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.

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.

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.

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.

The Current Status of Spinal Posttraumatic Deformity: A Systematic Review.

STUDY DESIGN: Systematic Review. OBJECTIVE: To systematically analyze the definitions and descriptions in literature of "Spinal Posttraumatic Deformity" (SPTD) in order to support the development of a uniform and comprehensive definition of clinically relevant SPTD. METHODS: A literature search in 11 international databases was performed using "deformity" AND "posttraumatic" and its synonyms. When an original definition or a description of SPTD (Patient factors, Radiological outcomes, Patient Reported Outcome Measurements and Surgical indication) was present the article was included. The retrieved articles were assessed for methodological quality and the presented data was extracted. RESULTS: 46 articles met the inclusion criteria. "Symptomatic SPTD" was mentioned multiple times as an entity, however any description of "symptomatic SPTD" was not found. Pain was mentioned as a key factor in SPTD. Other patient related parameters were (progression of) neurological deficit, bone quality, age, comorbidities and functional disability. Various ways were used to determine the amount of deformity on radiographs. The amount of deformity ranged from not deviant for normal to >30°. Sagittal balance and spinopelvic parameters such as the Pelvic Incidence, Pelvic Tilt and Sacral Slope were taken into account and were used as surgical indicators and preoperative planning. The Visual Analog Scale for pain and the Oswestry Disability Index were used mostly to evaluate surgical intervention. CONCLUSION: A clear-cut definition or consensus is not available in the literature about clinically relevant SPTD. Our research acts as the basis for international efforts for the development of a definition of SPTD.

Clinical, radiological, and patient-reported outcomes 13 years after pedicle screw fixation with balloon-assisted endplate reduction and cement injection.

PURPOSE: In management of traumatic thoracolumbar burst fractures, short-segment pedicle screw fixation with balloon-assisted endplate reduction (BAER) and cement injection is a safe, feasible, and effective technique to maintain radiological alignment with minimum spinal segments involved. However, 20% of patients report daily discomfort despite good spinal alignment and fusion after this technique. This study provides clinical, radiological, and patient-reported outcomes after a minimum 13 years of follow-up. METHODS: Eighteen patients were invited at the outpatient clinic for clinical/radiological examinations. The cohort (originally 20 patients) was treated 13-14 years earlier with pedicle screw fixation, BAER, and cement injection for traumatic thoracolumbar burst fractures. Patient-reported outcome measures were obtained at time of examinations. Current data were compared with data obtained at 6 years of follow-up. RESULTS: Seventeen patients (median age 50; range 32-80) cooperated. No/minimal back pain was reported by 15 patients, and 12 patients returned to their previous heavy labor work. Median visual analog score of health (80%; 50-100%) was similar to results at 6 years (80%; 60-100% p = 0.259). An Oswestry Disability Index score of less than 20% (reflecting minimal disability) was reported by 14 patients, compared with 15 patients at 6 years of follow-up. No significant differences were found in wedge or Cobb angle between the time points. Intravertebral cement resorption was not observed. CONCLUSION: Results from this study suggest that, 13 years after pedicle screw fixation with BAER and cement injection for traumatic thoracolumbar burst fractures, functional performance, pain and radiological outcomes of the current cohort were stable or had slightly improved. These slides can be retrieved under Electronic Supplementary Material.

Classification criteria for diffuse idiopathic skeletal hyperostosis: a lack of consensus.

Objectives: DISH is a condition characterized by flowing ossifications of the spine with or without ossifications of entheses elsewhere in the body. Studies on the prevalence and pathogenesis of DISH use a variety of partly overlapping combinations of classification criteria, making meaningful comparisons across the literature difficult. The aim of this study was to systematically summarize the available criteria to support the development of a more uniform set of diagnostic/classification criteria. Methods: A search was performed in Pubmed, Embase, Cochrane Library and Web of Science using the term DISH and its synonyms. Articles were included when two independent observers agreed that the articles proposed a new set of classification criteria for DISH. All retrieved articles were evaluated for methodological quality, and the presented criteria were extracted. Results: A total of 24 articles met the inclusion criteria. In all articles, spinal hyperostosis was required for the diagnosis of DISH. Peripheral, extraspinal manifestations were included as a (co-)requirement for the diagnosis DISH in five articles. Most discrepancies revolved around the threshold for the number of vertebral bodies affected and to defining different developmental phases of DISH. More than half of the retrieved articles described a dichotomous set of criteria and did not consider the progressive character of DISH. Conclusion: This systematic review summarizes the available different classification criteria for DISH, which highlights the lack of consensus on the diagnosis of (early) DISH. Consensus criteria, including consecutive phases of new bone formation that characterize DISH, can be developed based upon established diagnostic/classification criteria.