Does Operative Level Impact Dysphagia Severity After Anterior Cervical Discectomy and Fusion?: A Multicenter Prospective Analysis.

STUDY DESIGN: Prospective multicenter cohort study. OBJECTIVE: To explore the association between operative level and postoperative dysphagia after anterior cervical discectomy and fusion (ACDF). BACKGROUND: Dysphagia is common after ACDF and has several risk factors, including soft tissue edema. The degree of prevertebral soft tissue edema varies based on the operative cervical level. However, the operative level has not been evaluated as a source of postoperative dysphagia. PATIENTS AND METHODS: Adult patients undergoing elective ACDF were prospectively enrolled at 3 academic centers. Dysphagia was assessed using the Bazaz Questionnaire, Dysphagia Short Questionnaire, and Eating Assessment Tool-10 (EAT-10) preoperatively and at 2, 6, 12, and 24 weeks postoperatively. Patients were grouped based on the inclusion of specific surgical levels in the fusion construct. Multivariable regression analyses were performed to evaluate the independent effects of the number of surgical levels and the inclusion of each particular level on dysphagia symptoms. RESULTS: A total of 130 patients were included. Overall, 24 (18.5%) patients had persistent postoperative dysphagia at 24 weeks and these patients were older, female, and less likely to drink alcohol. There was no difference in operative duration or dexamethasone administration. Patients with persistent dysphagia were significantly more likely to have C4-C5 included in the fusion construct (62.5% vs . 34.9%, P = 0.024) but there were no differences based on the inclusion of other levels. On multivariable regression, the inclusion of C3-C4 or C6-C7 was associated with more severe EAT-10 (ß: 9.56, P = 0.016 and ß: 8.15, P = 0.040) and Dysphagia Short Questionnaire (ß: 4.44, P = 0.023 and (ß: 4.27, P = 0.030) at 6 weeks. At 12 weeks, C3-C4 fusion was also independently associated with more severe dysphagia (EAT-10 ß: 4.74, P = 0.024). CONCLUSION: The location of prevertebral soft tissue swelling may impact the duration and severity of patient-reported dysphagia outcomes at up to 24 weeks postoperatively. In particular, the inclusion of C3-C4 and C4-C5 into the fusion may be associated with dysphagia severity.

Bariatric Surgery and Low Back Pain: A Systematic Literature Review.

STUDY DESIGN: Systematic literature review. OBJECTIVE: It is estimated that one third of the world population is overweight and 20% of adults have some low back symptoms at some point of their lives. The association of obesity and low back pain and physical deterioration has been well established. We designed this study to evaluate the role of bariatric surgery (BS) for lumbar spine symptoms in obese patients. METHODS: A systematic literature review was performed using the PubMed database identifying lumbar spine symptoms (pain, functional status, disability index) and/or complications of lumbar spine surgery before and after BS. Study quality was assessed according to the Oxford Centre for Evidence-Based Medicine. RESULTS: Ten studies were identified. Nine evaluated the role of BS in low back pain and/or functional status before and after surgery: all reported that bariatric surgery had a positive impact in improving low back pain symptoms and decreasing disability in severely obese patients. One study evaluated the role of posterior lumbar surgery in patients who were obese at the time of surgery and those who had a previous bariatric procedure: bariatric surgery decreased postoperative surgical complications. The level of the evidence was low (III and IV). CONCLUSIONS: Bariatric surgery in severely obese patients decreases the intensity of low back symptoms and also decreases disability secondary to back problems. Additionally, bariatric surgery may be advantageous for patients who need a posterior lumbar surgery and are severely obese. Prospective studies with longer follow-up are necessary to confirm this conclusion.

Clinical and radiological outcome of non-surgical management of thoracic and lumbar spinal fracture-dislocations - a historical analysis in the era of modern spinal surgery.

Context: It is well established that traumatic spinal dislocations (AO Type C injuries) should be surgically treated. However, no recent comparative study of surgical versus non-surgical management of type C injuries was found attesting the superiority of surgical treatment.Objective: Due to the lack of information about the natural history of non-surgical management of type C injuries, we evaluated the outcome of historical conservative treatment of type C injuries.Methods: An extensive manual search of articles was performed in the Pubmed Database. We included articles that reported the clinical and/ or the radiological outcome of non-surgical management of thoracic and/ or lumbar spinal fracture-dislocations.Results: Three well described retrospective studies where fracture-dislocations of the thoracolumbar spine were managed non-surgically were included. Non-surgical management typically consisted in postural reduction and prolonged bed rest (about 10-13 weeks on average). Residual deformity was common, and some studies reported a high rate of post treatment pain syndromes. Some studies reported surgery for gibbus deformity after conservative treatment or persistent instability requiring further bed rest. Neurological deterioration was rare, and some patients had some improvement, although the vast majority of the patients had persistent, severe neurological deficits.Conclusions: Compared with historical non-surgical care, surgery for type C injuries decreases the chances of post-operative pain, late spinal deformity and also allowed early rehabilitation, once no bed restriction is necessary. Ethical issues based on this historical analysis may preclude performing a comparative study of non-surgical versus surgical management of these injuries in the modern spine era.

Reliability of the New AOSpine Classification System for Upper Cervical Traumatic Injuries.

BACKGROUND: The new AOSpine Upper Cervical Classification System (UCCS) was recently proposed by the AOSpine Knowledge Forum Trauma team to standardize the treatment of upper cervical traumatic injuries (UCI). In this context, evaluating its reliability is paramount prior to clinical use. OBJECTIVE: To evaluate the reliability of the new AOSpine UCCS. METHODS: A total of 32 patients with UCI treated either nonoperatively or with surgery by one of the authors were included in the study. Injuries were classified based on the new AO UCCS according to site and injury type using computed tomography scan images in 3 planes by 8 researchers at 2 different times, with a minimum interval of 4 wk between assessments. Intra- and interobserver reliability was assessed using the kappa index (K). Treatment options suggested by the evaluators were also assessed. RESULTS: Intraobserver agreement for sites ranged from 0.830 to 0.999, 0.691 to 0.983 for types, and 0.679 to 0.982 for the recommended treatment. Interobserver analysis at the first assessment was 0.862 for injury sites, 0.660 for types, and 0.585 for the treatment, and at the second assessment, it was 0.883 for injury sites, 0.603 for types, and 0.580 for the treatment. These results correspond to a high level of agreement of answers for the site and type analysis and a moderate agreement for the recommended treatment. CONCLUSION: This study reported an acceptable reproducibility of the new AO UCCS and safety in recommending the treatment. Further clinical studies with a larger patient sample, multicenter and international, are necessary to sustain the universal and homogeneity quality of the new AO UCCS.

Diagnosis, Risk Factors, and Management of Sacral and Pelvic Fractures After Instrumented Lumbar Fusions: A Systematic Review.

STUDY DESIGN: Systematic literature review. OBJECTIVES: To evaluate risk factors, diagnosis, and management of sacral and pelvic fractures (SPFs) after instrumented fusions. METHODS: A systematic review following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines was performed using the PubMed database. Articles with patients with an SPF after a lumbar instrumented fusion were included. The articles addressing specifically proximal junctional kyphosis were excluded. Eleven small cases series (level of evidence IV) were reviewed. RESULTS: The incidence of SPF was 1.86% in one study. The risk factors reported were elderly patients, multilevel surgery, long fusions stopping at L5 or S1 instead of the ilium, osteoporosis, obesity, and sagittal imbalance. Computed tomography scan was the preferential image modality for diagnosing. Nonsurgical treatment may be used in patients with tolerable pain and nondisplaced fracture. Persistent pain was an indication for surgery, as well as fracture displacement. The most common surgical treatment reported was an extension of the fusion to the iliac using iliac screws. CONCLUSION: SPFs after lumbar instrumented fusion are rare but clinically meaningful complications. The risk factors, diagnosis, and management of SPFs are described in our review.

Spinal Reconstruction Techniques for Traumatic Spinal Injuries: A Systematic Review of Biomechanical Studies.

STUDY DESIGN: Systematic literature review. OBJECTIVES: Many studies have provided evidence that short-segment posterior fixation (SSPF-1 level above and 1 below) with screws at the fracture level (SFL) are enough to achieve stability in some injury patterns, such as burst fractures, avoiding the need for circumferential reconstruction and long-segment instrumented fusion (LSIF-at least 2 levels above and 2 below). Given the potential benefits of avoiding unnecessary fusion in mobile healthy spinal segments, we performed a systematic review of biomechanical studies comparing different spinal reconstruction techniques for fractures of the thoracolumbar spine. METHODS: A systematic literature review was performed in the PubMed and OVID databases of biomechanical studies comparing biomechanical differences between techniques of spine reconstructions. RESULTS: Eight studies were included and evaluated. Five of 6 studies reported stiffness improvement with SSPF and SFL, even comparable to circumferential fusion for a burst fracture. Two studies reported that LSPF has higher stiffness and restricts range of motion better than SSPF, but inclusion of screws in the fracture level is similar to LSPF (1 study). Finally, although SSPF is less stiff than anterior reconstruction, adding a SFL in SSPF results in similar stiffness than circumferential fusion for unstable burst fractures. CONCLUSIONS: Biomechanical studies analyzed generally suggested that SFL in SSPF may improve construction stiffness, and can even be compared with long-segment fixation or circumferential reconstruction in some scenarios. This construct option may be used to enhance stiffness in selected injury patterns, avoiding the needs of an additional anterior approach.

A simplified treatment algorithm for treating thoracic and lumbar spine trauma.

CONTEXT: Current treatment of TLST should consider injury morphology, neurological status, clinical status (pain and disability) and also multimodal radiological evaluation (MMRE) with CT, MRI and dynamic/ standing plain radiographs. METHODS: A narrative literature review was performed to propose a treatment algorithm to guide the management of thoracolumbar spinal trauma (TLST). In order to classify injuries and surgical indications, we utilized the two most recent classification systems (TLICS and new AO spine classification) and related recent literature. RESULTS: Injuries were categorized into three groups according to stability: 1) Stable injuries, 2) Potentially unstable injuries/ delayed instability or 3) Clearly unstable injuries. Stable injuries included most of AO type A fractures without neurological deficit, mild clinical symptoms and without risk factors for late deformity. Potentially unstable injuries generally included patients without neurological deficits but with some risk factors for late deformity or with severe clinical symptoms. Surgery may be recommended in this group. Finally, clearly unstable injuries are those with spinal dislocations and/ or with neurological deficits, especially in the setting of persistent neural tissue compression, requiring early surgical treatment. CONCLUSIONS: The proposed treatment algorithm is intended to help surgeons select the best treatment modality for their patients, categorizing injuries according to their main characteristics into one of these three groups. Further studies addressing the reliability and safety of this algorithm are necessary.

Posterior L5-S1 transdiscal screws for high grade spondylolisthesis - a systematic review.

OBJECTIVE: The surgical management of high-grade lumbar spondylolisthesis (HGLS) is complex and aims to achieve both a solid fusion that is able to support the high shear forces of the lumbosacral junction, as well as neural decompression. We performed a systematic literature review of the safety and efficacy of posterior transdiscal (PTD) screw fixation from L5S1 for HGLS and its variations. METHODS: A systematic literature review following the PRISMA guidelines was performed in the PubMed database of the studies describing the use of PTD screw fixation for HGLS. Clinical and radiological data were extracted and discussed. Study quality was assessed with the Oxford Centre for Evidence-Based Medicine Levels of Evidence. RESULTS: Seven studies were included and reviewed; all of them were level IV of evidence. Two of them had large case series comparing different surgical techniques: one concluded that PTD was associated with better clinical outcomes when compared with standard screw fixation techniques and the other suggesting that the clinical and radiological outcomes of PTD were similar to those when an interbody fusion (TLIF) technique was performed, but PTD was technically less challenging. The remaining five studies included small case series and case reports. All of them reported the successful useful of PTD with or without technical variations. CONCLUSIONS: Our review concludes, with limited level of evidence that PTD fixation is a safe and efficient technique for treating HGLS patients. It is technically less demanding than a circumferential fusion, even though proper screw insertion is more demanding than conventional pedicle screw fixation.

Posterior L5-S1 transdiscal screws for high grade spondylolisthesis - a systematic review

SUMMARY OBJECTIVE: The surgical management of high-grade lumbar spondylolisthesis (HGLS) is complex and aims to achieve both a solid fusion that is able to support the high shear forces of the lumbosacral junction, as well as neural decompression. We performed a systematic literature review of the safety and efficacy of posterior transdiscal (PTD) screw fixation from L5S1 for HGLS and its variations. METHODS: A systematic literature review following the PRISMA guidelines was performed in the PubMed database of the studies describing the use of PTD screw fixation for HGLS. Clinical and radiological data were extracted and discussed. Study quality was assessed with the Oxford Centre for Evidence-Based Medicine Levels of Evidence. RESULTS: Seven studies were included and reviewed; all of them were level IV of evidence. Two of them had large case series comparing different surgical techniques: one concluded that PTD was associated with better clinical outcomes when compared with standard screw fixation techniques and the other suggesting that the clinical and radiological outcomes of PTD were similar to those when an interbody fusion (TLIF) technique was performed, but PTD was technically less challenging. The remaining five studies included small case series and case reports. All of them reported the successful useful of PTD with or without technical variations. CONCLUSIONS: Our review concludes, with limited level of evidence that PTD fixation is a safe and efficient technique for treating HGLS patients. It is technically less demanding than a circumferential fusion, even though proper screw insertion is more demanding than conventional pedicle screw fixation.

RESUMO OBJETIVOS: O tratamento cirúrgico das listeses de alto grau da coluna lombar (LAGCL) é complexo, objetivando alcançar uma fusão sólida capaz de suportar o estresse biomecânico da junção lombo-sacra, bem como descompressão do tecido neural. Realizamos revisão sistemática da literatura para avaliar a segurança e a eficácia da fixação transdiscal (FTD) L5S1 em LAGCL e suas variações. MÉTODOS: Realizamos revisão sistemática conforme metodologia Prisma na base de dados PubMed dos estudos que utilizaram FTD no tratamento das LAGCL e suas variações. Dados clínicos e radiológicos foram extraídos dos trabalhos e discutidos. A qualidade dos estudos foi avaliada segundo o Oxford Centre for Evidence-Based Medicine Levels of Evidence. RESULTADOS: Sete estudos foram incluídos e analisados, todos com nível IV de evidência. Dois estudos tinham séries de casos maiores, comparando diferentes técnicas cirúrgicas: um concluiu que a FTD foi associada a melhor prognóstico clínico quando comparada à fixação pedicular tradicional, e o outro sugeriu que os resultados clínicos e radiológicos com a FTD foram semelhantes à fusão intersomática, porém com menor demanda técnica na FTD. Os demais cinco estudos eram pequenas séries ou relatos de casos. Todos reportaram o uso da FTD com sucesso, com e sem variações da técnica. CONCLUSÃO: Concluímos que, embora com evidências limitadas, a FTD é segura e efetiva no tratamento das LAGCL. É tecnicamente mais simples do que a fusão circunferencial (intersomática), porém com maior complexidade que a fixação pedicular convencional.

Is There an Association With Spino-Pelvic Relationships and Clinical Outcome of Type A Thoracic and Lumbar Fractures Treated Non-Surgically?

BACKGROUND: The objective was to evaluate if there is an association of the spino-pelvic relationships and the global spinal alignment with the outcome of AO type A injuries treated nonsurgically. METHODS: This is a retrospective case series. Patients treated nonsurgically for AOSpine type A fractures (T1-L5) with at least 1 year follow-up identified. A standing antero-posterior and lateral 36-inch radiographs and measures of spino-pelvic relationships and sagittal alignment were obtained, as well as clinical assessment using the visual analog scale, the Short-Form 36 (SF-36) questionnaire, the Oswestry Disability Index (ODI), and labor status. RESULTS: Twenty-two patients with 33 fractures were included (L1 was the most injured level with 18.2%). There were 17 men (77.2%) and the mean age was 47.1 years. Follow-up ranged from 12 to 60 months (mean of 27.8 months). There were 22 type A1 (66.7%), 3 type A2 (9%), 6 type A3 (18%), and 2 type A4 (6%) fractures. The ODI ranged from 4% to 58%, with a mean of 24.4%. The SF-36 physical health score ranged from 23 to 82.25 (mean 49.59), and the mental health score ranged from 14.75 to 94.25 (mean 63.28). No association was identified between the spino-pelvic measurements, global alignment, and patient-reported outcomes. CONCLUSIONS: Type A fractures had a clinically relevant amount of long-term disability even when surgical treatment is not required. Spino-pelvic relationships and final global spinal alignment did not associate with outcome measurements.

Evaluation of the safety and reliability of the newly-proposed AO spine injury classification system.

OBJECTIVE: To evaluate the safety and reliability of the new AO Classification, a recent classification system for Thoraco-Lumbar Spine Trauma (TLST). DESIGN: Retrospective study. METHODS: We applied the new AO system in patients with TLST treated according to the TLICS. Two researchers classified injuries independently. Eight weeks later, the classification was repeated for intra and inter-observer agreement evaluation. To evaluate safety, we correlated the treatment performed based on the TLICS with the newer AO classification obtained. RESULTS: Fifty-four patients were included in this study, with a mean follow-up of 363.8 days. Twenty-three neurologically intact patients were initially treated conservatively. Their mean TLICS was 1.78 (1-4 points). Four patients underwent late surgery. Thirty-one patients were treated surgically. Their average TLICS was 7.22 points (4-10 points). Agreements in the four independent evaluations according to AO groups and subgroups were of 64.8% (35/54) and 55.5% (30/54) respectively. Kappa index for groups A, B and C was 0.75, 0.7 and 0.85 respectively. Kappa index for subgroups ranged from 0.16 to 0.85. Regarding safety, thirty (57.6%) patients with total subgroups agreement were analyzed. All patients with fracture in groups B and C underwent surgical treatment and patients in group A received surgery according to neurological status or failure of conservative treatment. CONCLUSION: The newer AO spine classification demonstrated good reliability at the level of groups. Subgroups demonstrated worse and varying reliability. Although the safety analysis was limited due to the low level of total concordance among all evaluations, patients from group A can be treated conservatively or surgically, whereas those from groups B and C are treated surgically.

Management of degenerative cervical myelopathy - An update.

INTRODUCTION: Degenerative cervical myelopathy (DCM) is the most common cause of spinal cord dysfunction in adult patients. Patients generally present with a slow, progressive neurological decline or a stepwise deterioration pattern. In this paper, we discuss the most important factors involved in the management of DCM, including a discussion about the surgical approaches. METHOD: The authors performed an extensive review of the peer-reviewed literature addressing the aforementioned objectives. RESULTS: Although the diagnosis is clinical, magnetic resonance imaging (MRI) is the study of choice to confirm stenosis and also to exclude the differential diagnosis. The severity the clinical symptoms of DCM are evaluated by different scales, but the modified Japanese Orthopedic Association (mJOA) and the Nürick scale are probably the most commonly used. Spontaneous clinical improvement is rare and surgery is the main treatment form in an attempt to prevent further neurological deterioration and, potentially, to provide some improvement in symptoms and function. Anterior, posterior or combined cervical approaches are used to decompress the spinal cord, with adjunctive fusion being commonly performed. The choice of one approach over the other depends on patient characteristics (such as number of involved levels, site of compression, cervical alignment, previous surgeries, bone quality, presence of instability, among others) as well as surgeon preference and experience. CONCLUSION: Spine surgeons must understand the advantages and disadvantages of all surgical techniques to choose the best procedure for their patients. Further comparative studies are necessary to establish the superiority of one approach over the other when multiple options are available.

Management of degenerative cervical myelopathy - An update / Manejo da mielopatia cervical degeneratiiva - Uma atualização

SUMMARY Introduction Degenerative cervical myelopathy (DCM) is the most common cause of spinal cord dysfunction in adult patients. Patients generally present with a slow, progressive neurological decline or a stepwise deterioration pattern. In this paper, we discuss the most important factors involved in the management of DCM, including a discussion about the surgical approaches. Method The authors performed an extensive review of the peer-reviewed literature addressing the aforementioned objectives. Results Although the diagnosis is clinical, magnetic resonance imaging (MRI) is the study of choice to confirm stenosis and also to exclude the differential diagnosis. The severity the clinical symptoms of DCM are evaluated by different scales, but the modified Japanese Orthopedic Association (mJOA) and the Nürick scale are probably the most commonly used. Spontaneous clinical improvement is rare and surgery is the main treatment form in an attempt to prevent further neurological deterioration and, potentially, to provide some improvement in symptoms and function. Anterior, posterior or combined cervical approaches are used to decompress the spinal cord, with adjunctive fusion being commonly performed. The choice of one approach over the other depends on patient characteristics (such as number of involved levels, site of compression, cervical alignment, previous surgeries, bone quality, presence of instability, among others) as well as surgeon preference and experience. Conclusion Spine surgeons must understand the advantages and disadvantages of all surgical techniques to choose the best procedure for their patients. Further comparative studies are necessary to establish the superiority of one approach over the other when multiple options are available.

RESUMO Introdução a mielopatia cervical degenerativa (MCD) é uma das causas mais comuns de disfunção medular em adultos. Os pacientes em geral apresentam declínio neurológico lento e progressivo, ou deterioração escalonada. No presente artigo, discutimos os mais importantes fatores envolvidos no manejo da MCD, incluindo considerações sobre os aspectos relacionados à escolha da abordagem cirúrgica. Método realizou-se extensa revisão da literatura de artigos peer-reviewed relacionados ao tema. Resultados embora o diagnóstico seja realizado clinicamente, a ressonância magnética (RM) é o estudo de imagem de escolha para confirmá-lo e excluir eventuais diagnósticos diferenciais. A gravidade do quadro clínico pode ser avaliado utilizando-se diferentes escalas, como a modified Japanese Orthopedic Association (mJOA) ou a de Nürick, provavelmente as mais comuns. Uma vez que a melhora clínica espontânea é rara, a cirurgia é a principal forma de tratamento, em uma tentativa de evitar dano neurológico adicional ou deterioração e, potencialmente, aliviar alguns sintomas e melhorar a função dos pacientes. Abordagens cirúrgicas por via anterior, posterior ou combinada podem ser usadas para descomprimir o canal, concomitantemente a técnicas de fusão. A escolha da abordagem depende das características dos pacientes (número de segmentos envolvidos, local de compressão, alinhamento cervical, cirurgias prévias, qualidade óssea, presença de instabilidade, entre outras), além da preferência e experiência do cirurgião. Conclusão os cirurgiões de coluna devem compreender as vantagens e desvantagens de todas as técnicas cirúrgicas para escolher o melhor procedimento para seus pacientes. Estudos futuros comparando as abordagens são necessários para orientar o cirurgião quando múltiplas opções forem possíveis.

Is It Necessary to Extend a Multilevel Posterior Cervical Decompression and Fusion to the Upper Thoracic Spine?

STUDY DESIGN: A retrospective cohort analysis. OBJECTIVE: The aim of this study was to determine if there is a difference in the revision rate in patients who undergo a multilevel posterior cervical fusions ending at C7, T1, or T2-T4. SUMMARY OF BACKGROUND DATA: Multilevel posterior cervical decompression and fusion is a common procedure for patients with cervical spondylotic myelopathy, but there is little literature available to help guide the surgeon in choosing the caudal level of a multilevel posterior cervical fusion. METHODS: Patients who underwent a three or more level posterior cervical fusion with at least 1 year of clinical follow-up were identified. Patients were separated into three groups on the basis of the caudal level of the fusion, C7, T1, or T2-T4, and the revision rate was determined. In addition, the C2-C7 lordosis and the C2-C7 sagittal vertical axis (SVA) was recorded for patients with adequate radiographic follow-up at 1 year. RESULTS: The overall revision rate was 27.8% (61/219 patients); a significant difference in the revision rates was identified between fusions terminating at C7, T1, and T2-T4 (35.3%, 18.3%, and 40.0%, P = 0.008). When additional variables were taken into account utilizing multivariate linear regression modeling, patients whose construct terminated at C7 were 2.29 (1.16-4.61) times more likely to require a revision than patients whose construct terminated at T1 (P = 0.02), but no difference between stopping at T1 and T2-T4 was identified. CONCLUSION: Multilevel posterior cervical fusions should be extended to T1, as stopping a long construct at C7 increases the rate of revision. LEVEL OF EVIDENCE: 3.

Thoracolumbar Injury Classification and Injury Severity Score System: A Literature Review of Its Safety.

Study Design Systematic literature review. Objective The Thoracolumbar Injury Classification and Severity Score System (TLICS) is widely used to help guide the treatment of thoracolumbar spine trauma. The purpose of this study is to evaluate the safety of the TLICS in clinical practice. Methods Using the Medline database without time restriction, we performed a systematic review using the keyword "Thoracolumbar Injury Classification," searching for articles utilizing the TLICS. We classified the results according to their level of evidence and main conclusions. Results Nine articles met our inclusion and exclusion criteria. One article evaluated the safety of the TLICS based on its clinical application (level II). The eight remaining articles were based on retrospective application of the score, comparing the proposed treatment suggested by the TLICS with the treatment patients actually received (level III). The TLICS was safe in surgical and nonsurgical treatment with regards to neurologic status. Some studies reported that the retrospective application of the TLICS had inconsistencies with the treatment of burst fractures without neurologic deficits. Conclusions This literature review suggested that the TLICS use was safe especially with regards to preservation or improvement of neurologic function. Further well-designed multicenter prospective studies of the TLICS application in the decision making process would improve the evidence of its safety. Special attention to the TLICS application in the treatment of stable burst fractures is necessary.

Evaluation of the SLICS use in the treatment of subaxial cervical spine injuries.

UNLABELLED: The SLICS (Sub-axial Cervical Spine Injury Classification System) was proposed to help in the decision-making of sub-axial cervical spine trauma (SCST), even though the literature assessing its safety and efficacy is scarce. METHOD: We compared a cohort series of patients surgically treated based on surgeon's preference with patients treated based on the SLICS. RESULTS: From 2009-10, 12 patients were included. The SLICS score ranged from 2 to 9 points (mean of 5.5). Two patients had the SLICS < 4 points. From 2011-13, 28 patients were included. The SLICS score ranged from 4 to 9 points (mean of 6). There was no neurological deterioration in any group. CONCLUSION: After using the SLICS there was a decrease in the number of patients with less severe injuries that were treated surgically. This suggests that the SLICS can be helpful in differentiating mild from severe injuries, potentially improving the results of treatment.

Evaluation of the SLICS use in the treatment of subaxial cervical spine injuries / Avaliação do SLICS no tratamento das lesões da coluna cervical sub-axial

The SLICS (Sub-axial Cervical Spine Injury Classification System) was proposed to help in the decision-making of sub-axial cervical spine trauma (SCST), even though the literature assessing its safety and efficacy is scarce. Method We compared a cohort series of patients surgically treated based on surgeon’s preference with patients treated based on the SLICS. Results From 2009-10, 12 patients were included. The SLICS score ranged from 2 to 9 points (mean of 5.5). Two patients had the SLICS < 4 points. From 2011-13, 28 patients were included. The SLICS score ranged from 4 to 9 points (mean of 6). There was no neurological deterioration in any group. Conclusion After using the SLICS there was a decrease in the number of patients with less severe injuries that were treated surgically. This suggests that the SLICS can be helpful in differentiating mild from severe injuries, potentially improving the results of treatment. .

O SLICS (Sub-axial Cervical Spine Injury Classification System) foi proposto para auxílio na tomada de decisão no tratamento do traumatismo da coluna cervical sub-axial. Contudo, existem poucos trabalhos que avaliem sua segurança e eficácia. Método Realizamos estudo comparativo de série histórica de pacientes operados baseados na indicação pessoal do cirurgião com pacientes tratados baseados na aplicação do SLICS. Resultados Entre 2009-10, 12 pacientes foram incluídos. O SLICS escore variou de 2 a 9 pontos (média de 5,5) com dois pacientes com escore menor que 4. Entre 2011-13, 28 pacientes foram incluídos. O escore de SLICS variou de 4 a 9 pontos, com média de 6. Conclusão Observamos que após o uso do SLICS houve uma diminuição do número de pacientes operados com lesões mais estáveis. Isso sugere que o SLICS pode ser útil para auxiliar a diferenciação de lesões leves das graves, eventualmente melhorando os resultados do tratamento. .