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

Molecular characterization and clinical relevance of metabolic expression subtypes in human cancers.

Metabolic reprogramming provides critical information for clinical oncology. Using molecular data of 9,125 patient samples from The Cancer Genome Atlas, we identified tumor subtypes in 33 cancer types based on mRNA expression patterns of seven major metabolic processes and assessed their clinical relevance. Our metabolic expression subtypes correlated extensively with clinical outcome: subtypes with upregulated carbohydrate, nucleotide, and vitamin/cofactor metabolism most consistently correlated with worse prognosis, whereas subtypes with upregulated lipid metabolism showed the opposite. Metabolic subtypes correlated with diverse somatic drivers but exhibited effects convergent on cancer hallmark pathways and were modulated by highly recurrent master regulators across cancer types. As a proof-of-concept example, we demonstrated that knockdown of SNAI1 or RUNX1—master regulators of carbohydrate metabolic subtypes-modulates metabolic activity and drug sensitivity. Our study provides a system-level view of metabolic heterogeneity within and across cancer types and identifies pathway cross-talk, suggesting related prognostic, therapeutic, and predictive utility

Postoperative lymphocele after revision circumferential long-segment scoliosis construct for pseudarthrosis

The patient was a 69-year-old female who had previously undergone a T10-ilium posterior spinal fusion for lumbar scoliosis and spinal stenosis. She presented 2 years after the index procedure for new complaints of low back pain and midthoracic pain, and a feeling of ‘‘tipping over.’’ Scoliosis survey and computed tomography (CT) revealed proximal junctional kyphosis with cephalad degeneration and pseudarthrosis at L5–S1 and L3–L4. She subsequently underwent anterior lumbar interbody fusion from L3 sacrum and revision posterior spinal fusion from T3 ilium the same day. She recovered uneventfully until she returned for follow-up approximately 3 weeks after surgery. At that time, she complained of a distention that manifested as her pants and clothing were not fitting properly. On examination, she exhibited a distended abdomen and fluid wave was percussed

Incidence and Risk Factors for Early Postoperative Complications and Mortality Following Adult Spinal Deformity Surgery Data From the National Surgical Quality Improvement Program From 2011 to 2013

Study Design: Retrospective cohort analysis using the American College of Surgeons National Surgical Quality Improvement Program database. Objective: The objective of this study was to investigate the incidence and risk factors of perioperative complications and mortality in patients undergoing adult spinal deformity (ASD) surgery. Summary of Background Data: Although ASD surgery has been associated with a relatively high complication rate, a focus on perioperative complications in a large cohort has rarely been reported. Materials and Methods: In the database of the 2011-2013 American College of Surgeons National Surgical Quality Improvement Program database, a cohort of patients (n = 1484) above 20 years and underwent ASD surgery was established by primary and other Current Procedural Terminology and International Classification of Disease, Ninth Revision codes. The incidences of perioperative (within 30 d postsurgery) minor/major complications and mortality was investigated. Risk factors for minor/major complications and mortality were assessed using logistic regression modeling. Results: Of 1484 patients undergoing ASD surgery, the overall complication rate was 15.8% (minor complications: 8.2%; major complications: 10.4%), and the mortality rate was 0.6% (9 patients). After multivariate analysis, dependent functional status [P = 0.003; odds ratios (ORs), 4.838], anterior or anterior+posterior approaches (P =0.001; OR, 2.022), and prolonged operative time ( > 5 h) (P = 0.004; OR, 1.821) were associated with an increased risk of minor complications. Male sex (P = 0.013; OR, 1.567), osteotomy procedure (P = 0.008; OR, 1.674) and prolonged operative time ( > 5 h) (P < 0.001; OR, 2.142) were associated with an increased risk of major complications. The American Society of Anesthesiologists 4 status (P= 0.009; OR, 34.697) was a strong risk factor for mortality. Conclusions: After ASD surgery, the rates of minor complications, major complications, and mortality was 8.2%, 10.4%, and 0.6%, respectively. While mortality depended on patient physical status represented by the American Society of Anesthesiologists 4, minor and major complications were associated with male sex, dependent functional status, and surgical factors such as osteotomy procedure, prolonged operative time ( > 5 h), and having an anterior surgical approach. Therefore, this information may be helpful in surgical counseling and preoperative surgical planning.N

Experimental evolution of dispersal : Unifying theory, experiments and natural systems

Dispersal is a central life history trait that affects the ecological and evolutionary dynamics of populations and communities. The recent use of experimental evolution for the study of dispersal is a promising avenue for demonstrating valuable proofs of concept, bringing insight into alternative dispersal strategies and trade-offs, and testing the repeatability of evolutionary outcomes. Practical constraints restrict experimental evolution studies of dispersal to a set of typically small, short-lived organisms reared in artificial laboratory conditions. Here, we argue that despite these restrictions, inferences from these studies can reinforce links between theoretical predictions and empirical observations and advance our understanding of the eco-evolutionary consequences of dispersal. We illustrate how applying an integrative framework of theory, experimental evolution and natural systems can improve our understanding of dispersal evolution under more complex and realistic biological scenarios, such as the role of biotic interactions and complex dispersal syndromes.Peer reviewe