RALEIGH ORTHOPEDIST

Regionally variability into use OF A novel OF thoracolumbar spine fractures assessment: United States versus internationally surgeons. "style="vertical align:middle. margin-right:3pt ". ©. 2007 Ratliff et aluminium licensee BioMed cent ral Ltd. regional variability into use OF A novel OF thoracolumbar spine fractures assessment: United States versus internationally surgeons and trauma Study Group Spine department OF Orthopaedics, Thomas Jefferson University hospital, Philadelphia, the USA department OF Orthpaedics, Cedars Sinai Medical center, Los Angeles, the USA department OF Orthpaedics University OF North Carolina, Raleigh, the USA department OF Orthpaedics University OF Pittsburgh, Pittsburgh, the USA department OF Neurosurgery, Kansas University, Kansas town center, the USA department OF Orthopaedic Surgery, University OF Toronto, Toronto, Ontario, Canada. OF Othopaedic Surgery, Brigham and Women's hospital, Boston, the USA. This is at open ACCESS article distributed more under the of term OF the Creative Commons Attribution License (.), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly CIT OD "style="vertical align:middle. margin-right:3pt "Considerable variability exists into clinical approaches ton of thoracolumbar fractures. Controversy in evaluation and nomenclature contribute ton this confusion, with significant differences found between physicians, between different specialties, and in different geographic region. A new classification system for thoracolumbar injuries, the Thoracolumbar Injury Severity Score (TLISS), which recently described by Vaccaro. NO assessment OF of regionally differences has been described. Incoming goods report regionally variability into use OF the TLISS system between United States and non US surgeons. spine surgeons (8 neurosurgeons and 20 orthopedic surgeons) reviewed 56 clinical thoracolumbar injury case histories, which included pertinent imaging studies Twenty eight. Cases were classified and scored using the TLISS system. The reliability and treatment validity OF the TLISS which assessed. Surgeons were grouped into US (n = 15) and non US (n = 13) cohorts. inter+ more rater agreement on management which moderate, although it tended tons more higher in US surgeons. inter+ more rater agreement between US and non US surgeons which similar tons within group inter+ more rater for all categories agreement. Intra more rater reliability for management which substantial in both US and non US surgeons. The TLISS of incorporates generally accepted feature OF spinal injury assessment into A simple patient evaluation tool. The TLISS May improve communication between health providers and May contribute ton more efficient management OF thoracolumbar injuries. "style="vertical align:middle. margin-right:3pt "Controversy persists with rain pool of broadcasting corporations ton treatment OF of thoracolumbar injuries. The diagnosis and definition OF clinically significant spinal instability remains unclear and of poses A SOURCE OF frequently disagreement into the literature. Some patients, more however, ultimately fail conservative treatment, developing symptomatic late deformity or instability. Modern operational techniques allow for restoration OF normally spinal alignment, correction OF instability, and decompression OF again ral of element. Determining prospectively which patients acres prone tons developing instability and hence might benefit from surgical treatment remains contentious [. Adding ton confusion over patient selection, NO consensus exists as ton choice OF treatment into thoracolumbar injuries. The therapeutic approach tons of thesis patients is hampered by lacquer OF accepted nomenclature and OF A useful and clinically valid classification system for thesis of injuries. While numerous classification system have been devised, each poses problem in implementation [. Many of system of acres overly complex, limiting their utility. Others omit important portion OF standard clinical decision making. Most classification pattern fail tons suggest treatment option [. A recently described treatment algorithm May aid in treatment OF thesis patients. Relevantly literature on thoracolumbar trauma, classification, and treatment which reviewed. A classification scheme and treatment algorithm were described (figure it patient is at 18 y/o paints who presents after A engine vehicle accident. Representative sagittal (A), coronal (B) and axially (C) computed tomography image were obtained. A compression fracture with angular deformity RK T5. Second illustrative case OF TLISS use. Patient is A 21 y/o paints who presents after A engine vehicle accident. The patient which neurologically intact. Representative sagittal (A) and axially (B) computed tomography and sagittal T2-weighted magnetic resonance. Initially testing showed poor reliability for the injury mechanism sub score OF the measure. A separate system, the Thoracolumbar Injury Severity and Classification Score (TLICS), has been recently forwarded [. Good validity in different specialties and different training level have been described, with similarly adequate reliability [. validation across geographic boundaries has emergency been assessed. Considerable geographic variation is consistently reported in surgical treatment OF spinal disorders. Incoming goods compare the inter and intra more rater reliability OF the TLISS within and between US and non US surgeons. Incoming goods demonstrate moderate ton substantial reliability into the use OF the scale and high treatment validity, as assessed by surgeon agreement with the algorithm's management recommendation. The TLISS is A promising tool into the evaluation OF spine trauma patients. "style="vertical align:middle. margin-right:3pt ". In order ton validate the management recommendations OF the TLISS algorithm, A booklet OF 56 thoracolumbar trauma TIC injury case studies which prepared. The case vignettes detailed the patient's age, description OF the trauma TIC injury, and neurological exam. Imaging of studies, including plain radio graph, CT, and MR (sagittal T. The cases were distributed ton surgeons for classification and grading using the TLISS algorithm. The finally severity score which used ton determine the recommendation for nonoperative or operational treatment according ton the treatment algorithm described in Table. Twenty eight surgeons completed the vignettes. The results were analyzed ton determine inter+ more rater reliability, and by cent agreement with the finally treatment recommendations. Three months more later, the numerical order OF the cases which scrambled and of lampoon were redistributed. Twenty two OF the original 48 surgeons who participated into the development OF the classification system completed both surveys. Their results were analyzed ton determine intra more rater reliability. Ton assess possible regionally differences into the validity and reliability OF this system, physicians were grouped into US and non US cohorts. The US cohort included surgeons from A variety OF trauma of center. The internationally group included surgeons from Canada, Australia, Germany, Mexico, France, Sweden, India, and the Netherlands. The DATA were then analyzed using SPSS software ton determine by cent agreement, unweighted Cohen's kappa, kappa with linear weighting, and Spearman's climb order correlation.0 (complete disagreement) through 0 (chance agreement) tons of 1. A guideline for interpreting Cohen's kappa VALUES is summarized in Table. For significance tests, all unweighted coefficients were converted into Fisher's of z-scores, and the difference into z-scores which divided by standard error "style="vertical align:middle. margin-right:3pt "inter and intra more rater agreement between the cohorts is reviewed in Tables. General results OF kappa scoring between the groups has been previously reviewed [. Non US spine surgeons had greater inter+ more rater reliability on mechanism sub score (p <. 0.05 as assessed by %), while US agreement surgeons had greater inter+ more rater reliability on neuro status (p <. 0.05 as assessed by % and Spearman's r) and PLC agreement integrity (p <. 0. US versus non US inter+ more rater agreement US versus non US intra more rater agreement absolute ones inter+ more rater agreement among non US surgeons on the finally TLISS score which more greater (p <. 0.05), totally TLISS of scores but more better correlated among US surgeons (p <. 0. With rain pool of broadcasting corporations ton the algorithm's finally recommendation for treatment (operational vs. non operational), inter+ more rater agreement within the US physician group and non US group which 75. inter+ more rater agreement on management between the groups which 74. Between the two groups, greatest agreement which found in assessment OF neurological status (96th thesis differences reached statistical significance as assessed by % for mechanism and agreement neurological status. Differences into intra more rater correlation reached statistical significance on neurological status, PLC, and totally TLISS (Table. Intra more rater reliability on management into the two cohorts which similar, with 78,8% intra more rater agreement in US surgeons (Cohen's kappa. US surgeons agreed with the management recommendation OF the TLISS in 93.4% OF the cases and non US surgeons agreed with the algorithm larva were in 91st "style="vertical align:middle. margin-right:3pt "initial attempts RK thoracolumbar fracture classification by Bohler in 1930, who classified fractures into five injury type based on anatomic appearance and mechanism [. forwarded the AO classification, using A mechanical anise TIC approach ton divide fractures into A totally OF 53 potential patterns based upon 3 injury categories and of 3 animal OF subcatagorization [. A separate load sharing classification OF spinal injury has thus been described [. The most commonly used system of acres Denis ' three column model OF spinal stability and the AO classification. The AO system has poor inter and intra more observer agreement [. Use OF 53 different fracture patterns is unwieldy and appears counterintuitive. This of makes routine clinical use OF the scale impractical. The Denis system May oversimplify complex fractures, and May emergency accurately assess need for operational intervention [. The TLISS clinical algorithm assesses thoracolumbar injuries based upon three accepted clinical decision making criteria: 1. Mechanism OF injury as determined by imaging studies, 2. Thesis criteria were thought tons independent predictors OF patient clinical outcome. Subgroups for scoring were developed within each component. POINTS of acres assigned into the treatment algorithm cumulatively for each criterion. Finally recommendation for is based upon finally injury score (1 and 2) treatment. The mechanism OF injury describes fracture pattern based upon three general descriptions, similar ton the AO thoracolumbar injury classification: 1. Angulation RK the fracture site for compression injuries indicates more greater instability, and separately May ADD 1 POINT ton finally TLICS score. Complex fractures May combine more than one OF the three basic morphologic element. In thesis cases, only the highest category is scored. Thoracolumbar injury severity score (TLISS) The PLC is composed OF the ligamentum flavum, the facet joint of capsules, and the interspinous and superspinous ligaments. The PLC is quantified in the TLICS as intact, indeterminate, or disrupted (Table. Imaging via MRI, CT, plain film, and physical exam (detecting A palpable gap between spinous processes) acres used ton evaluate the PLC. Presence or absence OF neurological deficit is independent on indicator OF the severity OF thoracolumbar injury. More severe injuries merit more higher scores, with incomplete spinal cord and cauda equina injuries scoring highest into the algorithm (Table. The injury score is obtained via summation OF individually element. A cumulative score OF 3 or less suggests A non operational injury, while A score OF 5 or more greater suggests surgical intervention May necessary (Table. Scores OF of 4 acres indeterminate, and May treated surgically or conservatively [. illustrative ones of cases of acres reviewed in Figures. Reliability and validity OF the TLISS The TLISS scale has been evaluated for both inter and intra more rater reliability. Acceptable reliability which found and surgeons agreed with the algorithm's treatment recommendation in more greater than 90% OF of cases [. Greater than 90% OF surgeons in each specialty were found ton agree with the TLISS management recommendations [ ], and the same trend OF outstanding construct validity is reported here when comparing US and non US surgeons. In contradistinction tons of OTHER classification schemes, the TLISS has demonstrated acceptable intra and inter+ more rater reliability and appears usable across specialty boundaries. This manuscript is the roofridge ton assess geographic differences using the TLISS thoracolumbar injuries in approach tons assessment tool. As noted by silk worm, "medicine is evidently A local phenomenon" [. Geographic of influences on choice OF surgical and medical therapies of acres significant. Geographic location consistently predicts yearly advice OF spine surgery [. advice OF surgery acres noted ton increase linearly with supply OF orthopedic and neurosurgical spine surgeons [. Similar geographic variation occurs in coronary artery bypass graft procedures, general orthopedic procedures, and medical treatment OF acute myocardial infarction [. parallel findings in system without financial incentive for clinical productivity would seem ton indicate on intrinsic regionally variability into health care use [. Geographic variation thus is found in development and adoption OF new technology [. Geographic of differences persist in evaluation and management OF trauma TIC of injuries. In A multi-center review OF trauma TIC spine injuries, NO consensus which found as tons optimally surgical timing [. Treatment approach, including imaging, seemed tons vary by research site [. For the TLISS ton A useful paradigm for assessment and management OF thoracolumbar injury, it must bridge thesis significant geographic differences in approach tons spinal pathology. The system must demonstrate adequate internationally reliability. To cathedral TIC versus internationally reliability and validity OF the TLISS incoming goods compared reliability and validity OF the TLISS in US and non US surgeons, eat-sing both inter and intra more rater reliability. inter+ more rater on management agreement within the US physician group and non US group which 75. Pair of overalls correlation on management between the groups which 74,2%, indicating adequate validity OF the measure. The TLISS of provides reliable and valid initially treatment recommendations, irrespective OF more rater geography. Thesis and similar results have lead tons of A recent modification OF the TLISS system [. Inferring the mechanism OF injury from initially imaging modalities May difficult. Into fact, this is the reliable sub score among both US and non US leases surgeons. Hence, injury morphology has been substituted for injury mechanism. Injury morphology is based simply upon the appearance OF the fracture or dislocation on imaging studies (plain film, CT, or MRI). The STSG has thus endeavored ton increase the reliability OF the PLC sub score. To tons this end, A of series OF of studies have been undertaken tons clearly DEFINE the principle of indicator OF PLC disruption on MRI. Thesis definition wants included in A revised classification system. This revised classification system is termed the Thoracolumbar Injury Classification and Severity Score (TLICS). Only the most severe (highest totally POINTS) injury morphology category is included into the scoring. Compression morphology garners 1 POINT, and additional POINT is assigned for burst on morphology. Three POINTS of acres assigned for A translational/rotational morphology and 4 POINTS for A distraction morphology. The descriptive "distraction" is only applied if there is objective imaging evidence OF distraction present. Scores OF the morphology subgroups acres emergency of additives if multiple morphologies of acres present. Studies of acres underway tons develop and validate this classification system. Controversy persists in management OF of thoracolumbar injuries. The TLISS clinical algorithm offers assessment OF injury stability and AIDS in making treatment decisions. The scale has shown adequate reliability between and within different specialties. Incoming goods show reliability and validity OF the TLISS scale across geographic boundaries, comparing US and non US surgeons. Differences between thesis broad geographic groups were subtle, with inter+ more rater reliability between groups similar tons reliability within groups. This suggests that the TLISS May help unifying clinical decision making in thoracolumbar trauma. The author(s) declare that they have NO competing interests. "style="vertical align:middle. margin-right:3pt "JR assembled cases for review and LED the manuscript preparation EFF place the manuscript. WELL participated into writing the and manuscript interpreting the results OF the reliability DATA. ACRE conceived OF and designed the study, and LED the development OF the TLISS. ML assisted in DATA analysis and manuscript preparation, including writing OF the methods section. JL LED DATA collection and analysis and assisted in manuscript preparation. Pa performed the literature review and assisted in manuscript preparation. JH which A more leader into the development OF the TLISS and wrote the discussion section OF the PAPERS. RR which A more leader into the development OF the TLISS and assisted in manuscript preparation. CB which A more leader into the development OF the TLISS and assisted in manuscript preparation. RG which A more leader into the development OF the TLISS and drove European participation in this project. The entire STSG participated into the evolution OF this classification system and served as case raters for this reliability study. All authors reviewed and approved OF the finally manuscript. The development OF the TLISS and TLICS of system which A collaborative EFF place by members OF the Spine trauma Study Group. This work which supported, in part, by on unrestricted educational and research grant by Medtronic Sofamor Danek, Memphis, TN. "style="vertical align:middle. margin-right:3pt ". Nonoperative treatment OF burst type thoracolumbar vertebra fractures: clinical and radiological results OF 29 patients. Wood K, butter man G, Mehbod A, Garvey T, Jhanjee R, Sechriest V, Butterman G. operational one compared with nonoperative treatment OF A thoracolumbar burst fracture without neurological deficit.[see comment][erratum appears in J Bone joint Surg to the Vaccaro ACRE, Zeiller sports club, Hulbert RJ, Anderson one Pa, Harris M, Hedlund R, Harrop J, Dvorak M, Wood K, Fehlings mg, Fisher C, Lehman RA Jr. The thoracolumbar injury severity score: A proposed treatment algorithm. Wood KB, Khanna G, Vaccaro ACRE, Arnold PM, Harris MT, Mehbod AA. Assessment OF two thoracolumbar fracture classification system as used by multiple surgeons. Vaccaro ACRE Lehman RA, Hurlbert RJ, Anderson one Pa, Harris M, Hedlund R, Harrop J, Dvorak M, Wood K, Fehlings mg, Fisher C, Zeiller sports club, Anderson one DG, Bono cm, stick GH, Brown AK, Kuklo T, Oner FC. A new classification OF of thoracolumbar injuries: The importance OF injury morphology, the integrity OF the posterior ligamentous complex, and neurologic status. The three column spine and its significance into the classification OF acute thoracolumbar spinal injuries. Cherkin DC, Deyo RA, Loeser JD, Bush T, Waddell G. Internationally comparison OF on bake surgery advice. Blauth M, Bastian L, Knop C, long U, Tusch G. [ inter+ more observer reliability into the classification OF thoraco lumbar spinal injuries ]. Harrop J Vaccaro ACRE, Hulbert RJ, Wilsey J, baron EM, Shaffrey C, Fisher C, Dvorak MF, Oner FC, Wood KB, Anand N, Anderson one DG, Lim M, Lee J, Bono cm, Arnold P, Fehlings mg. Irwin ZN Hilibrand A, Gustavel M, McLain R, Shaffer W, Myers M, glazier J, hard RA. Variation into surgical decision making for degenerative spinal disorders. Lee JY Vaccaro ACRE, Lim MR, Oner FC, Hulbert RJ, Hedlund R, Fehlings mg, Arnold P, Harrop J, Bono cm, Anderson one Pa, Anderson one DG, Harris MT, Brown AK, stick GH, baron EM. Thoracolumbar injury classification and severity score: A new paradigm for the treatment OF thoracolumbar spine trauma. Submitted ton journal OF Spinal Disorders and Techniques. Fractures, dislocations, and fracture dislocations OF the spine. Journal OF Bone &. joint Surgery - American volume. Magerl F Aebi M, Gertzbein SD, Harms J, Nazarian S. A comprehensive classification OF thoracic and of lumbar injuries. The load sharing classification OF spine fractures. Trend and geographic variation in major surgery for degenerative diseases OF the hip, knee, and spine. Advice OF advanced spinal imaging and spine surgery. Ashton cm, Petersen NJ, Souchek J, Menke TJ, Yu HJ, Pietz K, Eigenbrodt ML, Barbour G, Kizer KW, Wray NP. Geographic variation in utilization advice in veteran Affairs of hospital and clinics. The of veteran Affairs medical care system: hospital and clinic utilization statistics for 1994. Pedicle screw fixation in spinal disorders: A European view. World journal OF emergency surgery: WJES. Department OF Health and Human services