A novel scoring system concept for de novo spinal infection treatment, the Spinal Infection Treatment Evaluation Score (SITE Score): a proof-of-concept study

Abstract

OBJECTIVE De novo infections of the spine are an increasing healthcare problem. The decision for nonsurgical or surgical treatment is often made case by case on the basis of physician experience, specialty, or practice affiliation rather than evidence-based medicine. To create a more systematic foundation for surgical assessments of de novo spinal infections, the authors applied a formal validation process toward developing a spinal infection scoring system using principles gained from other spine severity scoring systems like the Spine Instability Neoplastic Score, Thoracolumbar Injury Classification and Severity Score, and AO Spine classification of thoracolumbar injuries. They utilized an expert panel and literature reviews to develop a severity scale called the "Spinal Infection Treatment Evaluation Score" (SITE Score). METHODS The authors conducted an evidence-based process of combining literature reviews, extracting key elements from previous scoring systems, and obtaining iterative expert panel input while following a formal Delphi process. The resulting basic SITE scoring system was tested on selected de novo spinal infection cases and serially refined by an international multidisciplinary expert panel. Intra- and interobserver reliabilities were calculated using the intraclass correlation coefficient (ICC) and Fleiss’ and Cohen’s kappa, respectively. A receiver operating characteristic analysis was performed for cutoff value analysis. The predictive validity was assessed through cross-tabulation analysis. RESULTS The conceptual SITE scoring system combines the key variables of neurological symptoms, infection location, radiological variables for instability and impingement of neural elements, pain, and patient comorbidities. Ten patients formed the first cohort of de novo spinal infections, which was used to validate the conceptual scoring system. A second cohort of 30 patients with de novo spinal infections, including the 10 patients from the first cohort, was utilized to validate the SITE Score. Mean scores of 6.73 ± 1.5 and 6.90 ± 3.61 were found in the first and second cohorts, respectively. The ICCs for the total score were 0.989 (95% CI 0.975–0.997, p < 0.01) in the first round of scoring system validation, 0.992 (95% CI 0.981–0.998, p < 0.01) in the second round, and 0.961 (95% CI 0.929–0.980, p < 0.01) in the third round. The mean intraobserver reliability was 0.851 ± 0.089 in the third validation round. The SITE Score yielded a sensitivity of 97.77% ± 3.87% and a specificity of 95.53% ± 3.87% in the last validation round for the panel treatment decision. CONCLUSIONS The SITE scoring concept showed statistically meaningful reliability parameters. Hopefully, this effort will provide a foundation for a future evidence-based decision aid for treating de novo spinal infections. The SITE Score showed promising inter- and intraobserver reliability. It could serve as a helpful tool to guide physicians’ therapeutic decisions in managing de novo spinal infections and help in comparison studies to better understand disease severity and outcomes.

Value of Spinal Infection Treatment Evaluation Score, Pola Classification, and Brighton Spondylodiscitis Score from Decision to Surgery in Patients with Spondylodiscitis: A Receiver-Operating Characteristic Curve Analysis

“…To the best of our knowledge, no guidelines exist for surgery versus conservative treatment relative to patients with spondylodiscitis, nor is there a threshold standard for operative intervention [3][4][5]. Our results show an acceptable accuracy performance for the SITE score in patients with spondylodiscitis.…”

“…The discrimination between surgery and conservative treatment appeared to be effective for the SITE score when compared with the other scores. Pluemer et al [ 4 ] reported a cutoff value of ≤8 (sensitivity, 100.0%; specificity, 95.7%). This observation is in accordance with our study results that the optimal cutoff value was ≤8.5 (sensitivity, 80.6%; specificity, 81.2%) when the panel decided in favor of surgery.…”

“…(3) SITE score This novel scoring system was presented by Pluemer et al [4] for the evaluation of de novo spinal infection treatment. It consists of five categories, namely, neurology, location, radiology, pain, and host comorbidities.…”

“…Tools will never replace human experts; however, they can help in screening and be used by experts to double-check their decisions. Various tools such as Spinal Infection Treatment Evaluation (SITE) score [ 4 ], Brighton Spondylodiscitis Score (BSDS) [ 3 ], and Pola classification [ 5 ], are available for predicting the need for surgical intervention in patients with spondylodiscitis. The abovementioned tools were established to calculate patient-specific surgical risks based on variables associated with their disease.…”

“…For many patients, decision-making is challenging. The decision-making tools were developed and validated to examine the factors that affect the decisionmaking process [3][4][5]. Tools will never replace human experts; however, they can help in screening and be used by experts to double-check their decisions.…”