Reliability and safety of a new upper cervical spine injury treatment algorithm

Joaquim, Andrei Fernandes; Brock, Roger Schmidt; Guirado, Vinicius Monteiro de Paula; Sandon, Luis Henrique; Silva, Otávio Turolo da; Taricco, Mário Augusto; Teixeira, Manoel Jacobsen; Figueiredo, Eberval Gadelha

doi:10.1590/0004-282X20160200

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ARTICLES • Arq. Neuro-Psiquiatr. 75 (2) • Feb 2017 • https://doi.org/10.1590/0004-282X20160200 copy

Reliability and safety of a new upper cervical spine injury treatment algorithm

Avaliação de reprodutibilidade e segurança de um novo algoritmo de tratamento das lesões cervicais altas

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

In the present study, we evaluated the reliability and safety of a new upper cervical spine injury treatment algorithm to help in the selection of the best treatment modality for these injuries.

Methods

Thirty cases, previously treated according to the new algorithm, were presented to four spine surgeons who were questioned about their personal suggestion for treatment, and the treatment suggested according to the application of the algorithm. After four weeks, the same questions were asked again to evaluate reliability (intra- and inter-observer) using the Kappa index.

Results

The reliability of the treatment suggested by applying the algorithm was superior to the reliability of the surgeons’ personal suggestion for treatment. When applying the upper cervical spine injury treatment algorithm, an agreement with the treatment actually performed was obtained in more than 89% of the cases.

Conclusion

The system is safe and reliable for treating traumatic upper cervical spine injuries. The algorithm can be used to help surgeons in the decision between conservative versus surgical treatment of these injuries.

spinal injuries; spinal cord injuries; therapeutics; classification

K value	Agreement
< 0.20	Slight
0.21–0.40	Fair
0.41–0.60	Moderate
0.61–0.80	Substantial
0.81–1.00	Excellent

Case	Age	Injury description	Etiology	AIS - Observations
1	21	Linear fracture of C2 body	Dive in shallow water	AIS E
2	58	Fracture of the anterior arch of C1 and also a linear fracture of C2 body	MVA	AIS E
3	28	Linear fracture of the posterior elements of C2 without displacement	MVA	AIS E
4	33	Linear fracture of the posterior elements of C2	MVA	AIS E
4	33	Linear fracture of the posterior elements of C2	MVA	AIS A - thoracic level (T3 fracture)
5	38	Fracture of the dens base without displacement	MVA	AIS E
6	60	Fracture of the body of C2	Fall from a height	AIS E
7	38	Fracture of the body of C2	MVA	AIS E
8	38	Fracture of the dens base	MVA	AIS E
9	26	Linear right side condyle fracture	MVA	AIS E
10	37	Fracture of both anterior and posterior arches of C1	MVA	AIS E
11	44	Linear fracture of the posterior elements of C2	MVA	AIS E
12	17	Fracture of the body of C2	MVA	AIS E
13	35	Fracture of the anterior arch of C1	Fall from the height	AIS E
14	43	Linear fracture of the body of C2	MVA	AIS E
15	36	Fracture of the posterior elements of C2 and mild increase of the angulation of C2 over C3	MVA	AIS E
16	43	Fracture of the body of C2 involving the left C12 joint but without any displacement	MVA	AIS E
17	48	Linear left side occipital condyle fracture without displacement of the facet joints	MVA	AIS E
18	59	Linear fracture of the posterior arch of C1 without displacement	MVA	AIS E
19	45	Linear fracture of the posterior elements of C2 without displacement	MVA	AIS E

Case	Age	Injury Description	Etiology	AIS - Observations
1	35	Fracture of the dens base	MVA	AIS E
				Posterior C12 fixation
				Heavy smoker
				Failure of conservative treatment due to pseudoarthrosis
2	60	Fracture of the dens base	MVA	AIS E
2	60	Fracture of the dens base	MVA	Posterior C12 fixation
3	45	Fracture of the posterior elements of C2 with unilateral subluxation C23	Fall from the roof	AIS E
3	45		Fall from the roof	Anterior C23 fixation
4	16	Fracture of the odontoid and C12 luxation	MVA	AIS C
4	16	Fracture of the odontoid and C12 luxation	MVA	Posterior C12 fixation
5	31	Fracture of the base of the dens with dens luxation anteriorly	MVA	AIS E
				Posterior C12 fixation
				Wound infection requiring antibiotics
6	37	Fracture of C1 and C2 and C12 subluxation	MVA	AIS E
		C2 fracture in the dens base		Posterior C123 fixation
				AIS E
7	37	Fracture of C1 lateral mass and unilateral subluxation of C12 and condyle-C1	MVA	AIS E
7	37		MVA	Occipito-C23 Fixation
8	16	C12 luxation and fracture of the dens base	MVA	AIS C
				Last follow up AIS E
				Posterior C12 fixation
9	77	Fracture of the dens with its displacement posteriorly	Fall from a height	AIS E
9	77	Fracture of the dens with its displacement posteriorly	Fall from a height	Posterior C12 fixation
10	20	Occipital C1-2 distraction	MVA	AIS C
				Last follow up AIS D
				Posterior occipital C23 fixation
11	31	C12 luxation	Fall from a height	AIS C
				Last follow up AIS D
				Posterior C12 fixation

Classification	N (first evaluation)	N (second evaluation)	Total
Anderson and D’Alonzo¹ (for fractures of the axis)	45	41	86
Primary injury description	27	36	63
Levine and Edwards¹¹ (for posterior elements of the axis fractures)	16	17	33
Benzel et al.¹⁶ (for axis body fractures)	8	8	16
Grauer et al.¹⁴ (for odontoid fractures)	7	9	16
Fujimura et al.¹⁷ (for axis body fractures)	6	8	14
Anderson and Montesano¹⁰ (for occipital condyle injuries)	5	1	6
“Jefferson” fracture^{12, 13} (for atlas injuries)	4	4	8
Fielding and Hawkings classification¹⁸ (for atlanto-axial instability)	4	4	8
Tuli et al.¹⁹ (for occipital condyles)	4	3	7
“Hangman’s fractures”¹¹ (for posterior elements of C2)	3	0	3

Evaluator	Kappa – first evaluation	Kappa – second evaluation
1^st	0.4828 (Moderate)	0.6667 (Substantial)
2^nd	0.7964 (Substantial)	0.6637 (Substantial)
3^rd	0.9333 (Excellent)	0.7183 (Substantial)
4^th	0.7945 (Substantial)	0.6666 (Substantial)

Evaluator	Kappa – first evaluation	Kappa – second evaluation
1^st	0.6193 (Substantial)	0.6479 (Substantial)
2^nd	0.8565 (Excellent)	0.7235 (Substantial)
3^rd	0.7964 (Substantial)	0.8507 (Excellent)
4^th	0.9296 (Excellent)	0.7333 (Substantial)

Evaluation	Kappa – personal treatment proposal	Kappa – treatment proposed by the algorithm
1^st	0.5996 (Moderate)	0.6326 (Substantial)
2^nd	0.4661 (Moderate)	0.5378 (Moderate)
1^st and 2^nd rounds together	0.5662 (Moderate)	0.6292 (Substantial)

Evaluator	Agreement of treatment proposal by the evaluator and the application of the algorithm	Application of the algorithm and treatment performed	Treatment proposal by the evaluator and treatment performed
1^st Round
1^st	22/30 (73.33%)	26/30 (86.67%)	23/30 (76.67%)
2^nd	27/30 (90%)	27/30 (90%)	27/30 (90%)
3^rd	27/30 (90%)	29/30 (96.67%)	28/30 (93.33%)
4^th	29/30 (96.67%)	27/30 (90%)	26/30 (86.67%)
2^nd Round
1^st	25/30 (83.33%)	25/30 (83.33%)	24/30 (80%)
2^nd	25/30 (83.33%)	26/30 (86.67%)	25/30 (83.33%)
3^rd	25/30 (83.33%)	26/30 (86.67%)	26/30 (86.67%)
4^th	26/30 (86.67%)	28/30 (93.33%)	24/30 (80%)
TOTAL	206/240 (85.83%)	214/240 (89.16%)	203/240 (84.5%)

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[1] Correspondence: Andrei F. Joaquim; Divisão de Neurocirurgia, UNICAMP; Rua Tessália Vieira de Camargo, 126; 13083-872 Campinas SP, Brasil; E-mail: andjoaquim@yahoo.com