TY - JOUR
T1 - The Reliability of the AO Spine Upper Cervical Classification System in Children
T2 - Results of a Multi-Center Study
AU - O'Neill, Nora P.
AU - Mo, Andrew Z.
AU - Miller, Patricia E.
AU - Glotzbecker, Michael P.
AU - Li, Ying
AU - Fletcher, Nicholas D.
AU - Upasani, Vidyadhar V.
AU - Riccio, Anthony I.
AU - Spence, David
AU - Garg, Sumeet
AU - Krengel, Walter
AU - Birch, Craig
AU - Hedequist, Daniel J.
N1 - Publisher Copyright:
© 2021 Wolters Kluwer Health, Inc. All rights reserved.
PY - 2023/4/1
Y1 - 2023/4/1
N2 - Background: There is no uniform classification system for traumatic upper cervical spine injuries in children. This study assesses the reliability and reproducibility of the AO Upper Cervical Spine Classification System (UCCS), which was developed and validated in adults, to children. Methods: Twenty-six patients under 18 years old with operative and nonoperative upper cervical injuries, defined as from the occipital condyle to the C2-C3 joint, were identified from 2000 to 2018. Inclusion criteria included the availability of computed tomography and magnetic resonance imaging at the time of injury. Patients with significant comorbidities were excluded. Each case was reviewed by a single senior surgeon to determine eligibility. Educational videos, schematics describing the UCCS, and imaging from 26 cases were sent to 9 pediatric orthopaedic surgeons. The surgeons classified each case into 3 categories: A, B, and C. Inter-rater reliability was assessed for the initial reading across all 9 raters by Fleiss's kappa coefficient (kF) along with 95% confidence intervals. One month later, the surgeons repeated the classification, and intra-rater reliability was calculated. All images were de-identified and randomized for each read independently. Intra-rater reproducibility across both reads was assessed using Fleiss's kappa. Interpretations for reliability estimates were based on Landis and Koch (1977): 0 to 0.2, slight; 0.2 to 0.4, fair; 0.4 to 0.6, moderate; 0.6 to 0.8, substantial; and >0.8, almost perfect agreement. Results: Twenty-six cases were read by 9 raters twice. Sub-classification agreement was moderate to substantial with ακ estimates from 0.55 for the first read and 0.70 for the second read. Inter-rater agreement was moderate (kF 0.56 to 0.58) with respect to fracture location and fair (kF 0.24 to 0.3) with respect to primary classification (A, B, and C). Krippendorff's alpha for intra-rater reliability overall sub-classifications ranged from 0.41 to 0.88, with 0.75 overall raters. Conclusion: Traumatic upper cervical injuries are rare in the pediatric population. A uniform classification system can be vital to guide diagnosis and treatment. This study is the first to evaluate the use of the UCCS in the pediatric population. While moderate to substantial agreement was found, limitations to applying the UCCS to the pediatric population exist, and thus the UCCS can be considered a starting point for developing a pediatric classification.
AB - Background: There is no uniform classification system for traumatic upper cervical spine injuries in children. This study assesses the reliability and reproducibility of the AO Upper Cervical Spine Classification System (UCCS), which was developed and validated in adults, to children. Methods: Twenty-six patients under 18 years old with operative and nonoperative upper cervical injuries, defined as from the occipital condyle to the C2-C3 joint, were identified from 2000 to 2018. Inclusion criteria included the availability of computed tomography and magnetic resonance imaging at the time of injury. Patients with significant comorbidities were excluded. Each case was reviewed by a single senior surgeon to determine eligibility. Educational videos, schematics describing the UCCS, and imaging from 26 cases were sent to 9 pediatric orthopaedic surgeons. The surgeons classified each case into 3 categories: A, B, and C. Inter-rater reliability was assessed for the initial reading across all 9 raters by Fleiss's kappa coefficient (kF) along with 95% confidence intervals. One month later, the surgeons repeated the classification, and intra-rater reliability was calculated. All images were de-identified and randomized for each read independently. Intra-rater reproducibility across both reads was assessed using Fleiss's kappa. Interpretations for reliability estimates were based on Landis and Koch (1977): 0 to 0.2, slight; 0.2 to 0.4, fair; 0.4 to 0.6, moderate; 0.6 to 0.8, substantial; and >0.8, almost perfect agreement. Results: Twenty-six cases were read by 9 raters twice. Sub-classification agreement was moderate to substantial with ακ estimates from 0.55 for the first read and 0.70 for the second read. Inter-rater agreement was moderate (kF 0.56 to 0.58) with respect to fracture location and fair (kF 0.24 to 0.3) with respect to primary classification (A, B, and C). Krippendorff's alpha for intra-rater reliability overall sub-classifications ranged from 0.41 to 0.88, with 0.75 overall raters. Conclusion: Traumatic upper cervical injuries are rare in the pediatric population. A uniform classification system can be vital to guide diagnosis and treatment. This study is the first to evaluate the use of the UCCS in the pediatric population. While moderate to substantial agreement was found, limitations to applying the UCCS to the pediatric population exist, and thus the UCCS can be considered a starting point for developing a pediatric classification.
KW - pediatric spine
KW - trauma
KW - upper cervical spinal injuries
UR - http://www.scopus.com/inward/record.url?scp=85149753330&partnerID=8YFLogxK
UR - http://www.scopus.com/inward/citedby.url?scp=85149753330&partnerID=8YFLogxK
U2 - 10.1097/BPO.0000000000002363
DO - 10.1097/BPO.0000000000002363
M3 - Article
C2 - 36706430
AN - SCOPUS:85149753330
SN - 0271-6798
VL - 43
SP - 273
EP - 277
JO - Journal of Pediatric Orthopaedics
JF - Journal of Pediatric Orthopaedics
IS - 4
ER -