This book attempts to achieve a difficult goal: to teach statistics to the novice so as to impart a liking and understanding of statistics. The book is geared toward a medical audience, since most examples are from the medical literature. The structure of the book consists of the following elements in each chapter: a small number of statistical rules of thumb, followed by a nontechnical explanation, a demonstration of how to work through the mechanics of doing the statistical test in question, a summary, and sample problems to be solved by the reader. (The answers, with explanations, are provided in an appendix.) Although a variety of univariate statistics are included, certain topics that are important in medical research are not. For example, there is little or no discussion of multiple regression, life-table techniques, or pooling of studies. These omissions, especially of multiple regression, are unfortunate. The Primer was derived from

Primer of Biostatistics

Study design The classification system was derived through a literature review and expert opinion of experienced spine surgeons. In addition, a multicenter reliability and validity study of the system was conducted on a collection of trauma cases. Objectives To define a novel classification system for subaxial cervical spine trauma that conveys information about injury pattern, severity, treatment considerations, and prognosis. To evaluate reliability and validity of this system. Summary of background data Classification of subaxial cervical spine injuries remains largely descriptive, lacking standardization and prognostic information. Methods Clinical and radiographic variables encountered in subaxial cervical trauma were identified by a working section of the Spine Trauma Study Group. Significant limitations of existing systems were defined and addressed within the new system. This system, as well as the Harris and Ferguson & Allen systems, was applied by 20 spine surgeons to 11 cervical trauma cases. Six weeks later, the cases were randomly reordered and again scored. Interrater reliability, intrarater reliability, and validity were assessed. Results Each of 3 main categories (injury morphology, disco-ligamentous complex, and neurologic status) identified as integrally important to injury classification was assigned a weighted score; the injury severity score was obtained by summing the scores from each category. Treatment options were assigned based on threshold values of the severity score. Interrater agreement as assessed by intraclass correlation coefficient of the DLC, morphology, and neurologic status scores was 0.49, 0.57, and 0.87, respectively. Intrarater agreement as assessed by intraclass correlation coefficient of the DLC, morphology, and neurologic status scores was 0.66, 0.75, and 0.90, respectively. Raters agreed with treatment recommendations of the algorithm in 93.3% of cases, suggesting high construct validity. The reliability compared favorably to the Harris and Ferguson & Allen systems. Conclusion The Sub-axial Injury Classification and Severity Scale provides a comprehensive classification system for subaxial cervical trauma. Early validity and reliability data are encouraging.

/pdf/the-subaxial-cervical-spine-injury-classification-system-a-251rpqq55f.pdf

The subaxial cervical spine injury classification system: a novel approach to recognize the importance of morphology, neurology, and integrity of the disco-ligamentous complex.

Dealing with complications: Neurovascular complications associated with total hip arthroplasty

Diagnostic imaging practice guidelines for musculoskeletal complaints in adults-an evidence-based approach-part 3: spinal disorders.

BACKGROUND: The treatment of unstable thoracolumbar burst fractures with short-segment posterior spinal instrumentation without anterior column reconstruction is associated with a high rate of screw breakage and progressive loss of reduction. The purpose of the present study was to evaluate the functional, neurologic, and radiographic results following transpedicular, balloon-assisted fracture reduction with anterior column reconstruction with use of calcium phosphate bone cement combined with short-segment posterior instrumentation and a laminectomy.

METHODS: A consecutive series of thirty-eight patients with an unstable thoracolumbar burst fracture with or without neurologic deficit were managed with transpedicular, balloon-assisted fracture reduction, calcium phosphate bone cement reconstruction, and short-segment spinal instrumentation from 2002 to 2005. Twenty-eight of the thirty-eight patients were followed for a minimum of two years. Demographic data, neurologic function, segmental kyphosis, the fracture severity score, canal compromise, the Short Form-36 score, the Oswestry Disability Index score, and treatment-related complications were evaluated prospectively.

RESULTS: All thirteen patients with incomplete neurologic deficits had improvement by at least one Frankel grade. The mean kyphotic angulation improved from 17° preoperatively to 7° at the time of the latest follow-up, and the loss of vertebral body height improved from a mean of 42% preoperatively to 14% at the time of the latest follow-up. Screw breakage occurred in two patients, and pseudarthrosis occurred in one patient.

CONCLUSIONS: The present study demonstrates that excellent reduction of unstable thoracolumbar burst fractures with and without associated neurologic deficits can be maintained with use of short-segment instrumentation and a transpedicular balloon-assisted reduction combined with anterior column reconstruction with calcium phosphate bone cement performed through a single posterior incision. The resultant circumferential stabilization combined with a decompressive laminectomy led to maintained or improved neurologic function in all patients with neurologic deficits, with a low rate of instrumentation failure and loss of correction.

LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence.

ORIGINAL ABSTRACT CITATION: “Thoracolumbar Burst Fractures Treated with Posterior Decompression and Pedicle Screw Instrumentation Supplemented with Balloon-Assisted Vertebroplasty and Calcium Phosphate Reconstruction” (2009;91:20-8).

Thoracolumbar Burst Fractures Treated with Posterior Decompression and Pedicle Screw Instrumentation Supplemented with Balloon-Assisted Vertebroplasty and Calcium Phosphate Reconstruction

Study design Prospective study of 5 spine surgeons rating 71 clinical cases of thoracolumbar spinal injuries using the Thoracolumbar Injury Severity Score (TLISS) and then re-rating the cases in a different order 1 month later. Objective To determine the reliability of the TLISS system. Summary of background data The TLISS is a recently introduced classification system for thoracolumbar spinal column injures designed to simplify injury classification and facilitate treatment decision making. Before being widely adopted, the reliability of the TLISS must be studied. Methods A total of 71 cases of thoracolumbar spinal trauma were distributed on CD-ROM to 5 attending spine surgeons, including clinical/radiographic data, details of the TLISS, and a scoring sheet in which cases would be scored using the system. The surgeons were later assigned the task with the cases reordered. Intraobserver and interobserver reliability was calculated for TLISS components, total score, and surgeon's treatment decision using the Cohen unweighted kappa coefficients and Spearman rank-order correlation. Results Interrater reliability assessed by generalized kappa coefficients was 0.33 +/- 0.03 for injury mechanism, 0.91 +/- 0.02 for neurologic status, 0.35 +/- 0.03 for posterior ligamentous complex status, 0.29 +/- 0.02 for TLISS total, and 0.52 +/- 0.03 for treatment recommendation. Respective results using the Spearman correlation were 0.35 +/- 0.04, 0.94 +/- 0.01, 0.48 +/- 0.04, 0.65 +/- 0.03, and 0.51 +/- 0.04. Surgeons agreed with the TLISS recommendation 96.4% of the time. Intrarater kappa coefficients were 0.57 +/- 0.04 for injury mechanism, 0.93 +/- 0.02 for neurologic status, 0.48 +/- 0.04 for posterior ligamentous complex status, 0.46 +/- 0.03 for TLISS total, and 0.62 +/- 0.04 for treatment recommendation. Respective results using the Spearman correlation were 0.70 +/- 0.04, 0.95 +/- 0.02, 0.59 +/- 0.05, 0.77 +/- 0.04, and 0.59 +/- 0.05. Conclusions The TLISS has good reliability and compares favorably to other contemporary thoracolumbar fracture classification systems.

Reliability of a novel classification system for thoracolumbar injuries: the Thoracolumbar Injury Severity Score

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Reliability of a novel classification system for thoracolumbar injuries: the Thoracolumbar Injury Severity Score