Said Sadiqi

The Influence of Spine Surgeons' Experience on the Classification and Intraobserver Reliability of the Novel AOSpine Thoracolumbar Spine Injury Classification System-An International Study.

Study Design. International validation study. Objective. To investigate the influence of the spine surgeons’ level of experience on the intraobserver reliability of the novel AOSpine Thoracolumbar Spine Injury Classification system, and the appropriate classification according to this system. Summary of Background Data. Wide variability has been demonstrated for intraobserver reliability of the AOSpine classification system. The spine surgeons’ level of experience may play a crucial role in the appropriate classification of thoracolumbar fractures, and the degree of reproducibility of the same observer on separate occasions. However, this has not been previously investigated. Methods. After a training on the classification system, high quality CT images together with clinical data from 25 patients with thoracolumbar fractures were independently assessed by 100 spine surgeons from across the world on 2 different occasions, 1 month apart from each other. The spine surgeons were allocated to a subgroup, according to their years of experience. Intraobserver reliability was calculated for each individual surgeon and for each subgroup, using the Kappa statistics (&kgr;). Descriptive statistics was used to describe any differences between the subgroups. Analysis of any misclassifications was performed by calculating sensitivity and specificity estimates. Results. Almost all surgeons demonstrated at least moderate intraobserver reliability. All surgeon subgroups demonstrated substantial reliability (&kgr; = 0.67–0.69) for fracture subtype grading, and almost all subgroups demonstrated excellent reliability (&kgr; = 0.79–0.83) for fracture morphology type regardless of subtype identified. In general, the fractures were most frequently misclassified by the most experienced surgeons. No major differences were observed among the subgroups when comparing the sensitivity and specificity rates. Conclusion. This international study demonstrated that the spine surgeons’ level of experience does not substantially influence the classification and intraobserver reliability of the recently described AOSpine Thoracolumbar Spine Injury Classification System. Level of Evidence: 4

Toward the development of a universal outcome instrument for spine trauma : A systematic review and content comparison of outcome measures used in spine trauma research using the ICF as reference

Study Design. A systematic literature review. Objective. The aim of this study was (1) to identify patient-reported and clinician-based outcome measures most frequently used to evaluate the function and health of spine trauma patients, (2) to identify and quantify the concepts of these measures using the International Classification of Functioning, Disability, and Health (ICF) as reference, and (3) to describe their clinimetric properties. Summary of Background Data. There is a real need for a disease-specific outcome instrument to measure the effect size of various treatment options in a variety of traumatic spinal column injuries. Methods. A systematic literature search was conducted in several databases. From the included studies, outcome measures were extracted. The items and underlying concepts of the identified outcome measures were specified and linked to the ICF categories. Finally, as far as available in literature, the clinimetric properties of the obtained measures were analyzed. Results. Out of 5117 screened references, 245 were included, and 17 different frequently used outcome measures were identified. Meaningful concepts of the items and response options of the retrieved outcome measures were linked to a total of 105 different ICF categories, aggregated to 57 first- or second-level categories. The categories were linked to the components activities and participation (n = 31), body functions (n = 17), environmental factors (n = 8), and body structures (n = 1). Overall, there is only limited evidence on the measurement properties, except for some disease-specific questionnaires, such as Oswestry Disability Index, Roland–Morris Disability Questionnaire, Neck Disability Index, and Cervical Spine Outcome Questionnaire. Conclusion. The current systematic literature review revealed great diversity in the use and content of outcome measures to evaluate the functioning and health of spine trauma patients, with 17 different outcome measures linked to 57 unique ICF categories. This study creates an evidence base for a consensus meeting during which a core set of ICF categories for outcome measurement in spine trauma will be decided. Level of Evidence: 2

Towards the development of an outcome instrument for spinal trauma: an international survey of spinal surgeons.

Study Design. International web-based survey. Objective. To identify the most relevant aspects of human function and health status from the perspective of health care professionals involved in the treatment of spinal trauma patients. Summary of Background Data. There is no universally accepted outcome instrument available that is specifically designed or validated for spinal trauma patients, contributing to controversies related to the optimal treatment and evaluation of many types of spinal injuries. Therefore, the AOSpine Knowledge Forum Trauma aims to develop such an instrument using the International Classification of Functioning, Disability, and Health (ICF) as its basis. Methods. Experts from the 5 AOSpine International world regions were asked to give their opinion on the relevance of a compilation of 143 ICF categories for spinal trauma patients on a 3-point scale: “not relevant,” “probably relevant,” or “definitely relevant.” The responses were analyzed using frequency analysis. Possible differences in responses between the 5 world regions were analyzed with the Fisher exact test and descriptive statistics. Results. Of the 895 invited AOSpine International members, 150 (16.8%) participated in this study. A total of 13 (9.1%) ICF categories were identified as definitely relevant by more than 80% of the participants. Most of these categories were related to the ICF component “activities and participation” (n = 8), followed by “body functions” (n = 4), and “body structures” (n = 1). Only some minor regional differences were observed in the pattern of answers. Conclusion. More than 80% of an international group of health care professionals experienced in the clinical care of adult spinal trauma patients indicated 13 of 143 ICF categories as definitely relevant to measure outcomes after spinal trauma. This study creates an evidence base to define a core set of ICF categories for outcome measurement in adult spinal trauma patients. Level of Evidence: N/A

Toward Developing a Specific Outcome Instrument for Spine Trauma : An Empirical Cross-sectional Multicenter ICF-Based Study by AOSpine Knowledge Forum Trauma

Study Design. Empirical cross-sectional multicenter study. Objective. To identify the most commonly experienced problems by patients with traumatic spinal column injuries, excluding patients with complete paralysis. Summary of Background Data. There is no disease or condition-specific outcome instrument available that is designed or validated for patients with spine trauma, contributing to the present lack of consensus and ongoing controversies in the optimal treatment and evaluation of many types of spine injuries. Therefore, AOSpine Knowledge Forum Trauma started a project to develop such an instrument using the International Classification of Functioning, Disability and Health (ICF) as its basis. Methods. Patients with traumatic spinal column injuries, within 13 months after discharge from hospital were recruited from 9 trauma centers in 7 countries, representing 4 AOSpine International world regions. Health professionals collected the data using the general ICF Checklist. The responses were analyzed using frequency analysis. Possible differences between the world regions and also between the subgroups of potential modifiers were analyzed using descriptive statistics and Fisher exact test. Results. In total, 187 patients were enrolled. A total of 38 (29.7%) ICF categories were identified as relevant for at least 20% of the patients. Categories experienced as a difficulty/impairment were most frequently related to activities and participation (n = 15), followed by body functions (n = 6), and body structures (n = 5). Furthermore, 12 environmental factors were considered to be a facilitator in at least 20% of the patients. Conclusion. Of 128 ICF categories of the general ICF Checklist, 38 ICF categories were identified as relevant. Loss of functioning and limitations in daily living seem to be more relevant for patients with traumatic spinal column injuries rather than pain during this time frame. This study creates an evidence base to define a core set of ICF categories for outcome measurement in adult spine trauma patients. Level of Evidence: 4

Toward a specific outcome instrument for spinal trauma: how to measure function and health.

Study Design. Validation study. Objective. To investigate the most valid, reliable, and comprehensible response scale for spinal trauma patients to compare their current level of function and health with their preinjury state. Summary of Background Data. In the context of a main project of the AOSpine Knowledge Forum Trauma to develop a disease-specific outcome instrument for adult spinal trauma patients, the need to identify a response scale that uniquely reflects the degree to which a spine trauma patient has returned to his or her preinjury state is crucial. Methods. In the first phase, 3 different question formats and 3 different response formats were investigated in a questionnaire, which was administered twice. Based on the results of the first phase, in the second phase, a modified questionnaire was administered once to a second group of patients to investigate 5 different response formats: 0–10 Numeric Rating Scale-11, 0–100 Numeric Rating Scale-101, Visual Analogue Scale, Verbal Rating Scale, and Adjective Scale. All patients were interviewed in a semistructured fashion to identify their preferences. Multiple statistical analyses were performed: test-retest reliability, internal consistency, and discriminant validity. Results. Twenty eligible patients were enrolled in the first phase and 59 in the second phase. The initial phase revealed the highest preference for 1 specific question format (60.0% and 86.7% after the first and second administration of the questionnaire, respectively). The second phase showed the Verbal Rating Scale as the most preferred response format (35.6%). The semistructured interviews revealed that overall, a subgroup of patients preferred a verbal response format (42.4%), and another group of patients preferred a numerical response format (49.1%). The statistical analysis showed good to excellent psychometric properties for all formats. Conclusion. The most preferred question and response formats were identified for use in a disease-specific outcome instrument for spinal trauma patients. Level of Evidence: 3

Surgeon Reported Outcome Measure for Spine Trauma: An International Expert Survey Identifying Parameters Relevant for the Outcome of Subaxial Cervical Spine Injuries

Study Design. International web-based survey. Objective. To identify clinical and radiological parameters that spine surgeons consider most relevant when evaluating clinical and functional outcomes of subaxial cervical spine trauma patients. Summary of Background Data. Although an outcome instrument that reflects the patients’ perspective is imperative, there is also a need for a surgeon reported outcome measure to reflect the clinicians’ perspective adequately. Methods. A cross-sectional online survey was conducted among a selected number of spine surgeons from all five AOSpine International world regions. They were asked to indicate the relevance of a compilation of 21 parameters, both for the short term (3 mo–2 yr) and long term (≥2 yr), on a five-point scale. The responses were analyzed using descriptive statistics, frequency analysis, and Kruskal-Wallis test. Results. Of the 279 AOSpine International and International Spinal Cord Society members who received the survey, 108 (38.7%) participated in the study. Ten parameters were identified as relevant both for short term and long term by at least 70% of the participants. Neurological status, implant failure within 3 months, and patient satisfaction were most relevant. Bony fusion was the only parameter for the long term, whereas five parameters were identified for the short term. The remaining six parameters were not deemed relevant. Minor differences were observed when analyzing the responses according to each world region, or spine surgeons’ degree of experience. Conclusion. The perspective of an international sample of highly experienced spine surgeons was explored on the most relevant parameters to evaluate and predict outcomes of subaxial cervical spine trauma patients. These results form the basis for the development of a disease-specific surgeon reported outcome measure, which will be a helpful tool in research and clinical practice. Level of Evidence: 4

The selection of core International Classification of Functioning, Disability, and Health (ICF) categories for patient-reported outcome measurement in spine trauma patients-results of an international consensus process

BACKGROUND CONTEXT There is no outcome instrument specifically designed and validated for spine trauma patients without complete paralysis, which makes it difficult to compare outcomes of different treatments of the spinal column injury within and between studies. PURPOSE The paper aimed to report on the evidence-based consensus process that resulted in the selection of core International Classification of Functioning, Disability, and Health (ICF) categories, as well as the response scale for use in a universal patient-reported outcome measure for patients with traumatic spinal column injury. STUDY DESIGN/SETTING The study used a formal decision-making and consensus process. PATIENT SAMPLE The sample includes patients with a primary diagnosis of traumatic spinal column injury, excluding completely paralyzed and polytrauma patients. OUTCOME MEASURES The wide array of function and health status of patients with traumatic spinal column injury was explored through the identification of all potentially meaningful ICF categories. METHODS A formal decision-making and consensus process integrated evidence from four preparatory studies. Three studies aimed to identify relevant ICF categories from three different perspectives. The research perspective was covered by a systematic literature review identifying outcome measures focusing on the functioning and health of spine trauma patients. The expert perspective was explored through an international web-based survey among spine surgeons from the five AOSpine International world regions. The patient perspective was investigated in an international empirical study. A fourth study investigated various response scales for their potential use in the future universal outcome instrument. This work was supported by AOSpine. AOSpine is a clinical division of the AO Foundation, an independent medically guided non-profit organization. The AOSpine Knowledge Forums are pathology-focused working groups acting on behalf of AOSpine in their domain of scientific expertise. RESULTS Combining the results of the preparatory studies, the list of ICF categories presented at the consensus conference included 159 different ICF categories. Based on voting and discussion, 11 experts from 6 countries selected a total of 25 ICF categories as core categories for patient-reported outcome measurement in adult traumatic spinal column injury patients (9 body functions, 14 activities and participation, and 2 environmental factors). The experts also agreed to use the Numeric Rating Scale 0-100 as response scale in the future universal outcome instrument. CONCLUSIONS A formal consensus process integrating evidence and expert opinion led to a set of 25 core ICF categories for patient-reported outcome measurement in adult traumatic spinal column injury patients, as well as the response scale for use in the future universal disease-specific outcome instrument. The adopted core ICF categories could also serve as a benchmark for assessing the content validity of existing and future outcome instruments used in this specific patient population.

The role of emergency medical service providers in the decision-making process of prehospital trauma triage

Purpose Severely injured patients should be treated at higher-level trauma centres, to improve chances of survival and avert life-long disabilities. Emergency medical service (EMS) providers must try to determine injury severity on-scene, using a prehospital trauma triage protocol, and decide the most appropriate type of trauma centre. The objective of this study is to investigate the role of EMS provider judgment in the prehospital triage process of trauma patients, by analysing the compliance rate to the protocol and administering a questionnaire among EMS providers. Methods All trauma patients transported to a trauma centre in two different regions of the Netherlands were analysed. Compliance rate was based on the number of patients meeting the triage criteria and transported to the corresponding level trauma centre. The questionnaire was administered among EMS providers. Descriptive statistics were used to analyse the data. Results For adult patients, the compliance rate to the level I criteria of the triage protocol was 72% in Central Netherlands and 42% in Brabant. For paediatric patients, this was 63% and 38% in Central Netherlands and Brabant, respectively. The judgment on injury severity was mostly based on the injury-type criteria. Additionally, the distance to a level I trauma centre influenced the decision for destination facility in the Brabant region. Conclusion The compliance rate varied between regions. Improvement of prehospital trauma triage depends on the accuracy of the protocol and compliance rate. A new protocol, including EMS provider judgment, might be the key to improvement in the prehospital trauma triage quality.

Injuries related to bicycle accidents: an epidemiological study in The Netherlands

Background This study aims to analyze the incidence and outcomes of bicycle-related injuries in hospitalized patients in The Netherlands. Methods Bicycle accidents resulting in hospitalization in a level-I trauma center in The Netherlands between 2007 and 2017 were retrospectively identified. We subcategorized data of patients involved in a regular bicycle, race bike, off-road bike or e-bike accident. The primary outcomes were mortality rate and incidence of multitrauma. Secondary outcomes were differences between bicycle subcategories. Independent risk factors were identified using multivariable logistic regression. All variables with a p value < 0.20 in univariable analysis were entered in multivariable analysis. Results We identified 1986 patients. The mortality rate after emergency room admission was 5.7%, and 41.0% were multitraumas. A higher age, multitrauma and cerebral haemorrhages were independent risk factors for in hospital mortality. Independent risk factors found for multitrauma were a higher age, two-sided trauma, e-bike accidents and cerebral haemorrhage. Conclusion Bicycle accidents resulting in hospitalization have a high mortality rate. Furthermore, a high incidence of multitrauma, fractures and cerebral haemorrhages were found. Considering the increasing incidence of bicycle accident victims needing hospital admission, new and more efficient prevention strategies are essential.

What is the Best Treatment for a Thoracolumbar Burst Fracture in a Neurologically Intact Patient in the Absence of Posterior Ligamentous Disruption : Surgical Treatment

Burst-type fractures of the thoracolumbar spine are common, accounting for approximately 45% of all major thoracolumbar trauma. These fractures are characterized by the common finding of retropulsion of a posterior vertebral body fragment into the spinal canal.1 Many consider a burst fracture as “stable” if the posterior (osteo)ligamentous complex (PLC) is intact, although the identification of a PLC injury is difficult, even with the use of magnetic resonance imaging. At least 50% of patients sustaining thoracolumbar burst fractures have no neurological deficit after injury.3 Different opinions exist regarding the optimal treatment of these neurologically intact patients with a thoracolumbar burst fracture. Surgical management offers the possibility of limiting the deformity, providing immediate stability and pain control, which contributes to early mobilization, limiting the need for burdensome orthotic treatment and protecting against late deformity with possible neurological complications. Nonoperative care offers the avoidance of surgical intervention with its attendant morbidity.4 Both surgical and nonsurgical treatment modalities, as well as the available diagnostic tools, have undergone considerable advancement during the last 2 decades. This makes it difficult to adequately interpret historical data. Several authors, especially from North American centers, have strongly advocated conservative management. In 2003, Wood et al5 presented the results of a randomized study among North American centers, in which 47 patients were followed up between 1992 and 1998. Outcomes were compared for operative and nonoperative treatment of thoracolumbar burst fractures in neurologically intact patients, which they considered as “stable.” No significant differences were found between the 2 groups with respect to clinical or radiologic outcomes at an average follow-up of 44 months. In a recent publication, they presented the long-term follow-up results from 16 to 22 years for the same cohort.6 Thirtyseven of the original randomized 47 patients could be included in this long-term analysis. Patients treated nonoperatively seemed to have significantly better outcomes for patient-reported pain and function. On the basis of their findings, the authors advocate for nonoperative management of neurologically intact patients with a “stable” thoracolumbar burst fracture. Previous series in the 1980s by Denis et al7 and Willen et al8 have shown contrary results. Higher rates of complications were observed in conservatively treated cases, including progressive deformity and even neurological deterioration. Unfortunately, none of these studies differentiate burst fractures with or without PLC injury or the residual loadsharing capacity of the fractured anterior column, making adequate comparisons between these series practically impossible. Furthermore, both the surgical techniques and the type of conservative management have changed considerably during this period. The surgical techniques used in the Wood study, while popular at the time, have been replaced by safer and more reliable procedures. In this multicenter study, the surgical approach was at the discretion of the treating surgeons and consisted of a remarkably wide array of techniques ranging from 2-level to 5-level posterior stabilization and fusion with pedicle screw-hook instrumentation to anterior-alone constructs with 1-level or 2-level fibular and rib-strut grafts. This may explain the contradicting results reported in a more recent prospective randomized trial by Siebenga et al.9 Patients sustaining a thoracolumbar burst fracture and no neurological deficit were included from 2 Dutch trauma centers. Sixteen patients treated nonoperatively were compared with 18 surgically treated patients. The surgical approach was the same in all cases, and consisted of Received for publication May 22, 2016; accepted June 13, 2016. From the Department of Orthopaedics, University Medical Center Utrecht, Utrecht, The Netherlands. The authors declare no conflict of interest. Reprints: Said Sadiqi, MD, Department of Orthopaedics, University Medical Center Utrecht, HP G05.228, P.O. Box 85500, 3508 GA Utrecht, The Netherlands (e-mail: s.sadiqi-3@umcutrecht.nl) and Evan O. Baird, MD, Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY 5 East 98th Street, P.O. Box 1188, New York, NY 10029 (e-mail: evan.baird@mountsinai.org). Copyright r 2016 Wolters Kluwer Health, Inc. All rights reserved. CONTROVERSIES IN SPINE SURGERY