Surgical treatment of traumatic fractures of the thoracic and lumbar spine: A systematic review.

Introduction: The treatment of traumatic thoracic and lumbar spine fractures remains controversial. To date no consensus exists on the correct choice of surgical approach and technique. Research question: to provide a comprehensive up-to-date overview of the available different surgical methods and their quantified outcomes. Methods: PubMed and EMBASE were searched between 2001 and 2020 using the term 'spinal fractures'. Inclusion criteria were: adults, ≥10 cases, ≥12 months follow-up, thoracic or lumbar fractures, and surgery <3 weeks of trauma. Studies were categorized per surgical technique: Posterior open (PO), posterior percutaneous (PP), stand-alone vertebral body augmentation (SA), anterior scopic (AS), anterior open (AO), posterior percutaneous and anterior open (PPAO), posterior percutaneous and anterior scopic (PPAS), posterior open and anterior open (POAO) and posterior open and anterior scopic (POAS). The PO group was used as a reference group. Results: After duplicate removal 6042 articles were identified. A total of 102 articles were Included, in which 137 separate surgical technique cohorts were described: PO (n = 75), PP, (n = 39), SA (n = 12), AO (n = 5), PPAO (n = 1), PPAS (n = 1), POAO (n = 2) and POAS (n = 2). Discussion and conclusion: For type A3/A4 burst fractures, without severe neurological deficit, posterior percutaneous (PP) technique seems the safest and most feasible option in the past two decades. If needed, PP can be combined with anterior augmentation to prevent secondary kyphosis. Furthermore, posterior open (PO) technique is feasible in almost all types of fractures. Also, this technique can provide for an additional posterior decompression or fusion. Overall, no neurologic deterioration was reported following surgical intervention.

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.

Low-Threshold-For-Surgery Versus Primarily-Conservative Treatment for Odontoid Fractures in the Elderly: Evaluating Practice Variation in The Netherlands.

STUDY DESIGN: Retrospective cohort study. OBJECTIVES: Odontoid fractures are the most common cervical spine fractures in the elderly. The optimal treatment remains controversial. The aim of this study was to compare results of a low-threshold-for-surgery strategy (surgery for dislocated fractures in relatively healthy patients) to a primarily-conservative strategy (for all patients). METHODS: Patient records from 5 medical centers were reviewed for patients who met the selection criteria (e.g. age ≥55 years, type II/III odontoid fractures). Demographics, fracture types/characteristics, fracture union/stability, clinical outcome and mortality were compared. The influence of age on outcome was studied (≥55-80 vs ≥80 years). RESULTS: A total of 173 patients were included: 120 treated with low-threshold-for-surgery (of which 22 primarily operated, and 23 secondarily) vs 53 treated primarily-conservative. No differences in demographics and fracture characteristics between the groups were identified. Fracture union (53% vs 43%) and fracture stability (90% vs 85%) at last follow-up did not differ between groups. The majority of patients (56%) achieved clinical improvement compared to baseline. Analysis of differences in clinical outcome between groups was infeasible due to data limitations. In both strategies, patients ≥80 years achieved worse union (64% vs 30%), worse stability (97% vs 77%), and - as to be expected - increased mortality <104 weeks (2% vs 22%). CONCLUSIONS: Union and stability rates did not differ between the treatment strategies. Advanced age (≥80 years) negatively influenced both radiological outcome and mortality. No cases of secondary neurological deficits were identified, suggesting that concerns for the consequences of under-treatment may be unjustified.

The changing landscape of spinal injuries: A narrative review.

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

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

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

Health professionals' perspective on the applicability of AO Spine PROST (patient reported outcome Spine trauma) in people with a motor-complete traumatic or non-traumatic spinal cord injury.

PURPOSE: The AO Spine PROST (Patient Reported Outcome Spine Trauma) was developed for people with spine trauma and minor or no neurological impairment. The purpose is to investigate health professionals' perspective on the applicability of the AO Spine PROST for people with motor-complete traumatic or non-traumatic spinal cord injury (SCI), using a discussion meeting and international survey study. METHODS: A discussion meeting with SCI rehabilitation physicians in the Netherlands was performed, followed by a worldwide online survey among the AO Spine International community, involved in the care of people with SCI. Participants rated the comprehensibility, relevance, acceptability, feasibility and completeness of the AO Spine PROST on a 1-5 point scale (5 most positive). Comments could be provided per question. RESULTS: The discussion meeting was attended by 13 SCI rehabilitation physicians. The survey was completed by 196 participants. Comprehensibility (mean ± SD: 4.1 ± 0.8), acceptability (4.0 ± 0.8), relevance (3.9 ± 0.8), completeness (3.9 ± 0.8), and feasibility (4.1 ± 0.7) of the AO Spine PROST were rated positively for use in people with motor-complete traumatic or non-traumatic SCI. Only a few participants questioned the relevance of items on the lower extremities (e.g., walking) or missed items on pulmonary functioning and complications. Some recommendations were made for improvement in instructions, terminology and examples of the tool. CONCLUSION: Health professionals found the AO Spine PROST generally applicable for people with motor-complete traumatic or non-traumatic SCI. This study provides further evidence for the use of the AO Spine PROST in spine trauma care, rehabilitation and research, as well as suggestions for its further development.

Validation of the Hierarchical Nature of the AO Spine Sacral Classification and the Development of the Sacral AO Spine Injury Score.

STUDY DESIGN: Global cross-sectional survey. OBJECTIVE: The objective of this study was to validate the hierarchical nature of the AO Spine Sacral Classification System and develop an injury scoring system. SUMMARY OF BACKGROUND DATA: Although substantial interobserver and intraobserver reliability of the AO Spine Sacral Classification System has been established, the hierarchical nature of the classification has yet to be validated. METHODS: Respondents numerically graded each variable within the classification system for severity. Based on the results, a Sacral AO Spine Injury Score (AOSIS) was developed. RESULTS: A total of 142 responses were received. The classification exhibited a hierarchical Injury Severity Score (ISS) progression (A1: 8 to C3: 95) with few exceptions. Subtypes B1 and B2 fractures showed no significant difference in ISS (B1 43.9 vs. B2 43.4, P =0.362). In addition, the transitions A3→B1 and B3→C0 represent significant decreases in ISS (A3 66.3 vs. B1 43.9, P <0.001; B3 64.2 vs. C0 46.4, P <0.001). Accordingly, A1 injury was assigned a score of 0. A2 and A3 received scores of 1 and 3 points, respectively. Posterior pelvic injuries B1 and B2 both received a score of 2. B3 received a score of 3 points. C0, C1, C2, and C3 received scores of 2, 3, 5, and 6 points, respectively. The scores assigned to neurological modifiers N0, N1, N2, N3, and NX were 0, 1, 2, 4, and 3, respectively. Case-specific modifiers M1, M2, M3, and M4 received scores of 0, 0, 1, and 2 points, respectively. CONCLUSIONS: The results of this study validate the hierarchical nature of the AO Spine Sacral Classification System. The Sacral AOSIS sets the foundation for further studies to develop a universally accepted treatment algorithm for the treatment of complex sacral injuries. LEVEL OF EVIDENCE: Level IV-Diagnostic.

Neurological recovery after early versus delayed surgical decompression for acute traumatic spinal cord injury.

The aim of this study was to determine whether early surgical treatment results in better neurological recovery 12 months after injury than late surgical treatment in patients with acute traumatic spinal cord injury (tSCI). Patients with tSCI requiring surgical spinal decompression presenting to 17 centres in Europe were recruited. Depending on the timing of decompression, patients were divided into early (≤ 12 hours after injury) and late (> 12 hours and < 14 days after injury) groups. The American Spinal Injury Association neurological (ASIA) examination was performed at baseline (after injury but before decompression) and at 12 months. The primary endpoint was the change in Lower Extremity Motor Score (LEMS) from baseline to 12 months. The final analyses comprised 159 patients in the early and 135 in the late group. Patients in the early group had significantly more severe neurological impairment before surgical treatment. For unadjusted complete-case analysis, mean change in LEMS was 15.6 (95% confidence interval (CI) 12.1 to 19.0) in the early and 11.3 (95% CI 8.3 to 14.3) in the late group, with a mean between-group difference of 4.3 (95% CI -0.3 to 8.8). Using multiply imputed data adjusting for baseline LEMS, baseline ASIA Impairment Scale (AIS), and propensity score, the mean between-group difference in the change in LEMS decreased to 2.2 (95% CI -1.5 to 5.9). Compared to late surgical decompression, early surgical decompression following acute tSCI did not result in statistically significant or clinically meaningful neurological improvements 12 months after injury. These results, however, do not impact the well-established need for acute, non-surgical tSCI management. This is the first study to highlight that a combination of baseline imbalances, ceiling effects, and loss to follow-up rates may yield an overestimate of the effect of early surgical decompression in unadjusted analyses, which underpins the importance of adjusted statistical analyses in acute tSCI research.

Reliability and Validity of the German Version of the AO Spine Patient Reported Outcome Spine Trauma Questionnaire.

STUDY DESIGN: A single-center validation study. OBJECTIVE: To translate and cross-culturally adapt the AO Spine PROST (Patient Reported Outcome Spine Trauma) into German, and to test its psychometric properties among German-speaking Swiss spine trauma patients. METHODS: Patients were recruited from a level-1 Swiss trauma center. Next to the AO Spine PROST, the EQ-5D-3L questionnaire was used for concurrent validity. Questionnaires were filled out at two-time points for test-retest reliability. Patient characteristics were analyzed using descriptive statistics. For content validity, floor, and ceiling effects, as well as any irrelevant and missing questions were analyzed. Construct validity of the AO Spine PROST questionnaire to the EQ-5D-3L was tested using Spearman correlation tests. RESULTS: The AOSpine PROST was translated and adapted into German using established guidelines. We included 179 patients. The floor effect for all items was well within the optimal range (below 15%), while the ceiling effect of seven items was within the optimal range. None of the items displayed a problematic floor or ceiling effect. The overall test-retest reliability of the total PROST score was excellent, with an ICC of .83 (95% CI .69-.91). The Spearman correlation coefficient between the total PROST summary score and EQ-5D-3 L was ρ = .63. CONCLUSIONS: The German version of the AO Spine PROST questionnaire demonstrated very good validity and reliability results.

Natural experiments for orthopaedic trauma research: An introduction.

Natural experiments are observational studies of medical treatments in which treatment allocation is determined by factors outside the control of the investigators, arguably resembling experimental randomisation. Natural experiments in the field of orthopaedic trauma research are scarce. However, they have great potential due to the process governing treatment allocation and the existence of opposing treatment strategies between hospitals or between regions as a result of local education, conviction, or cultural and socio-economic factors. Here, the possibilities and opportunities of natural experiments in the orthopaedic trauma field are discussed. Potential solutions are presented to improve the validity of natural experiments and how to assess the credibility of such studies. Above all, it is meant to spark a discussion about its role within the field of orthopaedic trauma research.

Research Practices and Needs Among Spine Surgeons Worldwide.

OBJECTIVE: Resource allocation to research activities is challenging and there is limited evidence to justify decisions. Members of AO Spine were surveyed to understand the research practices and needs of spine surgeons worldwide. METHODS: An 84-item survey was distributed to the AO Spine community in September of 2020. Respondent demographics and insights regarding research registries, training and education, mentorship, grants and financial support, and future directions were collected. Responses were anonymous and compared among regions. RESULTS: A total of 333 spine surgeons representing all geographic regions responded; 52.3% were affiliated with an academic/university hospital, 91.0% conducted clinical research, and 60.9% had 5+ years of research experience. There was heterogeneity among research practices and needs across regions. North American respondents had more research experience (P = .023), began conducting research early on (P < .001), had an undergraduate science degree (P < .001), and were more likely to have access to a research coordinator or support staff (P = .042) compared to other regions. While all regions expressed having the same challenges in conducting research, Latin America, and Middle East/Northern Africa respondents were less encouraged to do research (P < .001). Despite regional differences, there was global support for research registries and research training and education. CONCLUSION: To advance spine care worldwide, spine societies should establish guidelines, conduct studies on pain management, and support predictive analytic modeling. Tailoring local/regional programs according to regional needs is advised. These results can assist spine societies in developing long-term research strategies and provide justified rationale to governments and funding agencies.

Time to Surgical Treatment for Metastatic Spinal Disease: Identification of Delay Intervals.

STUDY DESIGN: Retrospective cohort study. OBJECTIVES: Minimizing delays in referral, diagnosis and treatment of patients with symptomatic spinal metastases is important for optimal treatment outcomes. The primary objective of this study was to investigate several forms of delay from the onset of symptoms until surgical treatment of spinal metastases for patients with and without a known preexisting known malignancy. METHODS: All patients receiving surgical treatment for spinal metastases in a single tertiary spine center were identified. Referral patterns were reconstructed and the total delay was divided into 4 categories: patient delay (onset of symptoms until medical consultation), diagnostic delay (medical consultation until diagnosis), referral delay (diagnosis until referral to spine surgeon) and treatment delay (referral spine to surgeon until treatment). These intervals were compared between patients with and without a known preexisting malignancy. RESULTS: The median total delay was 99 days, patient delay 19 days, diagnostic delay 21,5 days, referral delay 7 days, treatment delay 8 days and diagnosis and treatment delay combined 18,5 days. No difference in total delay was observed between patients with and without a known preexisting malignancy. Total delay was not significantly associated with patient age, sex, oncological history, tumor prognosis and spinal level of the tumor. CONCLUSIONS: Patients with symptomatic spinal metastases experience considerable delays, even after metastatic spinal disease has been diagnosed, regardless of a preexisting malignancy. By identifying and eliminating the causes of these delays, diagnosis, referral and treatment may be expedited leading to improved patient outcome.

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.

Assessment of Posterolateral Lumbar Fusion: A Systematic Review of Imaging-Based Fusion Criteria.

BACKGROUND: Noninvasive assessment of osseous fusion after spinal fusion surgery is essential for timely diagnosis of patients with symptomatic pseudarthrosis and for evaluation of the performance of spinal fusion procedures. There is, however, no consensus on the definition and assessment of successful posterolateral fusion (PLF) of the lumbar spine. This systematic review aimed to (1) summarize the criteria used for imaging-based fusion assessment after instrumented PLF and (2) evaluate their diagnostic accuracy and reliability. METHODS: First, a search of the literature was conducted in November 2018 to identify reproducible criteria for imaging-based fusion assessment after primary instrumented PLF between T10 and S1 in adult patients, and to determine their frequency of use. A second search in July 2021 was directed at primary studies on the diagnostic accuracy (with surgical exploration as the reference) and/or reliability (interobserver and intraobserver agreement) of these criteria. Article selection and data extraction were performed by at least 2 reviewers independently. The methodological quality of validation studies was assessed with the QUADAS-2 (Quality Assessment of Diagnostic Accuracy Studies 2) and QAREL (Quality Appraisal of Reliability Studies). RESULTS: Of the 187 articles included from the first search, 47% used a classification system and 63% used ≥1 descriptive criterion related to osseous bridging (104 articles), absence of motion (78 articles), and/or absence of static signs of nonunion (39 articles). A great variation in terminology, cutoff values, and assessed anatomical locations was observed. While the use of computed tomography (CT) increased over time, radiographs remained predominant. The second search yielded 11 articles with considerable variation in outcomes and quality concerns. Agreement between imaging-based assessment and surgical exploration with regard to demonstration of fusion ranged between 55% and 80%, while reliability ranged from poor to excellent. CONCLUSIONS: None of the available criteria for noninvasive assessment of fusion status after instrumented PLF were demonstrated to have both sufficient accuracy and reliability. Further elaboration and validation of a well-defined systematic CT-based assessment method that allows grading of the intertransverse and interfacet fusion mass at each side of each fusion level and includes signs of nonunion is recommended. LEVEL OF EVIDENCE: Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Evolution of the AO Spine Sacral and Pelvic Classification System: a systematic review.

OBJECTIVE: The purpose of this study was to describe the genesis of the AO Spine Sacral and Pelvic Classification System in the context of historical sacral and pelvic grading systems. METHODS: A systematic search of MEDLINE, EMBASE, Google Scholar, and Cochrane databases was performed consistent with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to identify all existing sacral and pelvic fracture classification systems. RESULTS: A total of 49 articles were included in this review, comprising 23 pelvic classification systems and 17 sacral grading schemes. The AO Spine Sacral and Pelvic Classification System represents both the evolutionary product of these historical systems and a reinvention of classic concepts in 5 ways. First, the classification introduces fracture types in a graduated order of biomechanical stability while also taking into consideration the neurological status of patients. Second, the traditional belief that Denis central zone III fractures have the highest rate of neurological deficit is not supported because this subgroup often includes a broad spectrum of injuries ranging from a benign sagittally oriented undisplaced fracture to an unstable "U-type" fracture. Third, the 1990 Isler lumbosacral system is adopted in its original format to divide injuries based on their likelihood of affecting posterior pelvic or spinopelvic stability. Fourth, new discrete fracture subtypes are introduced and the importance of bilateral injuries is acknowledged. Last, this is the first integrated sacral and pelvic classification to date. CONCLUSIONS: The AO Spine Sacral and Pelvic Classification is a universally applicable system that redefines and reorders historical fracture morphologies into a rational hierarchy. This is the first classification to simultaneously address the biomechanical stability of the posterior pelvic complex and spinopelvic stability, while also taking into consideration neurological status. Further high-quality controlled trials are required prior to the inclusion of this novel classification within a validated scoring system to guide the management of sacral and pelvic injuries.

Applicability of the AO Spine Patient Reported Outcome Spine Trauma (PROST) in people with motor-complete spinal cord injury: a cognitive interview study.

STUDY DESIGN: This is a cognitive interview study. OBJECTIVES: To examine the applicability of the Patient Reported Outcome Spine Trauma (AO Spine PROST) in people with motor-complete traumatic or non-traumatic spinal cord injury (SCI). SETTING: Two rehabilitation centers in The Netherlands. METHOD: Semi-structured cognitive interviews were conducted with 29 adults with a motor-complete SCI (AISA Impairment Scale A or B). Participants were asked to complete the AO Spine PROST and four additional evaluation questions rated on a 1-5-point Likert scale (5 most positive), while verbalizing their thoughts about their answers. Interviews were audio-recorded and transcribed. Codes were identified and linked to a coding scheme. Qualitative data were used to interpret the quantitative results. RESULTS: Almost three-quarters of the participants (71.4%) had a traumatic SCI. Positive ratings of the measure were obtained regards comprehensibility (mean 4.0), non-offensiveness (4.6), relevance (4.2), and completeness (3.6). A question about the emotional impact of SCI was indicated to be missing. How using an assistive device should weigh in the score was a recurring topic. The use of multiple examples per item raised uncertainty, mostly solved by averaging their score. Some individuals indicated that the possibility to express even better function compared to before the onset of injury would be valuable. CONCLUSIONS: Overall, the AO Spine PROST appears applicable in adults with a motor-complete traumatic or non-traumatic SCI. Recommendations are made for improvement in instructions, terminology, and examples used in the tool. This study contributes to the further development of the AO Spine PROST in spine trauma care and research.

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

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