Jared T. Wilsey

Reliability of a novel classification system for thoracolumbar injuries: the Thoracolumbar Injury Severity Score.

Study Design. Prospective study of 5 spine surgeons rating 71 clinical cases of thoracolumbar spinal injuries using the Thoracolumbar Injury Severity Score (TLISS) and then re-rating the cases in a different order 1 month later. Objective. To determine the reliability of the TLISS system. Summary of Background Data. The TLISS is a recently introduced classification system for thoracolumbar spinal column injures designed to simplify injury classification and facilitate treatment decision making. Before being widely adopted, the reliability of the TLISS must be studied. Methods. A total of 71 cases of thoracolumbar spinal trauma were distributed on CD-ROM to 5 attending spine surgeons, including clinical/radiographic data, details of the TLISS, and a scoring sheet in which cases would be scored using the system. The surgeons were later assigned the task with the cases reordered. Intraobserver and interobserver reliability was calculated for TLISS components, total score, and surgeons treatment decision using the Cohen unweighted kappa coefficients and Spearman rank-order correlation. Results. Interrater reliability assessed by generalized kappa coefficients was 0.33 ± 0.03 for injury mechanism, 0.91 ± 0.02 for neurologic status, 0.35 ± 0.03 for posterior ligamentous complex status, 0.29 ± 0.02 for TLISS total, and 0.52 ± 0.03 for treatment recommendation. Respective results using the Spearman correlation were 0.35 ± 0.04, 0.94 ± 0.01, 0.48 ± 0.04, 0.65 ± 0.03, and 0.51 ± 0.04. Surgeons agreed with the TLISS recommendation 96.4% of the time. Intrarater kappa coefficients were 0.57 ± 0.04 for injury mechanism, 0.93 ± 0.02 for neurologic status, 0.48 ± 0.04 for posterior ligamentous complex status, 0.46 ± 0.03 for TLISS total, and 0.62 ± 0.04 for treatment recommendation. Respective results using the Spearman correlation were 0.70 ± 0.04, 0.95 ± 0.02, 0.59 ± 0.05, 0.77 ± 0.04, and 0.59 ± 0.05. Conclusions. The TLISS has good reliability and compares favorably to other contemporary thoracolumbar fracture classification systems.

Agreement between orthopedic surgeons and neurosurgeons regarding a new algorithm for the treatment of thoracolumbar injuries: a multicenter reliability study.

Introduction Considerable variability exists in the management of thoracolumbar (TL) spine injuries. Although there are many influences, one significant factor may be the treating surgeons specialty and training (ie, orthopedic surgery vs. neurosurgery). Our objective was to assess the agreement between spinal orthopedic and neurologic surgeons in rating the severity of TL spine injuries with a new treatment algorithm. This information could be important in establishing consensus-based protocols for managing these challenging injuries. Methods Twenty-eight spinal surgeons (8 neurosurgeons and 20 orthopedic surgeons) reviewed 56 TL injury case histories. Each case was classified and scored according to the TL injury severity score (TLISS). The case histories were reordered and the physicians repeated the exercise 3 months later. At both intervals the surgeons were asked if they agreed with the final treatment recommendation of the TLISS algorithm. The reliability and decision validity of the TLISS was compared. Results Between-group interrater reliability was similar to within group reliabilities. Intrarater reliability was also similar between groups. The between speciality interrater reliability of the TLISS management recommendation was moderate (74% agreement, κ=0.532). Orthopedic and neurosurgeons agreed with the TLISS management recommendation 91.4% and 94.4% of the time, respectively. Conclusions The TLISS demonstrated good reliability in terms of intraobserver and interobserver agreement on the algorithmic treatment recommendations. The recommendation for operation seems to be consistent between fellowship-trained orthopedic and neurosurgical spine surgeons. This type of classification system may reduce the existing variability and initial management decision for treatment of TL injuries.

A review of the TLICS system : a novel, user-friendly thoracolumbar trauma classification system

The classification and treatment of thoracolumbar injuries remain controversial. The Spine Trauma Study Group (STSG) has developed a classification system that has prognostic significance and helps guide treatment decisions. It is based on three aspects: morphology of the injury, integrity of the posterior ligamentous complex, and neurological status of the patient. A severity score is used in conjunction with the classification system to help guide treatment decisions. This classification system has been shown to have good inter‐ and intra‐observer reliability.

Mean subaxial space available for the cord index as a novel method of measuring cervical spine geometry to predict the chronic stinger syndrome in American football players.

OBJECT The chronic stinger syndrome is a distinct entity from acute stingers and has been shown to have its own pathophysiology that, unlike acute stingers, may reflect long-standing geometrical changes of the subaxial spinal canal and chronic irritation/degeneration of the exiting nerve root complex. There is no method available, however, to accurately predict these symptoms in athletes. The mean subaxial cervical space available for the cord (MSCSAC) is a novel alternative to the Torg ratio for predicting neurological symptoms caused by cervical spondylosis in elite athletes. It is the goal of this study to determine critical values for this measurement index and to retrospectively correlate those values to neurological symptoms. METHODS Magnetic resonance images obtained in 103 male athletes participating in the 2005 and 2006 National Football League Scouting Combine and a control group of 42 age-matched male nonathletes were retrospectively reviewed. The Torg ratio and SAC values were calculated in triplicate at each cervical level from C3-6 by using lateral radiographs and midsagittal T2-weighted MR images of the cervical spine, respectively. These values were then averaged for each individual to produce mean subaxial cervical Torg ratio (MSCTR) and MSCSAC values. Receiver operating characteristic curves were constructed for each measurement technique and were compared based on their respective area under the curves (AUCs). RESULTS The MSCSAC difference between athletes with and without chronic stingers was statistically significant (p < 0.01). The difference between athletes with and without chronic stingers compared with controls was also statistically significant (p < 0.001 and p < 0.001, respectively). The AUC for the MSCSAC was 0.813, which was significantly greater than the AUC for both the MSCTR (p = 0.0475) and the individual Torg ratio (p = 0.0277). The MSCTR had the second largest AUC (0.676) and the conventional method of measuring individual Torg ratio values produced the lowest AUC (0.661). It was found that using the MSCSAC with a critical value of 5.0 mm produced a sensitivity of 80% and a negative likelihood ratio of 0.23 for predicting chronic stingers. Lowering the cutoff value to 4.3 mm for the MSCSAC resulted in a possible confirmatory test with a specificity of 96% and a positive likelihood ratio of 13.25. CONCLUSIONS A critical value of 5.0 mm for the MSCSAC provides the clinician with a screening test for chronic stingers and anything < 4.3 mm adds additional confidence as a confirmatory test. These results are approximately 20% more accurate than the classic Torg ratio based on our AUC analysis. It was found that measuring the spinal geometry throughout the length of the subaxial cervical spine produced a more reliable method by which to predict neurological symptoms than the traditional approach of measuring individual levels. This shows that the underlying pathogenesis of the chronic stinger syndrome is best characterized as a process that involves the entire subaxial region uniformly.

Evaluating the effects of recombinant human bone morphogenetic protein-2 on pain-associated behaviors in a rat model following implantation near the sciatic nerve

OBJECTIVE It has been hypothesized that the recombinant human bone morphogenetic protein-2 (rhBMP-2) amplification of the host inflammatory response interacts with nerves in the spine and contributes to the occurrence of new, postoperative complaints of radiculitis. This in vivo rat study was conducted to assess the capacity for rhBMP-2/ACS (rhBMP-2 applied to absorbable collagen sponge [ACS]) to stimulate pain-associated behaviors in the rat chronic constriction injury (CCI) model. METHODS Rats were randomly assigned to one of 14 treatment groups. Half of the animals underwent a sham procedure in which the left sciatic nerve was exposed and manipulated but no ligature was placed (Sham cohort), while the remaining animals had chromic gut sutures tied around the sciatic nerve to induce CCI (CCI cohort). The following test articles were applied to the sciatic nerve in each cohort: saline alone, saline applied to ACS, 0.1 mg/ml rhBMP-2 applied to ACS, or 1.0 mg/ml rhBMP-2 applied to ACS. The ACS was either wrapped around the sciatic nerve or implanted adjacent to the nerve. Thermal withdrawal latency was assessed on Days 7, 14, 21, and 28 postoperatively. Isolated nerves from selected rats in each group were examined and assessed for histopathological changes on Days 3, 7, 14, and 28. RESULTS CCI produced a significant pain behavioral response for all treatment groups at all time points. In the Sham cohort, 0.1 mg/ml rhBMP-2/ACS wrapped around the nerve (WRP) decreased thermal withdrawal on Day 28, and 1.0 mg/ml rhBMP-2/ACS placed adjacent to the nerve (ADJ) decreased thermal withdrawal on Days 21 and 28. Conversely, in the CCI cohort, 0.1 mg/ml rhBMP-2/ACS ADJ increased thermal withdrawal latencies on Day 7; 1.0 mg/ml rhBMP-2/ACS ADJ increased thermal withdrawal latencies on Day 7; and 1.0 mg/ml rhBMP-2/ACS WRP increased thermal withdrawal on Days 7 and 14. Histologically, the effect of rhBMP-2 on nerve inflammation was unclear, as inflammatory cell infiltration was similar in the rhBMP-2/ACS and saline/ACS groups. rhBMP-2 was variably associated with bone formation within the epineurium at 14 days, and more prevalently at 28 days, with no clear relationship between dose or ACS positioning. CONCLUSIONS In this study, rhBMP-2/ACS did not appear to induce pain independent of grossly visible ectopic bone formation. At the earliest time points, rhBMP-2 appeared to have a neuroprotective effect as evidenced by decreased pain exhibited by the rhBMP-2-treated animals in the CCI cohort, but this effect diminished over time, and by Day 28, the pain behavioral responses in the rhBMP-2-treated group were comparable to those in the group in which saline was applied to the nerve. In the Sham cohort, there was a dose-independent induction of pain at later time points, presumably due to new bone formation mechanically irritating the nerve. Histological examination revealed nerve lesions that appeared to be caused by mechanical trauma associated with surgical manipulation of the nerve during placement of the ACS and/or CCI sutures.