Evaluation of the Clinical and Radiographic Degenerative Spondylolisthesis (CARDS) classification system as a guide to surgical technique selection

Steven P Baltic; Keith W Lyons; Francine Mariaux; Anne F Mannion; Paul M Werth; Tamas Fekete; Francois Porchet; Christopher Kepler; Kevin J McGuire; Jon D Lurie; Adam M Pearson

doi:10.1016/j.spinee.2023.06.401

Evaluation of the Clinical and Radiographic Degenerative Spondylolisthesis (CARDS) classification system as a guide to surgical technique selection

Spine J. 2023 Nov;23(11):1641-1651. doi: 10.1016/j.spinee.2023.06.401. Epub 2023 Jul 3.

Authors

Affiliations

¹ Department of Orthopaedic Surgery, Dartmouth-Hitchcock Medical Center, 1 Medical Center Dr, Lebanon, NH 03756, USA.
² Department of Teaching, Research and Development, Spine Division, Schulthess Klinik, Lengghalde 2, Zurich 8008, CH, Switzerland.
³ Orthopaedics, Thomas Jefferson University, 833 Chestnut St, Suite 1402, Philadelphia, PA 19107, USA.
⁴ Department of Medicine, Dartmouth-Hitchcock Medical Center, 1 Medical Center Dr, Lebanon, NH 03756, USA.
⁵ Department of Orthopaedic Surgery, Dartmouth-Hitchcock Medical Center, 1 Medical Center Dr, Lebanon, NH 03756, USA. Electronic address: Adam.M.Pearson@hitchcock.org.

PMID: 37406861
DOI: 10.1016/j.spinee.2023.06.401

Abstract

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.

Keywords: Arthrodesis; Decompression; Degenerative spondylolisthesis; Fusion; Instability; Spine surgery; Stenosis.