Reliability analysis of the AOSpine thoracolumbar spine injury classification system by a worldwide group of naïve spinal surgeons

Purpose

The aims of this study were (1) to demonstrate the AOSpine thoracolumbar spine injury classification system can be reliably applied by an international group of surgeons and (2) to delineate those injury types which are difficult for spine surgeons to classify reliably.

Methods

A previously described classification system of thoracolumbar injuries which consists of a morphologic classification of the fracture, a grading system for the neurologic status and relevant patient-specific modifiers was applied to 25 cases by 100 spinal surgeons from across the world twice independently, in grading sessions 1 month apart. The results were analyzed for classification reliability using the Kappa coefficient (κ).

Results

The overall Kappa coefficient for all cases was 0.56, which represents moderate reliability. Kappa values describing interobserver agreement were 0.80 for type A injuries, 0.68 for type B injuries and 0.72 for type C injuries, all representing substantial reliability. The lowest level of agreement for specific subtypes was for fracture subtype A4 (Kappa = 0.19). Intraobserver analysis demonstrated overall average Kappa statistic for subtype grading of 0.68 also representing substantial reproducibility.

Conclusion

In a worldwide sample of spinal surgeons without previous exposure to the recently described AOSpine Thoracolumbar Spine Injury Classification System, we demonstrated moderate interobserver and substantial intraobserver reliability. These results suggest that most spine surgeons can reliably apply this system to spine trauma patients as or more reliably than previously described systems.

     

The surgical algorithm for the AOSpine thoracolumbar spine injury classification system

Purpose

The goal of the current study is to establish a surgical algorithm to accompany the AOSpine thoracolumbar spine injury classification system.

Methods

A survey was sent to AOSpine members from the six AO regions of the world, and surgeons were asked if a patient should undergo an initial trial of conservative management or if surgical management was warranted. The survey consisted of controversial injury patterns. Using the results of the survey, a surgical algorithm was developed.

Results

The AOSpine Trauma Knowledge forum defined that the injuries in which less than 30 % of surgeons would recommend surgical intervention should undergo a trial of non-operative care, and injuries in which 70 % of surgeons would recommend surgery should undergo surgical intervention. Using these thresholds, it was determined that injuries with a thoracolumbar AOSpine injury score (TL AOSIS) of three or less should undergo a trial of conservative treatment, and injuries with a TL AOSIS of more than five should undergo surgical intervention. Operative or non-operative treatment is acceptable for injuries with a TL AOSIS of four or five.

Conclusion

The current algorithm uses a meaningful injury classification and worldwide surgeon input to determine the initial treatment recommendation for thoracolumbar injuries. This allows for a globally accepted surgical algorithm for the treatment of thoracolumbar trauma.

     

Stereotactic Approach to Skull-Base Lesions

With improved knowledge of the anatomy and increased collaboration between the neurosurgeon and the otolaryngologist, successful surgical resection of skull-based tumors is being achieved with reduced mortality and morbidity. In spite of this, there remains a group of patients in whom an alternate surgical approach of stereotaxis may be indicated. This group of patients includes those in whom only biopsy is required, or those in whom brachytherapy using high-intensity ¹²⁵I is planned because the patients' general condition is not good enough to undergo open surgical resection of the tumor or the tumor is unresectable or the patient refuses open surgery. This article presents a preliminary report on stereotactic approach to skull base lesions with special emphasis on the technique.     

CD163 expression in leukemia cutis

Background: Proper diagnosis of myeloid leukemia cutis (LC) is of great clinical importance but can be difficult because no single immunohistochemical marker is adequately sensitive or specific for definitive diagnosis. Thus, a broader panel of markers is often desirable. CD163 is highly specific for normal and neoplastic cells of the monocyte/histiocyte lineage. In this study, we examined the value of CD163 in the diagnosis of acute myeloid LC. Methods: A total of 34 cases, including 18 cases of myelomonocytic or monocytic LC, 10 cases of myeloid LC without monocytic component and 6 cases of acute lymphoblastic leukemia/lymphoma (ALL), were stained with CD163. Results: CD163 was expressed in 8 of 18 (44%) of myelomonocytic or monocytic LC and 1 of 10 (10%) of other myeloid LC, but in none of the ALL cases (0/6). CD163 was highly specific (90%) for myeloid LC with a monocytic component, but showed low sensitivity in the diagnosis of both myeloid LC in general (24%) and myeloid LC with a monocytic component (44%). Conclusions: Our results suggest that CD163 has utility as a specific marker for myeloid LC in conjunction with currently used immunohistochemical stains, but should not be used alone for diagnosis. Harms PW, Bandarchi B, Ma L. CD163 expression in leukemia cutis.     

Hemorrhagic progression of a contusion after traumatic brain injury: a review

The magnitude of damage to cerebral tissues following head trauma is determined by the primary injury, caused by the kinetic energy delivered at the time of impact, plus numerous secondary injury responses that almost inevitably worsen the primary injury. When head trauma results in a cerebral contusion, the hemorrhagic lesion often progresses during the first several hours after impact, either expanding or developing new, non-contiguous hemorrhagic lesions, a phenomenon termed hemorrhagic progression of a contusion (HPC). Because a hemorrhagic contusion marks tissues with essentially total unrecoverable loss of function, and because blood is one of the most toxic substances to which the brain can be exposed, HPC is one of the most severe types of secondary injury encountered following traumatic brain injury (TBI). Historically, HPC has been attributed to continued bleeding of microvessels fractured at the time of primary injury. This concept has given rise to the notion that continued bleeding might be due to overt or latent coagulopathy, prompting attempts to normalize coagulation with agents such as recombinant factor VIIa. Recently, a novel mechanism was postulated to account for HPC that involves delayed, progressive microvascular failure initiated by the impact. Here we review the topic of HPC, we examine data relevant to the concept of a coagulopathy, and we detail emerging data elucidating the mechanism of progressive microvascular failure that predisposes to HPC after head trauma.