Abstract
Purpose
The objective of this study was to analyze the interobserver reliability and intraobserver reproducibility of the new AOSpine thoracolumbar spine injury classification system in young Chinese orthopedic surgeons with different levels of experience in spinal trauma. Previous reports suggest that the new AOSpine thoracolumbar spine injury classification system demonstrates acceptable interobserver reliability and intraobserver reproducibility. However, there are few studies in Asia, especially in China.
Methods
The AOSpine thoracolumbar spine injury classification system was applied to 109 patients with acute, traumatic thoracolumbar spinal injuries by two groups of spinal surgeons with different levels of clinical experience. The Kappa coefficient was used to determine interobserver reliability and intraobserver reproducibility.
Results
The overall Kappa coefficient for all cases was 0.362, which represents fair reliability. The Kappa statistic was 0.385 for A-type injuries and 0.292 for B-type injuries, which represents fair reliability, and 0.552 for C-type injuries, which represents moderate reliability. The Kappa coefficient for intraobserver reproducibility was 0.442 for A-type injuries, 0.485 for B-type injuries, and 0.412 for C-type injuries. These values represent moderate reproducibility for all injury types. The raters in Group A provided significantly better interobserver reliability than Group B (P < 0.05). There were no between-group differences in intraobserver reproducibility.
Conclusions
This study suggests that the new AO spine injury classification system may be applied in day-to-day clinical practice in China following extensive training of healthcare providers. Further prospective studies in different healthcare providers and clinical settings are essential for validation of this classification system and to assess its utility.
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References
Hu R, Mustard CA, Burns C (1996) Epidemiology of incident spinal fracture in a complete population. Spine (Phila Pa 1976) 21:492–499
Wood KB, Buttermann GR, Phukan R, Harrod CC, Mehbod A, Shannon B, Bono CM, Harris MB (2015) Operative compared with nonoperative treatment of a thoracolumbar burst fracture without neurological deficit: a prospective randomized study with follow-up at sixteen to twenty-two years. J Bone Joint Surg Am 97:3–9
Gertzbein SD (1992) Scoliosis Research Society. Multicenter spine fracture study. Spine (Phila Pa 1976) 17:528–540
Vaccaro AR, Oner C, Kepler CK, Dvorak M, Schnake K, Bellabarba C, Reinhold M, Aarabi B, Kandziora F, Chapman J, Shanmuganathan R, Fehlings M, Vialle L (2013) AOSpine thoracolumbar spine injury classification system: fracture description, neurological status, and key modifiers. Spine (Phila Pa 1976) 38:2028–2037
Denis F (1983) The three column spine and its significance in the classification of acute thoracolumbar spinal injuries. Spine (Phila Pa 1976) 8:817–831
Wood KB, Khanna G, Vaccaro AR, Arnold PM, Harris MB, Mehbod AA (2005) Assessment of two thoracolumbar fracture classification systems as used by multiple surgeons. J Bone Joint Surg Am 87:1423–1429
Magerl F, Aebi M, Gertzbein SD, Harms J, Nazarian S (1994) A comprehensive classification of thoracic and lumbar injuries. Eur Spine J 3:184–201
Vaccaro AR, Lehman RA Jr, Hurlbert RJ, Anderson PA, Harris M, Hedlund R, Harrop J, Dvorak M, Wood K, Fehlings MG, Fisher C, Zeiller SC, Anderson DG, Bono CM, Stock GH, Brown AK, Kuklo T, Oner FC (2005) A new classification of thoracolumbar injuries: the importance of injury morphology, the integrity of the posterior ligamentous complex, and neurologic status. Spine (Phila Pa 1976) 30:2325–2333
Harrop JS, Vaccaro AR, Hurlbert RJ, Wilsey JT, Baron EM, Shaffrey CI, Fisher CG, Dvorak MF, Oner FC, Wood KB, Anand N, Anderson DG, Lim MR, Lee JY, Bono CM, Arnold PM, Rampersaud YR, Fehlings MG (2006) Intrarater and interrater reliability and validity in the assessment of the mechanism of injury and integrity of the posterior ligamentous complex: a novel injury severity scoring system for thoracolumbar injuries. Invited submission from the Joint Section Meeting on Disorders of the Spine and Peripheral Nerves, March 2005. J Neurosurg Spine 4:118–122
Rihn JA, Yang N, Fisher C, Saravanja D, Smith H, Morrison WB, Harrop J, Vacaro AR (2010) Using magnetic resonance imaging to accurately assess injury to the posterior ligamentous complex of the spine: a prospective comparison of the surgeon and radiologist. J Neurosurg Spine 12:391–396
Kepler CK, Vaccaro AR, Koerner JD, Dvorak MF, Kandziora F, Rajasekaran S, Aarabi B, Vialle LR, Fehlings MG, Schroeder GD, Reinhold M, Schnake KJ, Bellabarba C, Cumhur Oner F (2016) Reliability analysis of the AOSpine thoracolumbar spine injury classification system by a worldwide group of naive spinal surgeons. Eur Spine J 25(4):1082–1086
Azimi P, Mohammadi HR, Azhari S, Alizadeh P, Montazeri A (2015) The AOSpine thoracolumbar spine injury classification system: a reliability and agreement study. Asian J Neurosurg 10(4):282–285
Kepler CK, Vaccaro AR, Schroeder GD, Koerner JD, Vialle LR, Aarabi B, Rajasekaran S, Bellabarba C, Chapman JR, Kandziora F, Schnake KJ, Dvorak MF, Reinhold M, Oner FC (2015) The Thoracolumbar AOSpine Injury Score. Global Spine J 6(4):329–334
Landis JR, Koch GG (1977) The measurement of observer agreement for categorical data. Biometrics 33:159–174
Urrutia J, Zamora T, Yurac R, Campos M, Palma J, Mobarec S, Prada C (2015) An independent interobserver reliability and intraobserver reproducibility evaluation of the new AOSpine Thoracolumbar Spine Injury Classification System. Spine (Phila Pa 1976) 40:E54–E58
Oner FC, Ramos LM, Simmermacher RK, Kingma PT, Diekerhof CH, Dhert WJ, Verbout AJ (2002) Classification of thoracic and lumbar spine fractures: problems of reproducibility. A study of 53 patients using CT and MRI. Eur Spine J 11:235–245
Blauth M, Bastian L, Knop C, Lange U, Tusch G (1999) Inter-observer reliability in the classification of thoraco-lumbar spinal injuries. Orthopade 28:662–681
Aebi M (2010) Classification of thoracolumbar fractures and dislocations. Eur Spine J 19(Suppl 1):S2–S7
Schnake KJ, von Scotti F, Haas NP, Kandziora F (2008) Type B injuries of the thoracolumbar spine: misinterpretations of the integrity of the posterior ligament complex using radiologic diagnostics. Unfallchirurg 111:977–984
Leferink VJ, Veldhuis EF, Zimmerman KW, ten Vergert EM, ten Duis HJ (2002) Classificational problems in ligamentary distraction type vertebral fractures: 30% of all B-type fractures are initially unrecognised. Eur Spine J 11:246–250
Whang PG, Vaccaro AR, Poelstra KA, Patel AA, Anderson DG, Albert TJ, Hilibrand AS, Harrop JS, Sharan AD, Ratliff JK, Hurlbert RJ, Anderson P, Aarabi B, Sekhon LH, Gahr R, Carrino JA (2007) The influence of fracture mechanism and morphology on the reliability and validity of two novel thoracolumbar injury classification systems. Spine (Phila Pa 1976) 32:791–795
Parizel PM, van der Zijden T, Gaudino S, Spaepen M, Voormolen MH, Venstermans C, De Belder F, van den Hauwe L, Van Goethem J (2010) Trauma of the spine and spinal cord: imaging strategies. Eur Spine J 19(Suppl 1):S8–S17
Bagley LJ (2006) Imaging of spinal trauma. Radiol Clin North Am 44:1–12 (vii)
Vaccaro AR, Rihn JA, Saravanja D, Anderson DG, Hilibrand AS, Albert TJ, Fehlings MG, Morrison W, Flanders AE, France JC, Arnold P, Anderson PA, Friel B, Malfair D, Street J, Kwon B, Paquette S, Boyd M, Dvorak MF, Fisher C (2009) Injury of the posterior ligamentous complex of the thoracolumbar spine: a prospective evaluation of the diagnostic accuracy of magnetic resonance imaging. Spine (Phila Pa 1976) 34(23):E841–E847. doi:10.1097/BRS.0b013e3181bd11be
Vaccaro AR, Lee JY, Schweitzer KM Jr, Lim MR, Baron EM, Oner FC, Hulbert RJ, Hedlund R, Fehlings MG, Arnold P, Harrop J, Bono CM, Anderson PA, Anderson DG, Harris MB (2006) Assessment of injury to the posterior ligamentous complex in thoracolumbar spine trauma. Spine J 6:524–528
Daffner RH, Deeb ZL, Goldberg AL, Kandabarow A, Rothfus WE (1990) The radiologic assessment of post-traumatic vertebral stability. Skeletal Radiol 19:103–108
Nagel DA, Koogle TA, Piziali RL, Perkash I (1981) Stability of the upper lumbar spine following progressive disruptions and the application of individual internal and external fixation devices. J Bone Joint Surg Am 63:62–70
Rajasekaran S, Vaccaro AR, Kanna RM, Schroeder GD, Oner FC, Vialle L, Chapman J, Dvorak M, Fehlings M, Shetty AP, Schnake K, Maheshwaran A, Kandziora F (2016) The value of CT and MRI in the classification and surgical decision-making among spine surgeons in thoracolumbar spinal injuries. Eur Spine J. doi:10.1007/s00586-016-4623-0
Sadiqi S, Oner FC, Dvorak MF, Aarabi B, Schroeder GD, Vaccaro AR (2015) The Influence of Spine Surgeons’ Experience on the Classification and Intraobserver Reliability of the Novel AOSpine Thoracolumbar Spine Injury Classification System-An International Study. Spine (Phila Pa 1976) 40:E1250–E1256
Sanders RW (1997) The problem with apples and oranges [editorial]. J Orthop Trauma 11:465–466
Lee GY, Lee JW, Choi SW, Lim HJ, Sun HY, Kang Y, Chai JW, Kim S, Kang HS (2015) MRI inter-reader and intra-reader reliabilities for assessing injury morphology and posterior ligamentous complex integrity of the spine according to the Thoracolumbar Injury Classification System and Severity Score. Korean J Radiol 16:889–898
Grunhagen J, Egbers HJ, Heller M, Reuter M (2005) Comparison of spine injuries by means of CT and MRI according to the classification of Magerl. Rofo 177:828–834
Lee HM, Kim HS, Kim DJ, Suk KS, Park JO, Kim NH (2000) Reliability of magnetic resonance imaging in detecting posterior ligament complex injury in thoracolumbar spinal fractures. Spine (Phila Pa 1976) 25:2079–2084
Oner FC, van Gils AP, Faber JA, Dhert WJ, Verbout AJ (2002) Some complications of common treatment schemes of thoracolumbar spine fractures can be predicted with magnetic resonance imaging: prospective study of 53 patients with 71 fractures. Spine (Phila Pa 1976) 27:629–636
van Middendorp JJ, Audige L, Hanson B, Chapman JR, Hosman AJ (2010) What should an ideal spinal injury classification system consist of? A methodological review and conceptual proposal for future classifications. Eur Spine J 19:1238–1249
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Cheng, J., Liu, P., Sun, D. et al. Reliability and reproducibility analysis of the AOSpine thoracolumbar spine injury classification system by Chinese spinal surgeons. Eur Spine J 26, 1477–1482 (2017). https://doi.org/10.1007/s00586-016-4842-4
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DOI: https://doi.org/10.1007/s00586-016-4842-4