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

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

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

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

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

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

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

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

An independent interobserver reliability and intraobserver reproducibility evaluation of the new AOSpine Thoracolumbar Spine Injury Classification System.

STUDY DESIGN: Agreement study. OBJECTIVE: To perform an independent interobserver and intraobserver agreement evaluation of the new AOSpine Thoracolumbar Spine Injury Classification System. SUMMARY OF BACKGROUND DATA: The new AOSpine Thoracolumbar Spine Injury Classification System was recently published. It showed substantial reliability and reproducibility among the surgeons who developed it; however, an independent evaluation has not been performed. METHODS: Anteroposterior and lateral radiographs, and computed tomographic scans of 70 patients with acute traumatic thoracolumbar injuries were selected and classified using the morphological grading of the new AOSpine Thoracolumbar Spine Injury Classification System by 6 evaluators (3 spine surgeons and 3 orthopedic surgery residents). After a 6-week interval, the 70 cases were presented in a random sequence to the same evaluators for repeat evaluation. The Kappa coefficient (κ) was used to determine the interobserver and intraobserver agreement. RESULTS: The interobserver reliability was substantial when considering the fracture type (A, B, or C), with a κ= 0.62 (0.57-0.66). The interobserver agreement when considering the subtypes was moderate; κ= 0.55 (0.52-0.57). The intraobserver reproducibility was also substantial, with 85.95% full intraobserver reproducibility considering the fracture type, with κ= 0.77 (0.72-0.83), and was also substantial when considering subtypes with 75.71% full agreement and κ= 0.71 (0.67-0.76). No significant differences were observed between spine surgeons and orthopedic residents in the overall interobserver reliability and intraobserver reproducibility, or in the inter- and intraobserver agreement of specific A, B, or C types of injuries. CONCLUSION: This classification allows adequate agreement among different observers and by the same observer on separate occasions. Future prospective studies should evaluate whether this classification improves clinical decision making.

Diagnosis and treatment of benign notochordal cell tumors of the spine: report of 3 cases and literature review.

STUDY DESIGN: Clinical case series. OBJECTIVE: To describe the clinical, radiological, and histological presentation of a series of patients presenting with benign notochordal tumors, and review the existing literature on the topic. SUMMARY OF BACKGROUND DATA: During the past decade, several authors have reported a spine tumor with benign clinical characteristics and histological resemblance to notochordal tissue. The prognosis and appropriate management remain controversial. METHODS: Description of clinical, radiological, and histological findings in 3 patients with benign notochordal tumors of the spine. RESULTS: All cases presented with subacute mild pain, without neurological deficit. Tumors developed at L3, S1, and S4, without canal involvement or apparent instability. The first 2 patients presented with classic imagenological findings were treated conservatively, showing no progression on follow-up. The last patient presented an atypical lytic pattern and contrast enhancement on magnetic resonance imaging, and underwent en bloc resection, with significant associated morbidity. Histopathology of the specimen revealed coexistent foci of incipient chordoma. CONCLUSION: Benign notochordal cell tumors represent a clinical entity derived from notochordal tissue, with characteristics distinct but closely related to the classic chordoma. Some radiological features may suggest the presence of chordoma precursors. Because its true potential for aggressiveness is still undetermined, a careful decision making must weigh the morbidity of en bloc procedures in the spine with uncertain natural history.

Polysomnographic findings in 320 infants evaluated for apneic events.

Apnea is a common problem that causes significant parental anxiety. The aim of this study was to describe polysomnographic findings in infants who were referred over a 4-year period for an apnea and/or cyanotic event. Our hypothesis was that most infants with apnea or cyanosis events will have normal polysomnography (PSG). In total, 320 patients younger than 2 years old were recruited sequentially and prospectively. Patients underwent a day or overnight PSG by computerized polysomnograph; 78% of studies were performed with pH probe in situ. Subjects' ages ranged from 10 days to 21 months (55% male and 84% full-term babies); 55% and 74% were younger than 3 and 6 months, respectively. The average total sleep time was 473.4 min (SD, 52.3), with mean sleep efficiency of 83.5%. The distribution of sleep stages was 56.5% active, 38.5%, quiet and 5.1% indeterminate sleep. Sixty-nine percent (n = 220) of PSG studies were done overnight. There were significant differences in average sleep efficiency (78.1% vs. 83.3%) and REM sleep time (63.6% vs. 59.1%) between PSGs done during the day and overnight (P < 0.05). In total, 34 patients with apneas were studied. The median apnea index for the whole study population was 1.01 (range, 0.1-9.1). In conclusion, our study showed a high prevalence of normal polysomnographic findings in infants referred because of apnea and/or cyanotic events. New clinical prospective studies should be conducted to evaluate whether there is a correlation between PSG findings and outcome at follow-up of infants with a history of apnea and cyanosis.

[Polysomnographic abnormalities in infants with gastroesophageal reflux]. / Alteraciones polisomnográficas en lactantes con reflujo gastroesofágico.

BACKGROUND: Infant apnea is a common problem that conveys significant burden to families and physicians. Its temporal relationship with gastroesophageal reflux (GER) is controversial. AIM: To establish whether infants with GER of different magnitude have a higher incidence of respiratory events than children without GER. PATIENTS AND METHODS: 146 consecutive patients were evaluated with polisomnography (PSG) and with an esophageal pH probe. Those infants without GER episodes or with an esophageal pH below 4.0 in less than 5% of total sleep time were considered as physiologic GER (Group I), between 5-10% as mild GER (Group II), and over 10% as severe GER (Group III). These groups were evaluated for demographic and polysomnographic characteristics. RESULTS: There were no differences in the demographic and global PSG characteristics neither in oxymetry, heart rate or electroencephalographic abnormalities. Group III infants had a higher percentage of active sleep compared to infants of Group I (p < 0.05) and higher incidence of central pauses and apneas compared to infants of Group I (p < 0.05). CONCLUSIONS: The presence of severe GER may modify the sleep pattern in infants, increasing the percentage of active sleep. The presence of central pauses and apneas in infants with severe GER suggest an association between the inmaturity of the respiratory centers and the adaptation of the anti-reflux mechanisms.