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Evaluation of the Clinical and Radiographic Degenerative Spondylolisthesis (CARDS) classification system as a guide
Steven P Baltic1, Keith W Lyons1, Francine Mariaux2
1Department of Orthopaedic Surgery, Dartmouth-Hitchcock Medical Center, 1 Medical Center Dr, Lebanon, NH 03756, USA.
Insights
Outcomes for instrumented and uninstrumented surgical techniques were similar across Clinical and Radiographic Degenerative Spondylolisthesis (CARDS) categories. This study did not validate CARDS for surgical technique selection in degenerative spondylolisthesis.
Area of Science:
- Spine surgery outcomes research
- Clinical classification systems validation
- Degenerative spondylolisthesis treatment
Background:
- The role of fusion in degenerative spondylolisthesis (DS) remains debated.
- The Clinical and Radiographic Degenerative Spondylolisthesis (CARDS) classification system aids surgical technique selection.
- Clinical validation of the CARDS system for guiding surgical technique is lacking.
Purpose of the Study:
- To assess if surgical outcomes differ across CARDS categories based on technique.
- To evaluate the utility of the CARDS classification in surgical decision-making for DS.
Main Methods:
- Prospective cohort study involving 508 patients with DS at two international spine centers.
- Patients classified using the CARDS system with dynamic radiographs.
- Surgical techniques categorized as uninstrumented or instrumented; outcomes assessed via Core Outcomes Measure Index (COMI) at 3 and 12 months.
Main Results:
- No significant differences in 3 or 12-month COMI scores between uninstrumented and instrumented techniques, stratified by CARDS category.
- A trend towards less improvement in COMI scores was observed in CARDS D patients treated with uninstrumented techniques.
- Reoperation rates did not significantly differ between surgical technique groups across CARDS categories.
Conclusions:
- Surgical outcomes were generally similar for both uninstrumented and instrumented techniques across CARDS categories.
- Surgeons appeared to consider CARDS factors in technique selection, leading to limited uninstrumented use in severe cases (CARDS D).
- The study did not validate the CARDS system as a definitive guide for surgical technique selection in DS due to limited statistical power.
Background Context:
The role of fusion in degenerative spondylolisthesis (DS) is controversial. The Clinical and Radiographic Degenerative Spondylolisthesis (CARDS) classification system was developed to assist surgeons in surgical technique selection based on individual patient characteristics. This system has not been clinically validated as a guide to surgical technique selection.
Purpose:
The purpose of this study was to determine if outcomes vary with different surgical techniques across the CARDS categories.
Study Design/Setting:
Prospective cohort study performed at one Swiss and one American spine center.
Patient Sample:
Five hundred eight patients with DS undergoing surgical treatment.
Outcome Measures:
Core Outcomes Measure Index (COMI) at 3 months and 12 months postoperatively.
Methods:
Patients undergoing surgery for DS were enrolled at 2 institutions and classified according to the CARDS system using dynamic radiographs. The Core Outcome Measure Index (COMI) was completed preoperatively, and 3 and 12 months postoperatively. Surgical technique was classified as uninstrumented (decompression alone or decompression with uninstrumented fusion) or instrumented (decompression with pedicle screw instrumentation with or without interbody fusion). Unadjusted analyses and mixed effect models compared COMI scores between the two surgery technique groups (uninstrumented vs instrumented), stratified by CARDS category over time. Reoperation rates were also compared between the surgery technique groups stratified by CARDS category. Partial funding was given through NASS grant for clinical research.
Results:
Five hundred five out of 508 patients enrolled in the study had sufficient data to be classified according to CARDS. Seven percent were classified as CARDS A, 28% as CARDS B, 48% as CARDS C, and 17% as CARDS D (CARDS A most "stable," CARDS D least "stable"). One hundred and thirty-three patients (26%) underwent decompression alone, 30 (6%) underwent decompression and uninstrumented fusion, 42 (8%) underwent decompression and posterolateral instrumented fusion, and 303 (60%) underwent decompression with posterolateral and interbody instrumented fusion. Patients in the least "stable" categories tended to be less likely to be treated with an uninstrumented technique (CARDS D 19% vs 32% for the other categories, p=.10). There were no significant differences in 3 or 12-month COMI scores between surgical technique groups stratified by CARDS category in the unadjusted or adjusted analyses. In the unadjusted analyses, there was a trend towards less improvement in 12-month COMI change score in the CARDS D patients in the uninstrumented group compared to the instrumented group (-2.7 vs -4.1, p=.10). Reoperation rates were not significantly different between the surgical technique groups stratified by CARDS category.
Conclusions:
In general, outcomes for uninstrumented and instrumented surgical techniques were similar across the CARDS categories. Surgeons likely took factors included in CARDS into account during surgical technique selection. This resulted in a low number of CARDS D (n=15) patients being treated with uninstrumented techniques, which limited the statistical power of this analysis. As such, this study does not validate CARDS as a useful classification system for surgical technique selection in DS.
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