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STUDY DESIGN The thoracolumbar injury classification system (TLICS) was evaluated in 20 consecutive pediatric spine trauma cases. OBJECTIVE The purpose of this study was to determine the reliability and validity of the TLICS in pediatric spine trauma. SUMMARY OF BACKGROUND DATA The TLICS was developed to improve the categorization and management of thoracolumbar trauma. TLICS has been shown to have good reliability and validity in the adult population. METHODS The clinical and radiographical findings of 20 pediatric thoracolumbar fractures were prospectively presented to 20 surgeons with disparate levels of training and experience with spinal trauma. These injuries were consecutively scored using the TLICS. Cohen unweighted κ coefficients and Spearman rank order correlation values were calculated for the key parameters (injury morphology, status of posterior ligamentous complex, neurological status, TLICS total score, and proposed management) to assess the inter-rater reliabilities. Five surgeons scored the same cases 3 months later to assess the intra-rater reliability. The actual management of each case was then compared with the treatment recommended by the TLICS algorithm to assess validity. RESULTS The inter-rater κ statistics of all subgroups (injury morphology, status of the posterior ligamentous complex, neurological status, TLICS total score, and proposed treatment) were within the range of moderate to substantial reproducibility (0.524-0.958). All subgroups had excellent intra-rater reliability (0.748-1.000). The various indices for validity were calculated (80.3% correct, 0.836 sensitivity, 0.785 specificity, 0.676 positive predictive value, 0.899 negative predictive value). Overall, TLICS demonstrated good validity. CONCLUSION The TLICS has good reliability and validity when used in the pediatric population. The inter-rater reliability of predicting management and indices for validity are lower than those in adults with thoracolumbar fractures, which is likely due to differences in the way children are treated for certain types of injuries. TLICS can be used to reliably categorize thoracolumbar injuries in the pediatric population; however, modifications may be needed to better guide treatment in this specific patient population. LEVEL OF EVIDENCE 4.

Study design: Retrospective review. Objective: To identify risk factors for cell saver transfusion in lumbar spinal surgery and determine if cell saver transfusions affected intraoperative or postoperative transfusion rates. Summary of background data: Cell saver has been used to minimize allogeneic blood transfusion in lumbar spinal surgery. Conflicting reports exist, which call into question the efficacy of cell saver use. Methods: We reviewed medical records of randomly selected patients who underwent posterolateral fusion with or without transforaminal interbody fusion from July 2010 to June 2011. Transfusion rates and transfusion-related complications were determined. Binary logistic regression was performed to identify risk factors for use of autologous cell saver transfusion. Results: There were 178 females and 107 males, with a mean age of 57.2 years. Of the 285 cases, 39 had no cell saver available, 147 had cell saver available but no autologous blood was recovered or transfused and 99 had an autologous cell saver transfusion. Patients who had cell saver transfusion had a higher rate of intraoperative allogeneic blood transfusion (52%) compared with those who did not (22%). There was no significant difference in the rate of postoperative transfusions or transfusion-related reactions between patients who did and did not have cell saver transfusion. Patient's age, smoking status, American Society of Anesthesiologists grade, use of anticoagulants preoperatively, primary or revision surgery, iliac crest bone graft harvest, anesthesiologist, or surgeon had no significant effect on cell saver infusion. Body mass index (odds ratio [OR] = 1.06), number of posterolateral fusion levels fused (OR = 2.50), and number of transforaminal interbody fusions performed (OR = 2.41) were independent risk factors for the use of autologous cell saver transfusion. Conclusion: Body mass index, multi-level fusion and transforaminal interbody fusion result in increased use of autologous cell saver transfusion in lumbar spinal surgery. Use of autologous cell saver transfusion did not reduce the requirement for intraoperative or postoperative allogeneic blood transfusion. Level of evidence: 2.

Study design Retrospective review. Objective To determine the incremental cost-effectiveness of cell saver for single-level posterior lumbar decompression and fusion (PLDF). Summary of background data Intraoperative cell salvage is used during surgery to reduce the need for perioperative allogeneic blood transfusion. Although the use of cell saver may be beneficial in certain circumstances, its utility has not been clearly established for the common procedure of an adult single-level PLDF. Methods Randomly selected adult patients treated with a single-level PLDF between July 2010 and June 2011 at a single institution were identified. Patients who had a combined anterior and posterior approach were excluded. The final study sample for analysis consisted of 180 patients. Hospital records were reviewed to determine whether: (1) cell saver was available during surgery, (2) recovered autologous blood was infused, and (3) the patient received intra- or postoperative allogeneic transfusions. Estimated blood loss, levels fused, volume(s) transfused, and all related complications were recorded. Costs included the cost of allogeneic blood transfusion, setting up the cell saver recovery system, and infusing autologous blood from cell saver, whereas effectiveness measures were allogeneic blood transfusions averted and quality adjusted life years. Results The incremental cost-effectiveness ratio was $55,538 per allogeneic transfusion averted, with a decrease in the transfusion rate from 40.0% to 38.7% associated with the cell saver approach. This translated into an incremental cost-effectiveness ratio of $5,555,380 per quality adjusted life years gained, which is well above the threshold for an intervention to be considered cost-effective ($100,000 per quality adjusted life years gained). Conclusion The use of cell saver during a single-level PLDF does not significantly reduce the need for allogeneic blood transfusion and is not cost-effective. The high cost of cell saver in combination with the low complication rate of allogeneic blood transfusion, suggest that cell saver should not be used for single-level PLDF. Further studies are needed to evaluate the necessity for cell saver among other types of spinal surgery.

Although clinical outcomes after lumbar disc herniations (LDHs) in the general population have been well studied, those in elite professional athletes have not. Because these athletes have different measures of success, studies on long-term outcomes in this patient population are necessary.This study seeks to define the outcomes after an LDH in a large cohort of professional athletes of American football, baseball, hockey, and basketball.Retrospective cohort study.A total of 342 professional athletes from four major North American sports from 1972 to 2008 diagnosed with an LDH were identified via a previously published protocol. Two hundred twenty-six players underwent lumbar discectomy, and 116 athletes were treated nonoperatively. Only those players who had at least 2 years of follow-up were included.Functional outcome measures as defined by successful return-to-play (RTP), career games, and years played for each player cohort were recorded both before and after treatment. Conversion factors based on games/regular season and expected career length (based on individual sport) were used to standardize the outcomes across each sport.Using Statistical Analysis Software v. 9.1, outcome measures were compared in each cohort both before and after treatment using linear and mixed regression analyses and Cox proportional hazards models. A Kaplan-Meier survivorship curve was calculated for career length after injury. Statistical significance was defined as p.05.After the diagnosis of an LDH, professional athletes successfully returned to sport 82% of the time, with an average career length of 3.4 years. Of the 226 patients who underwent surgical treatment, 184 successfully returned to play (81%), on average, for 3.3 years after surgery. Survivorship analysis demonstrated that 62.3% of players were expected to remain active 2 years after diagnosis. There were no statistically significant differences in outcome in the surgical and nonoperative cohorts. Age at diagnosis was a negative predictor of career length after injury, whereas games played before injury had a positive effect on outcome after injury. Major League Baseball (MLB) players demonstrated a significantly higher RTP rate than those of other sports, and conversely, National Football League (NFL) athletes had a lower RTP rate than players of other sports (p.05). However, the greatest positive treatment effect from surgery for LDH was seen in NFL players, whereas for MLB athletes, a lumbar discectomy led to a shorter career compared with the nonoperative cohort (p.05).Professional athletes diagnosed with an LDH successfully returned to play at a high rate with productive careers after injury. Whereas older athletes have a shorter career length after diagnosis of LDH, experienced players (high number of games played) demonstrate more games played after treatment than inexperienced athletes. Notably, surgical treatment in baseball players led to significantly shorter careers, whereas for NFL athletes, posttreatment careers were longer than those of the corresponding nonoperative cohort. The explanation for this is likely multifactorial, including the age at diagnosis, respective contractual obligations, and different physical demands imposed by each individual professional sport.