Posterolateral Fusion Versus Posterior Lumbar Interbody Fusion for Adult Low-Grade Isthmic Spondylolisthesis: Analysis of Sagittal Radiographic Parameters - A Randomized Controlled Trial.

STUDY DESIGN: Randomized controlled trial. OBJECTIVES: To compare the effect of posterolateral fusion (PLF) and posterior lumbar interbody fusion (PLIF) on sagittal radiographic parameters in patients with low-grade isthmic spondylolisthesis. Additionally, to explore the correlation between changes in these parameters and clinical outcomes. METHODS: Forty-six consecutive patients with single-level low-grade isthmic spondylolisthesis were initially enrolled. They were randomly assigned to undergo either PLF or PLIF. Patients were followed up for at least 24 months. Radiographic outcomes included pelvic incidence, pelvic tilt, sacral slope, lumbar lordosis, sagittal vertical axis, T1 pelvic angle, slip angle, slip degree and disc height. Clinical outcomes were assessed by the Oswestry Disability Index (ODI) and visual analogue scale (VAS). RESULTS: Four participants were lost to follow-up. Of the remaining 42 patients, 29 were female. The mean age was 40.23 ± 10.25 years in the PLF group and 35.81 ± 10.58 years in the PLIF group. There was a statistically significant greater correction of all radiographic parameters in the PLIF group. The ODI and VAS improved significantly in both groups, with no significant differences between the two groups. Changes in the ODI and VAS were significantly correlated with changes in disc height, slip angle and lumbar lordosis. CONCLUSIONS: In patients with low-grade isthmic spondylolisthesis, PLIF demonstrates superior efficacy compared to PLF in correcting sagittal radiographic parameters. Nevertheless, this distinction does not seem to influence short-term clinical results. Restoring disc height, correcting the slip angle, and reestablishing normal lumbar lordosis are crucial steps in the surgical management of isthmic spondylolisthesis.

Validation of the arabic version of the EuroQol-5-dimension 5-level (EQ-5D-5 L) in patients with spinal degenerative diseases.

OBJECTIVE: This study aims to test the reliability and validity of the translated Arabic version of EQ-5D-5 L. METHODS: The study was conducted on 100 patients operated upon for degenerative spine diseases coming for follow up in the outpatient clinic of a Tertiary care hospital. Test-retest reliability was assessed by completing the self-administered tool in two follow up visits, one week apart, by 50 patients. Internal consistency was evaluated by Cronbach's alpha. Intra-class correlation coefficients and kappa statistics were performed to test for the agreement between the two ratings. Criterion validity was assessed by comparing the responses of 100 patients to the EQ-5D-5 L with scores of two validated questionnaires; the Arabic version of the Oswestry disability index and the Arabic version of short-form health survey-36. The construct validity was assessed using known-groups comparison to test for hypothesized differences concerning demographic and clinical variables. RESULTS: The Arabic version of EQ-5D-5 L questionnaire had a high reliability with high observed internal consistency (Cronbach's alpha = 0.816, CI: 0.719-0.886). It showed strong temporal stability, with ICCs of the EQ-5D-5 L score, index and EQ-visual analog scale (EQ-VAS) of 0.852, 0.801, and 0.839 respectively. Agreement by kappa was moderate; above 0.4, for all domains, except for the "Usual activities" domain. EQ-5D-5 L domains, VAS and index had moderate to strong significant correlations with SF-36 and ODI subscales and total scores in the correct direction indicating a good criterion validity of the instrument. CONCLUSION: The Arabic version of EQ-5D-5 L is reliable and valid for assessment of HRQoL of Arabic speaking patients.

Autofusion in growing rod surgery for early onset scoliosis; what do we know so far?

The evolving landscape of early onset scoliosis management has shifted from the traditional paradigm of early definitive spinal fusion towards modern growth-friendly implants, particularly Growing Rods (GR). Despite the initial classification of GR treatment as a fusionless procedure, the phenomenon of autofusion has emerged as a critical consideration in understanding its outcomes. Studies have demonstrated the presence of autofusion since the early 1980s. The consequences of autofusion are extensive, impacting curve correction, diminishing trunk growth rate, and contributing to the "law of diminishing returns" in growing rod surgery. The literature suggests that autofusion may complicate definitive fusion surgery, leading to prolonged and intricate procedures involving multiple osteotomies. Additionally, it poses challenges in identifying anatomical landmarks during surgery, potentially increasing the risk of complications and revisions. While autofusion poses challenges to achieving optimal outcomes in growing rod treatment, it cannot be considered a standalone replacement for definitive fusion. Recent advances aim to limit autofusion and enhance treatment outcomes. In this review, we will delve into the existing literature on autofusion, examining studies that have documented its presence, probable causes, pathophysiology, potential implications for long-term patient outcomes, and possible new implants and techniques that decrease its incidence.

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

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

AO Spine Guideline for the Use of Osteobiologics (AOGO) in Anterior Cervical Discectomy and Fusion for Spinal Degenerative Cases.

STUDY DESIGN: Guideline. OBJECTIVES: To develop an international guideline (AOGO) about the use of osteobiologics in anterior cervical discectomy and fusion (ACDF) for treating degenerative spine conditions. METHODS: The guideline development process was guided by AO Spine Knowledge Forum Degenerative (KF Degen) and followed the Guideline International Network McMaster Guideline Development Checklist. The process involved 73 participants with expertise in degenerative spine diseases and surgery from 22 countries. Fifteen systematic reviews were conducted addressing respective key topics and evidence was collected. The methodologist compiled the evidence into GRADE Evidence-to-Decision frameworks. Guideline panel members judged the outcomes and other criteria and made the final recommendations through consensus. RESULTS: Five conditional recommendations were created. A conditional recommendation is about the use of allograft, autograft or a cage with an osteobiologic in primary ACDF surgery. Other conditional recommendations are about the use of osteobiologic for single- or multi-level ACDF, and for hybrid construct surgery. It is suggested that surgeons use other osteobiologics rather than human bone morphogenetic protein-2 (BMP-2) in common clinical situations. Surgeons are recommended to choose 1 graft over another or 1 osteobiologic over another primarily based on clinical situation, and the costs and availability of the materials. CONCLUSION: This AOGO guideline is the first to provide recommendations for the use of osteobiologics in ACDF. Despite the comprehensive searches for evidence, there were few studies completed with small sample sizes and primarily as case series with inherent risks of bias. Therefore, high-quality clinical evidence is demanded to improve the guideline.

Do Osteobiologics Augment Fusion in Anterior Cervical Discectomy and Fusion Surgery Performed With Mechanical Interbody Devices (Polyether ether ketone, Carbon Fiber, Metal Cages) and is the Fusion Rate Comparable to that With Autograft? A Systematic Review.

STUDY DESIGN: Systematic Review of the Literature. OBJECTIVE: The purpose of this study was to perform a systematic review describing fusion rates for anterior cervical discectomy and fusion (ACDF) using autograft vs various interbody devices augmented with different osteobiologic materials. METHODS: A systematic review limited to the English language was performed in Medline, Embase and Cochrane library using Medical Subject Heading (MeSH) terms. Studies that evaluated fusion after ACDF using autografts and osteobiologics combined with PEEK, carbon fibre, or metal cages were searched for. Articles in full text that met the criteria were included in the review. The main outcomes evaluated were the time taken to merge, the definition of the fusion assessment, and the modality of the fusion assessment. The risk of bias of each article was assessed by the MINORS score or ROB 2.0 depending on the randomisation process. RESULTS: The total number of references reviewed was six hundred and eighty-two. After applying the inclusion criteria, 54 were selected for the retrieval of the full text. Eight studies were selected and included for final analysis in this study. Fusion rates were reported between 83.3% and 100% for autograft groups compared to 46.5% and 100% for various interbody device/osteobiological combinations. The overall quality of the evidence in all radiographic fusion studies was considered insufficient due to a serious risk of bias. CONCLUSION: Mechanical interbody devices augmented with osteobiologics performed similarly to autografts in terms of reliability and efficacy. Their time to fusion and fusion rate were comparable to autografts at the end of the final follow-up.

Interobserver Reliability in the Classification of Thoracolumbar Fractures Using the AO Spine TL Injury Classification System Among 22 Clinical Experts in Spine Trauma Care.

STUDY DESIGN: Reliability study utilizing 183 injury CT scans by 22 spine trauma experts with assessment of radiographic features, classification of injuries and treatment recommendations. OBJECTIVES: To assess the reliability of the AOSpine TL Injury Classification System (TLICS) including the categories within the classification and the M1 modifier. METHODS: Kappa and Intraclass correlation coefficients were produced. Associations of various imaging characteristics (comminution, PLC status) and treatment recommendations were analyzed through regression analysis. Multivariable logistic regression modeling was used for making predictive algorithms. RESULTS: Reliability of the AO Spine TLICS at differentiating A3 and A4 injuries (N = 71) (K = .466; 95% CI .458 - .474; P < .001) demonstrated moderate agreement. Similarly, the average intraclass correlation coefficient (ICC) amongst A3 and A4 injuries was excellent (ICC = .934; 95% CI .919 - .947; P < .001) and the ICC between individual measures was moderate (ICC = .403; 95% CI .351 - .461; P < .001). The overall agreement on the utilization of the M1 modifier amongst A3 and A4 injuries was fair (K = .161; 95% CI .151 - .171; P < .001). The ICC for PLC status in A3 and A4 injuries averaged across all measures was excellent (ICC = .936; 95% CI .922 - .949; P < .001). The M1 modifier suggests respondents are nearly 40% more confident that the PLC is injured amongst all injuries. The M1 modifier was employed at a higher frequency as injuries were classified higher in the classification system. CONCLUSIONS: The reliability of surgeons differentiating between A3 and A4 injuries in the AOSpine TLICS is substantial and the utilization of the M1 modifier occurs more frequently with higher grades in the system.

Delayed presentation of lower cervical facet dislocations: What to learn from past reports?

Delayed presentation of lower cervical facet dislocations is uncommon, and there is no standardized way to approach these neglected injuries. The literature on neglected lower cervical facet dislocations is limited to case reports and few retrospective studies. This justifies the need for a comprehensive review of this condition. Our purpose was to elaborate a review on the epidemiology, clinical and radiological presentation, and treatment techniques and approach to these neglected injuries. Middle-aged adults from 30 to 50 represent 73.8% of reported cases, and most of them are males (72.0%). The most affected level is C5-C6 (43.0%). While most delays are due to missed injuries (52.1%) and ineffective non-operative treatment (36.2%), the other reason for delay is negligence in seeking medical care (11.7%). Patients present with variable degrees of neurological deficit, persistent neck pain, and neck stiffness. Reported approaches and techniques to reduce and stabilize these injuries are highly variable and depend on the surgeon's judgment, experience, and preference. Fibrotic tissues and bony fusion around the dislocated facet joint contribute to the reduction challenge, and 77.0% of closed reduction attempts fail. Anterior and posterior approaches to the cervical spine are used selectively or in combination for surgical release, reduction, and stabilization. Despite the lack of standardized treatment guidelines and different approaches, most of the authors reported improvement in pain, balance, and neurology post-surgery. Starting with the posterior surgical approach aims to achieve reduction compared to the anterior approach which largely aims at spinal decompression. Given the existing controversies, the need for quality prospective studies to determine the best treatment approach for lower cervical facet dislocations presenting with delay is evident.

An Assessment of the World's Contribution to Spine Trauma Care: A Bibliometric Analysis of Classifications and Surgical Management; An AO Spine Knowledge Forum Trauma Initiative.

STUDY DESIGN: Bibliometric analysis. OBJECTIVES: An analysis of the literature related to the assessment and management of spinal trauma was undertaken to allow the identification of top contributors, collaborations and research trends. METHODS: A search to identify original articles published in English between 2011 and 2020 was done using specific keywords in the Web of Science database. After screening, the top 300 most cited articles were analyzed using Biblioshiny R software. RESULTS: The highest number of contributions were from the Thomas Jefferson University, USA, University of Toronto and University of British Columbia, Canada. The top 3 most prolific authors were Vaccaro AR, Arabi B, and Oner FC. The USA and Canada were among the top contributing countries; Switzerland and Brazil had most multiple country co-authored articles. The most relevant journals were the European Spine Journal, Spine and Spine Journal. Three of the 5 most cited articles were about classification systems of fractures. The keyword analysis included clusters for different spinal regions, spinal cord injury, classification agreement and reliability studies, imaging related studies, surgical techniques and outcomes. CONCLUSIONS: The study identified the most impactful authors and affiliations, and determined the journals where most impactful research is published in the field. Study also compared the productivity and collaborations across countries. The study highlighted the impact of development of new classification systems, and identified research trends including instrumentation, fixation and decompression techniques, epidemiology and recovery after spinal trauma.

Can Orthopaedic Surgeons adequately assess an Electrocardiogram (ECG) trace paper? A cross sectional study.

Objectives: The primary objective was to evaluate the ECG trace paper evaluation current knowledge level in a group of Orthopaedic surgeons divided into juniors and seniors according to M.D. degree possession. Methods: A cross sectional study through self-administered questionnaires at a university hospital Orthopaedic and Trauma Surgery Department. The questionnaire included five sections: 1-Basic participants' characteristics, 2-Participants' perception of their ECG evaluation current knowledge level, 3-The main body of the questionnaire was an ECG quiz (seven); the participant was asked to determine if it was normal and the possible diagnosis, 4-Participants' desired ECG evaluation knowledge level, and 5-Willingness to attend ECG evaluation workshops. Results: Of the 121 actively working individuals in the department, 96 (97.3 %) finished the questionnaire, and 85 (77.3 %) were valid for final evaluation. The participants' mean age was 30.4 ± 6.92 years, 76.5 % juniors and 23.5 % seniors. 83.5 % of the participants perceived their current ECG evaluation knowledge as none or limited. For participants' ability to evaluate an ECG, higher scores were achieved when determining if the ECG was normal or abnormal, with a mean score percentage of 79.32 % ± 23.27. However, the scores were lower when trying to reach the diagnosis, with a mean score percentage of 43.02 % ± 27.48. There was a significant negative correlation between the participant's age and answering the normality question correctly (r = -0.277, p = 0.01); and a significant positive correlation between answering the diagnosis question correctly and the desired level of knowledge and the intention to attend a workshop about ECG evaluation, r = 0.355 (p = 0.001), and r = 0.223 (p = 0.04), respectively. Only 56.5 % of the participants desired to get more knowledge, and 81.2 % were interested in attending ECG evaluation workshops. Conclusion: Orthopaedic surgeons showed sufficient knowledge when determining the normality of ECG trace papers; however, they could not reach the proper diagnosis, and Junior surgeons performed slightly better than their senior peers. Most surgeons are willing to attend ECG evaluation and interpretation workshops to improve their knowledge level.

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

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

Management of C0 Sacral Fractures Based on the AO Spine Sacral Injury Classification: A Narrative Review.

The Arbeitsgemeinschaft fur Osteosynthese fragen Spine Sacral Injury Classification hierarchically separates fractures based on their injury severity with A-type fractures representing less severe injuries and C-type fractures representing the most severe fracture types. C0 fractures represent moderately severe injuries and have historically been referred to as nondisplaced "U-type" fractures. Injury management of these fractures can be controversial. Therefore, the purpose of this narrative review is to first discuss the Arbeitsgemeinschaft fur Osteosynthese fragen Spine Sacral Injury Classification System and describe the different fracture types and classification modifiers, with particular emphasis on C0 fracture types. The narrative review will then focus on the epidemiology and etiology of C0 fractures with subsequent discussion focused on the clinical presentation for patients with these injuries. Next, we will describe the imaging findings associated with these injuries and discuss the injury management of these injuries with particular emphasis on operative management. Finally, we will outline the outcomes and complications that can be expected during the treatment of these injuries.

Telemedicine in Spine Surgery: Global Perspectives and Practices.

STUDY DESIGN: Cross-sectional, anonymous, international survey. OBJECTIVES: The COVID-19 pandemic has resulted in the rapid adoption of telemedicine in spine surgery. This study sought to determine the extent of adoption and global perspectives on telemedicine in spine surgery. METHODS: All members of AO Spine International were emailed an anonymous survey covering the participant's experiences with and perceptions of telemedicine. Descriptive statistics were used to depict responses. Responses were compared among regions. RESULTS: 485 spine surgeons participated in the survey. Telemedicine usage rose from <10.0% to >39.0% of all visits. A majority of providers (60.5%) performed at least one telemedicine visit. The format of "telemedicine" varied widely by region: European (50.0%) and African (45.2%) surgeons were more likely to use phone calls, whereas North (66.7%) and South American (77.0%) surgeons more commonly used video (P < 0.001). North American providers used telemedicine the most during COVID-19 (>60.0% of all visits). 81.9% of all providers "agreed/strongly agreed" telemedicine was easy to use. Respondents tended to "agree" that imaging review, the initial appointment, and postoperative care could be performed using telemedicine. Almost all (95.4%) surgeons preferred at least one in-person visit prior to the day of surgery. CONCLUSION: Our study noted significant geographical differences in the rate of telemedicine adoption and the platform of telemedicine utilized. The results suggest a significant increase in telemedicine utilization, particularly in North America. Spine surgeons found telemedicine feasible for imaging review, initial visits, and follow-up visits although the vast majority still preferred at least one in-person preoperative visit.

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

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

Effect of surgical experience and spine subspecialty on the reliability of the AO Spine Upper Cervical Injury Classification System.

OBJECTIVE: The objective of this paper was to determine the interobserver reliability and intraobserver reproducibility of the AO Spine Upper Cervical Injury Classification System based on surgeon experience (< 5 years, 5-10 years, 10-20 years, and > 20 years) and surgical subspecialty (orthopedic spine surgery, neurosurgery, and "other" surgery). METHODS: A total of 11,601 assessments of upper cervical spine injuries were evaluated based on the AO Spine Upper Cervical Injury Classification System. Reliability and reproducibility scores were obtained twice, with a 3-week time interval. Descriptive statistics were utilized to examine the percentage of accurately classified injuries, and Pearson's chi-square or Fisher's exact test was used to screen for potentially relevant differences between study participants. Kappa coefficients (κ) determined the interobserver reliability and intraobserver reproducibility. RESULTS: The intraobserver reproducibility was substantial for surgeon experience level (< 5 years: 0.74 vs 5-10 years: 0.69 vs 10-20 years: 0.69 vs > 20 years: 0.70) and surgical subspecialty (orthopedic spine: 0.71 vs neurosurgery: 0.69 vs other: 0.68). Furthermore, the interobserver reliability was substantial for all surgical experience groups on assessment 1 (< 5 years: 0.67 vs 5-10 years: 0.62 vs 10-20 years: 0.61 vs > 20 years: 0.62), and only surgeons with > 20 years of experience did not have substantial reliability on assessment 2 (< 5 years: 0.62 vs 5-10 years: 0.61 vs 10-20 years: 0.61 vs > 20 years: 0.59). Orthopedic spine surgeons and neurosurgeons had substantial intraobserver reproducibility on both assessment 1 (0.64 vs 0.63) and assessment 2 (0.62 vs 0.63), while other surgeons had moderate reliability on assessment 1 (0.43) and fair reliability on assessment 2 (0.36). CONCLUSIONS: The international reliability and reproducibility scores for the AO Spine Upper Cervical Injury Classification System demonstrated substantial intraobserver reproducibility and interobserver reliability regardless of surgical experience and spine subspecialty. These results support the global application of this classification system.

The Impact of COVID-19 Pandemic on Spine Surgeons Worldwide: A One Year Prospective Comparative Study.

STUDY DESIGN: Survey. OBJECTIVE: In March of 2020, an original study by Louie et al investigated the impact of COVID-19 on 902 spine surgeons internationally. Since then, due to varying government responses and public health initiatives to the pandemic, individual countries and regions of the world have been affected differently. Therefore, this follow-up study aimed to assess how the COVID-19 impact on spine surgeons has changed 1 year later. METHODS: A repeat, multi-dimensional, 90-item survey written in English was distributed to spine surgeons worldwide via email to the AO Spine membership who agreed to receive surveys. Questions were categorized into the following domains: demographics, COVID-19 observations, preparedness, personal impact, patient care, and future perceptions. RESULTS: Basic respondent demographics, such as gender, age, home demographics, medical comorbidities, practice type, and years since training completion, were similar to those of the original 2020 survey. Significant differences between groups included reasons for COVID testing, opinions of media coverage, hospital unemployment, likelihood to be performing elective surgery, percentage of cases cancelled, percentage of personal income, sick leave, personal time allocation, stress coping mechanisms, and the belief that future guidelines were needed (P<.05). CONCLUSION: Compared to baseline results collected at the beginning of the COVID-19 pandemic in 2020, significant differences in various domains related to COVID-19 perceptions, hospital preparedness, practice impact, personal impact, and future perceptions have developed. Follow-up assessment of spine surgeons has further indicated that telemedicine and virtual education are mainstays. Such findings may help to inform and manage expectations and responses to any future outbreaks.

Global Validation of the AO Spine Upper Cervical Injury Classification: Geographic Region Affects Reliability and Reproducibility.

STUDY DESIGN: Global Survey. OBJECTIVE: To determine the accuracy, interobserver reliability, and intraobserver reproducibility of the AO Spine Upper Cervical Injury Classification System based on surgeons' AO Spine region of practice (Africa, Asia, Central/South America, Europe, Middle East, and North America). METHODS: A total of 275 AO Spine members assessed 25 upper cervical spine injuries and classified them according to the AO Spine Upper Cervical Injury Classification System. Reliability, reproducibility, and accuracy scores were obtained over two assessments administered at three-week intervals. Kappa coefficients (ƙ) determined the interobserver reliability and intraobserver reproducibility. RESULTS: On both assessments, participants from Europe and North America had the highest classification accuracy, while participants from Africa and Central/South America had the lowest accuracy (P < .0001). Participants from Africa (assessment 1 (AS1):ƙ = .487; AS2:0.491), Central/South America (AS1:ƙ = .513; AS2:0.511), and the Middle East (AS1:0.591; AS2: .599) achieved moderate reliability, while participants from North America (AS1:ƙ = .673; AS2:0.648) and Europe (AS1:ƙ = .682; AS2:0.681) achieved substantial reliability. Asian participants obtained substantial reliability on AS1 (ƙ = .632), but moderate reliability on AS2 (ƙ = .566). Although there was a large effect size, the low number of participants in certain regions did not provide adequate certainty that AO regions affected the likelihood of participants having excellent reproducibility (P = .342). CONCLUSIONS: The AO Spine Upper Cervical Injury Classification System can be applied with high accuracy, interobserver reliability, and intraobserver reproducibility. However, lower classification accuracy and reliability were found in regions of Africa and Central/South America, especially for severe atlas injuries (IIB and IIC) and atypical hangman's type fractures (IIIB injuries).

The AO spine upper cervical injury classification system: Do work setting or trauma center affiliation affect classification accuracy or reliability?

PURPOSE: To assess the accuracy and reliability of the AO Spine Upper Cervical Injury Classification System based on a surgeons' work setting and trauma center affiliation. METHODS: A total of 275 AO Spine members participated in a validation of 25 upper cervical spine injuries, which were evaluated by computed tomography (CT) scans. Each participant was grouped based on their work setting (academic, hospital-employed, or private practice) and their trauma center affiliation (Level I, Level II or III, and Level IV or no trauma center). The classification accuracy was calculated as percent of correct classifications, while interobserver reliability, and intraobserver reproducibility were evaluated based on Fleiss' Kappa coefficient. RESULTS: The overall classification accuracy for surgeons affiliated with a level I trauma center was significantly greater than participants affiliated with a level II/III center or a level IV/no trauma center on assessment one (p1<0.0001) and two (p2 = 0.0003). On both assessments, surgeons affiliated with a level I or a level II/III trauma center were significantly more accurate at identifying IIIB injury types (p1 = 0.0007; p2 = 0.0064). Academic surgeons and hospital employed surgeons were significantly more likely to correctly classify type IIIB injuries on assessment one (p1 = 0.0146) and two (p2 = 0.0015). When evaluating classification reliability, the largest differences between work settings and trauma center affiliations was identified in type IIIB injuries. CONCLUSION: Type B injuries are the most difficult injury type to correctly classify. They are classified with greater reliability and classification accuracy when evaluated by academic surgeons, hospital-employed surgeons, and surgeons associated with higher-level trauma centers (I or II/III).

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

BACKGROUND CONTEXT: Prior upper cervical spine injury classification systems have focused on injuries to the craniocervical junction (CCJ), atlas, and dens independently. However, no previous system has classified upper cervical spine injuries using a comprehensive system incorporating all injuries from the occiput to the C2-3 joint. PURPOSE: To (1) determine the accuracy of experts at correctly classifying upper cervical spine injuries based on the recently proposed AO Spine Upper Cervical Injury Classification System (2) to determine their interobserver reliability and (3) identify the intraobserver reproducibility of the experts. STUDY DESIGN/SETTING: International Multi-Center Survey. PATIENT SAMPLE: A survey of international spine surgeons on 29 unique upper cervical spine injuries. OUTCOME MEASURES: Classification accuracy, interobserver reliability, intraobserver reproducibility. METHODS: Thirteen international AO Spine Knowledge Forum Trauma members participated in two live webinar-based classifications of 29 upper cervical spine injuries presented in random order, four weeks apart. Percent agreement with the gold-standard and kappa coefficients (ƙ) were calculated to determine the interobserver reliability and intraobserver reproducibility. RESULTS: Raters demonstrated 80.8% and 82.7% accuracy with identification of the injury classification (combined location and type) on the first and second assessment, respectively. Injury classification intraobserver reproducibility was excellent (mean, [range] ƙ=0.82 [0.58-1.00]). Excellent interobserver reliability was found for injury location (ƙ = 0.922 and ƙ=0.912) on both assessments, while injury type was substantial (ƙ=0.689 and 0.699) on both assessments. This correlated to a substantial overall interobserver reliability (ƙ=0.729 and 0.732). CONCLUSIONS: Early phase validation demonstrated classification of upper cervical spine injuries using the AO Spine Upper Cervical Injury Classification System to be accurate, reliable, and reproducible. Greater than 80% accuracy was detected for injury classification. The intraobserver reproducibility was excellent, while the interobserver reliability was substantial.

Global Validation of the AO Spine Upper Cervical Injury Classification.

STUDY DESIGN: Global cross-sectional survey. OBJECTIVE: To determine the classification accuracy, interobserver reliability, and intraobserver reproducibility of the AO Spine Upper Cervical Injury Classification System based on an international group of AO Spine members. SUMMARY OF BACKGROUND DATA: Previous upper cervical spine injury classifications have primarily been descriptive without incorporating a hierarchical injury progression within the classification system. Further, upper cervical spine injury classifications have focused on distinct anatomical segments within the upper cervical spine. The AO Spine Upper Cervical Injury Classification System incorporates all injuries of the upper cervical spine into a single classification system focused on a hierarchical progression from isolated bony injuries (type A) to fracture dislocations (type C). METHODS: A total of 275 AO Spine members participated in a validation aimed at classifying 25 upper cervical spine injuries through computed tomography scans according to the AO Spine Upper Cervical Classification System. The validation occurred on two separate occasions, three weeks apart. Descriptive statistics for percent agreement with the gold-standard were calculated and the Pearson χ 2 test evaluated significance between validation groups. Kappa coefficients (κ) determined the interobserver reliability and intraobserver reproducibility. RESULTS: The accuracy of AO Spine members to appropriately classify upper cervical spine injuries was 79.7% on assessment 1 (AS1) and 78.7% on assessment 2 (AS2). The overall intraobserver reproducibility was substantial (κ=0.70), while the overall interobserver reliability for AS1 and AS2 was substantial (κ=0.63 and κ=0.61, respectively). Injury location had higher interobserver reliability (AS1: κ = 0.85 and AS2: κ=0.83) than the injury type (AS1: κ=0.59 and AS2: 0.57) on both assessments. CONCLUSION: The global validation of the AO Spine Upper Cervical Injury Classification System demonstrated substantial interobserver agreement and intraobserver reproducibility. These results support the universal applicability of the AO Spine Upper Cervical Injury Classification System. LEVEL OF EVIDENCE: 4.