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Cervical Spine Injury Severity Score: Assessment of Reliability

the Spinal Trauma Study Group; Anderson, Paul A. MD; Moore, Timothy A. MD; Davis, Kirkland W. MD; Molinari, Robert W. MD; Resnick, Daniel K. MD; Vaccaro, Alexander R. MD; Bono, Christopher M. MD; Dimar, John R. II MD; Aarabi, Bizhan MD, FRCSC; Leverson, Glen PhD

Journal of Bone & Joint Surgery - American Volume: May 2007 - Volume 89 - Issue 5 - p 1057–1065
doi: 10.2106/JBJS.F.00684
Scientific Articles
Supplementary Content

Background: Systems for classifying cervical spine injury most commonly use mechanistic or morphologic terms and do not quantify the degree of stability. Along with neurologic function, stability is a major determinant of treatment and prognosis. The goal of our study was to investigate the reliability of a method of quantifying the stability of subaxial (C3-C7) cervical spine injuries.

Methods: A quantitative system was developed in which an analog score of 0 to 5 points is assigned, on the basis of fracture displacement and severity of ligamentous injury, to each of four spinal columns (anterior, posterior, right pillar, and left pillar). The total possible score thus ranges from 0 to 20 points. Fifteen examiners assigned scores after reviewing the plain radiographs and computed tomography images of thirty-four consecutive patients with cervical spine injuries. The scores were then evaluated for interobserver and intraobserver reliability with use of intraclass correlation coefficients.

Results: The mean intraobserver and interobserver intraclass correlation coefficients for the fifteen reviewers were 0.977 and 0.883, respectively. Association between the scores and clinical data was also excellent, as all patients who had a score of ≥7 points had surgery. Similarly, eleven of the fourteen patients with a score of ≥7 points had a neurologic deficit compared with only three of the twenty with a score of <7 points.

Conclusions: The Cervical Spine Injury Severity Score had excellent intraobserver and interobserver reliability. We believe that quantifying stability on the basis of fracture morphology will allow surgeons to better characterize these injuries and ultimately lead to the development of treatment algorithms that can be tested in clinical trials.

1 Department of Orthopaedic Surgery and Rehabilitation, University of Wisconsin, 600 Highland Avenue, K4/736, Madison, WI 53792. E-mail address for P.A. Anderson:

2 Department of Orthopaedic Surgery, CASE School of Medicine, MetroHealth Medical Center, 2500 MetroHealth Drive, Cleveland, OH 44109. E-mail address:

3 Department of Radiology, University of Wisconsin, 600 Highland Avenue, E3/311, Madison, WI 53792. E-mail address:

4 Department of Orthopaedics, University of Rochester Medical Center, 601 Elmwood Avenue, Box 665, Rochester, NY 14560. E-mail address:

5 Department of Neurosurgery, University of Wisconsin, 600 Highland Avene, K4/834 mail 8660, Madison, WI 53792

6 The Rothman Institute, 925 Chestnut Street, 5th Floor, Philadelphia, PA 19107

7 Department of Orthopaedic Surgery, Boston University School of Medicine, 850 Harrison Avenue, Dowling 2 North, Boston, MA 02118

8 Department of Orthopedic and Neurologic Surgery, Kosair Children's Hospital, University of Louisville, 210 East Gray Street, Suite 900, Louisville, KY 40202

9 Department of Neurosurgery, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, 22 South Greene Street, Suite S-12-D, Baltimore, MD 21201. E-mail

Copyright 2007 by The Journal of Bone and Joint Surgery, Incorporated
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