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Unmarked Image Validation of the SRS-Schwab Adult Deformity Classification
Proceedings of the NASS 27th Annual Meeting / The Spine Journal 12 (2012) 99S–165S P129. Unmarked Image Validation of the SRS-Schwab Adult Deformity Classification Frank J. Schwab, MD1, Jason Demakakos, MS2, Benjamin Blondel, MD3, Jacob M. Buchowski, MD, MS4, Benjamin Ungar1, Jeffrey D. Coe, MD5, Donald Deinlein, MD6, Hossein Mehdian, FRCS7, Christopher I. Shaffrey, MD8, Virginie Lafage, PhD1, Jamie S. Terran2; 1NYU Hospital for Joint Diseases, New York, NY, US; 2New York, NY, US; 3New York University Medical Center, New York, NY, US; 4Washington University in St. Louis, St. Louis, MO, US; 5Silicon Valley Spine Institute, Campbell, CA, US; 6Birmingham, AL, US; 7Nottingham, England, UK; 8 University of Virginia Department of Neurosurgery, Charlottesville, VA, US
157S
P130. Does Approach Decide the Outcome of Surgical Decompression in Thoracolumbar Burst Fracture? Pankaj Kandwal, MD, Arvind Jayaswal, MD, Bhavuk Garg, MD, Upendra N. Bidre, MD; All India Instiute of Medical Sciences, New Delhi, India
BACKGROUND CONTEXT: A classification system can serve several purposes, including providing: a) consistent characterization of a clinical entity, b) a basis for comparing different treatments, and c) recommended treatments. Characteristics of a good classification system include ease of use, reliability, and clinical relevance. While classifications in the pediatric population are well established, there is still a need for a clinically relevant classification for adult spinal deformity. Previous adult spinal deformity classification systems have not included pelvic parameters, some of which have been shown to highly correlate with HRQOL measures. This study seeks to determine if the proposed classification system, which includes pelvic parameters, is clear and reliable in the clinical setting. PURPOSE: Based upon a Scoliosis Research Society effort, this study seeks to determine if the proposed new ASD classification system is clear and reliable with the use of unmarked images. STUDY DESIGN/SETTING: Inter- and intrarater reliability study. PATIENT SAMPLE: Twenty-one adult deformity cases selected to represent a wide distribution of possible classification grades. METHODS: Initiated by the SRS Adult Deformity Committee, this study used a classification system previously published by Schwab, revised to include pelvic parameters. Modifier cutoffs were determined using HRQOL data analysis from a multi-center database of adult deformity patients. On two separate occasions approximately one week apart, 7 readers graded 21 unmarked cases of coronal and sagittal radiographs of patients with adult spinal deformity, identifying curve type, PI-LL, PT, and SVA. Inter- and intra-rater reliability and inter-rater agreement were determined for the curve type and each modifier separately. Fleiss’ Kappa was used for reliability measures, with values of 0.00-0.20 considered slight, 0.21-0.40 fair, 0.41-0.60 moderate, 0.61-0.80 substantial, and 0.81-1.00 almost perfect agreement. RESULTS: Interrater Kappa for curve type was 0.69 and 0.72 for the two readings respectively, with modifier Kappas of 0.51 and 0.58 for PI-LL, 0.70 and 0.65 for PT, and 0.87 and 0.87 for SVA. Across all readers Kappa values averaged 0.89 for Curve Type, 0.71 for PI-LL, 0.82 for PT, and 0.91 for SVA. Intra-rater agreement was measured as 90% (0.83 kappa), while inter-rater agreement was measured as 52% (0.71 kappa). SVA type agreement was identified by all readers consistently in 71% of cases. CONCLUSIONS: This study shows that there is excellent intra and inter rater reliability with the proposed system. Unmarked classifications are a more accurate approach to replicate clinical usage for physicians as these images are typical in practice. Similar classification systems have shown a decrease in intra and inter rater reliability when comparing marked vs. unmarked grading. While this classification system has limitations in inter-observer agreement, it offers a substantial gain in clinically relevant information over previous systems by including pelvic parameters. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
BACKGROUND CONTEXT: The treatment of the burst fractures of thoracolumbar junction have generated much controversy over the past few decades and continue to do so. Surgeons agree to disagree on the optimal management of these common fractures. PURPOSE: We studied the clinical, radiological and functional outcomes of the anterior vs posterior approach for the surgical decompression of thoracolumbar burst fractures. STUDY DESIGN/SETTING: Department of orthopaedics, All India Institute of Medical Sciences (AIIMS) PATIENT SAMPLE: This retrospective study was carried out at the department of Orthopaedics, AIIMS. Patients within age group 18-60 yr, fresh traumatic fractures of thoracolumbar spine with neurological deficit were included in the study. Group A (Anterior decompression) n523, Group B (Posterior & posterolateral decompression) n515. OUTCOME MEASURES: Patients in both the groups were compared with respect to surgical time, blood loss, complications and duration of stay. The various radiological outcomes evaluated were correction in kyphosis, canal compromise & canal clearance (decompression). The functional outcome was assessed using VAS, ODI and SCIM scores. The improvement in neurological status was documented as per the ASIA impairment scale. METHODS: All the patients in the study had unstable Burst fracture with LSC(load sharing classification) more than 7 with neurological deficit. RESULTS: Group A: The mean age in anterior group was 29.3 years. #T12 (n56), # L1 (n514), # L2 (n53). In our series the mean blood loss and duration of surgery were 612.5þ379.6 ml and 301.25þ65.7 minutes respectively. The mean Cobb’s angle of 15.67 improved to 4.76 (p50.001). The average pre-op canal compromise was 55.26 %, while the post-op canal compromise was 0.00. The pre-op VAS of 4.52 improved to 0.24 (p50.001) at the end of 2wks. ODI score of 75.84 decreased to 17.60 (p50.001) at the end of last follow-up. The mean SCIM score in anterior approach was 30.67 which improved to 74.81 (p50.001). Group B: The mean age in posterior group was 27.8 years. #T12 (n56), #L1 (n57), # L2 (n51). The mean blood loss and duration of surgery were 1246.96 þ564.9 ml and 484.57þ245.08 minutes respectively. The mean Cobb’s angle was 12.57 improved to 3.43 (p50.018). The average canal compromise was 41% which improved to 14.53 following posterolateral decompression (p50.028). The pre-op VAS score of 4.86 improved to 0.29 at the end of two wks (p50.015). ODI score of 38.57 improved to 14.71 at final follow-up which was statistically significant. The mean SCIM score of 38.57 improved to 83.43 (p50.018) indicating good functional outcome. On comparing Group A and B, the improvement in VAS, ODI, SCIM and Kyphosis correction between the two groups was not significant, whereas the canal clearance was significantly more in anterior decompression group (Group A) when compared with Group B. The mean blood loss and duration of surgery were significantly higher in the Anterior approach. CSF leak was seen in one patient in Group A. There was no pseudarthosis or implant failure in either group. CONCLUSIONS: In a comparative study, with matched parameters, no significant difference in kyphosis correction was seen amid the two groups. Anterior approach for decompression takes significantly more duration and blood loss than posterolateral decompression and instrumentation. The extent of decompression by Anterior approach is significantly superior to Posterolateral approach. However the canal clearance and decompression did not translate to significantly better functional outcome or neurological recovery. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
http://dx.doi.org/10.1016/j.spinee.2012.08.403
http://dx.doi.org/10.1016/j.spinee.2012.08.404
All referenced figures and tables will be available at the Annual Meeting and will be included with the post-meeting online content.
157S
P130. Does Approach Decide the Outcome of Surgical Decompression in Thoracolumbar Burst Fracture? Pankaj Kandwal, MD, Arvind Jayaswal, MD, Bhavuk Garg, MD, Upendra N. Bidre, MD; All India Instiute of Medical Sciences, New Delhi, India
BACKGROUND CONTEXT: A classification system can serve several purposes, including providing: a) consistent characterization of a clinical entity, b) a basis for comparing different treatments, and c) recommended treatments. Characteristics of a good classification system include ease of use, reliability, and clinical relevance. While classifications in the pediatric population are well established, there is still a need for a clinically relevant classification for adult spinal deformity. Previous adult spinal deformity classification systems have not included pelvic parameters, some of which have been shown to highly correlate with HRQOL measures. This study seeks to determine if the proposed classification system, which includes pelvic parameters, is clear and reliable in the clinical setting. PURPOSE: Based upon a Scoliosis Research Society effort, this study seeks to determine if the proposed new ASD classification system is clear and reliable with the use of unmarked images. STUDY DESIGN/SETTING: Inter- and intrarater reliability study. PATIENT SAMPLE: Twenty-one adult deformity cases selected to represent a wide distribution of possible classification grades. METHODS: Initiated by the SRS Adult Deformity Committee, this study used a classification system previously published by Schwab, revised to include pelvic parameters. Modifier cutoffs were determined using HRQOL data analysis from a multi-center database of adult deformity patients. On two separate occasions approximately one week apart, 7 readers graded 21 unmarked cases of coronal and sagittal radiographs of patients with adult spinal deformity, identifying curve type, PI-LL, PT, and SVA. Inter- and intra-rater reliability and inter-rater agreement were determined for the curve type and each modifier separately. Fleiss’ Kappa was used for reliability measures, with values of 0.00-0.20 considered slight, 0.21-0.40 fair, 0.41-0.60 moderate, 0.61-0.80 substantial, and 0.81-1.00 almost perfect agreement. RESULTS: Interrater Kappa for curve type was 0.69 and 0.72 for the two readings respectively, with modifier Kappas of 0.51 and 0.58 for PI-LL, 0.70 and 0.65 for PT, and 0.87 and 0.87 for SVA. Across all readers Kappa values averaged 0.89 for Curve Type, 0.71 for PI-LL, 0.82 for PT, and 0.91 for SVA. Intra-rater agreement was measured as 90% (0.83 kappa), while inter-rater agreement was measured as 52% (0.71 kappa). SVA type agreement was identified by all readers consistently in 71% of cases. CONCLUSIONS: This study shows that there is excellent intra and inter rater reliability with the proposed system. Unmarked classifications are a more accurate approach to replicate clinical usage for physicians as these images are typical in practice. Similar classification systems have shown a decrease in intra and inter rater reliability when comparing marked vs. unmarked grading. While this classification system has limitations in inter-observer agreement, it offers a substantial gain in clinically relevant information over previous systems by including pelvic parameters. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
BACKGROUND CONTEXT: The treatment of the burst fractures of thoracolumbar junction have generated much controversy over the past few decades and continue to do so. Surgeons agree to disagree on the optimal management of these common fractures. PURPOSE: We studied the clinical, radiological and functional outcomes of the anterior vs posterior approach for the surgical decompression of thoracolumbar burst fractures. STUDY DESIGN/SETTING: Department of orthopaedics, All India Institute of Medical Sciences (AIIMS) PATIENT SAMPLE: This retrospective study was carried out at the department of Orthopaedics, AIIMS. Patients within age group 18-60 yr, fresh traumatic fractures of thoracolumbar spine with neurological deficit were included in the study. Group A (Anterior decompression) n523, Group B (Posterior & posterolateral decompression) n515. OUTCOME MEASURES: Patients in both the groups were compared with respect to surgical time, blood loss, complications and duration of stay. The various radiological outcomes evaluated were correction in kyphosis, canal compromise & canal clearance (decompression). The functional outcome was assessed using VAS, ODI and SCIM scores. The improvement in neurological status was documented as per the ASIA impairment scale. METHODS: All the patients in the study had unstable Burst fracture with LSC(load sharing classification) more than 7 with neurological deficit. RESULTS: Group A: The mean age in anterior group was 29.3 years. #T12 (n56), # L1 (n514), # L2 (n53). In our series the mean blood loss and duration of surgery were 612.5þ379.6 ml and 301.25þ65.7 minutes respectively. The mean Cobb’s angle of 15.67 improved to 4.76 (p50.001). The average pre-op canal compromise was 55.26 %, while the post-op canal compromise was 0.00. The pre-op VAS of 4.52 improved to 0.24 (p50.001) at the end of 2wks. ODI score of 75.84 decreased to 17.60 (p50.001) at the end of last follow-up. The mean SCIM score in anterior approach was 30.67 which improved to 74.81 (p50.001). Group B: The mean age in posterior group was 27.8 years. #T12 (n56), #L1 (n57), # L2 (n51). The mean blood loss and duration of surgery were 1246.96 þ564.9 ml and 484.57þ245.08 minutes respectively. The mean Cobb’s angle was 12.57 improved to 3.43 (p50.018). The average canal compromise was 41% which improved to 14.53 following posterolateral decompression (p50.028). The pre-op VAS score of 4.86 improved to 0.29 at the end of two wks (p50.015). ODI score of 38.57 improved to 14.71 at final follow-up which was statistically significant. The mean SCIM score of 38.57 improved to 83.43 (p50.018) indicating good functional outcome. On comparing Group A and B, the improvement in VAS, ODI, SCIM and Kyphosis correction between the two groups was not significant, whereas the canal clearance was significantly more in anterior decompression group (Group A) when compared with Group B. The mean blood loss and duration of surgery were significantly higher in the Anterior approach. CSF leak was seen in one patient in Group A. There was no pseudarthosis or implant failure in either group. CONCLUSIONS: In a comparative study, with matched parameters, no significant difference in kyphosis correction was seen amid the two groups. Anterior approach for decompression takes significantly more duration and blood loss than posterolateral decompression and instrumentation. The extent of decompression by Anterior approach is significantly superior to Posterolateral approach. However the canal clearance and decompression did not translate to significantly better functional outcome or neurological recovery. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
http://dx.doi.org/10.1016/j.spinee.2012.08.403
http://dx.doi.org/10.1016/j.spinee.2012.08.404
All referenced figures and tables will be available at the Annual Meeting and will be included with the post-meeting online content.