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|Year : 2020 | Volume
| Issue : 4 | Page : 741-759
The 100 Most-Cited Papers in Traumatic Injury of the Spine
Muhammad B Tariq1, Osmond C Wu2, Marc A Agulnick3, Manish K Kasliwal2
1 Department of Orthopedic Surgery, NYU-Winthrop Hospital, Mineola, New York; Department of Neurological Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
2 Department of Neurological Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
3 Department of Orthopedic Surgery, NYU-Winthrop Hospital, Mineola, New York, USA
|Date of Web Publication||26-Aug-2020|
Dr. Manish K Kasliwal
11100 Euclid Avenue, Mailstop HAN 5042, Cleveland, OH 44106
Source of Support: None, Conflict of Interest: None
Background: Traumatic injury to the spine can be a complex diagnostic and therapeutic entity often with devastating consequences. Outside of the isolated vertebral column injury costs; annual costs associated with spinal cord injury (SCI) are estimated to exceed $9.7 billion.
Objective: To identify the 100 most-cited articles on spine trauma.
Methods: The Thomson Reuters Web of Science citation indexing service was queried. The articles were sorted by times cited in descending order. Two independent reviewers reviewed the article titles and abstracts to identify the top 100 most-cited articles.
Results: The top 100 articles were found to be cited between 108 (articles #99-100) and 1595 times (article #1). The most-cited basic science article was cited 340 times (#12 on the top 100 list). The oldest article on the top 100 list was from 1953 and most recent from 2012. The number of patients, when applicable, in a study ranged from 9 (article #34) to 34,069 (article #5). Top 100 articles were published in 41 different journals with a wide range of specialities and fields most commonly multidisciplinary. Basic science research encompassed 34 of the 100 articles on the list.
Conclusions: We present the 100 most-cited articles in spinal trauma with emphases on important contributions from both basic science and clinical research across a wide range of authors, specialties, patient populations, and countries. Recognizing some of the most important contributions in the field of spinal trauma may provide insight and guide future work.
Keywords: Acute spine injury, acute vertebral fracture, spinal cord 2 injury, spinal injury, spine, spine trauma, trauma
Key Messages: This article reviews the most cited papers in the complex field of spinal trauma, reviewing both basic science and clinical research. It also emphasizes the wide diversity in the field while reviewing current trends of scientific investigation in traumatic injuries to the spine.
|How to cite this article:|
Tariq MB, Wu OC, Agulnick MA, Kasliwal MK. The 100 Most-Cited Papers in Traumatic Injury of the Spine. Neurol India 2020;68:741-59
Traumatic injury to the spine can be a complex diagnostic and therapeutic entity often with devastating consequences. Fractures of the vertebral column represent 3-6% of all skeletal injuries. Furthermore, spine injury risks the stability of the vertebral column with potential harm to adjacent neurological structures. As such, injury to the spinal cord itself occurs in 15-40 patients per million and represents a devastating event with tremendous personal, psychosocial, and financial consequences. Annual costs associated with spinal cord injury (SCI) are estimated to exceed $9.7 billion. No wonder, extensive research over the past few decades has focused on describing and elucidating the mechanisms as well as treatment options of traumatic injury to the spine.
Treatment of injuries to the spine commonly involves a multidisciplinary team across different subspecialties including Orthopedic surgery, Neurosurgery, Emergency Medicine, Trauma surgery, Radiology, Physical Medicine and Rehabilitation, and Critical care. Therefore, scientific literature and research on spinal trauma encompass a wide host of neuroscientists, researchers, speciality fields, countries, and scientific journals.
One method of identifying scientific studies that have a high impact on medicine is through citation analysis. This type of analysis has previously been utilized to describe literature on spinal oncology, cervical spine surgery, SCI, spinal fractures, lumbar spine surgery, and spinal deformity surgery.,,,,, However, there is an absence of such an effort encompassing the broad subject of spinal trauma.
Therefore, the purpose of this study was to identify the 100 most-cited articles on traumatic injury to the spine to identify some of the most essential scientific contributions to the literature in this field.
| » Methods|| |
The Thomson Reuters Web of Science citation indexing service was queried. The search algorithm ([spine OR spinal OR vertebral] AND [acute OR emergent OR trauma OR acute fracture]) was used to identify articles of interest. All articles relating to the topic of interest available in English and published prior to May 2018 were included. The articles were sorted by times cited in descending order. Two independent reviewers reviewed the article titles and abstracts to identify the top 100 most-cited articles related to the area of traumatic injury to the spine. The following variables were recorded: author, title, year of publication, journal of publication, author specialty, study type, spinal level studied, number of patients, male to female ratio, mean or median age, country of origin, and the number of citations. To account for the year of publication, citations per year (CPY) index was calculated as previously described. Level of evidence for studies was designated according to criteria set by the North American Spine Society (https://www.spine.org/documents/researchclinicalcare/levelsofevidence.pdf).
| » Results|| |
Articles pertaining to spinal trauma were searched and the top 100 were identified based on the number of times they were cited [Table 1].- The top 100 articles were found to be cited between 108 (articles #99-100) and 1595 times (article #1). The most-cited basic science article was cited 340 times (#12 on the top 100 list). Collectively, all articles were cited a total of 22,788 times (mean of 227.9 citations for each paper). The oldest article on the top 100 list was from 1953. The most recent article on the list was from 2012.
Based on the CPY index, the top article was cited 57 times per year and was also #1 on the top 100 list. The bottom article had been cited 1.8 times per year (#79 on top 100 list).
The number of patients, when applicable, in a study ranged from 9 (article #34) to 34,069 (article #5). The patient age (median) ranged from 10.3 years (article #47) to 77 years (article #66) with a median age of 40 years.
The United States was the country with the highest number of articles (62 of 100 articles); followed by Canada (15 articles). The most published decade was the 1990s with 36 articles followed by 2000s with 30 articles on the top 100 list [Graph 1].
The author with the most number of articles on the top 100 list was M. B. Bracken with 7 articles,,,,,,; followed by J.R. Hoffman,, and I.M. Tarlov,, with 3 articles each.
Top 100 articles were published in 41 different journals, with the Journal of Neurosurgery containing the most studies (17 articles) followed by Radiology (9 articles) and Experimental Neurology (6 articles) [Table 2].
A wide range of specialties and fields originated the top 100 articles with multidisciplinary being the most common with 33 articles followed by neurosurgery, radiology, and epidemiology with 19, 10, and 7 articles, respectively [Table 3].
The level of injury on the spine most commonly studied was SCI at any level (32 articles), followed by cervical injury (26 articles), and thoracic injury (21 articles) [Graph 2].
When stratified by study type, there were: 34 basic science articles, 7 case series, 1 cost-effectiveness/theoretical model, 1 appraisal study, 17 prospective cohorts, 9 randomized controlled trials (RCTs), 6 retrospective cohorts, 17 review articles, 4 surveys, 2 systematic reviews, and 2 non-randomized trials.
| » Discussion|| |
This study identifies the topics and authors that have made the greatest impact in the field of traumatic injury of the spine over the course of the last century. The identification of the most cited work in the field allows us to gain insight into the history, advancements, and current trends of research in spinal trauma. The field of spinal trauma has grown significantly during the last decades and our study highlights the 100 most-cited articles in the field. Considering the rapid growth of medical literature in the current era, the present effort to filter the 100 most-cited papers in the field of spine trauma could be extremely valuable for clinicians and all other allied subspecialties involved to keep them abreast with the most relevant literature that could assist in better patient care and also help direct further research efforts in this field.
The most-cited clinical and overall cited article was found to be “A Randomized, Controlled Trial of Methylprednisolone or Naloxone in the Treatment of Acute Spinal-Cord Injury - Results of the 2nd National Acute Spinal-Cord Injury Study“ by Bracken et al. (1990) published in the New England Journal of Medicine. This study presents the results of a multicenter trial on the efficacy of corticosteroid use after SCI. This is a topic of high debate in the literature with subsequent literature rebutting the utility of corticosteroids., Therefore, it is not unexpected to see this study in the 100 most-cited list.
The second most-cited overall article was “The 3 column spine and its significance in the classification of acute thoracolumbar spinal-injuries“ by F. Denis (1983) published in Spine. This is a landmark observational study describing the 3 column theory of spinal stability as it relates to spinal injuries. Since the stability of the spine is one of many key considerations to surgical management of patients with a spine injury, the impact of this study can be appreciated in theoretical and clinical practice.
The most-cited basic science article was “ Acute inflammatory response in spinal cord following impact injury“ by Carlson et al. (1998) published in Experimental Neurology. This paper highlights the mechanistic role of secondary injury to the spinal cord after blunt trauma using a rat model. The authors quantitively correlate the inflammatory response as measured by the number of macrophages and reactive microglia with tissue damage. This study sets the precedence that treatments targeting the inflammatory response after SCI may be beneficial in mitigating secondary injury. Furthermore, this study falls in line with the highly discussed topic of SCI treatments similar to the National acute spinal cord injury study (NASCIS) above.
The top 10 most-cited studies focused on the topics of SCI and spinal stability with the inclusion of all three NASCIS trials, Canadian C-spine rule study, and 3-column spine articles. This highlights the most popular topics in spinal trauma, which can be summarized as themes of vertebral column stability and SCI. Both topics, which are integrally related to one another with damage to the vertebral column either directly correlating or indirectly risking damage to the spinal cord or nerves. Due to the tremendous consequences from damage or risk of damage to neural tissue, the high amount of scientific investigation concentrated around it can be recognized.
Looking at the top-cited articles in each field of medicine can further help identify certain trends. For example, the top papers were published in journals considered to be very high impact globally and/or within the specific field. In Neurosurgery, the most-cited article “Review of the secondary injury theory of acute spinal-cord trauma with emphasis on vascular mechanisms” by Tator et al. (1991) was published in Journal of Neurosurgery. In Orthopaedic Surgery, “The 3 column spine and its significance in the classification of acute thoracolumbar spinal-injuries” by Denis (1983) was published in Spine. In Trauma, “Cervical spine injuries in children: a review of 103 patients treated consecutively at a level 1 pediatric trauma center” by Brown et al. (2001) was published in Journal Pediatric Surgery. In Emergency Medicine, “Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma” by Hoffman et al. (2000) was published in NEJM. In Radiology, “Vertebroplasty versus conservative treatment in acute osteoporotic vertebral compression fractures (Vertos II): an open-label randomised trial” by Klazen (2010) was published in Lancet.Furthermore, the highest cited articles in the various fields did not convey to a specific time period or particular spine level or theme. It is not surprising that the highest cited articles were in the highest impact journals since the impact factor is one of the known measures of a journal's significance within a field. From molecular pathophysiology and initial diagnostic evaluation to final treatment, our study highlights the current leading studies in all forms of traumatic injury of the spine. In addition, we highlight the value of basic science as well as clinical literature. From bench to bedside, we present a wide diversity of study types: case studies, review articles, clinical trials, cohort studies, and basic science articles. As such, 34 of the 100 studies in the top 100 list were basic science, which emphasizes the role of experimental research in the scientific investigation of traumatic injury to the spine.
Some limitations can be appreciated in our study. First, it has previously been suggested that citation analyses may favor older studies because these studies have more time to accumulate citations. To minimize this potential bias, we utilized the CPY index, which takes into account time since publication. Furthermore, the Web of Science has commonly been used for citation analyses similar to ours; we acknowledge that this index may not include citations from journals or textbooks written in other languages. Second, although articles were ranked according to the number of citations, we excluded some studies in a subjective manner (that did not fit inclusion criteria) and it may be possible that other relevant articles were missed. To minimize this, we had two independent reviewers screen through the list of top 100 articles. Third, the topic of spinal trauma encompasses a wide range of complex pathologies, etiologies, and extensive research. Therefore, it may be possible that some relevant articles, such as those focusing on chronic and long-term effects of spinal trauma, may have not been captured by our search. Finally, it is worth noting that the number of times an article has been cited does not directly reflect its quality.
| » Conclusions|| |
We present the 100 most-cited articles in spinal trauma with emphases on important contributions from both basic science and clinical research across a wide range of authors, specialities, patient populations, and countries. Thirty-four of the 100 articles were basic science investigations. The most popular topics in spinal trauma can be broadly encompassed as themes of vertebral column stability and SCI. Recognition of some of the most important contributions from a wide variety of research studies encompassing bench to bedside in the field of spinal trauma may guide future work.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3]