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ABSTRACT: The Editors welcome topical correspondence from readers relating to articles published in the Journal. Responses should be sent electronically via the BJS website (http://www.bjs.co.uk). All letters will be reviewed and, if approved, appear on the website. A selection of these will be edited and published in the Journal. Letters must be no more than 250 words in length. Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.
British Journal of Surgery 08/2012; 99(8):1164; author reply 1165. · 4.61 Impact Factor
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ABSTRACT: Introduction & aim: Pelvic morphology in the sagittal plane is usually described by the pelvic incidence (PI), pelvic tilt, and sacral slope. However, the ischium is not included in this assessment. Yet, the position and orientation of the ischium relative to the SI-joint is essential for enabling the typical human fully upright way of ambulation with fully extended hips and knees, carrying the weight of the upper body constantly positioned above the pelvis. This provided an evolutionary advantage, and is believed to be the decisive step forward in human evolution. This so called "pelvic lordosis (PL)" has never been quantified in the normal asymptomatic population. In addition, the significance of the PL in relation to the sagittal spinopelvic alignment is investigated by correlation analysis between the PL and the PI. Materials and methods: PL was defined as the angle between the axis of the ischium, and the line connecting the midpoint of the sacral endplate to the hip axis when the pelvis is projected in the sagittal plane. Using in-house developed software, the PL and PI were measured semi-automatically from three-dimensional CT scan data of the pelvis in a total of 348 normal subjects. Results: The mean PL was 25° (range, 9-46) with an SD of 6.7°. No statistical difference was observed between the genders. A weak but significant correlation between the PL and age was only found in males (r=0.14, P=0.02) but not in females. A strong correlation was observed between the PL and PI in both genders (r=0.51, P=0.00). Discussion & conclusion: A relatively wide range of values for the PL was observed, illustrating a relatively wide natural variation in the normal population. The PL was strongly positively correlated with the PI. A well-developed PL may increase the pelvis's ability to retroflex, and thus might be an important factor in maintaining congruent spinal balance. Therefore the role of the PL in spinal pathology warrants further investigation.
Studies in health technology and informatics 01/2012; 176:462.
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ABSTRACT: Diffuse idiopathic skeletal hyperostosis (DISH) is a systemic condition leading to ossification of spinal ligaments and has been shown to behave similarly to ankylosing spondylitis (AS) often leading to unstable hyperextension fractures. Currently, no quantitative data are available on the spatial relationship between the bridging anterolateral ossification mass (ALOM) and the vertebral body/intervertebral disc to explain the propensity in DISH to fracture through the vertebral body instead of through the intervertebral disc as more often seen in AS. Furthermore, no reasonable explanation is available for the typical flowing wax morphology observed in DISH. In the current study, a quantitative analysis of computed tomography (CT) data from human cadaveric specimens with DISH was performed to better understand the newly formed osseous structures and fracture biomechanics. Additionally, the results were verified using computed tomography angiography data from ten patients with DISH and ten controls. Transverse CT images were analyzed to obtain ALOM area and centroid angle relative to the anteroposterior axis; intervertebral disc and adjacent cranial and caudal levels. The ALOM area at the mid-vertebral body level averaged 57.9 ± 50.0 mm(2); at the mid-intervertebral disc space level it averaged 246.4 ± 95.9 mm(2). The mean ALOM area at the adjacent level caudal to the mid-vertebral body level was 169.6 ± 81.3 mm(2); at the adjacent cranial level, it was 161.7 ± 78.2 mm(2). The main finding was the significant difference between mean ALOM area at the mid-vertebral body level and other three levels (p < 0.0001). The subsequent verification study showed the presence of vertebral segmental arteries at the mid-vertebral body level in nearly all images irrespective of the presence of DISH. A larger area of ALOM seemed associated with increased counter-clockwise rotation (away from the aorta) of the centroid relative to the anteroposterior axis. The results from the present study suggest a predisposition for fractures through the vertebral body and a role for the arterial system in the inhibition of soft tissue ossification.
European Spine Journal 02/2011; 20(9):1474-9. · 1.97 Impact Factor
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ABSTRACT: Bone regeneration is one of the major focus points in the field of regenerative medicine. A well-known stimulus of bone formation is bone morphogenetic protein-2 (BMP-2), which has already been extensively used in clinical applications. We investigated the possibility of achieving osteogenic differentiation both in vitro and in vivo as a result of prolonged presence of BMP-2 using plasmid DNA-based gene therapy. By delivering BMP-2 cDNA in an alginate hydrogel, a versatile formulation is developed. High transfection efficiencies of up to 95% were obtained in both human multipotent stromal cells (MSCs) and MG-63 cells using naked DNA in vitro. Over a period of 5 weeks, an increasing amount of biologically active BMP-2 was released from the cells and remained present in the gel. In vivo, transfected cells were found after both two and six weeks implantation in naked mice, even in groups without seeded cells, thus indicating in vivo transfection of endogenous cells. The protein levels were effective in inducing osteogenic differentiation in vitro, as seen by elevated alkaline phosphatase (ALP) production and in vivo, as demonstrated by the production of collagen I and osteocalcin in a mineralised alginate matrix. We conclude that BMP-2 cDNA incorporated in alginate hydrogel appears to be a promising new strategy for minimal-invasive delivery of growth factors in bone regeneration.
European cells & materials 01/2011; 21:230-42; discussion 242. · 3.03 Impact Factor
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ABSTRACT: In degenerative intervertebral discs (IVDs) collagen type X expression and calcifications have been demonstrated, resembling advanced osteoarthritis (OA), which is associated with hypertrophic differentiation, characterized by the production of collagen type X, Runt-related transcription factor 2 (Runx2), osteoprotegerin (OPG), alkaline phosphatase (ALP) and calcifications.
The aim of this study was to determine if hypertrophic differentiation occurs during IVD degeneration.
IVDs from all Thompson degeneration grades were prepared for histology, extraction of nucleus pulposus (NP) and annulus fibrosis (AF) tissue (N=50) and micro-CT (N=27). The presence of collagen type X, OPG and Runx2 was determined by immunohistochemistry, with OPG levels also determined by Enzyme-linked immunosorbent assay (ELISA). The presence of calcification was determined by micro-CT, von Kossa and Alizarin Red staining.
Immunohistochemical staining for collagen type X, OPG, Runx2 appeared more intense in the NP of degenerative compared to healthy IVD samples. OPG levels correlated significantly with degeneration grade (NP: P<0.000; AF: P=0.002) and the number of microscopic calcifications (NP: P=0.002; AF: P=0.008). The extent of calcifications on micro-CT also correlated with degeneration grade (NP: P<0.001, AF: P=0.001) as did von Kossa staining (NP: P=0.015, AF: P=0.016). ALP staining was only incidentally seen in the transition zone of grades IV and V degenerated IVDs.
This study for the first time demonstrates that hypertrophic differentiation occurs during IVD degeneration, as shown by an increase in OPG levels, the presence of ALP activity, increased immunopositivity of Runx2 and collagen type X.
Osteoarthritis and Cartilage 11/2010; 18(11):1487-95. · 3.90 Impact Factor
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Andrew J Schoenfeld,
Kirkham B Wood,
Charles F Fisher,
Michael Fehlings, F C Oner,
Kim Bouchard,
Paul Arnold,
Alexander R Vaccaro,
Lali Sekhorn,
Mitchel B Harris,
Christopher M Bono
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ABSTRACT: Multinational survey of spine trauma surgeons.
To survey a multinational group of spine trauma surgeons and develop an updated consensus definition of posttraumatic kyphosis (PTK), and the most current methods for diagnosis and treatment.
PTK remains a potential problematic sequela of thoracolumbar trauma. Although most surgeons have devised their own approaches for detecting and treating this condition, broad agreement in terms of the diagnosis and management of PTK has not been achieved. There is a lack of consensus-based guidelines, as the current literature largely consists of small case series or anecdotal expert opinions.
A survey questionnaire was circulated among 35 multinational spine trauma surgeons. The questionnaire consisted of 29 questions divided into 8 domains: definition, diagnosis, risk factors, symptoms, radiographic evaluation, surgical indications, treatment, and expected outcome. Answers from respondents were compiled and evaluated to generate a consensus.
All 35 surgeons completed the survey. Consensus was achieved that PTK represents "a painful kyphotic angulation that can occur anywhere in the posttraumatic spine." Agreement was also reached that asymptomatic PTK can exist, although no true consensus could be reached on the extent of angular deformity that results in PTK. Untreated or maltreated flexion-distraction injuries, or severe burst fractures of the thoracolumbar spine, were felt to be the 2 injuries most likely to produce PTK. Computed tomography, magnetic resonance, and dynamic radiographs were all recommended for evaluation. If surgery is necessary, posteriorly based osteotomies, especially pedicle subtraction osteotomies, have become the principal means of correction.
An updated understanding of PTK and its treatment has been achieved. Posterior osteotomies seem to be the most popular means of surgical correction. In the future, multicenter prospective studies are necessary to ascertain, with greater precision, the most appropriate treatment for this condition.
Journal of spinal disorders & techniques 10/2010; 23(7):e1-8. · 1.21 Impact Factor
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ABSTRACT: The intervertebral disc (IVD) is dependent on nutrient provision through a cartilage layer with underlying subchondral bone, analogous to joint cartilage. In the joint, subchondral bone remodeling has been associated with osteoarthritis (OA) progression due to compromised nutrient and gas diffusion and reduced structural support of the overlaying cartilage. However, subchondral bone changes in IVD degeneration have never been quantified before.
The aim of this study is to determine the subchondral bone changes at different stages of IVD degeneration by micro-CT.
Twenty-seven IVDs including the adjacent vertebral endplates were obtained at autopsy. Midsagittal slices, graded according the Thompson score, were scanned. Per scan 12 standardized cylindrical volumes of interest (VOI) were selected. Six VOIs contained the bony endplate and trabeculae (endplate VOIs) and six accompanying VOIs only contained trabecular bone (vertebral VOIs). Bone volume as percentage of the total volume (BV/TV) of the VOI, trabecular thickness (TrTh) and connectivity density (CD) were determined.
An increase in BV/TV and TrTh was found in endplate VOIs of IVDs with higher Thompson score whereas these values remained stable or decreased in the vertebral VOIs.
The increase in bone volume combined with the increase in TrTh in endplate VOIs strongly suggest that the subchondral endplate condenses to a more dense structure in degenerated IVDs. This may negatively influence the diffusion and nutrition of the IVD. The endplate differences between intact and mild degenerative IVDs (grade II) indicate an early association of subchondral endplate changes with IVD degeneration.
Osteoarthritis and Cartilage 10/2010; 19(1):89-95. · 3.90 Impact Factor
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ABSTRACT: Diffuse idiopathic skeletal hyperostosis (DISH) is a systemic disorder of the axial and peripheral skeleton in humans and has incidentally been described in dogs. The aims of this retrospective radiographic cohort study were to determine the prevalence of DISH in an outpatient population of skeletally mature dogs and to investigate if dogs can be used as an animal model for DISH. The overall prevalence of canine DISH was 3.8% (78/2041). The prevalence of DISH increased with age and was more frequent in male dogs, similar to findings in human studies. In the Boxer breed the prevalence of DISH was 40.6% (28/69). Dog breeds represent closed gene pools with a high degree of familiar relationship and the high prevalence in the Boxer may be indicative of a genetic origin of DISH. It is concluded that the Boxer breed may serve as an animal model for DISH in humans.
European Spine Journal 08/2010; 19(8):1325-9. · 1.97 Impact Factor
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D Delawi,
W J A Dhert,
L Rillardon,
E Gay,
D Prestamburgo,
C Garcia-Fernandez,
E Guerado,
N Specchia,
J L C Van Susante,
N Verschoor,
H M E Quarles van Ufford, F C Oner
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ABSTRACT: A prospective, randomized, controlled, multicenter clinical study.
To evaluate the safety and feasibility of osteogenic protein (OP)-1 in 1-level lumbar spine instrumented posterolateral fusions.
Instrumented posterolateral fusion with the use of autograft is a commonly performed procedure for a variety of spinal disorders. However, harvesting of bone from the iliac crest is associated with complications. A promising alternative for autograft are bone morphogenetic proteins.
As part of a larger prospective, randomized, multicenter study, 36 patients were included, who received a 1-level instrumented posterolateral fusion of the lumbar spine. All patients had a degenerative or isthmic spondylolisthesis with symptoms of neurologic compression. There were 2 treatment arms: OP-1 combined with locally available bone from laminectomy (OP-1 group) or iliac crest autograft (autograft group). The primary outcome was the fusion rate based on a computed tomography scan after 1-year follow-up. The clinical outcome was measured using the Oswestry Disability Index. Additionally, the safety of OP-1 was evaluated by comparing the number and severity of adverse events that occurred between both groups.
Using strict criteria, fusion rates of 63% were found in the OP-1 group and 67% in the control group (P = 0.95). There was a decrease in Oswestry scores at subsequent postoperative time points compared with preoperative values (P > 0.001). There were no significant differences in the mean Oswestry scores between the study group and control group at any time point (P = 0.56). No product-related adverse events occurred.
The results demonstrate that OP-1 combined with locally obtained autograft is a safe and effective alternative for iliac crest autograft in instrumented single-level posterolateral fusions of the lumbar spine. The main advantage of OP-1 is that it avoids morbidity associated with the harvesting of autogenous bone grafts from the iliac crest.
Spine 05/2010; 35(12):1185-91. · 2.08 Impact Factor
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ABSTRACT: Matrix metalloproteinases (MMPs) regulate connective tissue architecture and cell migration through extracellular matrix (ECM) degradation and are associated with both physiological and pathological processes. Although they are known to play a role in skeletal development, little is known about the role of MMPs in intervertebral disc (IVD) development. Sixteen fetal human lumbar spine segments, obtained at autopsy, were compared with five normal, non-fetal L4-L5 IVDs. Intensity and/or localization of immunohistochemical staining for MMP-1, -2, -3 and -14 were evaluated by three independent observers. MMP-2 production and activation was quantified by gelatin zymography. MMP-1 and -14 were abundantly present in the nucleus pulposus (NP) and notochordal (NC) cells of the fetal IVDs. In non-fetal IVDs, MMP-1 and -14 staining was significantly less intense (p = 0.001 and p < 0.001, respectively). MMP-3 was found in almost the entire IVD with no significant difference from non-fetal IVDs. MMP-2 staining in the NC and NP cells of the fetal IVD was moderate, but weak in the non-fetal IVD. Gelatin zymography showed a negative correlation of age with MMP-2 activity (p < 0.001). MMP-14 immunostaining correlated positively with MMP-2 activity (p = 0.001). For the first time, the presence of MMP-1, -2, -3 and -14 in the fetal human IVD is shown and the high levels of MMP-1, -2 and -14 suggest a role in the development of the IVD. In particular, the gradual decrease in MMP-2 activation during gestation pinpoints this enzyme as key player in fetal development, possibly through activation by MMP-1 and -14.
European Spine Journal 04/2010; 19(8):1340-6. · 1.97 Impact Factor
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ABSTRACT: To evaluate and compare nonoperative treatment methods for traumatic thoracic and lumbar compression fractures and burst fractures.
Prospective randomized controlled trial with long-term follow-up.
Two general hospitals in the Netherlands.
Patients with a traumatic thoracic or lumbar spine fracture, without neurologic damage, with less than 50% loss of height of the anterior column and less than 30% reduction of the spinal canal were included.
Patients in the compression group were randomized to physical therapy and postural instructions, a brace for 6 weeks, or a Plaster of Paris cast for 6 or 12 weeks. Patients in the burst group received a brace or a Plaster of Paris cast, both for 12 weeks.
Follow-up examinations included radiographs, Visual Analogue Scores for toleration of treatment and persistent pain, and an Oswestry Disability Index at long-term follow-up.
There were 133 patients: 108 in the compression group and 25 in the burst group. For compression fractures, physical therapy and brace were considered the most tolerable. Brace therapy scored significantly better on the Visual Analogue Scores for residual pain and on the Oswestry Disability Index. None of the treatments had any significant effect on the residual deformity measurements. For burst fractures, no significant differences were found.
Brace treatment with supplementary physical therapy is the treatment of choice for patients with compression fractures of the thoracic and lumbar spine. Furthermore, more than 20% of all patients had moderate or severe back pain at long-term follow-up.
Journal of orthopaedic trauma 10/2009; 23(8):588-94. · 1.78 Impact Factor
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Journal of Neurosurgery Spine 12/2008; 9(5):511. · 1.53 Impact Factor
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ABSTRACT: Thoracic spinal cord injury (SCI) without fractures or discoligamentary injuries in adults is extremely uncommon. This is because of the inherent stability of the thoracic spine provided by the structure of the ribcage, and the increasing stiffness of the overall spine with rising age. Till date, the pathogenesis of this disorder in adults is still unclear.
To present a case of thoracic SCI without any bony or ligamentous injury of the vertebral column in an adult patient together with an overview of the literature.
Case report.
Retrospective description of a case. The charts and the radiological exams of the case were reviewed to explain the unusual neurologic deficit of a 27-year-old male motorcyclist who got involved in a traffic accident and presented with multiple injuries.
Clinically, there were signs of an incomplete SCI at the level of T8. Initial radiographs, computed tomography scan, and magnetic resonance images (MRI) revealed no osseoligamentous injury. Multiple rib fractures were seen on the left side. Subsequent MRI performed two days later showed focal cord contusion at level T4 and avulsion of nerve root T4 on the left side.
Multiple rib fractures including the 4th rib resulted in violent avulsion of nerve root T4, possibly causing focal myelum contusion. This is an unusual mechanism of neurologic injury in adults, which has not been described before.
The spine journal: official journal of the North American Spine Society 06/2008; 9(3):e5-8. · 2.90 Impact Factor
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ABSTRACT: A center parallel cohort study with blinded inclusion based on clinical equipoise.
To compare outcomes of nonoperative and operative treatment strategies in terms of quality of life and neurologic and functional status.
Despite a considerable body of literature, sound evidence regarding the optimal treatment for traumatic thoracic and lumbar spine fractures is lacking.
Medical records of patients hospitalized for traumatic spinal fractures between 1991 and 2002 were identified in 2 trauma centers in the same country with established and different treatment strategies. Eligibility was retrospectively assessed for each case by a panel of orthopaedic surgeons who were representative of the 2 medical centers, and who were blinded to the treatment actually administered. Patients were included in the study when there was disagreement on the suggested treatment method. Thus, 2 comparable groups were identified undergoing nonoperative or operative treatment. Outcome assessment and comparison across groups focused on quality of life, residual pain, neurologic recovery, and employment in the middle-long-term follow-up.
Discordance in regards to choice of treatment was identified in 190 (95 treated nonoperative, 95 operative) of 636 potentially eligible patients. Patients were comparable regarding baseline characteristics, except for a somewhat higher proportion of males and neurologic impairment in the operative group. Seventeen percent of the nonoperative and 21% of the operative group developed complications and 3 patients displayed neurologic deterioration for which a treatment change was considered necessary. Follow-up was complete in 79%; mean follow-up time was 6.2 years with a minimum of 2 years. Pain scores, disability indexes, and general health outcome were comparable at follow-up. Compared with matched population norms, outcomes were poorer regardless of treatment method. Neurologic recovery was better in the operative group, but this difference did not reach statistical significance. Multivariate regression analyses revealed that female gender and neurologic impairment were independent predictors of poor functional outcome. Eighty-eight and 83% of the nonoperatively and operatively treated patients were employed at some point after a rehabilitation period.
Overall outcome of nonoperative and operative treatment in middle-long-term follow up is comparable, although there seems to be a difference in neurologic recovery patterns. Studies on the cost-effectiveness of treatment options and the patterns of recovery within 2 years after injury would assist in guideline development and stimulate interest for future research.
Spine 05/2008; 33(9):1006-17. · 2.08 Impact Factor
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ABSTRACT: Prospective studies have failed to demonstrate the superiority of either operative or nonoperative treatment of thoracolumbar fractures. Similar to other surgical fields, research has been limited by the variability in surgical interventions, difficult recruitment, infrequent pathology, and the urgency of interventions.
To outline factors precluding randomized controlled trials in spinal fractures research, and describe a novel methodology that seeks to improve on the design of observational studies.
A preliminary report describing an observational study design with clinical equipoise as an inclusion criterion. The proposed methodology is a cohort study with head-to-head comparison of operative and nonoperative treatment regimens in an expertise-based trial fashion. Patients are selected retrospectively by an expert panel and clinical outcomes are assessed to compare competing treatment regimens. Surgeon equipoise served as an inclusion criterion.
Patients with closed or open thoracolumbar spinal fracture with or without neurological impairment, presenting to one of two different trauma centers between 1991 and 2005 (N = 760).
Homogeneity of baseline clinical and demographic data and distribution of prognostic risk factors between the operative and the nonoperative cohort.
Patients treated for spine fractures at two University hospitals practicing opposing methods of fracture intervention were identified by medical diagnosis code searches (n = 760). A panel of spine treatment experts, blinded to the treatment received clinically has assessed each case retrospectively. Patients were included in the study when there was disagreement on the preferred treatment, that is, operative or nonoperative treatment of the injury. Baseline and initial data of a study evaluating nonoperative versus operative spinal fracture treatment are presented.
One hundred and ninety patients were included in the study accounting for a panel discordance rate of 29%. The distribution of baseline characteristics and demographics of the study populations were equal across the parallel cohorts enrolled in the study, that is, no differences in prognostic factors were observed.
The use of clinical equipoise as an inclusion criterion in comparative studies may be used to avoid selection bias. Using multivariate analysis of retrospectively assembled parallel cohorts, a valid comparison of operative and nonoperative spine fracture treatment strategies and their outcomes is possible.
The Spine Journal 03/2008; 8(6):975-81. · 3.29 Impact Factor
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ABSTRACT: An 83-year-old woman was admitted to hospital with complaints of fever, abdominal pain and other complaints suggesting urosepsis. Additional analyses did not reveal the cause of her complaints. After cessation of antibiotic therapy, there was a spontaneous decrease in the infection parameters and she was subsequently discharged. Two and a half months later she was presented in our hospital with low back pain with radiating to the legs. MRI showed signs ofa spondylodiscitis at the level of LIII-LIV existing for some time. Finally, a gram-positive streptococcus infection was found and she was treated with antibiotics for 13 weeks. 6 months later she was free of symptoms. A 57-year-old man was admitted to the intensive care with a double-sided olecranon bursitis and sepsis. An endocarditis caused by Staphylococcus aureus was thought to be the cause of the sepsis and the patient was treated with surgical intervention and antibiotics. Because of persistent sepsis, different CT-scans were performed, and after one and a half months an extensive spondylodiscitis with abscess formation was diagnosed and subsequently treated surgically. A delay in diagnosing spondylodiscitis is the rule rather the exception. The diagnosis should be considered in any patient with localised back pain, especially when accompanied by fever, high ESR, and the presence of risk factors such as high age, diabetes mellitus, immunosuppression, and/or rheumatoid arthritis.
Nederlands tijdschrift voor geneeskunde 12/2007; 151(45):2485-90.
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ABSTRACT: Systematic review of literature and expert clinical opinions of the members of the Spine Trauma Study Group were combined to develop and refine this algorithm.
To develop an evidence-based algorithm for surgical approaches to manage subaxial cervical injuries using a systematic review of the literature, expert opinion, and anticipated patient preferences.
There is lack of consensus in the management of subaxial cervical spine trauma, in part, because of the lack of a clinically relevant system for classifying these injuries. The newly developed Subaxial Injury Classification scoring system categorizes injury morphology into 3 broad groups, includes an assessment of the integrity of the discoligamentous soft tissue structures and the patient's neurologic status, and thus guides surgical or nonsurgical treatment. The choice of a specific surgical technique and approach is currently not evidence based, and this gap in knowledge is one which the current article seeks to address.
A literature review followed by a consensus of experts approach was used to develop the algorithm and to ensure face and content validity.
An algorithm is presented to guide the choice of surgical approach in cervical subaxial burst fractures, distraction injuries, and translation or rotation injuries. The burst or compression injuries and distraction injuries are more likely to be treated with a single anterior approach, whereas the more severe translation or rotation injuries may more commonly be approached posteriorly or with combined anterior and posterior surgery.
This algorithm; derived from the Subaxial Injury Classification scoring system, will assist surgeons in answering the 2 most common questions they face when managing subaxial cervical spine trauma: "Should I operate?" and "Which surgical approach should I select?"
Spine 12/2007; 32(23):2620-9. · 2.08 Impact Factor
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Alexander R Vaccaro,
R John Hulbert,
Alpesh A Patel,
Charles Fisher,
Marcel Dvorak,
Ronald A Lehman,
Paul Anderson,
James Harrop, F C Oner,
Paul Arnold,
Michael Fehlings,
Rune Hedlund,
Ignacio Madrazo,
Glenn Rechtine,
Bizhan Aarabi,
Mike Shainline
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ABSTRACT: The classification system was derived through a literature review and expert opinion of experienced spine surgeons. In addition, a multicenter reliability and validity study of the system was conducted on a collection of trauma cases.
To define a novel classification system for subaxial cervical spine trauma that conveys information about injury pattern, severity, treatment considerations, and prognosis. To evaluate reliability and validity of this system.
Classification of subaxial cervical spine injuries remains largely descriptive, lacking standardization and prognostic information.
Clinical and radiographic variables encountered in subaxial cervical trauma were identified by a working section of the Spine Trauma Study Group. Significant limitations of existing systems were defined and addressed within the new system. This system, as well as the Harris and Ferguson & Allen systems, was applied by 20 spine surgeons to 11 cervical trauma cases. Six weeks later, the cases were randomly reordered and again scored. Interrater reliability, intrarater reliability, and validity were assessed.
Each of 3 main categories (injury morphology, disco-ligamentous complex, and neurologic status) identified as integrally important to injury classification was assigned a weighted score; the injury severity score was obtained by summing the scores from each category. Treatment options were assigned based on threshold values of the severity score. Interrater agreement as assessed by intraclass correlation coefficient of the DLC, morphology, and neurologic status scores was 0.49, 0.57, and 0.87, respectively. Intrarater agreement as assessed by intraclass correlation coefficient of the DLC, morphology, and neurologic 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 compared favorably to the Harris and Ferguson & Allen systems.
The Sub-axial Injury Classification and Severity Scale provides a comprehensive classification system for subaxial cervical trauma. Early validity and reliability data are encouraging.
Spine 11/2007; 32(21):2365-74. · 2.08 Impact Factor
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ABSTRACT: A 34-year-old woman with a known congenital pain-insensitivity syndrome presented because of increasing weakness and sensory loss in her right leg. The cause was a rapidly progressive partial caudal compression syndrome in the absence ofknown prior trauma. Radiology revealed a lumbar Charcot spine, i.e. total destruction of the spine with compression of the dural sac. Emergency surgery included opening of the lumbar canal and spondylodesis. Postoperatively, there was almost full neurological recovery. In the pathogenesis the absence of protective pain sensation combined with trophic degeneration due to neurovascular dysregulation may play a role.
Nederlands tijdschrift voor geneeskunde 08/2007; 151(27):1527-32.
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ABSTRACT: To determine the symptoms in patients who presented with persistent or recurrent backache or leg pain after implantation of an artificial disc prosthesis.
Descriptive.
During the past II years in the Maastricht University Hospital (n=65) and the Utrecht University Medical Centre (n=2), 67 patients were seen with persistent or recurrent backache or leg pain in whom, an average of 53 months previously, one or more SB Charité-III lumbar-disc prostheses had been implanted elsewhere. The results were evaluated.
The most prominent findings were: migration of the prosthesis (n=6); subsidence into the vertebra (n=35); disc degeneration at one or more neighbouring levels (n=34) and arthrosis of facet joints (n=24). In 9 cases, rupture of the metal wire around the polyethylene core was observed and in 5 cases there were radiological signs of polyethylene wear. Re-operation (spondylodesis) was generally unsatisfactory if the prosthesis was left in place. In 21 patients, the prosthesis was removed; all specimens showed polyethylene wear or rupture.
Published results are mostly case series and suffer from observer bias; moreover, the benefits are moderate. Given the uncertain role ofdisc degeneration in patients with chronic backache, the real risk of complications and the uncertain advantages, the implantation ofa disc prosthesis is difficult to defend.
Nederlands tijdschrift voor geneeskunde 08/2007; 151(28):1577-84.
