The Sub-axial Cervical Spine Injury Classification System (SLIC): A Novel Approach to Recognize The Importance of Morphology, Neurology and Integrity of the Disco-ligamentous complex

Abstract Background Context Despite technological advances in spine surgery, classification of sub-axial cervical spine injuries remains largely descriptive, lacking standardization and any relationship to prognosis or clinical decision making. Purpose The primary purpose of this paper is to define a classification system for sub-axial cervical spine trauma that conveys information about injury pattern and severity as well as treatment considerations and prognosis. The proposed system is designed to be both comprehensive and easy to use. The secondary objective is to evaluate the classification system in the basic principles of classification construction, namely reliability and validity. Study Design/Setting Derivation of the classification was from a synthesis of the best cervical classification parameters gleaned from an exhaustive literature review and expert opinion of experienced spine surgeons. Multi-center reliability and validity study of a cervical classification system using previously collected CT, MRI, and plain film x-ray images of sub-axial cervical trauma. Methods Important clinical and radiographic variables encountered in sub-axial cervical trauma were identified by a working section of the Spine Trauma Study Group (STSG). Significant limitations of existing injury classification systems were defined and addressed within the new system. It was then introduced to the STSG and applied to 11 cervical trauma cases selected to represent a spectrum of subaxial injury. Six weeks later, the cases were randomly re-ordered and again scored using the novel classification system. Twenty surgeons completed both intervals. Inter-rater and intra-rater reliability and several forms of validity were assessed. For comparison, the reliability of both the Harris and the Ferguson & Allen systems were also evaluated. Results Each of three main categories (injury morphology; disco-ligamentous complex integrity; and neurological status) identified as integrally important to injury description, treatment, and prognosis was assigned an ordinal score range, weighted according to its perceived contribution to overall injury severity. A composite injury severity score was modeled by summing the scores from all three categories. Treatment options were assigned based upon threshold values of the severity score. Inter-rater agreement as assessed by ICC of the DLC, Morphology, and Neurological Status scores was 0.49, 0.57, and 0.87, respectively. Intra-rater agreement as assessed by ICC of the DLC, Morphology, and Neurological Status scores was 0.66, 0.75, and 0.90, respectively. Raters agreed with treatment recommendations of the algorithm in 93.3 % of cases, suggesting high construct validity. The reliability if the SLIC treatment algorithm compared favorably to the earlier classification systems of Harris and Ferguson & Allen. Conclusions The Sub-axial Injury Classification (SLIC) and Severity Scale provides a comprehensive classification system for sub-axial cervical trauma, incorporating pertinent characteristics for generating prognoses and courses of management. Early data on validity and reliability are encouraging. Further testing is necessary before introducing the SLIC score into clinical practice

External validation of a model to predict the survival of patients presenting with a spinal epidural metastasis

The surgical treatment of spinal metastases is evolving. The major problem is the selection of patients who may benefit from surgical treatment. One of the criteria is an expected survival of at least 3 months. A prediction model has been previously developed. The present study has been performed in order to validate externally the model and to demonstrate that this model can be generalized to other institutions and other countries than the Netherlands. Data of 356 patients from five centers in Germany, Spain, Sweden, and the Netherlands who were treated for metastatic epidural spinal cord compression were collected. Hazard ratios in the test population corresponded with those of the developmental population. However, the observed and the expected survival were different. Analysis revealed that the baseline hazard function was significantly different. This tempted us to combine the data and develop a new prediction model. Estimating iteratively, a baseline hazard was composed. An adapted prediction model is presented. External validation of a prediction model revealed a difference in expected survival, although the relative contribution of the specific hazard ratios was the same as in the developmental population. This study emphasized the need to check the baseline hazard function in external validation. A new model has been developed using an estimated baseline hazar

Thoracolumbar injury classification and severity score: a new paradigm for the treatment of thoracolumbar spine trauma

BACKGROUND: Contemporary understanding of the biomechanics, natural history, and methods of treating thoracolumbar spine injuries continues to evolve. Current classification schemes of these injuries, however, can be either too simplified or overly complex for clinical use. METHODS: The Spine Trauma Group was given a survey to identify similarities in treatment algorithms for common thoracolumbar injuries, as well as to identify characteristics of injury that played a key role in the decision-making process. RESULTS: Based on the survey, the Spine Trauma Group has developed a classification system and an injury severity score (thoracolumbar injury classification and severity score, or TLICS), which may facilitate communication between physicians and serve as a guideline for treating these injuries. The classification system is based on the morphology of the injury, integrity of the posterior ligamentous complex, and neurological status of the patient. Points are assigned for each category, and the final total points suggest a possible treatment option. CONCLUSIONS: The usefulness of this new system will have to be proven in future studies investigating inter- and intraobserver reliability, as well as long-term outcome studies for operative and nonoperative treatment methods

Long-term randomised comparison between a carbon fibre cage and the Cloward procedure in the cervical spine

A prospective randomised study. To compare the long-term outcome of anterior cervical decompression and fusion (ACDF) with a cervical intervertebral fusion cage (CIFC) and the Cloward procedure (CP). We have previously shown that the 2 year outcome of ACDF with the CIFC is the same as for the CP. The fusion rate in CIFC group was, however, only 55%, compared to 85% in CP group. The long-term outcome of CIFC is poorly documented. Ninety-five patients with at least 6 months duration of neck pain and radicular arm pain were randomly allocated for ACDF with the CIFC or the CP. Radiographs were obtained at 2 years. Questionnaires about pain, disability (Neck Disability Index, NDI), distress, quality of life and global outcome were obtained from 83 patients (87%) (43 CIFC, 40 CP) at a mean follow-up time of 6 years (range 56–94 months). There were no significant differences in any outcome variable between the two treatments. For both CP and CIFC the pain intensity improved (P<0.0001) whereas the NDI was unchanged at long-term follow-up compared to preoperatively. In the CIFC group patients with a healed fusion had significantly less mean pain (24 mm) and NDI (26%) than patients with pseudarthrosis (42 and 41, respectively). Furthermore, the mean pain and NDI reported by CIFC patients with a healed fusion was significantly less than in healed CP patients (37 and 38, respectively). The long-term outcome is the same for the CIFC and the CP, with similar improvements of pain but with considerable remaining functional disability. However, in the subgroup of patients with healed CIFC the outcome was clearly better than for the non-healed CIFC group, and also clearly better than for the healed CP group. Thus, if the healing problem associated with the CIFC can be solved the results indicate that a better outcome can be expected with the cage than with the CP

Predictive factors for the outcome of fusion in adult isthmic spondylolisthesis.

STUDY DESIGN: A prospective study on predictive factors for the outcome of 164 patients with adult isthmic spondylolisthesis operated on with fusion. OBJECTIVE: In view of the need to better select patients for fusion, we investigated the use of the pain drawing (PD) and other potential factors for predicting the outcome of fusion. SUMMARY OF BACKGROUND DATA: Results on predictive factors of outcome after spinal fusion have been contradictory and large, well-defined, patient samples with adequate observation times are lacking. METHODS: Questionnaires including possible predictive factors and PDs were obtained before surgery. Degree and level of slip were documented. Outcome was quantified by measurement of pain (VAS), Disability Rating Index, the Oswestry Disability Index, and global assessment by the patient into "much better," "better," "unchanged," or "worse." The 2-year follow-up rate was 160 of 164 (98%). RESULTS: In the total sample 49% of patients were much better, 25% better, 14% unchanged, and 12% worse. The following preoperative factors correlated to a worse outcome in the univariate analysis: not working, no regular exercise, female gender, shortness in stature, and a nonorganic PD. The multivariate regression analysis showed that work status was the main determinant of outcome. Gender and exercise had less but significant impact (P = 0.004 and 0.02, respectively). In the multivariate regression analysis the PD was not a significant predictor (P = 0.06). CONCLUSION: The present study shows that patients working before surgery have a more favorable outcome. Also male gender and regular exercise are indicators of a better outcome after fusion. Female patients not working, not exercising or, if these factors are not known, with nonorganic PDs, should be informed about their suboptimal chances of an excellent outcome after fusion

The long-term effect of posterolateral fusion in adult isthmic spondylolisthesis: a randomized controlled study.

BACKGROUND: Today there is some evidence-based medicine support for a positive short-term treatment effect of fusion in chronic low back pain in spondylolisthesis and in nonspecific degenerative lumbar spine disorders. The long-term effect is, however, unknown. PURPOSE: To determine the long-term outcome of lumbar fusion in adult isthmic spondylolisthesis. STUDY DESIGN: Prospective, randomized controlled study comparing a 1-year exercise program with instrumented and non-instrumented posterolateral fusion with average long-term follow-up of 9 years (range, 5-13). PATIENT SAMPLE: 111 patients aged 18 to 55 years with adult lumbar isthmic spondylolisthesis at L5 or L4 level of all degrees, and at least 1-year's duration of severe lumbar pain with or without sciatica. OUTCOME MEASURES: Pain and functional disability was quantified by pain (VAS), the Disability Rating Index (DRI), the Oswestry Disability Index (ODI) work status, and global assessment of outcome by the patient into much better, better, unchanged or worse. Quality of life was assessed by the SF-36. METHODS: The patients were randomly allocated to treatment with 1) a 1-year exercise program (n=34), 2) posterolateral fusion without pedicle screw instrumentation (n=37), or 3) posterolateral fusion with pedicle screw instrumentation (n=40). Long-term follow-up was obtained in 101 (91%) patients. Nine patients in the exercise group were eventually operated on. RESULTS: Longitudinal analysis: At long-term follow-up pain and functional disability were significantly better than before treatment in both surgical groups. No significant differences were observed between instrumented and non-instrumented patients in any variable studied. In the exercise group the pain was significantly reduced but not the functional disability. Compared with the 2-year follow-up a significant increase in functional disability was observed, as measured by the DRI, but not the ODI, in the surgical group at long term. In the exercise group no significant changes were observed between the 2-year and the long-term follow-up. Cross-sectional analysis: Between the surgical and conservative group no significant differences were observed in any outcome measurement at long-term follow-up except for global assessment, which was significantly better for surgical patients. Of surgical patients 76% classified the overall outcome as much better or better compared with 50% of conservatively treated patients (p=0.015). Quality of life as estimated by the SF-36 at long term was not different between treatment groups in any of the eight domains studied but was considerably lower than for the normal population. CONCLUSIONS: Posterolateral fusion in adult lumbar isthmic spondylolisthesis results ina modestly improved long-term outcome compared with a 1-year exercise program. Although the results show that some of the previously reported short-term improvement is lost at long term, patients with fusion still classify their global outcome as clearly better than conservatively treated patients. Furthermore, because the long-term outcome of the patients conservatively treated most likely reflects the natural course, one can also conclude that no considerable spontaneous improvement should be expected over time in adult patients with symptomatic isthmic spondylolisthesis. Substantial pain, functional disability and a reduced quality of life will in most patients most likely remain unaltered over many years

A Comparison Between the Carbon Fiber Cage and the Cloward Procedure in Cervical Spine Surgery A Ten- to Thirteen-Year Follow-Up of a Prospective Randomized Study

Study Design. Ten- to 13-year follow-up of a prospective randomized study. Objective. To compare the 10- to 13-year outcomes of anterior cervical decompression and fusion (ACDF) with a cervical intervertebral fusion cage (CIFC), and the Cloward procedure (CP) using a broad clinical and patient-centered assessment. Summary of Background Data. There are few prospective studies and none with a follow-up of 10 years or more. Methods. Patient questionnaires completed 10 years or more after ACDF. Seventy-three patients (77%) responded. Radiographs were obtained at 2 years. Results. Apart from greater fulfillment of preoperative expectation (P = 0.01) and less headache (P = 0.005) in the CIFC group compared with the CP group, there were no significant differences in the outcomes of the two surgical methods. Pain intensity improved in comparison with preoperative levels in both the CIFC and CP groups (P andlt; 0.0001), but the Neck Disability Index (NDI) only improved in the CIFC group (P = 0.04). Only those with a healed fusion benefited from an improved NDI (P = 0.02). There was no deterioration in pain intensity or NDI after the 2-year follow-up. Conclusion. The outcomes of the two surgical methods, with a few exceptions, were equal at 10- to 13-year follow-up, and there was no deterioration in outcome after the 2-year follow-up. Pain intensity improved more than disability, which may indicate that further improvement of physical function requires early more extensive postoperative rehabilitation. Despite persisting disability, repeat surgery was relatively uncommon.Original Publication: Anna Hermansen, Rune Hedlund, Ludek Vavruch and Anneli Peolsson, A Comparison Between the Carbon Fiber Cage and the Cloward Procedure in Cervical Spine Surgery A Ten- to Thirteen-Year Follow-Up of a Prospective Randomized Study, 2011, SPINE, (36), 12, 919-925. http://dx.doi.org/10.1097/BRS.0b013e3181e8e4a3 Copyright: J B Lippincott Co http://www.lww.com/</p