An international consensus based on the Delphi method to define failure of medical treatment in pyogenic spinal infections.

BACKGROUND CONTEXT: Pyogenic spinal infections (PSIs) are severe conditions with high morbidity and mortality. If medical treatment fails, patients may require surgery, but there is no consensus regarding the definition of medical treatment failure. PURPOSE: To determine criteria for defining failure of medical treatment in PSI through an international consensus of experts. STUDY DESIGN: A two-round basic Delphi method study. SAMPLE: One hundred and fifty experts from 22 countries (authors or co-authors of clinical guidelines or indexed publications on the topic) were invited to participate; 33 answered both rounds defining the criteria. OUTCOME MEASURES: A scale of 1 to 9 (1: no relevance; 9: highly relevant) applied to each criterion. METHODS: We created an online survey with 10 criteria reported in the literature to define the failure of medical treatment in PSIs. We sent this survey via email to the experts. Agreement among the participants on relevant criteria (score ≥7) was determined. One month later, the second round of evaluations was sent. An extra criterion suggested by six responders in the first round was incorporated. The final version was reached with the criteria considered relevant and with high agreement. RESULTS: The consensus definition is: (1) There is an uncontrolled sepsis despite broad spectrum antibiotic treatment, and (2) There is an infection relapse, following a six-week period of antibiotics with clinical and laboratory improvement. CONCLUSIONS: Our definition of failure following nonsurgical treatment of PSI can offer a standardized approach to guide clinical decision-making. Furthermore, it has the potential to enhance scientific reporting within this field.

Update on the Diagnosis and Management of Spinal Infections.

Pyogenic spinal infections are uncommon, but their incidence has increased. Diagnosis is based on clinical, laboratory, and imaging findings. Delayed diagnosis occurs frequently and can lead to poor outcomes. Early radiographic findings are nonspecific; MRI is the best imaging study for diagnosis. The goal of treatment is to eradicate infection, prevent recurrence, preserve spinal stability, avoid deformity, relieve pain, and prevent or reverse neurologic deficit. Current guidelines recommend antibiotics be administered for 6 weeks if there is resolution of symptoms and normalization of inflammatory parameters. Surgery is required in patients with neurologic deficit, uncontrolled sepsis, spinal instability, deformity, and failure of medical treatment and to manage epidural abscess. Classic treatment of epidural abscess is surgical, but recent studies have challenged this approach. Surgical techniques used to manage these infections are varied; they include anterior, posterior, and combined approaches, and minimally invasive surgery. Current management has decreased mortality; however, the prognosis is affected by treatment failure, recurrent infection, or potential of persistent disability secondary to deformity, chronic pain, or permanent neurologic impairment.

Mid and lower thoracic kyphosis changes during adulthood: the influence of age, sex and thoracic coronal curvature.

INTRODUCTION: There is conflicting data on how thoracic kyphosis changes throughout adulthood. We evaluated mid and lower thoracic kyphosis (MTK) in various age groups and the influence of age, sex and coronal curve (CC) on MTK. MATERIAL AND METHODS: We studied 1323 patients 15-80 years-old (54.4% females) previously evaluated with chest radiographs. We established three groups: patients 15-40 (group 1); 41-60 (group 2) and 61-80 years old (group 3). MTK (T5-T12) and CC were measured using Cobb's method. We established differences in MTK between groups using ANOVA with Bonferroni correction. We performed a correlation analysis of MTK with age and CC, and a linear regression analysis to determine if age, sex and CC independently predicted MTK. RESULTS: MTK increased with older age: mean MTK group 1 = 23.4°; group 2 = 27.9° and group 3 = 34.4°, p < 0.01. The increase in MTK was observed in both genders. Scoliosis was more common in females (15.4%) than in males (6.7%), p < 0.01. MTK was correlated with age (r = 0.4; p < 0.01) and slightly correlated with CC (r = 0.07, p < 0.01). MTK was larger in females than in males (29.1° vs. 27.6°, p < 0.01). Age (ß-coefficient = 0.26) and CC (ß-coefficient = 0.14), but not sex, independently influenced MTK in the regression analysis. CONCLUSION: MTK increases with advancing age during adulthood in both genders; CC, but not sex, was an independent predictor of MTK.

Infecciones piógenas de la columna vertebral / Pyogenic spinal infections

Las infecciones espinales son cuadros clínicos poco frecuentes, que exigen un alto índice de sospecha. La prevalencia de infecciones piógenas de la columna ha ido en aumento, en parte debido al envejecimiento de la población y a un mayor número de pacientes inmunocomprometidos. El estudio imagenológico se puede iniciar con radiografías simples, pero la resonancia magnética es el examen imagenológico de elección, ya que puede dar resultados positivos de forma precoz, entregando información más detallada del compromiso vertebral y tejidos blandos adyacentes. Aunque la clínica y los hallazgos imagenológicos nos pueden orientar, es importante intentar un diagnóstico microbiológico tomando cultivos y muestras para identificar al agente causal antes de iniciar los antibióticos; aunque es óptimo un tratamiento agente-específico, hasta un 25% de los casos queda sin diagnóstico del agente. El tratamiento es inicialmente médico, con antibióticos e inmovilización, pero se debe considerar la cirugía en casos de compromiso neurológico, deformidad progresiva, inestabilidad, sepsis no controlada o dolor intratable. El manejo quirúrgico actual consiste en el aseo y estabilización precoz de los segmentos vertebrales comprometidos. Descartar una endocarditis concomitante y el examen neurológico seriado son parte del manejo de estos pacientes.

Spinal infections are unusual conditions requiring a high index of suspicion for clinical diagnosis. There has been a global increase in the number of pyogenic spinal infections due to an aging population and a higher proportion of immunocompromised patients. The imaging study should start with plain radiographs, but magnetic resonance imaging (mri) is the gold standard for diagnosis. Mri can detect bone and disc changes earlier than other methods, and it provides detailed information on bone and adjacent soft tissues. Blood cultures and local samples for culture and pathology should be obtained, trying to identify the pathogen. According to the result, the most appropriate drug must be selected depending on susceptibility and penetration into spinal tissues. Treatment should start with antibiotics and immobilization; surgery should be considered in cases with neurological impairment, progressive deformity, spine instability, sepsis, or non-controlled pain. Current surgical treatment includes debridement and early stabilization. Practitioners should rule out endocarditis and perform a serial neurological examination managing these patients.

An Independent Validation of the Brighton Spondylodiscitis Score and a Proposal to Modify the Score.

INTRODUCTION: The Brighton Spondylodiscitis Score (BSS) aims to identify patients with pyogenic spinal infections (PSIs) requiring surgery; an independent assessment of the BSS is required. METHODS: We evaluated 60 patients with PSIs. Using the BSS, we determined whether patients with low, moderate, and high risk (LMHR) had different rates of surgery. We proposed a modified score (MS) using a logistic regression (LOGR). Applying the MS, we determined whether patients with LMHR exhibited different rates of surgery. Another LOGR determined the association of the BSS and the MS with surgery. A C-statistic using the BSS and the MS was generated. RESULTS: We studied 60 patients (mean age = 63 years); 37 (62%) were men; 30 (50%) required surgery. Using the BSS, patients with LMHR had similar rates of surgery (P = 0.53). LOGR showed that cervical PSIs had a larger chance of surgery (odds ratio [OR] = 7.3 [1.1 to 51.3]) than other locations. Using the MS, patients with moderate- and high-risk were operated more frequently than low-risk patients (P = 0.04). The BSS did not predict surgery (OR = 1.07; P = 0.31), but the MS did (OR = 1.16; P = 0.02). The C-statistic using the BSS (0.59) improved using the MS (0.69), P = 0.03. DISCUSSION: The discriminatory capacity to predict surgery of the BSS augmented using the MS. LEVEL OF EVIDENCE: II (Diagnostic study: Transverse study).

A New Classification System for Pilon Fractures Based on CT Scan: An Independent Interobserver and Intraobserver Agreement Evaluation.

BACKGROUND DATA: A new pilon fracture classification system based on CT scan data was recently published, showing almost perfect interobserver and intraobserver agreement among the authors who developed it. However, an independent assessment has not been done. OBJECTIVE: To do an independent agreement evaluation of the new pilon fracture classification system with physicians with different levels of expertise in the management of pilon fractures. METHODS: Seventy-one cases of acute pilon fracture were retrospectively collected. Fractures were classified by six evaluators (three foot and ankle surgeons and three orthopaedic surgery residents) using CT scans according to the morphological grading of the new pilon fracture classification system developed by Leonetti et al. Cases were presented to the same evaluators in a random sequence after a 6-week interval to determine intraobserver agreement. The kappa coefficient (κ) was used to determine agreement among evaluators. RESULTS: The interobserver agreement was substantial regarding the main fracture type (I, II, III, or IV), with an overall κ value of 0.69 (0.65 to 0.72). When including the II and III subtypes, the overall agreement was still substantial, with a κ value of 0.61 (95% confidence interval: 0.58 to 0.64). The intraobserver agreement was substantial when considering the main fracture categories (I, II, III, or IV), with a κ value of 0.78 (confidence interval: 0.72 to 0.84), and full agreement at the type level was observed in 76% (324/426) of evaluations. There was no notable difference between the foot and ankle surgeons and orthopaedic surgery residents in the interobserver and intraobserver agreement. CONCLUSION: The new classification system demonstrated substantial interobserver and intraobserver agreement between evaluators with different levels of expertise in the management of pilon fractures. Prospective studies should be done to evaluate its prognostic value and utility in clinical practice.

Incidental identification of vertebral compression fractures in patients over 60 years old using computed tomography scans showing the entire thoraco-lumbar spine.

INTRODUCTION: Vertebral compression fractures (VCF) are frequently asymptomatic; incidental diagnosis is a valuable opportunity to identify low bone mass and to start treatment. We aimed to determine the proportion of patients over 60 years old evaluated with chest plus abdominal and pelvic computed tomography (CT) scans, allowing visualization of the entire thoraco-lumbar spine, who incidentally present VCF. MATERIALS AND METHODS: We evaluated 300 patients over 60 years old who under went chest plus abdominal and pelvic CT scans. Using sagittal reformats we looked for VCF using the method described by Genant. Accordingly, VCF were classified into mild, moderate or severe. We also determined the percentage of VCF described in the radiological reports. RESULTS: In our cohort [median age 72.5 years (61-94)], 45.67% were males and 54.33% were females. In total, 43 patients (14.33%) had at least one VCF; 32 (10.67%) had one VCF, whereas 11 (3.67%) exhibited multiple VCF, with a total of 84 fractures. 42 were mild fractures, 29 moderate and 13 severe. The proportion of males (13.87%) and females (14.72%) with VCF was not different (p = 0.83). Patients with VCF were older than those without VCF (p < 0.01). Only age but not sex was independently associated with the presence of VCF. Only 32.56% of patients we identified as having a VCF had a description in their report (14 patients). CONCLUSION: An important proportion of patients over 60 years old evaluated with chest plus abdominal and pelvic CT scans present VCF. The reporting of these VCF is insufficient; radiologists and clinicians should include their detection in their search pattern.

Does the META score evaluating osteoporotic and metastatic vertebral fractures have enough agreement to be used by orthopaedic surgeons with different levels of training?

PURPOSE: Differentiating osteoporotic vertebral fractures (OVF) from metastatic vertebral fractures (MVF) is difficult. A magnetic resonance imaging (MRI)-based score (META score) aiming to differentiate OVF and MVF was recently published; however, an independent agreement assessment is required before the score is used. We performed such independent agreement evaluation, including raters with different levels of training. METHODS: Sixty-four patients with confirmed OVF or MVF were evaluated by six raters (three spine surgeons and three orthopaedic residents) using the META score. We used the intra-class correlation coefficient (ICC) to evaluate inter- and intra-observer agreement and the kappa statistic (κ) to determine the agreement for individual score criteria. We calculated the area under the receiver-operating characteristic curve (AUC) to establish the score accuracy. RESULTS: The inter-observer agreement was poor [ICC = 0.22 (0.12-0.33)]; spine surgeons [ICC = 0.75 (0.66-0.83)] had better agreement than that of residents [ICC = 0.06 (- 0.07 to 0.23)]. The intra-observer agreement was poor [ICC = 0.15 (- 0.04 to 0.30)]; both spine surgeons [ICC = 0.21 (0.05-0.41)] and residents exhibited poor agreement [ICC = - 0.06 (- 0.40 to 0.20)]. The agreement for each specific criterion varied from κ = 0.24 to κ = 0.38. The AUC was 0.57 (0.64 for spine surgeons and 0.51 for residents, p < 0.01). CONCLUSION: The inter-observer agreement using the META score was adequate for spine surgeons but not for residents; the intra-observer agreement was poor. These results do not support the standard use of the META score to differentiate OVF and MVF. These slides can be retrieved under Electronic Supplementary Material.

The META score for differentiating metastatic from osteoporotic vertebral fractures: an independent agreement assessment.

BACKGROUND CONTEXT: Differentiating osteoporotic vertebral fractures (OVFs) from metastatic vertebral fractures (MVFs) is an important clinical challenge. A novel magnetic resonance imaging (MRI)-based score (the META score) was described, aiming to differentiate OVF from MVF. This score showed an almost perfect agreement by the group developing it, but an independent agreement evaluation is pending. PURPOSE: We aimed to perform an independent inter- and intraobserver agreement evaluation of the META score and to test the score's capability of differentiating OVF from MVF. STUDY DESIGN: This is an agreement study of the META score. METHODS: Sixty-four patients with confirmed OVF or MVF were assessed by six independent evaluators (three spine surgeons and three fellowship-trained radiologists) using the META score. We used the intraclass correlation coefficient (ICC) to determine the overall inter-and intraobserver agreement, and the kappa statistic (κ) to express the agreement for each individual score criterion. The score accuracy was determined by calculating the area under the receiver operating characteristic curve. Finally, we used κ to evaluate the agreement among raters to determine whether the fracture was OVF or MVF. RESULTS: The overall interobserver agreement was poor [ICC=0.10 (0.02-0.20)]; spine surgeons [ICC=0.75 (0.66-0.83)] had better agreement than radiologists did [ICC=0.05 (-0.08 to 0.21)]. The intraobserver agreement was poor [ICC=0.17 (0.01-0.32)]; both spine surgeons [ICC=0.21 (0.05-0.41)] and radiologists had a poor agreement [ICC=0.03 (-0.29 to 0.27)]. The agreement for each specific criterion varied from κ=0.24 to κ=0.60. The area under the receiver operating characteristic curve was 0.58 (0.64 for spine surgeons and 0.52 for radiologists, p<.01). CONCLUSIONS: The interobserver agreement using the META score was adequate for spine surgeons but not for other potential users (radiologists); the intraobserver agreement was poor. Further studies are thus necessary before the use of this score is recommended.

A prevalence study of thoracic scoliosis in Chilean patients aged 10-20 years using chest radiographs as a screening tool.

To determine the prevalence of thoracic scoliosis in patients 10-20 years old using radiographs as a screening tool, we studied 783 patients who obtained chest radiographs for nonspinal reasons. We measured thoracic curvature in coronal and sagittal planes; we determined whether age, sex, and sagittal curvature predicted the coronal curvature. The prevalence of scoliosis was 9.3%: 7.0% had curvatures 10°-20°; 1.0% had curvatures 20°-30°; and 1.3% had curvatures of at least 30°. Females (13%) presented larger prevalence of scoliosis than males (4.8%) (P<0.01), also with a larger proportion of larger curvatures. Sex and thoracic kyphosis were independent predictors of the coronal curvature, age was not.

Does the Prevalence of Spondylolysis and Spina Bifida Occulta Observed in Pediatric Patients Remain Stable in Adults?

STUDY DESIGN: Cross-sectional study. OBJECTIVE: To compare the prevalence of lumbar spondylolysis and spina bifida occulta (SBO) in pediatric and adult populations. SUMMARY OF BACKGROUND DATA: The prevalence of spondylolysis reported from radiograph-based studies in children had been questioned in computed tomography (CT)-based studies in adults; however, a recent CT-based study in pediatric patients has confirmed the previously reported data in pediatric populations. SBO, which has been associated with spondylolysis, has demonstrated a decreasing prevalence with increasing age during childhood and adolescence. No studies have compared the prevalence of spondylolysis and SBO in pediatric and adult patients using CT as a screening method. METHODS: We studied 228 pediatric patients (4-15 y old) and 235 adults (30-45 y old) who underwent abdominal and pelvic CT scans for reasons not related to the spine. The entire lumbosacral spine was evaluated to detect the presence of spondylolysis and SBO. We compared the prevalence of spondylolysis and SBO in pediatric patients and adults. RESULTS: The prevalence of spondylolysis in pediatric patients was 3.5% (1.1%-5.9%), and in adults, it was 3.8% (1.7%-6.8%), P=1. The prevalence of SBO in pediatric subjects was 41.2% (34.8%-59.2%) and dropped to 7.7% (4.3%-11.5%) in adults, P<0.01. The male prevalence of SBO in pediatric patients was 51.4%, whereas it was 32.2% in females (P<0.01); this sex difference was not significant in the adult population (P=0.8). CONCLUSIONS: The prevalence of lumbar spondylolysis remained constant from pediatric age through adulthood. The prevalence of SBO decreased from 41.2% in children to 7.7% in adults; this finding suggests that closure of the vertebral arch may not be completed in early childhood in a large percentage of subjects.

Do Orthopaedic Oncologists Agree on the Diagnosis and Treatment of Cartilage Tumors of the Appendicular Skeleton?

BACKGROUND: Distinguishing a benign enchondroma from a low-grade chondrosarcoma is a common diagnostic challenge for orthopaedic oncologists. Low interrater agreement has been observed for the diagnosis of cartilaginous neoplasms among radiologists and pathologists, but, to our knowledge, no study has evaluated inter- and intraobserver agreement among orthopaedic oncologists grading these lesions using initial clinical and imaging information. Determining such agreement is important since it reflects the certainty in the diagnosis by orthopaedic oncologists. Agreement also is important as it will guide future treatment and prognosis, considering that there is no gold standard for diagnosis of these lesions. QUESTIONS/PURPOSES: (1) to determine inter- and intraobserver agreement among a multinational panel of expert orthopaedic oncologists in diagnosing cartilaginous neoplasms based on their assessment of clinical symptoms and imaging at diagnosis. (2) To describe the most important clinical and imaging features that experts use during the initial diagnostic process. (3) To determine interobserver agreement for proposed initial treatment strategies for cartilaginous neoplasms by this panel of evaluators. METHODS: Thirty-nine patients with intramedullary cartilaginous neoplasms of the appendicular skeleton of various histopathologic grades were selected and classified as having benign, low-grade malignant, or intermediate- or high-grade malignant neoplasms by 10 experienced orthopaedic oncologists based on clinical and imaging information. Additionally, they chose the three most important clinical or imaging features for the diagnosis of these neoplasms, and they proposed a treatment strategy for each patient. The Kappa coefficient (κ) was used to determine inter- and intraobserver agreement. RESULTS: Inter- and intraobserver agreements were only fair to good, κ = 0.44(95% CI, 0.41-0.48) and κ = 0.62 (95% CI, 0.52-0.72), respectively. The three factors most frequently identified as helpful in making the diagnosis by our panel were cortical involvement in 65% of evaluations (253/390), neoplasm size in 51% (198/390), and pain in 50% (194/390). The interobserver agreement for the proposed initial treatment strategy after diagnosis was poor (κ = 0.21; 95% CI, 0.18-0.24). CONCLUSIONS: This study showed barely fair interobserver and fair to good intraobserver agreement for grading of intramedullary cartilaginous neoplasms by orthopaedic oncologists using initial clinical and imaging findings. These results reflect the insufficient guidance interpreting clinical and imaging features, and the limitations of the systems we use today when making these diagnoses. In the same way, they generate concern for the implications that this may have on different treatment strategies and the future prognosis of our patients. Future studies should build on these observations and focus on clarifying our criteria of diagnosis so that treatment recommendations are standardized regardless of the treating institution or oncologist. LEVEL OF EVIDENCE: Level III, diagnostic study.

An Independent Inter- and Intraobserver Agreement Evaluation of the AOSpine Subaxial Cervical Spine Injury Classification System.

STUDY DESIGN: An agreement study. OBJECTIVE: The aim of this study was to perform an independent interobserver and intraobserver agreement assessment of the AOSpine subaxial cervical spine injury classification system. SUMMARY OF BACKGROUND DATA: The AOSpine subaxial cervical spine injury classification system was recently described. It showed substantial inter- and intraobserver agreement in the study describing it; however, an independent evaluation has not been performed. METHODS: Anteroposterior and lateral radiographs, computed tomography scans, and magnetic resonance imaging of 65 patients with acute traumatic subaxial cervical spine injuries were selected and classified using the morphologic grading of the subaxial cervical spine injury classification system by 6 evaluators (3 spine surgeons and 3 orthopedic surgery residents). After a 6-week interval, the 65 cases were presented to the same evaluators in a random sequence for repeat evaluation. The kappa coefficient (κ) was used to determine the inter- and intraobserver agreement. RESULTS: The interobserver agreement was substantial when considering the fracture main types (A, B, C, or F), with κ = 0.61 (0.57-0.64), but moderate when considering the subtypes: κ = 0.57 (0.54-0.60). The intraobserver agreement was substantial considering the fracture types, with κ = 0.68 (0.62-0.74) and considering subtypes, κ = 0.62 (0.57-0.66). No significant differences were observed between spine surgeons and orthopedic residents in the overall inter- and intraobserver agreement, or in the inter- and intraobserver agreement of specific A, B, C, or F type of injuries. CONCLUSION: This classification allows adequate agreement among different observers and by the same observer on separate occasions. Future prospective studies should determine whether this classification allows surgeons to decide the best treatment for patients with subaxial cervical spine injuries. LEVEL OF EVIDENCE: 3.

Calcium hydroxyapatite crystal deposition with intraosseous penetration involving the posterior aspect of the cervical spine: a previously unreported cause of neck pain.

PURPOSE: Calcific tendinitis is a frequent disorder caused by hydroxyapatite crystal deposition; however, bone erosions from calcific tendinitis are unusual. The spinal manifestation of this disease is calcific tendinitis of the longus colli muscle; this disease has never been described in the posterior aspect of the spine. We report a case of calcium hydroxyapatite crystal deposition involving the posterior cervical spine eroding the bone cortex. METHODS: A 57-year-old woman presented with a 5-month history of left-sided neck pain. Radiographs showed C4-C5 interspinous calcification with lytic compromise of the posterior arch of C4. Magnetic resonance imaging confirmed a lytic lesion of the posterior arch of C4, with a soft tissue mass extending to the C4-C5 interspinous space; calcifications were observed as very low signal intensity areas on T1 and T2 sequences, surrounded by gadolinium-enhanced soft tissues. A computed tomography (CT) scan confirmed the bone erosions and the soft tissue calcifications. RESULTS: A CT-guided needle biopsy was performed; it showed vascularized connective tissue with inflammatory histiocytic infiltration and multinucleated giant cells; Alizarin Red stain confirmed the presence of hydroxyapatite crystals. The patient was treated with anti-inflammatories for 2 weeks. She has been asymptomatic in a 6-month follow-up; a CT scan at the last follow-up revealed reparative remodeling of bone erosions. CONCLUSION: This is the first report of calcium hydroxyapatite crystal deposition with intraosseous penetration involving the posterior aspect of the cervical spine. Considering that this unusual lesion can be misinterpreted as a tumor or infection, high suspicion is required to avoid unnecessary surgical procedures.

A comparative agreement evaluation of two subaxial cervical spine injury classification systems: the AOSpine and the Allen and Ferguson schemes.

PURPOSE: We performed an agreement study using two subaxial cervical spine classification systems: the AOSpine and the Allen and Ferguson (A&F) classifications. We sought to determine which scheme allows better agreement by different evaluators and by the same evaluator on different occasions. METHODS: Complete imaging studies of 65 patients with subaxial cervical spine injuries were classified by six evaluators (three spine sub-specialists and three senior orthopaedic surgery residents) using the AOSpine subaxial cervical spine classification system and the A&F scheme. The cases were displayed in a random sequence after a 6-week interval for repeat evaluation. The Kappa coefficient (κ) was used to determine inter- and intra-observer agreement. RESULTS: Inter-observer: considering the main AO injury types, the agreement was substantial for the AOSpine classification [κ = 0.61 (0.57-0.64)]; using AO sub-types, the agreement was moderate [κ = 0.57 (0.54-0.60)]. For the A&F classification, the agreement [κ = 0.46 (0.42-0.49)] was significantly lower than using the AOSpine scheme. Intra-observer: the agreement was substantial considering injury types [κ = 0.68 (0.62-0.74)] and considering sub-types [κ = 0.62 (0.57-0.66)]. Using the A&F classification, the agreement was also substantial [κ = 0.66 (0.61-0.71)]. No significant differences were observed between spine surgeons and orthopaedic residents in the overall inter- and intra-observer agreement, or in the inter- and intra-observer agreement of specific type of injuries. CONCLUSION: The AOSpine classification (using the four main injury types or at the sub-types level) allows a significantly better agreement than the A&F classification. The A&F scheme does not allow reliable communication between medical professionals.

An assessment of the Chilean National Examination of Orthopaedic Surgery.

BACKGROUND: The Chilean National Examination of Orthopaedic Surgery (EMNOT) has been administered since 2009. It was developed to determine whether individual residents are meeting minimal knowledge standards at the end of their training programs. METHODS: We performed a retrospective evaluation of the EMNOT for all years it has been administered (2009-2015). The test was analyzed for content, taxonomy of questions asked (1: direct recall; 2: diagnosis; 3: evaluation/decision-making), residents' performance, difficulty index and discrimination index. RESULTS: During the years of EMNOT administration, the most frequently tested areas have been pediatric orthopaedics (22.9 %), spine (13.8 %), general orthopaedics (13.8 %) and musculoskeletal trauma (9.9 %). A significant increase in questions with images was observed, as well as a significant decrease in the percentage of Type 1 and an increase in Type 3 questions. The Difficulty Index showed a medium level of difficulty for all years the examination has been administered. The Discrimination Index showed good discrimination in 2009, fair discrimination from 2010 through 2012, and excellent discrimination from 2013 through 2015. CONCLUSION: The EMNOT has evolved over several years to include better quality questions, better discrimination, and a more representative distribution of questions covering the different orthopaedic sub-specialties. This examination represents an effective instrument for quality assurance of orthopaedic residency programs in Chile.

Spondylolysis and spina bifida occulta in pediatric patients: prevalence study using computed tomography as a screening method.

PURPOSE: The prevalence of spondylolysis reported from radiograph-based studies has been questioned in recent computed tomography (CT)-based studies in adults; however, no new data are available in pediatric patients. Spina bifida occulta (SBO), which has been associated to spondylolysis, may be increasing its prevalence, according to recent studies in adults in the last decades, but without new data in pediatric patients. We aimed to determine the prevalence of spondylolysis and SBO in pediatric patients using abdomen and pelvis CT as a screening tool. METHODS: We studied 228 patients 4-15 years old (107 males), who were evaluated with abdomen and pelvis CT scans for reasons not related to the spine. The entire lumbo-sacral spine was evaluated to detect the presence of spondylolysis and SBO. We compared the prevalence of spondylolysis in patients with and without SBO. A logistic regression analysis was performed to determine the effect of age and sex as independent predictors of spondylolysis and SBO. RESULTS: The prevalence of spondylolysis was 3.5 % (1.1-5.9 %); 2/8 patients presented with olisthesis, both with grade I slip. The prevalence of SBO was 41.2 % (34.8-59.2 %) (94 patients). Spondylolysis was not more frequent in patients with SBO than in patients without SBO. Male sex and decreasing age independently predicted the presence of SBO, but not of spondylolysis. CONCLUSION: We observed a 3.5 % prevalence of spondylolysis and a 41.2 % prevalence of SBO. SBO was significantly more frequent in males and younger patients.

The prevalence of degenerative or incidental findings in the lumbar spine of pediatric patients: a study using magnetic resonance imaging as a screening tool.

PURPOSE: Several studies using magnetic resonance imaging (MRI) to evaluate the lumbar spine in adults have shown a large prevalence of degenerative changes in asymptomatic subjects; however, studies in pediatric patients are scarce. Those studies have suggested a lower rate of degenerative findings in adolescents than in adults, but the actual prevalence of MRI findings in the pediatric population has not yet been determined. We aimed to determine the prevalence of degenerative changes in the lumbar spine of pediatric patients using abdominal and pelvic MRI as the screening tool. METHODS: We studied 103 patients (mean age 6.6 years) who were evaluated with abdominal and pelvic MRI for indications that were not spine related. The entire lumbo-sacral spine was evaluated to detect the presence of disc degeneration (DD), disc displacement, anular rupture with high-intensity zone (HIZ) and Modic changes. RESULTS: In our population, 10.7 % [4.9-16.5] had at least one disc classified as Pfirrmann 2, and no patients presented discs classified as Pfirrmann 3, 4 or 5; patients exhibiting discs classified as Pfirrmann 2 were significantly older than patients who had only Pfirrmann 1 discs. The prevalence of disc bulging was 1 % [0-2.9]. No patients presented disc herniation (including protrusion or extrusions); additionally, no patients exhibited HIZ or Modic changes. CONCLUSIONS: Incidental findings related to DD are very uncommon at this early age, in contrast to findings described in adults or later in adolescence.

Inter and intra-observer agreement evaluation of the AO and the Tronzo classification systems of fractures of the trochanteric area.

INTRODUCTION: We performed an agreement study of the AO and the Tronzo classifications of fractures of the trochanteric area to determine if they allow communication among practitioners with different levels of expertise. MATERIAL AND METHODS: Complete radiographs of 70 patients with trochanteric fractures were classified by nine evaluators (three hip sub-specialists, three orthopaedic surgery residents and three medical interns) using the AO and the Tronzo classifications. After a six-week interval, all cases were presented in a random sequence for repeat evaluation. The Kappa coefficient (k) was used to determine inter- and intra-observer agreement. RESULTS: Inter-observer: considering the main AO fracture types, the agreement was moderate for sub-specialists (k = 0.60 [0.50-0.70]), residents (k = 0.58 [0.48-0.69]) and medical interns (k = 0.56 [0.45-0.69]). Using AO sub-types, all groups achieved fair agreement (sub-specialists: k = 0.31 [0.25-0.38]; residents: k = 0.32 [0.26-0.38]; medical interns: k = 0.30 [0.24-0.36]). For the Tronzo classification, sub-specialists (k = 0.56 [0.48-0.65]) and residents (k = 0.47 [0.39-0.55]) obtained moderate agreement; medical interns reached fair agreement (k = 0.33 [0.25-0.41]). Intra-observer: considering the main AO fracture types, sub-specialists (k = 0.79 [0.69-0.89]), residents (k = 0.71 [0.60-0.81]) and medical interns (k = 0.70 [0.59-0.82]) obtained substantial agreement. Considering AO sub-types, sub-specialists (k = 0.50 [0.45-0.56]) and medical interns (k = 0.54 [0.48-0.69]) achieved moderate agreement; residents (k = 0.39 [0.33-0.45]) achieved fair agreement. Using the Tronzo classification, all groups obtained substantial agreement (sub-specialists: k = 0.66 [0.58-0.74]; residents: k = 0.63 [0.55-0.71]; medical interns: k = 0.68 [0.60-0.76]). CONCLUSION: The AO classification allows an adequate communication when considering the main fracture types; the agreement within sub-types is not satisfactory. The Tronzo classification does not allow reliable communication between medical professionals.

An assessment of the Surgical Apgar Score in spine surgery.

BACKGROUND CONTEXT: The Surgical Apgar Score (SAS), a simple metric based on intraoperative heart rate, blood pressure, and blood loss, was developed in general and vascular surgery to predict 30-day major postoperative complications and mortality. No validation of SAS has been performed in spine surgery. PURPOSE: To perform a prospective assessment of SAS in spine surgery. STUDY DESIGN: Prospective study. PATIENT SAMPLE: Two hundred sixty-eight consecutive patients undergoing major and intermediate spinal surgeries in an 18-month period. OUTCOME MEASURES: Occurrence of major complications or death within 30 days of surgery. METHODS: Intraoperative parameters were registered, and SAS was calculated immediately after surgery. Outcome data were collected during a 30-day follow-up. The relationship between SAS and the outcomes was analyzed calculating relative risks (RRs) and likelihood ratios (LRs) for different scoring groups. A univariate logistic regression analysis was also performed. The discriminatory accuracy of SAS was evaluated calculating a C-statistic. RESULTS: Eighteen patients had ≥1 complications (6.72%). Patients with SAS 9-10 exhibited a 1.64% complication rate (RR=1; LR=0.23), which monotonically augmented as the score decreased: (SAS 7-8=2.75%; RR=1.68; LR=0.39), (SAS 5-6=13.33%; RR=8.13; LR=2.14), (SAS≤4=17.39%; RR=10.61; LR=2.92). The regression analysis odds ratio was 0.66 (95% confidence interval, 0.54-0.82), p<.01. The C-statistic was 0.77 (95% confidence interval, 0.66-0.88). CONCLUSIONS: Surgical Apgar Score allows risk stratification and has a good discriminatory power in patients undergoing spine surgery.