Chronic low back pain is often caused by facet joint arthropathy. Inflammatory features are often evident on MRI. While several grading systems of facet arthropathy have been described, there is scant data on the reliability of these systems, and none focus exclusively on inflammatory features. MATERIALS AND METHODS: We describe a grading system that assesses facet joint effusion, bone marrow edema, and soft tissue edema. Each feature was graded from 0 to 3 (facet edema) or 0 to 2 (bone marrow edema intensity and extent, soft tissue edema intensity and extent). Four spine experts graded MRIs of 50 subjects at the bilateral L3/4, L4/5, and L5/S1 levels. All subjects had symptomatic facet arthropathy and received therapeutic facet joint injections. We assessed the intra-reader and inter-reader reliability of each feature at each joint and summarized across all six joints. RESULTS: The mean age of subjects was 56 years (SD = 17), and 48% were female. The injections occurred at the L3/4 level in 12% of cases, at L4/5 in 88%, and at L5/S1 in 80% of cases. The intra-reader reliability kappa's for each feature ranged from 0.42 to 0.81. In contrast, the inter-reader reliability kappa values for each feature ranged from 0.37 to 0.54. CONCLUSION: MRI inflammatory features of the lumbar facet joints are often noted in patients with low back pain. The proposed grading system is reliable and could serve as a research tool for studies assessing the clinical relevance and prognostic value of these features.

Reporting of Facet Joint Inflammation in Lumbar Spine MRI Studies in Patients With Low Back Pain.

STUDY DESIGN: Retrospective. OBJECTIVE: We aimed to assess the frequency of facet joint inflammatory features noted in routine radiology reports of lumbar spine magnetic resonance imaging (MRI) studies among patients with chronic low back pain. SUMMARY OF BACKGROUND DATA: Facet joint arthropathy is one of the most common causes of chronic low back pain. It may encompass various inflammatory imaging characteristics, such as facet joint effusion, bone marrow edema, and soft tissue edema. The extent to which radiology reports mention inflammatory features of the lumbar facet joints and the accuracy of these reports have not been investigated. MATERIALS AND METHODS: The authors performed a chart review on 49 subjects with previous facet-related interventions ( i.e . medial branch blocks or intra-articular facet joint injection) and MRI available in the medical record. One senior musculoskeletal radiologist and a musculoskeletal radiology fellow graded the inflammatory features using a published facet joint inflammation grading system [Gold Standard (GS)]. The authors identified the inflammatory markers mentioned in the radiology reports and calculated the sensitivity and positive predictive value of the radiology reports compared with GS readings. RESULTS: Compared with the GS, the sensitivity of radiology reports for facet joint effusion, bone marrow, and soft tissue edema ranged from 6% to 22%, and the positive predictive value ranged from 25% to 100%. L4/5 had the highest number of cases with inflammatory features noted on the reports. CONCLUSION: Inflammatory findings, such as facet joint effusion, bone marrow edema, and soft tissue edema, are not commonly identified in radiology reports. Further investigations are needed to determine the clinical importance of MRI-detected lumbar facet joint inflammatory features as a potential mechanism of nociception and as a predictor of outcomes following injections or other therapies.

Grading Systems of Lumbar Facet Joint Inflammatory Changes on Magnetic Resonance Imaging: A Scoping Review.

STUDY DESIGN: A scoping review. OBJECTIVE: We aimed to identify and characterize grading systems of the inflammatory features of the lumbar facet joints (FJs) noted on magnetic resonance imaging and summarize their reliability. SUMMARY OF BACKGROUND DATA: Chronic low back pain is one of the most common causes of disability worldwide and is frequently accompanied by FJ osteoarthritis. Inflammatory changes in the lumbar FJs are commonly noted in imaging studies of patients with FJ osteoarthritis and low back pain. Several grading systems for these inflammatory changes have been developed. However, these grading system's features and reliability have yet to be reviewed. MATERIALS AND METHODS: We performed a literature search of studies reporting grading systems for FJ inflammatory changes published in English or Spanish between 1985 and 2022. We collected data on reported interreader reliability measures of each grading system. Finally, we compared the features of inflammation described by each system. RESULTS: Six studies met the inclusion criteria and were used in our analysis. Features commonly graded in these systems are the hyperintensity signal noted within the FJ, bone marrow edema, and the extent of the soft-tissue edema surrounding the FJs. We found that the interreader reliability measures ranged from 0.56 to 0.96. CONCLUSIONS: Only 6 studies have reported methods for documenting inflammation in the FJs. Studies varied in the precise tissues and phenomena included in the grading systems. However, the systems were generally reliable. Future studies should document the reliability of these methods when independent investigators are not involved in developing the classification schemes. Further work might combine one or more of these measures to establish a standard and reliable grading system for inflammatory changes in the FJs, including signal intensity within the joint, bone marrow edema, and soft-tissue inflammation.

Predictors of Outcomes After Lumbar Intra-Articular Facet Joint Injections and Medial Branch Blocks: A Scoping Review.

STUDY DESIGN: A scoping review. OBJECTIVE: We aimed to identify and describe the factors associated with the patient-reported response after lumbar intra-articular facet joint (FJ) injections or medial branch blocks (MBBs). SUMMARY OF BACKGROUND DATA: FJ osteoarthritis is among the most common causes of chronic low back pain. Management often includes FJ intra-articular injection and MBBs (which may be followed by radiofrequency ablation of the nerves innervating these joints). However, the success of these approaches is variable, prompting interest in identifying patient characteristics (imaging features, clinical signs, and among others) associated with response to these types of facet injections. MATERIALS AND METHODS: We performed a literature search on factors associated with patient-reported outcomes after lumbar FJ intra-articular injections or MBBs for patients with low back pain published in English or Spanish between 2000 and 2023. We excluded duplicate papers that did not describe factors associated with outcomes or those describing other interventions. We collected data on the association of these factors with patient-reported outcomes. RESULTS: Thirty-seven studies met the inclusion criteria and were analyzed. These studies evaluated factors, such as age, depression, and single photon emission computed tomography (SPECT), and among variables. Age and imaging findings of facet arthropathy were the most frequently described factors. Imaging findings of FJ arthropathy and positive SPECT were often associated with positive results after intra-articular FJ injections or MBBs. In contrast, younger age and smoking were frequently associated with less favorable clinical outcomes. CONCLUSION: Numerous factors were considered in the 37 studies included in this review. Imaging findings of facet arthropathy, duration of pain, and positive SPECT were consistently associated with favorable results after facet interventions.

Surgical treatment options in patients with impaired bone quality.

BACKGROUND: Bone quality should play an important role in decision-making for orthopaedic treatment options, implant selection, and affect ultimate surgical outcomes. The development of decision-making tools, currently typified by clinical guidelines, is highly dependent on the precise definition of the term(s) and the appropriate design of basic and clinical studies. This review was performed to determine the extent to which the issue of bone quality has been subjected to this type of process. QUESTIONS/PURPOSES: We address the following issues: (1) current methods of clinically assessing bone quality; (2) emerging technologies; (3) how bone quality connects with surgical decision-making and the ultimate surgical outcome; and (4) gaps in knowledge that need to be closed to better characterize bone quality for more relevance to clinical decision-making. METHODS: PubMed was used to identify selected papers relevant to our discussion. Additional sources were found using the references cited by identified papers. RESULTS: Bone mineral density remains the most commonly validated clinical reference; however, it has had limited specificity for surgical decision-making. Other structural and geometric measures have not yet received enough study to provide definitive clinical applicability. A major gap remains between the basic research agenda for understanding bone quality and the transfer of these concepts to evidence-based practice. CONCLUSIONS: Basic bone quality needs better definition through the systematic study of emerging technologies that offer a more precise clinical characterization of bone. Collaboration between basic scientists and clinicians needs to improve to facilitate the development of key questions for sound clinical studies.

Comparison of 5766 vertebral compression fractures treated with or without kyphoplasty.

BACKGROUND: The majority of the 700,000 osteoporotic vertebral compression fractures (VCFs) that occur annually in the United States affect women. The total treatment costs exceed $17 billion and approximate the total costs of breast cancer ($13 billion) and heart disease ($19 billion). Balloon-assisted percutaneous vertebral augmentation with bone cement (kyphoplasty) reportedly reduces VCF-related pain and accelerates return of independent functional mobility. Kyphoplasty may decrease overall cost of VCF treatment costs by reducing use of posttreatment medical resources. QUESTIONS/PURPOSES: We evaluated complications, mortality, posthospital disposition, and treatment costs of kyphoplasty compared with nonoperative treatment using the Nationwide Inpatient Sample database. METHODS: We identified 5766 VCFs (71% female) in patients 65 years of age or older with nonneoplastic VCF as the primary diagnosis in nonroutine hospital admissions; 15.3% underwent kyphoplasty. Demographic data, medical comorbidities, and fracture treatment type were recorded. Outcomes, including complications, mortality, posthospital disposition, and treatment costs, were compared for each treatment type. RESULTS: Women were more likely to be treated with kyphoplasty than were men. Patients undergoing kyphoplasty had comorbidity indices equivalent to those treated nonoperatively. Kyphoplasty was associated with a greater likelihood of routine discharge to home (38.4% versus 21.0% for nonoperative treatment), a lower rate of discharge to skilled nursing (26.1% versus 34.8%) or other facilities (35.7% versus 47.1%), a complication rate equivalent to nonoperative treatment (1.7% versus 1.0%), and a lower rate of in-hospital mortality (0.3% versus 1.6%). Kyphoplasty was associated with higher cost of hospitalization (mean $37,231 versus $20,112). CONCLUSIONS: Kyphoplasty for treatment of VCF in well-selected patients may accelerate the return of independent patient function as indicated by improved measures of hospital discharge. The initially higher cost of treatment may be offset by the reduced use of posthospital medical resources. LEVEL OF EVIDENCE: Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Is focused magnetic resonance imaging adequate for treatment decision making in acute traumatic thoracic and lumbar spine fractures seen on whole spine computed tomography?

PURPOSE: To assess whether a focused magnetic resonance imaging (MRI) limited to the region of known acute traumatic thoracic or lumbar fracture(s) would miss any clinically significant injuries that would change patient management. STUDY DESIGN/SETTING: A multicenter retrospective clinical study. PATIENT SAMPLE: Adult patients with acute traumatic thoracic and/or lumbar spine fracture(s). OUTCOME MEASURES: Pathology identified on MRI (ligamentous disruption, epidural hematoma, and cord contusion), outside of the focused zone, an alteration in patient management, including surgical and nonsurgical, as a result of the identified pathology outside the focused zone. METHODS: Records were reviewed for all adult trauma patients who presented to the emergency department between 2008 and 2016 with one or more fracture(s) of the thoracic and/or lumbar spine identified on computed tomography (CT) and who underwent MRI of the entire thoracic and lumbar spine within 10 days. Exclusion criteria were patients with >4 fractured levels, pathologic fractures, isolated transverse, and/or spinous process fractures, prior vertebral augmentation, and prior thoracic or lumbar spine instrumentation. Patients with neurologic deficits or cervical spine fractures were also included. MRIs were reviewed independently by one spine surgeon and one musculoskeletal fellowship-trained emergency radiologist for posterior ligamentous complex (PLC) integrity, vertebral injury, epidural hematoma, and cord contusion. The surgeon also commented on the clinical significance of the pathology identified outside the focused zone. All cases in which pathology was identified outside of the focused zone (three levels above and below the fractures) were independently reviewed by a second spine surgeon to determine whether the pathology was clinically significant and would alter the treatment plan. RESULTS: In total, 126 patients with 216 fractures identified on CT were included, with a median age of 49 years. There were 81 males (64%). Sixty-two (49%) patients had isolated thoracolumbar junction injuries and 36 (29%) had injuries limited to a single fractured level. Forty-seven (37%) patients were managed operatively. PLC injury was identified by both readers in 36 (29%) patients with a percent agreement of 96% and κ coefficient of 0.91 (95% CI 0.87-0.95). Both readers independently agreed that there was no pathology identified on the complete thoracic and lumbar spine MRIs outside the focused zone in 107 (85%) patients. Injury outside the focused zone was identified by at least one reader in 19 (15%) patients. None of the readers identified PLC injury, cord edema, or noncontiguous epidural hematoma outside the focused zone. Percent agreement for outside pathology between the two readers was 92% with a κ coefficient of 0.60 (95% CI 0.48-0.72). The two spine surgeons independently agreed that none of the identified pathology outside of the focused zone altered management. CONCLUSIONS: A focused MRI protocol of three levels above and below known thoracolumbar spine fractures would have missed radiological abnormality in 15% of patients. However, the pathology, such as vertebral body edema not appreciated on CT, was not clinically significant and did not alter patient care. Based on these findings, the investigators conclude that a focused protocol would decrease the imaging time while providing the information of the injured segment with minimal risk of missing any clinically significant injuries.

Lewis A. Sayre: the first Professor of Orthopaedic Surgery in America.

Lewis Albert Sayre (1820-1900) is considered to be among the founding fathers of orthopaedic surgery in the United States. He studied medicine at the College of Physicians and Surgeons (now of Columbia University). Sayre later helped establish the first academic department of orthopaedics at the Bellevue Medical College where he served as their first Professor of Orthopaedics. Lewis Sayre treated a considerable diversity of musculoskeletal conditions and meticulously documented them with written notes, sketches, and photographs. As a public figure, his methods were controversial, attracting praise by some and inviting criticism by other prominent members of the international community. He made great strides for physicians, helping to charter the American Medical Association and to establish the weekly publication of the Journal of the American Medical Association.

Establishing objective volume-outcome measures for anterior and posterior cervical spine fusion.

OBJECTIVES: There is a growing literature on the relationship between provider volume and patient outcomes, specifically within joint arthroplasty and lumbar spine surgery. Such benchmarks have yet to be established for many other spinal procedures, including cervical fusion. We sought to determine whether outcomes-based volume measures for both surgeons and hospitals can be established for cervical spine fusion procedures. PATIENTS AND METHODS: This was a retrospective review of patient data in the Florida Statewide Inpatient Dataset (SID; 2011-14). Patients identified in the Florida SID who underwent either anterior or posterior cervical fusion were identified along with the operative surgeons and the hospitals where the procedures were performed. Socio-demographic data, as well as medical and surgical characteristics were obtained, as were the development of complications and readmissions up to 90days following hospital discharge. Surgeon and hospital volume were plotted separately against the number of complications and readmissions in an adjusted spline analysis. Multivariable logistic regression analysis was subsequently performed to assess the effect of surgeon and hospital volume on post-operative complications and readmissions. RESULTS: There were 8960 patients with posterior cervical fusion and 57,108 anterior cervical fusions (total=66,068) identified for inclusion in the analysis. The patients of low-volume surgeons were found to have an increased (OR 1.83; 95% CI 1.65, 2.02) likelihood of complications following anterior and posterior (OR 1.45; 95% CI 1.24, 1.69) cervical fusion. Low-volume surgeons demonstrated increased likelihood of readmission, irrespective of anterior (OR 1.37; 95% CI 1.29, 1.47) or posterior (OR 1.31; 95% CI 1.16, 1.48) approach. No clinically meaningful differences in the likelihood of complications or readmissions were detected between high- and low-volume hospitals. CONCLUSIONS: This study demonstrates objective volume-outcome measures for surgeons who perform anterior and posterior cervical fusions. Our results have immediate applicability to clinical practice and may be used to benchmark procedural volume. Findings with respect to hospitals speak against the need for healthcare regionalization in this specific clinical context.

Gunshot injuries of the spine.

BACKGROUND CONTEXT: Spinal gunshot injuries (spinal GSIs) are a major cause of morbidity and mortality in both military and civilian populations. These injuries are likely to be encountered by spine care professionals in many treatment settings. A paucity of resources is available to summarize current knowledge of spinal GSI evaluation and management. PURPOSE: The aim was to summarize the ballistics, epidemiology, evaluation, treatment, and outcomes of spinal GSI among civilian and military populations. STUDY DESIGN: This was a review of the current literature reporting spinal GSI management. METHODS: MEDLINE (PubMed) was queried for recent studies and case reports of spinal GSI evaluation and management. RESULTS: Spinal GSI now comprise the third most common cause of spinal injury. Firearms that produce spinal GSI can be divided into categories of high- and low-energy depending on the initial velocity of the projectile. Neural and mechanical spinal damage varies with these types and results from several factors including direct impact, concussion waves, tissue cavitation, and thermal energy. Management of spinal GSI also depends on several factors including neurologic function and change over time, spinal stability, missile tract through the body, and concomitant injury. Surgical treatment is typically indicated for progressive neurologic changes, spinal instability, persistent cerebrospinal fluid leak, and infection. Surgical treatment for GSI affecting T12 and caudal often has a better outcome than for those cranial to T12. Surgical exploration and removal of missile fragments in the spinal canal are typically indicated for incomplete or worsening neurologic injury. CONCLUSIONS: Treatment of spinal GSI requires a multidisciplinary approach with the goal of maintaining or restoring spinal stability and neurologic function and minimizing complications. Concomitant injuries and complications after spinal GSI can present immediate and ongoing challenges to the medical, surgical and rehabilitative care of the patient.

Survival after concurrent traumatic dislocation of the atlanto-occipital and atlanto-axial joints: a case report and review of the literature.

STUDY DESIGN: A case report of a patient who survived a traumatic disassociation of both atlanto-occipital and atlantoaxial joints. OBJECTIVE.: To describe a rare case of concurrent atlanto-occipital and atlantoaxial dislocation with a review of the related literature regarding occipitocervical dislocation. SUMMARY OF BACKGROUND DATA: Cases of isolated atlanto-occipital or atlantoaxial dislocation have typically resulted in death or devastating neurologic deficit. Survival after the simultaneous dislocation at both joints is extremely rare. METHODS: The initial evaluation, subsequent management, and surgical treatment of a 25-year-old male who sustained a concurrent dislocation of the atlantoaxial and atlanto-occipital joints from a motor vehicle collision are reported and the related literature is discussed. RESULTS: The patient was transferred to our hospital after initial stabilization according to Emergency Medical Service criteria and management based on the Advanced Trauma Life Support protocol. A complete (ASIA A) spinal cord injury was diagnosed on admission. Radiographic evaluation revealed dislocations of the atlanto-occipital and atlantoaxial joints. Subsequently, the patient underwent surgical stabilization with instrumented posterior fusion from the occiput to C5. Intraoperatively, traumatic pseudomeningocele was diagnosed and repaired with pericranial autograft. The vital function parameters currently remain stable, but the patient is ventilator-dependent and did not regain motor or sensory function. CONCLUSION: The rapid response time of emergency medical services and stabilization according to the Advanced Trauma Life Support protocol now lead to the survival of patients with significant deficit from occipitocervical injuries. A high index of suspicion is required to appropriately manage a patient with this devastating injury in order to maximize the chance for survival.