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Background: The recently developed Spine Oncology Study Group Outcomes Questionnaire (SOSGOQ2.0) was proven a valid and reliable instrument measuring health-related quality of life (HRQOL) for patients with spinal malignancies. A German version was not available.Objective: A cross-cultural adaptation of the SOSGOQ2.0 to the German language and its multicenter evaluation.Methods: In a multistep process, a cross-cultural adaptation of the SOSGOQ2.0 was conducted. Subsequently, a multicenter, prospective observational cohort study was initiated to assess the reliability and validity of the German adaptation. To assess external construct validity of the cross-cultural adapted questionnaire, a comparison to the established questionnaire QLQ-C30 from the European Organisation for Research and Treatment of Cancer was conducted. Mean-difference plots were used to measure the agreement between the questionnaires in total score and by domain (deviation from mean up to 10% allowed). Further reliability and validity tests were carried out. Change to baseline was analysed 3-16 weeks later after different interventions occurred. Clinically relevant thresholds in comparison to the EORTC QLQ-C30 questionnaire were evaluated by ROC curve analysis.Results: We could enroll 113 patients from four different university hospitals (58 females, 55 males). Mean age was 64.11 years (sd 11.9). 80 patients had an ECOG performance status of 2 or higher at baseline. External construct validity in comparison to the EORTC QLQ-C30 questionnaire in total score and by domain was confirmed (range of deviation 4.4 to 9.0%). Good responsiveness for the domains Physical Functioning (P < .001) and Pain (P < .001) could be shown. The group mean values also displayed a difference in the domains of Social Functioning (P = .331) and Mental Health (P = .130), but not significant. The minimum clinically relevant threshold values for the questionnaire ranged from 4.0 to 7.5 points.Conclusions: According to our results, the cross-cultural adapted questionnaire is a reliable and valid tool to measure HRQOL in German speaking patients with spinal malignancies. Especially the domains Physical Functioning and Pain showed overall good psychometric characteristics. In this way, a generic questionnaire, such as the EORTC QLQ-C30, can be usefully supplemented by spine-specific questions to increase the overall accuracy measuring HRQOL in patients with spinal malignancies. [ABSTRACT FROM AUTHOR]

In this study, mapping of ultrashort T2 and T2* of acutely isolated porcine menisci at B0 = 9.4 T was investigated. Maps of T2 were measured from a slice through the pars intermedia with a spin echo-prepared two-dimensional ultrashort-TE T2 mapping technique published previously. T2* mapping was performed by two-dimensional ultrashort-TE MRI with variable acquisition delay. The measured signal decays were fitted by monoexponential, biexponential and Gaussian-exponential fitting functions. The occurrence of Gaussian-like signal decays is outlined theoretically. The quality of the curve fits was visualized by mapping the value δ = abs(1 - χ2red). For T2* mapping, the Gaussian-exponential fit showed the best performance, whereas the monoexponential and biexponential fits showed regionally high values of δ ( δ > 20). Interpretation of the Gaussian-exponential parameter maps was found to be difficult, because a Gaussian signal component can be related to mesoscopic (collagen texture) or macroscopic (slice profile, shim, sample geometry) magnetic field inhomogeneities and/or residual 1H dipole-dipole couplings. It seems likely that an interplay of these effects yielded the observed signal decays. Modulation of the T2* signal decay caused by chemical shift was observed and addressed to fat protons by means of histology. In the T2 measurements, no modulation of the signal decay was observed and the biexponential and Gaussian-exponential fits showed the best performance with comparable values of δ. Our results suggest that T2 mapping provides the more robust method for the characterization of meniscal tissue by means of MRI relaxometry. However, mapping of ultrashort T2, as performed in this study, is time consuming and provides less signal-to-noise ratio per time than the mapping of T2*. If T2* mapping is used, pixel-wise monitoring of the fitting quality based on reduced χ2 should be employed and great care should be taken when interpreting the parameter maps of the fits. Copyright © 2013 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Purpose: The appropriate extrication techniques for trauma patients after car accidents remain a topic of controversy. Various techniques for immobilizing the cervical spine during prehospital extrication have been investigated., Methods: This explorative study compared the amount of spinal motion during five different extrication procedures from a racecar and a rallycar performed by two teams: a professional motorsport extrication team and a team of professional emergency medical technicians (EMTs). Two different microelectromechanical systems were used to measure spinal motion, and a motionscore was calculated to compare the amount of remaining spinal motion. A high motionscore indicates high remaining motion and a low motionscore indicates low remaining motion., Results: The use of an extricable seat results in a mean overall motion score of 1617 [95% CI 308-2926]. Emergency extrication without equipment resulted in the lowest overall motionscore 1448 [95% CI 1070-1826]. In case of urgent extrication the Extrication team attained a motionscore of 2118 [95% CI 517-3718] and the EMT team a motionscore of 2932 [95% CI 1427-4435]. When performing the procedure with the aid of a rescue boa, the EMT team achieved an overall mean motionscore in the same range 2725 [95% CI 568-4881] with boa vs. 2932 [95% CI 1427-4435] without boa. When mean scores of individual spinal segments were analyzed, we found that the EMT team did especially worse in immobilizing the cervical spine 198 vs. 758., Conclusions: Regular training of extrication procedures has paid off considerably in reducing spinal movement during extrication from a racecar. If an extricable seat is available, extrication should be performed using it. However, if emergency extrication is necessary, an additional manual cervical spine immobilization should be conducted using the Rautek maneuver to sufficiently reduce cervical spine movement., Competing Interests: Declarations. Ethical approval: This study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the Ethics Committee of the State Medical Association of the Rhineland-Palatinate (ID 837.508.15 (10,276)) and registered in the German Clinical Trials Register (ID DRKS00009505). Consent to participate: Informed consent was obtained from all individual participants included in the study. Consent for publication: All participants and co-authors gave their consent to publish the acquired data and images presented in the article. Competing interests: The authors declare no competing interests., (© 2024. The Author(s).)

Introduction: Data on the resumption of sporting activity (return-to-sport, RTS) after traumatic spine injuries are mainly available for elite athletes. This study aimed to determine the RTS rate in amateurs after spine injury and to identify factors possibly influencing RTS., Methods: First, a retrospective analysis of clinical data of patients with traumatic spine injuries receiving inpatient treatment at a national trauma center from 2016 to 2020 was performed. Patients up to the age of 60 who were active in sports before the injury were included. Patients with the following relevant concomitant injuries were excluded: spinal cord injury, pelvic injury, extremity injuries, as well as craniocerebral trauma grade 2 or higher. A telephone interview on participants' RTS within the first year after the injury was conducted. Participants with early and those with late or no RTS were compared in univariate analysis regarding potential influencing factors. The level of significance was set to p < .05., Results: Thirty-seven women (39%) and 57 men (61%) were included. The mean age was 44 years (16-60). The numbers of patients per injured segment of the spine were: cervical 15 (16%), thoracic 28 (30%), lumbar 33 (35%), multiple spine segments 18 (19%). Thirty patients (32%) were treated conservatively and 64 (68%) surgically. The RTS rate after six months was 62%, corresponding to 57 patients. Compared to patients with late or no RTS, patients with RTS within six months had a significantly lower BMI (24.6 vs. 27.4 kg/qm, p = .004), had isolated cervical spine injuries significantly more often (24% vs. 6%, p = .020), and had undergone outpatient or inpatient rehabilitation significantly less often (35% vs. 72%, p < .001). There were non-significant trends regarding mean age (42 vs. 46 years, p = .175), surgical therapy (66% vs. 75%, p = .333), and the proportion of patients who, before the injury, had been physically active for at least five hours per week (50% vs. 33%, p = .113). Patients with RTS within six months had sustained their spinal injury in a sports accident twice as often (28% vs. 14%, p = .121). Gender, preexisting medical or spinal conditions, severe injuries (types A4, B or C according to AO Spine), and surgical therapy were not significantly associated with RTS. The RTS rate within twelve months was 81% (76 patients)., Conclusion: The RTS rate in amateur athletes after an isolated spinal injury without spinal cord injury was high, with 62% after six and 81% after twelve months. This reflects the effectiveness of the existing treatment and posttreatment concepts. Normal-weight patients and isolated cervical injury are favorable factors for RTS. The use of inpatient rehabilitation as a marker of protracted healing is associated with delayed or no RTS., Competing Interests: Declarations Ethics approval and consent to participate This study was approved by the ethics committee in charge (Ethics Committee of the State Medical Association Rhineland-Palatinate, Mainz, Germany; application number 2022–16283). Every participant provided their informed consent. Consent for publication Not applicable. Competing interests The authors declare no competing interests., (© 2024. The Author(s).)

Introduction: There is a lack of information on return to sport and patient-reported outcome measures (PROMs) in amateur athletes after isolated spine injuries., Methods: A single-center cohort study in amateur athletes aged 18 to 60 with isolated spine injuries; clinical data collection and follow-up via telephone interview and standardized PROMs (Short-Form 36, Oswestry and Neck Disability Index, Tampa Scale of Kinesiophobia, Hospital Anxiety and Depression Scale, Pain Visual Analog Scale). Bivariate analyses of potential influencing factors on PROMs were conducted using the Wilcoxon Signed-Rank Test. p -values < 0.05 were considered statistically significant., Results: Out of the 80 included participants, 78% (n = 62) were active in sport at follow-up. PROMs were slightly worse than those described for the age-adjusted general population. There were consistent associations of better PROMs with having reached the subjective preinjury level of performance in sport, while injury severity and surgical or conservative therapy did not show consistent associations with PROMs., Conclusion: Most amateur athletes resume their sports activity after a spine injury. Better outcomes are associated with individuals' resumption of sport and subjective level of performance, while injury severity and surgical or conservative therapy do not show consistent associations with PROMs, highlighting the importance of patient education, rehabilitation, and encouragement.

Purpose: To determine the incidence of severe surgical adverse events (sSAE) after surgery of patients with subaxial cervical spine injury (sCS-Fx) and to identify patient, treatment, and injury-related risk factors., Methods: Retrospective analysis of clinical and radiological data of sCS-Fx patients treated surgically between 2010 and 2020 at a single national trauma center. Baseline characteristics of demographic data, preexisting conditions, treatment, and injury morphology were extracted. Incidences of sSAEs within 60 days after surgery were analyzed. Univariate analysis and binary logistic regression for the occurrence of one or more sSAEs were performed to identify risk factors. P-values < .05 were considered statistically significant., Results: Two hundred and ninety-two patients were included. At least one sSAE occurred in 49 patients (16.8%). Most frequent were sSAEs of the surgical site (wound healing disorder, infection, etc.) affecting 29 patients (9.9%). Independent potential risk factors in logistic regression were higher age (OR 1.02 [1.003-1.04], p = .022), the presence of one or more modifiers in the AO Spine Subaxial Injury Classification (OR 2.02 [1.03-3.96], p = .041), and potentially unstable or unstable facet injury (OR 2.49 [1.24-4.99], p = .010). Other suspected risk factors were not statistically significant, among these Injury Severity Score, the need for surgery for concomitant injuries, the primary injury type according to AO Spine, and preexisting medical conditions., Conclusion: sSAE rates after treatment of sCS-Fx are high. The identified risk factors are not perioperatively modifiable, but their knowledge should guide intra and postoperative care and surgical technique., (© 2024. The Author(s).)

Background: Paediatric thoracolumbar spine injuries are rare, and meaningful epidemiological data are lacking., Objectives: The aim of this study was to provide epidemiological data for paediatric patients with thoracolumbar spinal trauma in Germany with a view to enhancing future decision-making in relation to the diagnostics and treatment of these patients., Materials and Methods: A retrospective multicentre study includes patients up to 16 years of age who were suffering from thoracolumbar spine injuries who had been treated in six German spine centres between 01/2010 and 12/2016. The clinical database was analysed for patient-specific data, trauma mechanisms, level of injury, and any accompanying injuries. Diagnostic imaging and subsequent treatment were investigated. Patients were divided into three age groups for further evaluation: age group I (0-6 years), age group II (7-9 years) and age group III (10-16 years)., Results: A total of 153 children with 345 thoracolumbar spine injuries met the inclusion criteria. The mean age at the time of hospitalization due to the injury was 12.9 (± 3.1) years. Boys were likelier to be affected (1:1.3). In all age groups, falls and traffic accidents were the most common causes of thoracolumbar spine injuries. A total of 95 patients (62.1%) were treated conservatively, while 58 (37.9%) of the children underwent surgical treatment. Minimally invasive procedures were the most chosen procedures. Older children and adolescents were likelier to suffer from higher-grade injuries according to the AOSpine classification. The thoracolumbar junction (T11 to L2) was the most affected level along the thoracolumbar spine (n = 90). Neurological deficits were rarely seen in all age groups. Besides extremity injuries (n = 52, 30.2%), head injuries represented the most common accompanying injuries (n = 53, 30.8%). Regarding spinal injuries, most of the patients showed no evidence of complications during their hospital stay (96.7%)., Conclusions: The thoracolumbar junction was more frequently affected in older children and adolescents. The majority of thoracolumbar spinal column injuries were treated conservatively. Nevertheless, 37.9% of hospitalized children had to be treated surgically, and there was an acceptable complication rate for the surgeries that were performed., (© 2023. The Author(s).)

(1) Background: In elderly patients with type II odontoid fractures, accompanying severe atlantoaxial instability (AAI) is discussed as a marker possibly warranting more aggressive surgical therapy. This study aimed to characterize adverse events as well as the radiological and functional outcomes of surgical vs. conservative therapy in patients with odontoid fracture and AAI. (2) Methods: Patients aged 65 years and older with type II odontoid fracture and AAI treated were included. AAI was assumed if the mean subluxation across both atlantoaxial facet joints in the sagittal plane was greater than 50%. Data on demographics, comorbidities, treatment, adverse events, radiological, and functional outcomes were analyzed. (3) Results: Thirty-nine patients were included. Hospitalization time was significantly shorter in conservatively treated patients compared to patients with ventral or dorsal surgery. Adverse events occurred in 11 patients (28.2%), affecting 10 surgically treated patients (35.7%), and 1 conservatively treated patient (9.1%). Moreover, 25 patients were followed-up (64.1%). One secondary dislocation occurred in the conservative group (11.1%) and three in the surgical group (18.8%). (4) Conclusions: Despite the potential for instability in this injury, conservative treatment does not seem to lead to unfavorable short-term results, less adverse events, and a shorter hospital stay and should thus be considered and discussed with patients as a treatment option, even in the presence of severe AAI.

Introduction: This study analyzed the incidence of secondary dislocations (sDLs) after surgical stabilization of AO Spine type B and C injuries of the subaxial cervical spine (sCS)., Materials and Methods: Patients treated for injuries of the sCS from 2010 to 2020 were retrospectively analyzed for the incidence of sDL within 60 days after first surgery. A univariate analysis of variables potentially influencing the risk of sDL was performed. Patients with solitary anterior stabilization underwent subgroup analysis. The treatment of sDLs was described., Results: A total of 275 patients were included. sDLs occurred in 4.0% of patients ( n = 11) in the total sample, most frequently after solitary anterior stabilization with 8.0% ( n = 10, p = 0.010). Only one sDL occurred after combined stabilization and no sDLs after posterior stabilization. In the total sample and the anterior subgroup, variables significantly associated with sDL were older age ( p = 0.001) and concomitant unstable facet joint injury ( p = 0.020). No neurological deterioration occurred due to sDL and most patients were treated with added posterior stabilization. sDL is frequent after solitary anterior stabilization and rare after posterior or combined stabilization., Discussion: Patients of higher age and with unstable facet joint injuries should be followed up diligently to detect sDLs in time. Neurological deterioration does not regularly occur due to sDL, and most patients can be treated with added posterior stabilization.

Background: Different treatment options are discussed for geriatric odontoid fracture. The aim of this study was to compare the treatment options for geriatric odontoid fractures., Methods: Included were patients with the following criteria: age ≥ 65 years, identification of seniors at risk (ISAR score ≥ 2), and odontoid fracture type A/B according to Eysel and Roosen. Three groups were compared: conservative treatment, surgical therapy with ventral screw osteosynthesis or dorsal instrumentation. At a follow-up examination, the range of motion and the trabecular bone fracture healing rate were evaluated. Furthermore, demographic patient data, neurological status, length of stay at the hospital and at the intensive care unit (ICU) as well as the duration of surgery and occurring complications were analyzed., Results: A total of 72 patients were included and 43 patients could be re-examined (range: 2.7 ± 2.1 months). Patients with dorsal instrumentation had a better rotation. Other directions of motion were not significantly different. The trabecular bone fracture healing rate was 78.6%. The patients with dorsal instrumentation were hospitalized significantly longer; however, their duration at the ICU was shortest. There was no significant difference in complications., Conclusion: Geriatric patients with odontoid fracture require individual treatment planning. Dorsal instrumentation may offer some advantages., (© 2023. The Author(s).)

Study Design: Mutlidisciplinary consensus recommendations for patients suffering from multiple myeloma (MM) involvement of the spinal column by the Spine Section of the German Association of Orthopaedic and Trauma Surgeons., Objective: To provide a comprehensive multidisciplinary diagnostic and therapeutic approach and to summarize the current literature on the management of pathological thoracolumbar vertebral fractures in patients with multiple myeloma., Methods: Multidisciplinary recommendations using a classical consensus process provided by radiation oncologists, medical oncologists, orthopaedic- and trauma surgeons. A narrative literature review of the current diagnostic and treatment strategies was conducted., Results: Treatment decision has to be driven by a multidisciplinary team of oncologists, radiotherapists and spine surgeons. When considering surgery in MM patients, differing factors compared to other secondary spinal lesions have to be included into the decision process: probable neurological deterioration, the stage of the disease and prognosis, patient's general condition, localization and number of the lesions as well as patient's own wishes or expectations. Aiming to improve quality of life, the major goal of surgical treatment is to preserve mobility by reducing pain, secure neurological function and stability., Conclusion: The goal of surgery is primarily to improve quality of life by restoring stability and neurological function. Interventions with an increased risk of complications due to MM-associated immunodeficiency must be avoided whenever feasible to allow early systemic treatment. Hence, treatment decisions should be based on a multidisciplinary team that considers patient's constitution and prognosis.

Objectives: The aim of this study was to provide epidemiological data of pediatric patients suffering from cervical spinal trauma in Germany, in order to integrate these data in future decision-making processes concerning diagnosis and therapy., Materials and Methods: Retrospective multicenter study includes all patients up to 16 years suffering from cervical spine injuries who were treated in six German spine centers between 01/2010 and 12/2016. The clinical databases were screened for specific trauma mechanism, level of injury as well as accompanying injuries. Diagnostic imaging and the chosen therapy were analyzed. Patients were divided into three age groups for further evaluation: age group I (0-6 years), age group II (7-9 years), age group III (10-16 years)., Results: A total of 214 children with 265 cervical spine injuries were included during the mentioned period. The mean age at the time of injury was 11.9 (± 3.9) years. In age group I, 24 (11.2%) patients were included, age group II consisted of 22 patients (10.3%), and 168 patients belonged to age group III (78.5%). Girls and boys were equally affected. In all age groups, falls and traffic accidents were the most common causes of cervical spine injuries. A total of 180 patients (84.1%) were treated conservatively, while 34 (15.9%) children underwent surgery. Distorsion/whiplash injury was the most common entity (n = 165; 68.2%). Children aged 0-9 years had significantly (p < 0.001) more frequent injuries of the upper cervical spine (C0-C2) compared to older age groups. Patients of age group III were more likely to suffer from injuries in subaxial localizations. Neurological deficits were rarely seen in all age groups. Head injuries did represent the most common accompanying injuries (39.8%, n = 92)., Conclusions: The upper cervical spine was more frequently affected in young children. Older children more often suffered from subaxial pathologies. The majority of cervical spinal column injuries were treated conservatively. Nevertheless, 15% of the hospitalized children had to be treated surgically., (© 2023. The Author(s).)

The aim of this study was to determine whether early surgical treatment results in better neurological recovery 12 months after injury than late surgical treatment in patients with acute traumatic spinal cord injury (tSCI). Patients with tSCI requiring surgical spinal decompression presenting to 17 centres in Europe were recruited. Depending on the timing of decompression, patients were divided into early (≤ 12 hours after injury) and late (> 12 hours and < 14 days after injury) groups. The American Spinal Injury Association neurological (ASIA) examination was performed at baseline (after injury but before decompression) and at 12 months. The primary endpoint was the change in Lower Extremity Motor Score (LEMS) from baseline to 12 months. The final analyses comprised 159 patients in the early and 135 in the late group. Patients in the early group had significantly more severe neurological impairment before surgical treatment. For unadjusted complete-case analysis, mean change in LEMS was 15.6 (95% confidence interval (CI) 12.1 to 19.0) in the early and 11.3 (95% CI 8.3 to 14.3) in the late group, with a mean between-group difference of 4.3 (95% CI -0.3 to 8.8). Using multiply imputed data adjusting for baseline LEMS, baseline ASIA Impairment Scale (AIS), and propensity score, the mean between-group difference in the change in LEMS decreased to 2.2 (95% CI -1.5 to 5.9). Compared to late surgical decompression, early surgical decompression following acute tSCI did not result in statistically significant or clinically meaningful neurological improvements 12 months after injury. These results, however, do not impact the well-established need for acute, non-surgical tSCI management. This is the first study to highlight that a combination of baseline imbalances, ceiling effects, and loss to follow-up rates may yield an overestimate of the effect of early surgical decompression in unadjusted analyses, which underpins the importance of adjusted statistical analyses in acute tSCI research., Competing Interests: The authors have no conflicts of interest to declare., (© 2023 Author(s) et al.)

Introduction: There are no evidence-based recommendations for the post-operative treatment and application of soft or rigid cervical collars after operative treatment of injuries of the subaxial cervical spine. Cervical collars can restrict peak range of motion and serve as a reminder to the patient. However, they can also cause pressure ulcers. The aim of this online-based survey among German spine centres was to gain an overview of post-operative treatment and the application of soft or rigid cervical collars after surgical treatment of injuries of the subaxial cervical spine., Materials and Methods: An online-based survey was conducted among 59 spine centres certified by the German Spine Society. It comprised seven items and the option of adding remarks in the form of open-ended responses., Results: The return rate was 63% (37 out of 59). Of the 37 analysed spine centres, 51% routinely apply a cervical collar post-operatively, 27% apply a soft and 16% a rigid cervical collar, 8% sequentially apply first a rigid and later a soft cervical collar. Less than half of the spine centres (43%) routinely use no cervical collar. Rigid collars are applied for more than 6 weeks and soft collars up to 6 weeks at some spine centres. Standardised post-operative treatment plans are common. The selection of the post-operative treatment plan depends primarily on the type of injury and method of operation and partly on patient age and bone quality. The satisfaction of German spine centres with the current handling of post-operative treatment of subaxial cervical spine injuries is high., Discussion: The post-operative treatment of injuries of the subaxial cervical spine at German spine centres is heterogeneous, and the evidence on advantages and disadvantages of the post-operative application of cervical collars is insufficient. Planning and implementation of randomised controlled clinical trials in subaxial cervical spine injuries is challenging., Competing Interests: The authors declare that they have no conflict of interest./Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)

Purpose: This study aimed to identify the prevalence and predictors of spinal injuries that are suitable for immobilization., Methods: Retrospective cohort study drawing from the multi-center database of the TraumaRegister DGU ® , spinal injury patients ≥ 16 years of age who scored ≥ 3 on the Abbreviated Injury Scale (AIS) between 2009 and 2016 were enrolled., Results: The mean age of the 145,833 patients enrolled was 52.7 ± 21.1 years. The hospital mortality rate was 13.9%, and the mean injury severity score (ISS) was 21.8 ± 11.8. Seventy percent of patients had no spine injury, 25.9% scored 2-3 on the AIS, and 4.1% scored 4-6 on the AIS. Among patients with isolated traumatic brain injury (TBI), 26.8% had spinal injuries with an AIS score of 4-6. Among patients with multi-system trauma and TBI, 44.7% had spinal injuries that scored 4-6 on the AIS. Regression analysis predicted a serious spine injury (SI; AIS 3-6) with a prevalence of 10.6% and cervical spine injury (CSI; AIS 3-6) with a prevalence of 5.1%. Blunt trauma was a predictor for SI and CSI (OR 4.066 and OR 3.640, respectively; both p < 0.001) and fall > 3 m for SI (OR 2.243; p < 0.001) but not CSI (OR 0.636; p < 0.001). Pre-hospital shock was predictive for SI and CSI (OR 1.87 and OR 2.342, respectively; both p < 0.001), and diminished or absent motor response was also predictive for SI (OR 3.171) and CSI (OR 7.462; both p < 0.001). Patients over 65 years of age were more frequently affected by CSI., Conclusions: In addition to the clinical symptoms of pain, we identify '4S' [spill (fall) > 3 m, seniority (age > 65 years), seriously injured, skull/traumatic brain injury] as an indication for increased attention for CSIs or indication for spinal motion restriction., (© 2020. The Author(s).)

Purpose: For trauma surgeons, the evaluation of the stability of the upper cervical spine may be demanding. The aim of this study was to develop a protocol for decision-making on upper cervical spine stability in trauma patients based on established parameters obtained by CT imaging as well as testing the protocol by having it applied by trauma surgeons., Methods: A structured literature search on upper cervical spine stability was performed. The best evaluated instability criteria in CT imaging were determined. Based on these parameters a protocol for stability evaluation of the injured upper cervical spine was developed. A first application testing was performed. In addition to the assessment of instability, the time required for the assessment was analyzed., Results: A protocol for CT-based stability evaluation of the injured upper cervical spine based on the current literature was developed and displayed in a flow chart. Testing of the protocol found the stability of the cervical spine was correctly assessed in 55 of 56 evaluations (98.2%). In one test run, a stable upper cervical spine was judged to be unstable. Further analysis showed that this case was based on a measurement error. The assessment time of CT-images decreased significantly during repeat application of the protocol (p < 0.0001), from 336 ± 108 s (first case) to 180 ± 30 s (fourth case)., Conclusion: The protocol can be applied quickly and safely by non-specialized trauma surgeons. Thus, the protocol can support the decision-making process in CT-based evaluation of the stability of the injured upper cervical spine., (© 2021. Springer-Verlag GmbH Germany, part of Springer Nature.)

Objectives: The purpose of this study was to (i) develop a protocol that supports decision making for prehospital spinal immobilization in pediatric trauma patients based on evidence from current scientific literature and (ii) perform an applicability test on emergency medicine personnel., Methods: A structured search of the literature published between 1980 and 2019 was performed in MEDLINE using PubMed. Based on this literature search, a new Emergency Medicine Spinal Immobilization Protocol for pediatric trauma patients (E.M.S. IMMO Protocol Pediatric) was developed. Parameters found in the literature, such as trauma mechanism and clinical findings that accounted for a high probability of spinal injury, were included in the protocol. An applicability test was administered to German emergency medicine personnel using a questionnaire with case examples to assess correct decision making according to the protocol., Results: The E.M.S. IMMO Protocol Pediatric was developed based on evidence from published literature. In the applicability test involving 44 emergency medicine providers revealed that 82.9% of participants chose the correct type of immobilization based on the protocol. A total of 97.8% evaluated the E.M.S. IMMO Protocol Pediatric as helpful., Conclusions: Based on the current literature, the E.M.S. IMMO Protocol Pediatric was developed in accordance with established procedures used in trauma care. The decision regarding immobilization is made on based on the cardiopulmonary status of the patient, and life-threatening injuries are treated with priority. If the patient presents in stable condition, the necessity for full immobilization is assessed based upon the mechanisms of injury, assessment of impairment, and clinical examination., Competing Interests: Disclosure: The authors declare no conflict of interest., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Along with the growing geriatric population, the number of odontoid fractures is steadily increasing. However, the effectiveness of immobilizing geriatric odontoid fractures using a cervical collar has been questioned. The aim of the present study is to analyze the physiological and pathological motion in odontoid fractures and to assess limitation of motion in the cervical spine when applying a cervical collar., Methods: Motion analysis was performed with wireless motion tracker on unfixed geriatric human cadavers. First, a new geriatric type II odontoid fracture model was developed. In this model, the type II odontoid fracture is operated via a transoral approach. The physiological and pathological flexion and lateral bending of the cervical spine resulting from this procedure was measured. The resulting motion after external stabilization using a cervical collar was analyzed., Results: The new geriatric type II odontoid fracture model was successfully established using seven unfixed human cadavers. The pathological flexion of the cervical spine was significantly increased compared to the physiological flexion (p = 0.027). Furthermore, the flexion was significantly reduced when a cervical collar was applied. In case of flexion the mean remaining motion was significantly reduced (p = 0.0017) from 41° to 14°. For lateral bending the mean remaining motion was significantly reduced (p = 0.0137) from 48° to 18°., Conclusions: In case of type II odontoid fracture, flexion and lateral bending of the cervical spine are increased due to spinal instability. Thus, if an odontoid fracture is suspected in geriatric patients, the application of a cervical collar should always be considered since external stabilization can significantly reduce flexion and lateral bending., Competing Interests: The authors have declared that no competing interests exist.

The aim of this study was to compare the remaining motion of an immobilized cervical spine using an innovative cervical collar as well as two traditional cervical collars. The study was performed on eight fresh human cadavers. The cervical spine was immobilized with one innovative (Lubo Airway Collar) and two traditional cervical collars (Stifneck and Perfit ACE). The flexion and lateral bending of the cervical spine were measured using a wireless motion tracker (Xsens). With the Weinman Lubo Airway Collar attached, the mean remaining flexion was 20.0 ± 9.0°. The mean remaining flexion was lowest with the Laerdal Stifneck (13.1 ± 6.6°) or Ambu Perfit ACE (10.8 ± 5.8°) applied. Compared to that of the innovative Weinmann Lubo Airway Collar, the remaining cervical spine flexion was significantly decreased with the Ambu Perfit ACE. There was no significant difference in lateral bending between the three examined collars. The most effective immobilization of the cervical spine was achieved when traditional cervical collars were implemented. However, all tested cervical collars showed remaining motion of the cervical spine. Thus, alternative immobilization techniques should be considered., (© 2021. The Author(s).)

Background Context: Patients' outcome following traumatic atlanto-occipital dislocation (AOD) has been poor. In recent years, an increasing number of patients surviving the initial trauma are admitted to hospital. In order to further improve the management of these patients, the knowledge of diagnostics and therapy as well as possible complications should be increased., Purrpose: The aim of this study was to evaluate diagnostic parameters, therapy, early complications and outcome of patients with traumatic AOD., Study Design: Monocentric retrospective cohort study., Patient Sample: A total of 12 patients were included in this study., Outcome Measures: The main outcome measure was functional patient outcome. Furthermore, radiographic and treatment data were analyzed., Methods: All patients suffering from traumatic AOD within an 8-year time period were included. Demographic data, radiological diagnostic parameters (condylar sum, basion dens interval, basion axis interval, power´s ratio, x-line method), as well as treatment data and complications of every patient were analyzed. Radiological parameters were compared with each other. Outcome was analyzed by a follow up examination., Results: The accident mechanisms were motor vehicle accidents (MVA), fall from high and low height. Basion dens interval, basion axis interval, power's ratio and x-line method were not reliable in identifying traumatic AOD (only up to 33% of the patients were identified). Twelve patients could be reviewed. Three patients were treated with surgery, five patients were treated nonsurgically. Four patients died before surgical therapy. All seven surviving patients (survival rate: 58.3%) were re-examined (mean follow-up time: 6.7 months). All patients had a GCS of 15. Three surviving patients suffered from persisting neurological deficits., Conclusions: The most reliable way to diagnose AOD in Computer Topography is using the condylar sum. Surgical and nonsurgical measures can be employed with reasonable outcomes. Patient specific injury burden and clinical presentation should be taken into account when making treatment decisions for AOD., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Introduction: Demographic changes have resulted in an increase in injuries among geriatric patients. For these patients, a rigid cervical collar is crucial for immobilizing the cervical spine. However, evidence suggests that patients with a geriatric facial structure require a different means of immobilization than patients with an adult facial structure. This study aimed to analyze the remaining motion of the immobilized cervical spine based on facial structure., Materials and Methods: This study was performed on 8 fresh human cadavers. Facial structure was evaluated via ascertaining the mandibular angle by computer tomography. A mandibular angle below 130°, belongs to the adult facial structure group ( n = 4) and a mandibular angle above 130°, belongs to the geriatric facial structure group ( n = 4). The flexion and lateral bending of the immobilized cervical spine were analyzed in both groups using a wireless motion tracker system., Results: A flexion of up to 19.0° was measured in the adult facial structure group. The mean flexion in the adult vs. geriatric facial structure groups were 14.5° vs. 6.5° (ranges: 9.0-19.0 vs. 5.0-7.0°), respectively. Thus, cervical spine motion was ( p = 0.0286) significantly more reduced in the adult facial structure group. No ( p = 0.0571) significant difference was oberserved in the mean lateral bending of the adult facial structure group (14.5°) compared to the geriatric facial structure group (7.5°)., Conclusion: Emergency medical service personnel should therefore follow current guidelines and recommendations and perform cervical spine immobilization with a cervical collar, including in patients with a geriatric facial structure., Competing Interests: Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2021.)

Objective: Dorsal stabilization is a frequently used procedure in the treatment of acute traumatic vertebral body fractures. Besides the traditional open surgical procedure, the percutaneous positioning of pedicle screws is now widely used. The aim of the current study is to compare pedicle screw misplacement following open vs. percutaneous dorsal instrumentation after traumatic spinal fracture of the thoracic and lumbar spine and to assess possible risk factors associated with pedicle screw misplacement., Methods: All patients who suffered a traumatic spinal fracture that were treated with dorsal stabilization in our level I trauma center in the period from 01/2007 to 03/2014 were included in this retrospective therapeutic cohort study. From 01/2007 to 06/2009, an open surgical procedure was used, and from 06/2009 to 03/2014, the percutaneous procedure was used for all types of fractures. Retrospectively, the positioning of every single pedicle screw was evaluated in the post-operative computed tomography scan and classified. Epidemiological data were also documented to compare the two treatment groups., Results: A total of 491 patients with 681 vertebral body fractures were included. Of 733 pedicle screws placed during the open surgery procedure, 96.0% were within the safe zone. There was no significant difference compared with pedicle screws placed percutaneously (95.3% of 1884 screws). In all other categories, the number of misplaced pedicle screws also showed no differences between the two treatment groups. There is a positive correlation between pedicle screw misplacement and duration of the operation. Most pedicle screws are misplaced at the levels T12, L1 and T7, T8., Conclusion: The current study shows that percutaneous surgery using dorsal stabilization allows the positioning of pedicle screws in an equivalently safe manner compared with an open surgical procedure in the acute care of spinal trauma.

Purpose: It remains controversial how to immobilize the cervical spine (CS) in trauma patients. Therefore, we analyzed different CS immobilization techniques during prehospital patient transport., Methods: In this explorative, biomechanical analysis of immobilization techniques conducted in a standardized setting, we recorded CS motion during patient transport using a wireless human motion tracker on a volunteer. To interpret spinal movement a benchmark called motionscore (MS) was developed based on biomechanics of the injured spine., Results: We found the best spinal motion restriction using a spine board, head blocks and immobilization straps with and without a cervical collar (CC) (MS 45 vs. 27). Spinal motion restriction on a vacuum mattress with CC and head blocks was superior to no CC or head blocks (MS 103 vs. 152). An inclined vacuum mattress was more effective with head blocks than without (MS 124 vs. 187). Minimal immobilization with an ambulance cot, CC, pillow and tape was slightly superior to a vacuum mattress with CC and head blocks (MS 92 vs. 103). Minimal immobilization without CC showed the lowest spinal motion restriction (MS 517)., Conclusions: We suggest an immobilization procedure customized to the individual situation. A spine board should be used whenever spinal motion restriction is indicated and the utilization is possible. In some cases, CS immobilization by a vacuum mattress with CC and head blocks could be more beneficial. In an unstable status of the patient, minimal immobilization may be performed using an ambulance cot, pillow, CC and tape to minimize time on scene caused by immobilization.

Background: Spinal stabilization by an anterior vertebral body replacement is frequently used in patients suffering from destroyed vertebral bodies. The aim of this study was to analyse (i) the choice of endplate size and positioning of vertebral body replacements in daily patient care and (ii) if these factors have an influence on clinical and radiological outcomes., Method: Patients' outcomes were analysed three years after vertebral body replacement implantation using the visual analogue scale spine score. Safe zones on the vertebral body endplates were defined. Overall endplate coverage and implant subsidence were evaluated by CT and X-ray. Compression tests were performed on 22 lumbar vertebral bodies to analyse endplates sizes' influence on subsidence., Finding: Mean coverage of the vertebral body's superior and inferior endplates by the vertebral body replacement was 27.8% and 30.8%, respectively. Mean overlap of the safe zone by the implant was 49.8% and 40.6%. Mean subsidence was 1.1 ± 1.2 mm, but it did not have any effect on the outcome. In the compression tests, no significant difference (p = 0.468) was found between the two endplate sizes., Interpretation: Coverage of vertebral body endplates and positioning of implants in the safe zone did not entirely comply with the given recommendations. The amount of endplate coverage had no influence on subsidence or long-term outcomes in daily patient care. On the other hand, correct positioning of the implant may influence its subsidence., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Background: Spinal immobilization is a standard procedure in daily out-of-hospital emergency care. Homogenous recommendations concerning the immobilization of trauma patients during the first therapy in the emergency department do not exist. The aim of the current study was the analysis of the existing strategies concerning spinal immobilization in German level I trauma centers by an internet-based survey., Materials and Methods: The current study is a survey-based analysis of the current strategies concerning spinal immobilization in all 107 level I trauma centers in Germany. The internet-based survey consists of 6 items asking about immobilization in the emergency department., Results: The return rate was 47.7%. In 14 (28.6%) level I trauma centers the patients remained immobilized on the immobilization tool used by the professional emergency care providers. In 19 (38.8%) level I trauma centers the patients were transferred to a stretcher with a soft positioning mattress on it. Patient transfer to a spineboard or to a TraumaMattress was performed in 11 (22.4%) and 7 (14.3%) level I trauma centers, respectively. Trauma patients were never transferred to a vacuum mattress. Cervical spine protection was most of the time performed by a cervical collar (n = 48; 98.0%). In general, the survey's participants were mainly satisfied (mean = 84/100) with the current strategy of spinal immobilization. The satisfaction was best if the spineboard is used., Discussion: Patient positioning during initial emergency therapy in the emergency department of German level I trauma centers is highly heterogenous. Besides complete full body immobilization, also the lack of any immobilization was reported by the survey's participants., Competing Interests: The authors declare that they have no conflict of interest./Die Autoren geben an, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)

Background: Immobilization of the cervical spine by Emergency Medical Services (EMS) personnel is a standard procedure. In most EMS, multiple immobilization tools are available.The aim of this study is the analysis of residual spine motion under different types of cervical spine immobilization., Methods: In this explorative biomechanical study, different immobilization techniques were performed on three healthy subjects. The test subjects' heads were then passively moved to cause standardized spinal motion. The primary endpoints were the remaining range of motion for flexion, extension, bending, and rotation measured with a wireless human motion detector., Results: In the case of immobilization of the test person (TP) on a straight (0°) vacuum mattress, the remaining rotation of the cervical spine could be reduced from 7° to 3° by additional headblocks. Also, the remaining flexion and extension were reduced from 14° to 3° and from 15° to 6°, respectively. The subjects' immobilization was best on a spine board using a headlock system and the Spider Strap belt system (MIH-Medical; Georgsmarienhütte, Germany). However, the remaining cervical spine extension increased from 1° to 9° if a Speedclip belt system was used (Laerdal; Stavanger, Norway). The additional use of a cervical collar was not advantageous in reducing cervical spine movement with a spine board or vacuum mattress., Conclusions: The remaining movement of the cervical spine is minimal when the patient is immobilized on a spine board with a headlock system and a Spider Strap harness system or on a vacuum mattress with additional headblocks. The remaining movement of the cervical spine could not be reduced by the additional use of a cervical collar.

Study Design: Retrospective cohort study., Objectives: Doubts still remain whether a sufficient reduction of vertebral body fractures can be achieved if a percutaneous surgical approach is adopted. The aim of this retrospective cohort study was to analyze the reduction and perioperative complications using a percutaneous versus open surgical approach for dorsal stabilization., Methods: Patients suffering from a traumatic injury of the thoracic or lumbar spine who were treated with dorsal stabilization at our level 1 trauma center were included. From January 2007 through June 2009, only the open approach was used; from June 2009 through March 2014, only the percutaneous approach with a special reduction technique was used. Retrospectively, total reduction, perioperative and intraoperative data, and postoperative complications were analyzed., Results: Using the percutaneous (n=185) versus open surgical approach (n=91), the mean reduction over all spinal injuries was 7.7±6.6 versus 8.3±5.5 degrees, respectively. The mean operation time was 75.5±50.2 versus 71.5±41.9 minutes, respectively. There was no significant difference between the 2 treatment groups in terms of the total reduction (P=0.753) or operation time (P=0.814).After the percutaneous and open surgical approach, 7 (3.8%) and 22 (24.2%) complications were documented. Complications requiring interventions were more frequent in the open treatment group., Conclusions: Percutaneous dorsal stabilization seems to be a good alternative to the traditional open surgical approach. The fracture's reduction is similar, whereas severe complications are reduced and the operation time is not prolonged., Level of Evidence: Level III-retrospective cohort study.

Objective: The diagnosis of instability of the injured upper cervical spine remains controversial, due to its complicated anatomical configuration and biomechanical property. Since identifying unstable injuries of the upper cervical spine is essential for immediate stabilizing therapy, this article reviews the current classification systems of upper cervical spine injuries and their statements towards instability., Methods: A systematic review of literature concerning upper cervical spine injuries was performed on the PubMed database from inception to December 2019. An English literature search was conducted using various combinations of keyword terms., Results: Numerous separate classification systems for each specific injury of the upper cervical spine were obtained. The early classifications are based primarily on injury morphology and mechanism. The recent classifications pay more attention to the investigation of ligamentous status. Various instability criteria were established as well. The determinants involve translation, vertical distraction, angulation, rotation, obliquity of fracture line, comminution, and ligamentous disruption. The status of crucial ligaments plays a key role in determining instability of upper cervical spine injuries. CT scan is more sensitive and reliable than X-ray in detecting misalignment of the upper cervical spine., Conclusion: Only a few classification systems support decision-making concerning instability leading to early operative treatment. The ligamentous integrity is the key element of impacting the stability of the upper cervical spine injuries. The transverse ligament serves as the most crucial element in determining the stability of occipital condyle fractures and atlas fractures as well as atlanto-axial injury. The integrity of anterior longitudinal ligament, disc, and facet joint attributes to the stability of axis fractures. The integrity of tectorial membrane and alar ligaments determines the stability of atlanto-occipital dislocation. The development of a newly classification system concerning ligamentous instability with a high clinical and scientific impact is recommended.

Objectives: The extrication of patients following a road traffic collision is among the basic procedures in emergency medicine. Thus, extrication is a frequently performed procedure by most of the emergency medical services worldwide. The appropriate extrication procedure depends on the patient's current condition and accompanying injuries. A rapid extrication should be performed within a few minutes, and the cervical spine (at least) should be immobilized. To our knowledge, the scientific literature and current guidelines do not offer detailed recommendations on the extrication of injured patients. Thus, the aim of the current study is to compare the effectiveness of spinal stabilization during various out-of-hospital extrication procedures., Methods: This is an explorative, biomechanical analysis of spine motion during different extrication procedures on an example patient. Movement of the cervical spine was measured using a wireless human motion tracker. Movement of the thoracic and lumbar spine was quantified with 12 strain gauge sensors, which were positioned paravertebrally on both sites along the thoracic and lumbar spine. To interpret angular movement, a motionscore was developed based on newly defined axioms on the biomechanics of the injured spine., Results: Self-extrication showed the least spinal movement (overall motionscore sum = 667). Movement in the cervical spine could further be reduced by applying a cervical collar. The extrication by a rescue boa showed comparable results in overall spinal movement compared to the traditional extrication via spineboard (overall motionscore sum = 1862vs. 1743). Especially in the cervical spine, the spinal movement was reduced (motionscore sum = 339 vs. 595). However, the thoracic spine movement was increased (motionscore sum = 812 vs. 432)., Conclusion: In case of a suspected cervical spine injury, guided self-extrication seems to be the best option. If the patient is not able to perform self-extrication, using a rescue boa might reduce cervical spinal movement compared to the traditional extrication procedure. Since promising results are shown in the case of extrication using a patient transfer sheet that has already been placed below the driver, future developments should focus on novel vehicle seats that already include an extrication device., Competing Interests: Declaration of Competing Interest DH and LS are PHTLS instructors. BG is consulting the PAX company and receives revenue from the sale of the rescue boa. The other authors declare that they have no competing interests., (Copyright © 2019 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Background: In professional motorbike racing falls with high velocities are common. Nonetheless, severe injuries or deaths are rare when compared to regular road traffic., Methods: In this study, falls in all courses of the largest German race series IDM*Superbike between 2007 and 2013 were analyzed regarding injury patterns and hospital admissions. All races were accompanied by a medical team, including at least one physician who assessed every patient., Results: A total of 728 falls were included. A specific fall mechanism could be determined in 45.5% of the cases. 40.5% were admitted to a trauma center for further diagnostics. A definitive diagnosis was found in 45.4%. In most cases (29.9%) the injury pattern was a fracture of the extremities. In collisions a significantly higher odds ratio of 2.52 (P=0.0001) and in undetermined falls a significantly lower odds ratio of 0.47 (P<0.0001) was observed., Conclusions: Fall patterns in professional motorbike racing do not significantly correlate with the severity of the injury. Thus, as in regular patient evaluation, each patient has to be examined thoroughly to avoid misinterpretation.

Introduction: Although open procedures are the gold standard, the alternative approach of minimal invasive reduction using percutaneous screws for thoracic and lumbar spine fractures is under discussion. Aim of this study was to investigate the results of reduction and the accuracy of screw placement in minimally invasive percutaneous posterior instrumentation for these fractures., Materials and Methods: One hundred and twenty-seven patients with thoraco-lumbar and lumbar burst fractures and minimal invasive dorsal instrumentation were analyzed retrospectively in terms of the accuracy of pedicle screw placement and results of fracture reduction., Results: In total, 542 screws were placed. Thirty-four (6.3%) screws of 22 patients (17.3%) were misplaced, but misplacement was minimal, replacement of any screw position due to instability was not necessary, and no new neurological deficit occurred. In thoraco-lumbar fractures (82/64.5%), reduction succeeded from 2.5 ± 6° kyphosis to 5.6 ± 5.7° lordosis (p < 0.001) and in lumbar spine fractures from 6.9° ± 10.3° lordosis to 14.5° ± 8.8° lordosis (p < 0.001)., Conclusion: Minimal invasive percutaneous dorsal instrumentation of burst fractures of the thoraco-lumbar and lumbar spine provides adequate reduction and reliable regular screw placement., Level of Evidence: Level IV (retrospective series).

Purpose: To analyze the compression of the dural sac and the cervical spinal movement during performing different airway interventions in case of atlanto-occipital dislocation., Methods: In six fresh cadavers, atlanto-occipital dislocation was performed by distracting the opened atlanto-occipital joint capsule and sectioning the tectorial membrane. Airway management was done using three airway devices (direct laryngoscopy, video laryngoscopy, and insertion of a laryngeal tube). The change of dural sac's width and intervertebral angulation in stable and unstable atlanto-occipital conditions were recorded by video fluoroscopy with myelography. Three-dimensional overall movement of cervical spine was measured in a wireless human motion track system., Results: Compared with a mean dural sac compression of - 0.5 mm (- 0.7 to - 0.3 mm) in stable condition, direct laryngoscopy caused an increased dural sac compression of - 1.6 mm (- 1.9 to - 0.6 mm, p = 0.028) in the unstable atlanto-occipital condition. No increased compression on dural sac was found using video laryngoscopy or the laryngeal tube. Moreover, direct laryngoscopy caused greater overall extension and rotation of cervical spine than laryngeal tube insertion in both stable and unstable conditions. Among three procedures, the insertion of a laryngeal tube took the shortest time., Conclusion: In case of atlanto-occipital dislocation, intubation using direct laryngoscopy exacerbates dural sac compression and may cause damage to the spinal cord.

The quantification of spinal movement to investigate the efficacy of prehospital immobilization devices and techniques remains difficult. Therefore, we aim to systematically review the literature on reported measurement tools applicable within this research field. A keyword literature search of relevant articles was performed using the database of PubMed including international literature published in English between January 2010 and December 2015. Only studies describing methods applicable to estimate spinal movement during prehospital immobilization were included. Six measurement tools were found that have either been used (goniometer/inclinometer, imaging modalities, electromagnetic systems, and optoelectronic systems) or have the potential to be used (inertial measurement units and a combination of strain gauge technology and accelerometers) in this research field. Novel devices can assess spinal motion during prehospital care including extrication, application of immobilization devices, and transportation from the site of the accident to the final destination, and therefore can be considered for usage.

Background: Unstable conditions of the craniocervical junction such as atlanto-occipital dislocation (AOD) or atlanto-axial instability (AAI) are severe injuries with a high risk of tetraplegia or death. Immobilization by a cervical collar to protect the patient from secondary damage is a standard procedure in trauma patients. If the application of a cervical collar to a patient with an unstable craniocervical condition may cause segmental motion and secondary injury to the spinal cord is unknown. The aim of the current study is (i) to analyze compression on the dural sac and (ii) to determine relative motion of the cervical spine during the procedure of applying a cervical collar in case of ligamentous unstable craniocervical junction., Methods and Findings: Ligamentous AOD as well as AOD combined with ligamentous AAI was simulated in two newly developed cadaveric trauma models. Compression of the dural sac and segmental angulation in the upper cervical spine were measured on video fluoroscopy after myelography during the application of a cervical collar. Furthermore, overall three-dimensional motion of the cervical spine was measured by a motion tracking system. In six cadavers each, the two new trauma models on AOD and AOD combined with AAI could be implemented. Mean dural sac compression was significantly increased to -1.1 mm (-1.3 to -0.7 mm) in case of AOD and -1.2 mm (-1.6 to -0.6 mm) in the combined model of AOD and AAI. Furthermore, there is a significant increased angulation at the C0/C1 level in the AOD model. Immense three-dimensional movement up to 22.9° of cervical spine flexion was documented during the procedure., Conclusion: The current study pointed out that applying a cervical collar in general will cause immense three-dimensional movement. In case of unstable craniocervical junction, this leads to a dural sac compression and thus to possible damage to the spinal cord.

Primary Objective: We evaluated the neurologic, psychological and vegetative outcome, the health status and changes of the personal and occupational status of patients after traumatic brain injuries (TBIs). Correlations between outcome parameters and basic demographic factors and initial clinical status parameters of the patients were assessed., Research Design: Monocentric, retrospective follow-up analysis., Methods and Procedures: We evaluated the neurologic, psychological and vegetative outcome and health status of patients, who survived TBI with a mean follow-up time of 54 months. Glasgow Outcome Scale (GOS), Disability Rating Scale (DRS) and a questionnaire on Quality of Life were used for outcome measurement. The personal and occupational status, trauma-derived changes to that status and medical and demographic factors that have an impact on the health condition of patients after TBI were assessed., Main Outcomes and Results: With a median GOS of 5.0 and median DRS of 3.0, our patients showed just moderate disabilities. Fifty-six per cent of the patients felt 'very good' or 'good'. Age, gender, the preclinical Glasgow Coma Scale (GCS), state of pupil reaction and surgical treatment did not seem to affect the GOS or DRS. Correlations between body mass index, age and gender and distinct neurologic, psychological and vegetative symptoms were found. The personal status did not change significantly after TBI. Changes to occupational and socioeconomic status were evident., Conclusions: One-third of the patients are heavily affected by neurological, psychological and vegetative symptoms after surviving TBI. Some demographic factors affected this integrity.

Introduction: Emergency management of upper cervical spine injuries often requires cervical spine immobilisation and some critical patients also require airway management. The movement of cervical spine created by tracheal intubation and cervical spine immobilisation can potentially exacerbate cervical spinal cord injury. However, the evidence that previous studies have provided remains unclear, due to lack of a direct measurement technique for dural sac's space during dynamic processes. Our study will use myelography method and a wireless human motion tracker to characterise and compare the change of dural sac's space during tracheal intubations and cervical spine immobilisation in the presence of unstable upper cervical spine injury such as atlanto-occipital dislocation or type II odontoid fracture., Methods and Analysis: Perform laryngoscopy and intubation, video laryngoscope intubation, laryngeal tube insertion, fiberoptic intubation and cervical collar application on cadaveric models of unstable upper cervical spine injury such as atlanto-occipital dislocation or type II odontoid fracture. The change of dural sac's space and the motion of unstable cervical segment are recorded by video fluoroscopy with previously performing myelography, which enables us to directly measure dural sac's space. Simultaneously, the whole cervical spine motion is recorded at a wireless human motion tracker. The maximum dural sac compression and the maximum angulation and distraction of the injured segment are measured by reviewing fluoroscopic and myelography images., Ethics and Dissemination: This study protocol has been approved by the Ethics Committee of the State Medical Association Rhineland-Palatinate, Mainz, Germany. The results will be published in relevant emergency journals and presented at relevant conferences., Trial Registration Number: DRKS00010499., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Purpose: The aim of the current study is to analyze perioperative data and complications of open vs. percutaneous dorsal instrumentation after dorsal stabilization in patients suffering from fractures of the thoracic or lumbar spine., Methods: In the time period from 01/2007 to 06/2009, open surgical approach was used for dorsal stabilization. The percutaneous surgical approach was used from 05/2009 to 03/2014. In every time period, all types of fractures were treated only by open or by percutaneous approach, respectively, to avoid any selection bias. Retrospectively, epidemiological data, complications and perioperative data were documented and statistically analyzed., Results: A total of 491 patients met the inclusion criteria. Open surgery procedure was carried out on 169 patients, and percutaneous surgery procedure was carried out on 322 patients. Fracture level ranged from T1 to L5, and fractures were classified types A, B, and C. In 91.4% of all patients, no complication occured following dorsal stabilization after traumatic spine fracture during their hospital stay. However, 42 complications related to dorsal stabilization have been documented during the hospital stay. The complication rate was 14.8% if open surgical approach has been used and was significantly reduced to 5.3% using percutaneous surgical approach. Post-operative hospital stay was also reduced significantly using the percutaneous surgical approach., Conclusions: According to the current study, percutaneous dorsal stabilization of the spine could also be safely used in trauma cases and is not restricted to degenerative spinal surgery.

Study Design: A prospective monocentric study., Objective: The aim of the current study was the analysis of patient outcome and radiological results 3 years after implantation of a hydraulic expandable vertebral body replacement (VBR) system., Summary of Background Data: Around 70% to 90% of all traumatic spinal fractures are located in the thoracic and lumbar spine. Dorso-ventral stabilization is a frequently used procedure in traumatic vertebral body fracture treatment. VBR systems can be used to bridge bony defects. In the current study, a new VBR expanded by water pressure with adjustable endplates is used., Methods: All patients who suffered a singular traumatic fracture to a thoracic or lumbar vertebral body (Th 5-L 5) in the period from November 2009 to December 2010 and (i) underwent dorsal instrumentation and (ii) afterwards received the implantation of a hydraulic VBR were included in this study. The clinical outcome (visual analogue scale [VAS] spine score, questionnaire) and radiological findings (sagittal angle, implant subsidence, and implant position) 3 years after implantation were analyzed., Results: The follow-up was successful for n = 47 patients (follow-up rate: 89%). Most of the patients (n = 40) were "generally/very satisfied" with their outcome. The mean rating of the VAS spine score was 65.2 ± 23.1 (range: 20.5-100.0). The analysis of the radiological data showed an average subsidence of the implants of 1.1 ± 1.2 mm (range 0.0-5.0 mm). After the initial operation, the local sagittal angle remained stable in the follow-up 3 years later both for the thoracic spine and lumbar spine. Furthermore, no change in the implant's position was observed., Conclusion: The implantation of a hydraulically expandable VBR allows a permanent stable fixation after traumatic fractures of the thoracic and lumbar spine., Level of Evidence: 2.

Study Design: Retrospective cohort study., Objectives: The aims of the current study were (i) to analyze prehospital and emergency room treatment of patients with acute traumatic spinal cord injury (SCI) and (ii) to analyze whether recommendations given by the current guidelines are implemented., Setting: German level I trauma center., Methods: All patients suffering from traumatic SCI who were initially surgically treated in our hospital in the period from January 2008 to December 2013 were included in this study. Available data documented as a standard procedure in our trauma center included patient's demographic and medical information, as well as trauma mechanisms, cause of injury, neurological diagnosis and detailed clinical information about prehospital and early hospital management procedures. Retrospectively, statistical analysis was performed to describe spinal immobilization rates, transportation times and methylprednisolone administration., Results: A total of 133 patients (mean age: 50.5±21.2 years) met the inclusion criteria. Immobilization was performed on 69.9% of the patients with traumatic SCI. From 60 patients suffering from cervical traumatic SCI, 47 patients had a cervical collar. Full immobilization was only performed in 34 of these 60 patients. Mean time from accident site to emergency room was 61.3±28.7 min. In 25 out of the 133 patients included in the current study, early surgery was not possible because of insufficient circulation and/or increased intracranial pressure. A total of 108 patients could be prepared for early surgery within 322.8±254.1 min after the accident., Conclusion: The current study shows that recommendations of the current literature and guidelines are mostly followed.

The influence of complications and comorbidities on the outcome of patients with traumatic spinal cord injury after early surgery is unclear. The aim of the current study was to analyze the influence of previous comorbidities and common complications on motor function outcome of patients with traumatic spinal cord injury if early surgery was performed. All patients with a traumatic spinal cord injury who were initially surgically treated in our hospital in the period from January 2008 to December 2013 were included in this study. Epidemiological data and previous comorbidities (cardiovascular, pulmonary, metabolic, spinal) were documented. A neurological assessment was performed using the American Spinal Injury Association (ASIA) score. Retrospectively, patients' personal data (age, gender, comorbidities) and clinical data (complications, ASIA score, motor function) were analyzed statistically. A total of 133 patients met the inclusion criteria. The level of spinal cord injury ranged from C3 to L4. Motor function was improved from 51.5 ± 24.8 to 60.1 ± 25.0 (improvement: 25.7%). The most common complications were urinary tract infection and pneumonia. There is a significant relationship between a lack of previous spinal comorbidities and a better outcome in terms of motor function. No other comorbidities or complications showed any effect on motor function outcome. The current study shows that motor function was able to be improved in patients who were given early surgery after a traumatic spinal cord injury. Common complications as well as previous cardiovascular, pulmonary, and metabolic comorbidities do not impair motor function outcome. The final motor function score is reduced if patients have previous spinal comorbidities.

Introduction: The Göttingen Minipig (GM) is used as large animal model in articular cartilage research. The aim of the study was to introduce osteoarthritis (OA) in the GM by resecting the anterior cruciate ligament (ACLR) according to Pond and Nuki, verified by histological and magnetic resonance imaging (MRI) scoring as well as analysis of gene and protein expression., Materials and Methods: The eight included skeletally mature female GM were assessed after ACLR in the left and a sham operation in the right knee, which served as control. 26 weeks after surgery the knee joints were scanned using a 3-Tesla high-field MR tomography unit with a 3 T CP Large Flex Coil. Standard proton-density weighted fat saturated sequences in coronal and sagittal direction with a slice thickness of 3 mm were used. The MRI scans were assessed by two radiologists according to a modified WORMS-score, the X-rays of the knee joints by two evaluators. Osteochondral plugs with a diameter of 4mm were taken for histological examination from either the main loading zone or the macroscopic most degenerated parts of the tibia plateau or condyle respectively. The histological sections were blinded and scored by three experts according to Little et al. Gene expression analysis was performed from surrounding cartilage. Expression of adamts4, adamts5, acan, col1A1, col2, il-1ß, mmp1, mmp3, mmp13, vegf was determined by qRT-PCR. Immunohistochemical staining (IH) of Col I and II was performed. IH was scored using a 4 point grading (0-no staining; 3-intense staining)., Results and Discussion: Similar signs of OA were evident both in ACLR and sham operated knee joints with the histological scoring result of the ACLR joints with 6.48 ± 5.67 points and the sham joints with 6.86 ± 5.84 points (p = 0.7953) The MRI scoring yielded 0.34 ± 0.89 points for the ACLR and 0.03 ± 0.17 for the sham knee joints. There was no correlation between the histological and MRI scores (r = 0.10021). The gene expression profiles as well as the immunohistochemical findings showed no significant differences between ACLR and sham knee joints. In conclusion, both knee joints showed histological signs of OA after 26 weeks irrespective of whether the ACL was resected or not. As MRI results did not match the histological findings, MRI was obviously unsuitable to diagnose the OA in GM. The analysis of the expression patterns of the 10 genes could not shed light on the question, whether sham operation also induced cartilage erosion or if the degeneration was spontaneous. The modified Pond-Nuki model may be used with reservation in the adult minipig to induce an isolated osteoarthritis., Competing Interests: The authors have declared that no competing interests exist.

Background/objective: The menisci of the mammalian knee joint balance the incongruence between femoral condyle and tibial plateau and thus menisci absorb and distribute high loads. Degeneration processes of the menisci lead to pain syndromes in the knee joint. The origin of such degenerative processes on meniscal tissue is rarely understood and may be described best as an imbalance of anabolic and catabolic metabolism. A standardized animal model of meniscal degeneration is needed for further studies. The aim of the current study was to develop a porcine animal model with early meniscal degeneration., Material and Methods: Resection of the anterior cruciate ligament (ACLR) was performed on the left knee joints of eight Göttingen minipigs. A sham operation was carried out on the right knee joint. The grade of degeneration was determined 26 weeks after the operation using histology and magnetic resonance imaging (MRI). Furthermore, the expression of 14 genes which code for extracellular matrix proteins, catabolic matrix metalloproteinases and inflammation mediators were analyzed., Results: Degenerative changes were detected by a histological analysis of the medial meniscus after ACLR. These changes were not detected by MRI. In terms of their gene expression profile, these degenerated medial menisci showed a significantly increased expression of COL1A1., Conclusion: This paper describes a new animal model for early secondary meniscal degeneration in the Göttingen minipig. Histopathological evidence of the degenerative changes could be described. This early degenerative changes could not be seen by NMR imaging.

Background: In order to match the challenges of quickly recognizing and treating any life-threatening injuries, the ABCDE principles were established for the assessment and treatment of trauma patients. The high priority of spine protection is emphasized by the fact that immobilization of the cervical spine is performed at the very first step in the ABCDE principles. Immobilization is typically performed to prevent or minimize secondary damage to the spinal cord if instability of the spinal column is suspected. Due to increasing reports about disadvantages of spinal immobilization, the indications for performing spinal immobilization must be refined. The aim of this study was (i) to develop a protocol that supports decision-making for spinal immobilization in adult trauma patients and (ii) to carry out the first applicability test by emergency medical personnel., Methods: A structured literature search considering the literature from 1980 to 2014 was performed. Based on this literature and on the current guidelines, a new protocol that supports on scene decision-making for spinal immobilization has been developed. Parameters found in the literature concerning mechanisms and factors increasing the likelihood of spinal injury have been included in the new protocol. In order to test the applicability of the new protocol two surveys were performed on German emergency care providers by means of a questionnaire focused on correct decision-making if applying the protocol., Results: Based on the current literature and guidelines, the Emergency Medicine Spinal Immobilization Protocol (E.M.S. IMMO Protocol) for adult trauma patients was developed. Following a fist applicability test involving 21 participants, the first version of the E.M.S. IMMO Protocol has to be graphically re-organized. A second applicability test comprised 50 participants with the current version of the protocol confirmed good applicability. Questions regarding immobilization of trauma patients could be answered properly using the E.M.S. IMMO Protocol., Discussion: Current literature increasingly reports of disadvantages that may be associated with immobilization. Based on the requirements of the current guidelines, a new protocol that supports decision-making for indications for out-of-hospital spinal immobilization has been developed in this study. In contrast to established protocols, the new protocol offers different options for immobilization as well as a decicion-support., Conclusions: The E.M.S. IMMO protocol provides a decision-support tool for indications for spinal immobilization in adult trauma patients that permits variable decision-making depending on the current condition of the trauma patient and the pattern of injuries for immobilization in general and for immobilization method in particular.

The origin of the age-associated degenerative processes in meniscal tissue is poorly understood and may be related to an imbalance of anabolic and catabolic metabolism. The aim of the current study was to compare medial menisci isolated from juvenile pigs and degenerated medial menisci from adult pigs in terms of gene expression profile and ultrastructure. Medial menisci were isolated from the knee joints of juvenile and adult pigs (n = 8 for each group). Degeneration was determined histologically according to a scoring system. In addition, the gene expression profiles of 14 genes encoding extracellular matrix proteins, catabolic matrix metalloproteinases and mediators of inflammation were analyzed. Changes in the ultrastructure of the collagen network of the meniscal tissue were analyzed by using transmission electron microscopy. The histologic analysis of menisci showed significantly higher grade of degeneration in tissue isolated from adult porcine knee joints compared with menisci isolated from juvenile knee joints. In particular, destruction of the collagen network was greater in adult menisci than in juvenile menisci. Degenerated menisci showed significantly decreased gene expression of COL1A1 and increased expression of MMP2, MMP13, and IL8. The menisci from adult porcine knee joints can serve as a model for meniscal degeneration. Degenerative changes were manifested as differences in histopathology, gene expression and ultrastructure of collagen network.

The precise role of hormones binding to Gαq protein-coupled receptors (H-GαqPCRs) in chronic heart diseases remains poorly understood. To address this, we used a model of cultured adult rat ventricular myocytes stimulated with endothelin-1 (ET-1) or phenylephrine (PE) over a period of 8 days in vitro (DIV). Chronically treated cells showed an increased number of arrhythmogenic Ca(2+) transients when electrically paced at 0.5 Hz. While their post-rest behaviour was preserved, from DIV6 onwards the amplitude of caffeine-evoked Ca(2+) transients was increased in hormone-treated cells, suggesting an elevated sarcoplasmic reticulum Ca(2+) load. The duration of electrically evoked global Ca(2+) transients gradually increased over the culturing time indicating decreased activity of processes removing cytosolic Ca(2+). In treated cells, spontaneous Ca(2+) sparks displayed smaller amplitudes from DIV6 onwards, and a slower decay period for PE (from DIV3) and for ET-1 (from DIV6). This cellular functional remodelling was associated with changes in gene expression: chronic ET-1 treatment decreased PKCγ transcripts, whereas PE increased PKCγ and SERCA2a transcripts as probed by qPCR. Western blot analysis confirmed the upregulation of PKCγ with PE. To study ET-1 receptor desensitization in vivo, osmotic minipumps containing either NaCl or ET-1 were implanted in mice and Ca(2+) signalling was studied in acutely isolated ventricular myocytes after 2 weeks of chronic treatment. Interestingly, while cellular responses to isoproterenol stimulation were preserved in ET-1 treated animals, the inotropic response of myocytes to ET-1 stimulation was abrogated. We therefore conclude that chronic stimulation of cardiac myocytes by H-GαqPCRs induces cellular remodelling of Ca(2+) cycling with altered PKCγ expression and promotion of arrhythmogenic cellular responses., (Copyright © 2016 Elsevier Ltd. All rights reserved.)