Web-based Cervical Spine Trauma Report Generation Facilitates Accurate and Consistent Reporting Patrick Do, MD Jeffrey Dorr, MD Priya Krishnarao, MD Mahesh Patel, MD Santa Clara Valley Medical Center, San Jose, CA

Disclosure Statement The authors have no actual or potential conflict of interest in relation to this presentation

Goals and Objectives Review the history and present state of cervical spine injury classification systems Discuss their importance in guiding treatment decisions Introduce a novel interactive web-based application for the reporting of subaxial cervical spine injury

Background Subaxial cervical spine injury is common and serious Imaging findings play a crucial role in management The radiologist therefore must provide accurate and consistent reports

Classification Systems Classification systems attempt to standardize reporting nomenclature this provides a framework for not only guiding management, but also reporting treatment outcomes Surgery and radiology literature provide several such systems ABCD (2014), Subaxial Cervical Injury Description System (SCIDS, 2011), Subaxial Injury Classification (SLIC, 2007), Allen and Ferguson (1982), Daffner (2000)

Subaxial Injury Classification (SLIC)1 1Vaccaro AR et al. Spine 2007

Subaxial Injury Classification (SLIC) 3 categories Morphology Disco-ligamentous Complex Neurological Status Each category has gradated scoring based on severity of injury The overall SLIC score assists surgeons in determining operative vs non- operative management and identifying surgical approach2

MOrphology 0 points No abnormality 1 point Compression (e.g. visible loss of height, endplate disruption) +1 point with “Burst” fracture 3 points Distraction (anatomic dissociation in the vertical axis, e.g. perched facet, hyperextension) 4 points Rotation/Translation (horizontal displacement, e.g. facet dislocation, unstable teardrop) Vaccaro AR et al. Spine 2007

Disco-ligamentous Complex (DLC) 0 points Intact 1 point Indeterminate (isolated interspinous widening, MRI signal change only) 2 points Disrupted (disc space widening, facet perch/dislocation) Vaccaro AR et al. Spine 2007

Neurological status 0 points Intact 1 point Root injury 2 points Complete cord injury (e.g. ASIA A) 3 points Incomplete cord injury +1 point Ongoing cord compression in the setting of neurological deficit Vaccaro AR et al. Spine 2007

Surgical Planning Based on SLIC2 2Dvorak MF et al. Spine 2007

Surgical Planning Based on SLIC2 2Dvorak MF et al. Spine 2007

Surgical Planning Based on SLIC2 2Dvorak MF et al. Spine 2007

Surgical Planning Based on SLIC2 2Dvorak MF et al. Spine 2007

A New Web 2.0 Approach Modern web-development tools are used to achieve: dynamic, interactive report generation universal accessibility without special hardware or software interactive ability to show differentiating features or teaching points

Web Development Standard web-development languages are used: HTML, JavaScript, CSS Modern open-source libraries (collections of optimized pre-written code) facilitate the creation of an intuitive user interface jQuery: ubiquitous library enabling interactive manipulation of visible elements Bootstrap: popular framework developed by @Twitter allowing custom HTML and CSS theming elements

Single-Page web application

1. Select a Cervical spine level

2. Choose morphologic injury

3. Choose disco-ligamentous complex injury

4. Choose Neurologic status

5. Repeat as necessary

Educational Hints

Summary Cervical spine injury reporting can be confusing and inconsistent The Subaxial Cervical Injury Classification (SLIC) has proven to be useful in radiologic reporting and surgical management We have developed a simple, accessible, graphical web application to encourage the use of SLIC nomenclature http://patrickdo.github.io/cspine/

References Vaccaro AR, Hulbert RJ, Patel AA, Fisher C, Dvorak M, Lehman Jr RA, Anderson P, Harrop J, Oner FC, Arnold P, Fehlings M, Hedlund R, Madrazo I, Rechtine G, Aarabi B, Shainline M, and the Spine Trauma Study Group. The Subaxial Cervical Spine Injury Classification System: A Novel Approach to Recognize the Importance of Morphology, Neurology, and Integrity of the Disco- Ligamentous Complex. Spine 2007; 32: 2365-2374. Dvorak MF, Fisher CG, Fehlings MG, Rampersaud YR, Oner FC, Aarabi B, Vaccaro AR. The Surgical Approach to Subaxial Cervical Spine Injuries: An Evidence-Based Algorithm Based on the SLIC Classification System. Spine 2007; 32: 2620-2629. Whang PG, Patel AA, Vaccaro AR. The Development and Evaluation of the Subaxial Injury Classification Scoring System for Cervical Spine Trauma. Clin Orthop Relat Res 2011; 469: 723-731.