Objectives
Previous literature showed that the diagnostic accuracy of computed tomographic angiography (CTA) is not equally comparable with that of the rarely used golden standard of digital ...subtraction angiography (DSA) for detecting blunt cerebrovascular injuries (BCVI) in trauma patients. However, advances in CTA technology may prove CTA to become equally accurate. This study investigated the diagnostic accuracy of CTA in detecting BCVI in comparison with DSA in trauma patients.
Methods
An electronic database search was performed in PubMed, EMBASE, and Cochrane Library. Summary estimates of sensitivity, specificity, positive and negative likelihood, diagnostic odds ratio, and 95% confidence intervals were determined using a bivariate random-effects model.
Results
Of the 3293 studies identified, 9 met the inclusion criteria. Pooled sensitivity was 64% (95% CI, 53–74%) and specificity 95% (95% CI, 87–99%) The estimated positive likelihood ratio was 11.8 (95%, 5.6–24.9), with a negative likelihood ratio of 0.38 (95%, 0.30–0.49) and a diagnostic odds ratio of 31 (95%, 17–56).
Conclusion
CTA has reasonable specificity but low sensitivity when compared to DSA in diagnosing any BCVI. An increase in channels to 64 slices did not yield better sensitivity. There is a risk for underdiagnosis of BCVI when only using DSA to confirm CTA-positive cases, especially in those patients with low-grade injuries.
Key Points
•
Low sensitivity and high specificity were seen in identifying BCVI with CTA as compared to DSA.
•
Increased CTA detector channels (≤ 64) did not lead to higher sensitivity when detecting BCVI.
•
The use of CTA instead of DSA may lead to underdiagnosis and, consequently, undertreatment of BCVI.
Purpose
To evaluate feasibility, internal consistency, inter-rater reliability, and prospective validity of AO Spine CROST (Clinician Reported Outcome Spine Trauma) in the clinical setting.
Methods
...Patients were included from four trauma centers. Two surgeons with substantial amount of experience in spine trauma care were included from each center. Two separate questionnaires were administered at baseline, 6-months and 1-year: one to surgeons (mainly CROST) and another to patients (AO Spine PROST—Patient Reported Outcome Spine Trauma). Descriptive statistics were used to analyze patient characteristics and feasibility, Cronbach’s α for internal consistency. Inter-rater reliability through exact agreement, Kappa statistics and Intraclass Correlation Coefficient (ICC). Prospective analysis, and relationships between CROST and PROST were explored through descriptive statistics and Spearman correlations.
Results
In total, 92 patients were included. CROST showed excellent feasibility results. Internal consistency (
α
= 0.58–0.70) and reliability (ICC = 0.52 and 0.55) were moderate. Mean total scores between surgeons only differed 0.2–0.9 with exact agreement 48.9–57.6%. Exact agreement per CROST item showed good results (73.9–98.9%). Kappa statistics revealed moderate agreement for most CROST items. In the prospective analysis a trend was only seen when no concerns at all were expressed by the surgeon (CROST = 0), and moderate to strong positive Spearman correlations were found between CROST at baseline and the scores at follow-up (
r
s
= 0.41–0.64). Comparing the CROST with PROST showed no specific association, nor any Spearman correlations (
r
s
= −0.33–0.07).
Conclusions
The AO Spine CROST showed moderate validity in a true clinical setting including patients from the daily clinical practice.
Purpose
Blunt cerebrovascular injuries (BCVI), which can result in ischemic stroke, are identified in 1–2% of all blunt trauma patients. Computed tomography angiography (CTA) scanning has improved ...and is the diagnostic modality of choice in BCVI suspected patients. Data about long-term functional outcomes and the incidence of ischemic stroke after BCVI are limited. The aim of this study was to determine BCVI incidence in relation to imaging modality improvements and to determine long-term functional outcomes.
Methods
All consecutive trauma patients from 2007 to 2016 with BCVI were identified from the level 1 trauma center prospective trauma database. Three periods were identified where CTA diagnostic modalities for trauma patients were improved. Long-term functional outcomes using the EuroQol six-dimensional (EQ-6D™) were determined.
Results
Seventy-one BCVI patients were identified among the 12.122 (0.59%) blunt trauma patients. In the first period BCVI incidence among the overall study cohort, polytrauma, basilar skull fracture and cervical trauma subgroups was found to be 0.3%, 0.9%, 1.2%, 4.6%, respectively, which more than doubled towards the third period (0.8, 2.4, 1.9 and 8.5% respectively). Ischemic stroke as a result of BCVI was found in 20 patients (28%). In-hospital stroke rate was lower in patients receiving antiplatelet therapy (
p
< 0.01). Six in-hospital deaths were BCVI related. Long-term follow-up (follow-up rate of 83%) demonstrated lower functional outcomes compared to Dutch reference populations (
p
< 0.01). Ischemic stroke was identified as a major cause of functional impairment at long-term follow-up.
Conclusions
Improved CTA diagnostic modalities have increased BCVI incidence. Furthermore, BCVI patients reported significant functional impairment at long-term follow-up. Antiplatelet therapy showed a significant effect on in-hospital stroke rate reduction.
In the past, spinal trauma was frequent in high- and middle-income regions of the world with high rates of automobility and was considered a “young men’s disease.” However, over the last 2 decades, ...both of these factors have changed dramatically. This has had important implications for our methods of diagnosis, treatment, and the organization of care.
Comparative, prospective follow-up study.
Comparison of outcome between patients treated with Percutaneous VertebroPlasty (PVP) using low and medium viscosity PolyMethylMetAcrylate (PMMA) bone ...cement.
Viscosity is the characterizing parameter of PMMA bone cement, currently the standard augmentation material in PVP, and influences interdigitation, cement distribution inside the vertebral body, injected volume and extravasation, thereby affecting the clinical outcome of PVP. Currently, low, medium, and high viscosity PMMA bone cements are used interchangeably. However, effect of viscosity on clinical outcome in patients with Osteoporotic Vertebral Compression Fractures (OVCFs) has not yet been explicit subject of investigation.
Follow-up was conducted using a 0 to 10 Pain Intensity Numerical Rating Scale (PI-NRS) and the Short Form 36 (SF-36) Quality of Life questionnaire before PVP and at 7 days (PI-NRS only), 1, 3, and 12 months after PVP. Injected cement volume, degree of interdigitation, and cement leakage were analyzed on direct postoperative computed tomography scanning. At 6 and 52 weeks and at suspicion, patients were analyzed for new fractures.
A total of 30 consecutive patients received PVP using low viscosity PMMA bone cement (OsteoPal-V) for 62 OVCFs, followed by 34 patients who received PVP using medium viscosity PMMA bone cement (Disc-O-Tech) for 67 OVCFs. Results regarding PI-NRS and SF-36 were comparable between both groups. Postoperative comparison of injected cement volume, degree of interdigitation, proportion of bipedicular procedures, incidence of new vertebral fractures and complications revealed no differences between both groups. Viscosity was identified as a risk factor for the occurrence of cement leakage (yes/no, OR: 2.925, 95% confidence interval: 1.072-7.984, P = 0.036).
No major differences in clinical outcome after PVP in OVCFs using low and medium viscosity PMMA bone cement were found. Viscosity of PMMA bone cement was identified as an independent predictor of cement leakage.
Purpose
To report on the development of AOSpine CROST (Clinician Reported Outcome Spine Trauma) and results of an initial reliability study.
Methods
The AOSpine CROST was developed using an iterative ...approach of multiple cycles of development, review, and revision including an expert clinician panel. Subsequently, a reliability study was performed among an expert panel who were provided with 20 spine trauma cases, administered twice with 4-week interval. The results of the developmental process were analyzed using descriptive statistics, the reliability per parameter using Kappa statistics, inter-rater rater agreement using intraclass correlation coefficient (ICC), and internal consistency using Cronbach’s
α
.
Results
The AOSpine CROST was developed and consisted of 10 parameters, 2 of which are only applicable for surgically treated patents (‘Wound healing’ and ‘Implants’). A dichotomous scoring system (‘yes’ or ‘no’ response) was incorporated to express expected problems for the short term and long term. In the reliability study, 16 (84.2%) participated in the first round and 14 (73.7%) in the second. Intra-rater reliability was fair to good for both time points (
κ
= 0.40–0.80 and
κ
= 0.31–0.67). Results of inter-rater reliability were lower (
κ
= 0.18–0.60 and
κ
= 0.16–0.46). Inter-rater agreement for total scores showed moderate results (ICC = 0.52–0.60), and the internal consistency was acceptable (
α
= 0.76–0.82).
Conclusions
The AOSpine CROST, an outcome tool for the surgeons, was developed using an iterative process. An initial reliability analysis showed fair to moderate results and acceptable internal consistency. Further clinical validation studies will be performed to further validate the tool.
Study Design:
Systematic Review.
Objective:
To systematically analyze the definitions and descriptions in literature of “Spinal Posttraumatic Deformity” (SPTD) in order to support the development of ...a uniform and comprehensive definition of clinically relevant SPTD.
Methods:
A literature search in 11 international databases was performed using “deformity” AND “posttraumatic” and its synonyms. When an original definition or a description of SPTD (Patient factors, Radiological outcomes, Patient Reported Outcome Measurements and Surgical indication) was present the article was included. The retrieved articles were assessed for methodological quality and the presented data was extracted.
Results:
46 articles met the inclusion criteria. “Symptomatic SPTD” was mentioned multiple times as an entity, however any description of “symptomatic SPTD” was not found. Pain was mentioned as a key factor in SPTD. Other patient related parameters were (progression of) neurological deficit, bone quality, age, comorbidities and functional disability. Various ways were used to determine the amount of deformity on radiographs. The amount of deformity ranged from not deviant for normal to >30°. Sagittal balance and spinopelvic parameters such as the Pelvic Incidence, Pelvic Tilt and Sacral Slope were taken into account and were used as surgical indicators and preoperative planning. The Visual Analog Scale for pain and the Oswestry Disability Index were used mostly to evaluate surgical intervention.
Conclusion:
A clear-cut definition or consensus is not available in the literature about clinically relevant SPTD. Our research acts as the basis for international efforts for the development of a definition of SPTD.
Survey among spine experts.
To investigate the different views and opinions of clinically relevant spinal post-traumatic deformity (SPTD).
There is no clear definition of clinically relevant SPTD. ...This leads to a wide variation in characteristics used for diagnosis and treatment indications of SPTD. To understand the current concepts of SPTD a survey was conducted among spine trauma surgeons.
Members of the AO Spine Knowledge Forum Trauma participated in an online survey. The survey was divided in 4 domains: Demographics, criteria to define SPTD, risk factors, and management. The data were collected anonymously and analyzed using descriptive statistics, absolute, and relative frequencies. Consensus on dichotomous outcomes was set to 80% of agreement.
Fifteen members with extensive experience in treatment of spinal trauma participated, representing the 5 AO Spine Regions. Back pain was the only criterion for definition of SPTD with complete agreement. Consensus (≥80%) was reached for kyphotic angulation outside normative ranges and impaired function. Eighty-seven percent and 100% agreed that a full-spine conventional radiograph was necessary in diagnosing and treating SPTD, respectively. The "missed B-type injury" was rated at most important by all but 1 participant. There was no agreement on other risk factors leading to clinically relevant SPTD. Concerning the management, all participants agreed that an asymptomatic patient should not undergo surgical treatment and that neurological deficit is an absolute surgical indication. For most of the participants the preferred surgical treatment of acute injury in all spine regions but the subaxial region is posterior fixation.
Some consensus exists among leading experts in the field of spine trauma care concerning the definition, diagnosis, risk factors, and management of SPTD. This study acts as the foundation for a Delphi study among the global spine community.
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