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The basis for assessing thoracolumbar vertebral body fractures are two established classification systems. Important, especially in terms of further treatment, is the distinction between osteoporotic and healthy bones. The AO Spine classification offers a comprehensive tool for healthy bones to reliably specify the morphological criterias (alignment, integrity of the intervertebral disc, fragment separation, stenosis of the spinal canal). In addition to the fracture morphology, the OF classification for osteoporotic fractures includes patient-specific characteristics to initiate adequate therapy. In general an adequate pain therapy is required for early rehabilitation. While in the bone healthy population, physiotherapy reduces the risk of muscle deconditioning, in the osteoporotic population it additionally serves to prevent subsequent fractures. Unlike osteoporotic patients, bone healthy patients with vertebral fractures should not undergo a corset/orthosis treatment.Das Therapieziel bei thorakalen oder lumbalen Wirbelkörperfrakturen besteht in der Erhaltung bzw. der Wiederherstellung des Alignments und der Stabilität der Wirbelsäule. Eine zufriedenstellende Schmerzreduktion, Mobilität und Alltagskompetenz sind Schwerpunkte in der operativen und konservativen Behandlung. Dieser Artikel soll einen Überblick über die konservativen Therapiemaßnahmen für „knochengesunde“ und osteoporotische Wirbelkörperfrakturen verschaffen.

Instrumented fusion of lumbar motion segments using a minimally invasive technique.Degenerative disc disease, segmental degeneration, degenerative spondylolisthesis, isthmic spondylolisthesis, pseudarthrosis, other spinal lumbar instabilities, disc prolapse, revision for failed back surgery syndrome, unilateral neuroforaminal stenosis, facet joint arthrosis.High-grade spondylolisthesis (Meyerding grades III/IV, spondyloptosis), bilateral nerve root compression, vertebral fractures, tumors, high-grade spinal instabilities, primary spinal deformities, multilevel pathologies.Ipsilateral minimally invasive approach using a self-retaining tubular retractor system, partial or complete facetectomy, insertion of pedicle screws, transforaminal lumbar interbody fusion (TLIF) cage insertion preserving nerve roots, fusion, contralateral insertion of pedicle screws using a minimally invasive or percutaneous technique.Mobilization with physiotherapy, followed by standing plain x‑ray examinations, clinical and radiological follow-up at 6-12 weeks and 1 year postoperatively.Fusion rates90%, comparable to open TLIF. Complication rates lower than open TLIF. Shorter radiation exposure during surgery, lower blood loss. Less surgical trauma leads to shorter hospitalization time and earlier return-to-work. Oswestry Disability index (ODI) scores and visual analog scale (VAS) scores significantly decreased.

Demographic development in Germany has led to an aging of the population. Particularly for these patients, osteoporosis-induced vertebral fractures represent a significant decrease in quality of life and level of activity. According to current guidelines, the initial treatment of stable osteoporotic vertebral fractures is conservative management with analgesic, anti-osteoporotic, physical therapy, and orthotic measures as first line options. Personal experience, however, suggests that patients benefit from timely surgical treatment through rapid improvement of pain symptoms and thus, more rapid mobilization. The poor bone quality of elderly patients presents the treating spine surgeon a challenge in achieving stable spinal fusion with or without support, for example, through augmentation. Minimally invasive procedures have increasingly established themselves for such purposes in recent years. With over 1000 fracture treatments in the last 3.5 years, we have developed a differentiated treatment concept depending on patient age and fracture morphology, which we would like to introduce. Unstable fractures with posterior edge involvement are stabilized from posterior with a percutaneous fixator. Patients over 60 years were treated percutaneously with a polyaxial screw system. Increased stability was achieved by PMMA cement augmentation of the fenestrated screws. In elderly patients with Magerl A3 fractures without neurologic deficit, the index vertebra is supplementally treated with kyphoplasty (hybrid treatment). In acute, stable osteoporotic vertebral fractures with severe pain despite analgesics, we perform kyphoplasty, which is possible even in high thoracic fractures to T3 with smaller balloons and thinner trocars. Vertebroplasty is another option in the lumbar and lower thoracic spine. Because of invasiveness, extended posterior-anterior correction procedures are generally avoided in this population, which has frequent multiple comorbidities.Die demografische Entwicklung in Deutschland führt zu einer Überalterung der Bevölkerung. Gerade bei diesen Patienten stellen die osteoporosebedingten Wirbelfrakturen einen deutlichen Einschnitt in das Leben und das Aktivitätsniveau dar. Nach aktueller Leitlinie stellt zunächst die konservative Behandlung der stabilen osteoporotischen Wirbelfraktur, bestehend aus analgetischen, antiosteoporotischen, physiotherapeutischen und orthetischen Maßnahmen die Therapie der ersten Wahl dar, aus eigener Erfahrung hingegen profitieren die Patienten von einer zeitnahen operativen Behandlung durch eine schnelle Verbesserung der Schmerzsituation und damit schnelleren Mobilisierung. Die schlechte Knochenqualität der betagten Patienten stellt den behandelnden Wirbelsäulenchirurgen vor die große Aufgabe, eine entsprechend stabile Spondylodese zu erzielen oder diese z. B. durch Augmentation weiter zu unterstützen. Hier haben sich in den letzten Jahren in zunehmenden Maße minimalinvasive Verfahren etablieren können. In Abhängigkeit vom Alter des Patienten und von der Frakturmorphologie haben wir bei über 1000 Frakturversorgungen in den letzten 3,5 Jahren ein differenziertes Behandlungskonzept entwickelt, das wir vorstellen möchten. Instabile Frakturen mit Beteiligung der Hinterkante werden dabei von dorsal mit einem Fixateur perkutan stabilisiert. Patienten über 60 Jahre werden perkutan mit einem polyaxialen Schraubensystem behandelt. Zur Erhöhung der Stabilität werden die fenestrierten Schrauben mit PMMA-Zement augmentiert. Beim älteren Patienten mit Magerl-A3-Frakturen ohne neurologisches Defizit wird der Indexwirbel ergänzend kyphoplastiert (Hybridversorgung). Bei frischen stabilen osteoporotischen Wirbelfrakturen mit starken Schmerzen trotz Analgetika führen wir eine Kyphoplastie durch, die mit kleineren Ballons und dünneren Arbeitstrokaren auch bei hoch thorakalen Frakturen bis Th III möglich ist. Eine Vertebroplastie stellt im LWS- und unteren BWS-Bereich ebenfalls eine Option dar. Ausgedehnte dorsoventrale Korrektureingriffe sind bei der häufig multimorbiden Patientengruppe aufgrund der Invasivität eher Ausnahmefällen vorbehalten.

Auch niederenergetische Traumen konnen zu gravierenden Frakturen der ankylosierten Wirbelsaule fuhren. Patienten mit Spondylitis ankylosans (AS), die ein Wirbelsaulentrauma erleiden, haben ein groseres Risiko, neurologische Ausfallsymptome zu entwickeln. Diese konnen auch mit einer Verzogerung von einigen Tagen auftreten. Neu aufgetretene Ruckenschmerzen bei einem Bechterew-Patienten auch ohne erinnerliches Trauma sind bis zum Beweis des Gegenteils als Fraktur zu werten. Dies unterstreicht die Wichtigkeit einer genauen klinischen und radiologischen Untersuchung, die engmaschig wiederholt werden sollte, insbesondere dann, wenn der Patient uber undefinierbare Schmerzen klagt oder neurologische Symptome bestehen. Einfache Rontgenuntersuchungen der Wirbelsaule reichen besonders in den Junktionszonen in der Regel nicht aus, um eine Fraktur auszuschliesen. Eine CT sollte in jedem Fall erfolgen, im Zweifel auch eine MRT in der fettunterdruckten STIR-Wichtung. Die operative Versorgung von Bechterew-Verletzungen ist das sicherste und effektivste Verfahren der Behandlung. Die unmittelbare Stabilisierung der Frakturzone ermoglicht eine Fruhmobilisation, wodurch das Risiko immobilitatsbedingter Komplikationen vermieden werden kann. Daneben kann hierdurch effektiv der neurologische Status verbessert werden. Dennoch ist die chirurgische Versorgung von Frakturen der Halswirbelsaule bei AS sehr herausfordernd. Das Operationsverfahren der ersten Wahl ist die langstreckige dorsale Spondylodese. Aufgrund der kyphotischen Deformierungen und der pulmonalen und kardialen Begleitrisiken ist die primare ventrale Versorgung in der Regel nicht sinnvoll. Bei entsprechend langstreckiger dorsaler Fusion ist die sekundare ventrale Versorgung meist nicht erforderlich.

Klassifikationen in der Orthopadie und Unfallchirurgie sind relevant fur die Kommunikation zwischen Therapeuten, fur die Patientenbehandlung und auch fur die wissenschaftliche Forschung. Idealerweise sollten Klassifikationen einfach und reproduzierbar sein und die jeweiligen fur die Behandlung relevanten Charakteristika der Verletzungstypen hervorheben. Sie sollten der prazisen und strukturierten Analyse einer Verletzung dienen, um eine adaquate Planung der Behandlung zu ermoglichen. Als Einstieg in das Themenheft „Verletzungen der Halswirbelsaule“, mochten wir Sie im vorliegenden Ubersichtsbeitrag mit den unterschiedlichen Klassifikationssystemen zur Einteilung von Verletzungen/Frakturen an der oberen und unteren Halswirbelsaule vertraut machen.

In a consensus process with four sessions in 2017, the working group on "the upper cervical spine" of the German Society for Orthopaedic and Trauma Surgery (DGOU) formulated "Therapeutic Recommendations for the Diagnosis and Treatment of Fractures to the Upper Cervical Spine", incorporating their own experience and current literature. The following article describes the recommendations for the atlas vertebra. About 10% of all cervical spine injuries include the axis vertebra. The diagnostic process primarily aims to detect the injury and to determine joint incongruency and integrity of the atlas ring. For classification purposes, the Gehweiler classification and the Dickman classification are suitable. The Canadian c-spine rule is recommended for clinical screening for c-spine injuries. CT is the preferred imaging modality; MRI is needed to determine the integrity of the Lig. transversum atlantis in complete atlas ring fractures. Conservative treatment is appropriate in very many atlas fractures. Surgical treatment is recommended in existing or potential joint incongruity or instability, which are frequently seen in Gehweiler IIIB or Gehweiler IV fractures. Posterior atlanto-axial stabilisation and fusion using transarticular screws or an internal fixator are regarded as a gold standard in the majority of surgical cases. Especially in young patients, the possibility of isolated atlas osteosynthesis should be checked. A possible option for Gehweiler IV fractures is halo-fixation with mild distraction for ligamentotaxis. Secondary dislocation should be checked for frequently. Involvement of the occipito-atlantal joint complex requires stabilisation of the occiput as well.Im Jahr 2017 erstellten die Mitglieder der AG „obere HWS“ der Sektion „Wirbelsäule“ der DGOU in einem Konsensusprozess mit 4 Sitzungen Empfehlungen zur Diagnostik und Therapie oberer Halswirbelsäulenverletzungen unter Berücksichtigung der aktuellen Literatur. Der folgende Artikel beschreibt die Empfehlung für Frakturen des Atlasrings. Etwa 10% aller HWS-Verletzungen betreffen den Atlas. Die Diagnostik zielt im Wesentlichen auf die Detektion der Verletzung sowie die Beurteilung der Gelenkflächen hinsichtlich einer Lateralisationstendenz der Atlasmassive. Zur Klassifikation haben sich die Gehweiler-Klassifikation und ergänzend die Dickman-Klassifikation bewährt. Zum primären klinischen Screening hat sich die Canadian C-Spine Rule bewährt. Bildgebendes Verfahren der Wahl bei klinischem Verdacht auf eine Atlasverletzung ist die CT. Die MRT dient der Beurteilung der Integrität des Lig. transversum atlantis bei vorderer und hinterer Bogenfraktur. Die Indikation zur Gefäßdarstellung sollte großzügig gestellt werden. Viele Atlasfrakturen können konservativ in einer Zervikalorthese behandelt werden. Eine OP-Indikation ist gegeben bei bestehender oder drohender massiver Gelenkinkongruenz oder -instabilität, die am häufigsten bei Gehweiler-IIIB-Frakturen oder bei Gehweiler-IV-Frakturen vorliegt. Operative Standardtherapie ist die dorsale atlantoaxiale Fixation, entweder in transartikulärer Technik oder mittels Fixateur interne. Insbesondere bei jüngeren Patienten sollte die Möglichkeit einer isolierten Atlasosteosynthese geprüft werden. Dislozierte Gehweiler-IV-Frakturen mit sagittaler Spaltbildung können auch probatorisch im Halofixateur unter Ausnutzung der Ligamentotaxis behandelt werden; eine engmaschige Dislokationskontrolle ist obligat. Im Falle einer sekundären Dislokation ist auch hier eine operative Stabilisierung indiziert. Bei Mitbeteiligung des okzipitozervikalen Gelenks ist eine Einbeziehung des Okziputs in die Instrumentierung notwendig.

Study Design: Narrative review. Objectives: To provide an updated overview of the management of acute traumatic central cord syndrome (ATCCS). Methods: A comprehensive narrative review of the literature was done to identify evidence-based treatment strategies for patients diagnosed with ATCCS. Results: ATCCS is the most commonly encountered subtype of incomplete spinal cord injury and is characterized by worse sensory and motor function in the upper extremities compared with the lower extremities. It is most commonly seen in the setting of trauma such as motor vehicles or falls in elderly patients. The operative management of this injury has been historically variable as it can be seen in the setting of mechanical instability or preexisting cervical stenosis alone. While each patient should be evaluated on an individual basis, based on the current literature, the authors’ preferred treatment is to perform early decompression and stabilization in patients that have any instability or significant neurologic deficit. Surgical intervention, in the appropriate patient, is associated with an earlier improvement in neurologic status, shorter hospital stay, and shorter intensive care unit stay. Conclusions: While there is limited evidence regarding management of ATCCS, in the presence of mechanical instability or ongoing cord compression, surgical management is the treatment of choice. Further research needs to be conducted regarding treatment strategies and patient outcomes.

Reoperation rate because of failing fixation construct in osteoporotic bone is high (about 30%). Especially proximal junctional kyphosis (PJK) with balance problems of the spine is seen frequently after internal fixation of the aging spine. Multiple possible reasons were found regarding adjacent segment problems, but it is still unknown, if there are special rules in osteoporotic bone and in sagittal balance of elderly population. In this chapter a case of PJK as a typical complication will be described and possible pearls and pitfalls are highlighted.

Severe trauma has a high probability for spinal injuries. Therefore, proper spinal immobilization is recommended. Additionally, in the multiple injured patient, the most important issue is to get a quick overview about the plentity of possible injuries - some of them do have a higher priority than spinal injuries, some of them do not. And even the spinal injuries can be categorized into different priorities. In this example case, we illustrate, how to immobilize the spine properly, how to set the indication for immobilization and how to prioritize the treatment in the multiple injured patient. This case will detail the following problems: 1. Pre-hospital management of spinal injuries 2. How to immobilize the spinal injured patient 3. Prioritization of treatment in multiple injured patients.

The posterior stabilisation is the Gold Standard in the operative treatment of spinal fractures. We want to focus on the question which cases might benefit from an additional anterior stabilisation.

Study Design:Narrative review.Objectives:To describe the current AOSpine Trauma Classification system for spinal trauma and highlight the value of patient-specific modifiers for facilitating communication and nuances in treatment.Methods:The classification for spine trauma previously developed by The AOSpine Knowledge Forum is reviewed and the importance of case modifiers in this system is discussed.Results:A successful classification system facilitates communication and agreement between physicians while also determining injury severity and provides guidance on prognosis and treatment. As each injury may be unique among different patients, the importance of considering patient-specific characteristics is highlighted in this review. In the current AOSpine Trauma Classification, the spinal column is divided into 4 regions: the upper cervical spine (C0-C2), subaxial cervical spine (C3-C7), thoracolumbar spine (T1-L5), and the sacral spine (S1-S5, including coccyx). Each region is classified according to a hierarchical system with increasing levels of injury or instability and represents the morphology of the injury, neurologic status, and clinical modifiers. Specifically, these clinical modifiers are denoted starting with M followed by a number. They describe unique conditions that may change treatment approach such as the presence of significant soft tissue damage, uncertainty about posterior tension band injury, or the presence of a critical disc herniation in a cervical bilateral facet dislocation. These characteristics are described in detail for each spinal region.Conclusions:Patient-specific modifiers in the AOSpine Trauma Classification highlight unique clinical characteristics for each injury and facilitate communication and treatment between surgeons.

Study Design: Expert opinion. Objectives: Osteoporotic vertebral fractures are of increasing medical importance. For an adequate treatment strategy, an easy and reliable classification is needed. Methods: The working group “Osteoporotic Fractures” of the Spine Section of the German Society for Orthopaedics and Trauma (DGOU) has developed a classification system (OF classification) for osteoporotic thoracolumbar fractures. The consensus decision followed an established pathway including review of the current literature. Results: The OF classification consists of 5 groups: OF 1, no vertebral deformation (vertebral edema); OF 2, deformation with no or minor (1/5) of the posterior wall; OF 4, loss of integrity of the vertebral frame or vertebral body collapse or pincer-type fracture; OF 5, injuries with distraction or rotation. The interobserver reliability was substantial (κ = .63). Conclusions: The proposed OF classification is easy to use and provides superior clinical differentiation of the typical osteoporotic fracture morphologies.

Even though in recent years the number of transoral spinal interventions has decreased in Europe and North America - mainly because of the progress in the drug therapy of rheumatism, there are still pathologies that can only be addressed by a transoral approach. The classical transoral approach can be expanded in collaboration with oral-maxillofacial surgery and ear, nose and throat surgery, but this is rarely necessary. The transoral approach is now mainly used for resection of pathological tissue. Additional stabilisation is often necessary and is performed in Europe and North America via a posterior approach, due to the lack of availability of anterior plate systems. Anterior plate systems are still used in India and China. In these countries, the numbers of transoral operations are generally still increasing. Today the indications for transoral spinal surgery consist mainly of infections and tumours, and more rarely of trauma and congenital malformations of the craniocervical junction. The numbers of surgical interventions for these indications has remained constant in recent years. The most recent advancement is the use of endoscopes and transnasal access. With these techniques, additional alternatives and supplements are available for further reducing the morbidity of transoral surgery. Despite the low number of cases, surgical therapy of the corresponding pathologies can be offered to patients with a calculable risk.Auch wenn die Anzahl der transoralen Wirbelsäuleneingriffe in den letzten Jahren in Nordamerika und Europa vor allem durch die Fortschritte in der medikamentösen Rheumatherapie abgenommen hat, gibt es immer noch Pathologien, die nur durch einen transoralen Zugang adäquat zu adressieren sind. Der klassische transorale Zugang kann in Zusammenarbeit mit der Mund-Kiefer-Gesichts-Chirurgie und der Hals-Nasen-Ohren-Heilkunde auch erweitert werden, allerdings ist dies in der Praxis nur selten notwendig. Über den transoralen Zugang erfolgt heute vor allem die Resektion der Pathologie. Die häufig notwendige additive Stabilisierung erfolgt in Europa und Nordamerika aufgrund der mangelnden Verfügbarkeit von ventralen Plattensystemen vor allem über dorsale Zugänge. In Indien und China finden die ventralen Plattensysteme weiterhin Verwendung. Dort sind die Eingriffszahlen der transoralen Chirurgie insgesamt auch zunehmend. Die Indikationen für die transorale Wirbelsäulenchirurgie bestehen im Wesentlichen aus Infektionen und Tumoren sowie seltener aus Traumata und angeborenen Fehlbildungen im Bereich des kraniozervikalen Übergangs. Im Hinblick auf diese Indikationen sind die Operationszahlen in den letzten Jahren auch konstant geblieben. Als neueste Weiterentwicklung sind vor allem der Einsatz von Endoskopen und auch der transnasale Zugang zu nennen. Durch diese Techniken stehen der transoralen Wirbelsäulenchirurgie weitere Alternativen und Ergänzungen zur Verfügung, um die Zugangsmorbidität weiter zu senken. Trotz der insgesamt geringen Fallzahlen kann den Patienten heute aber eine operative Therapie der entsprechenden Pathologien mit kalkulierbarem Risiko angeboten werden.

Es gibt keinen allgemeingultigen Konsens uber die Indikationen zur chirurgischen Therapie der degenerativen Spondylolisthesis. Dies liegt zumindest teilweise an der geringen Evidenz der vorliegenden Literatur und den begrenzten Kenntnissen zum naturlichen Verlauf und zu den Langzeitergebnissen konservativer Therapie. Neurologische Defizite und konservativ-therapieresistente Instabilitatsbeschwerden stellen absolute Indikationen dar. Neben der Dekompression neuraler Strukturen ist die Stabilisation der 2. integrale Bestandteil der Operation. Die Dekompression und instrumentierte Fusion stellt den Standard dar. Die Wahl des Operationsverfahrens ist aber eine Herausforderung angesichts der zahlreichen Techniken und Implantate. Der Operateur sollte seine Entscheidung fur jeden Patienten individuell treffen, um allen spezifischen Besonderheiten Rechnung zu tragen. Der Artikel gibt einen Uberblick uber die derzeitige Evidenz bei der operativen Versorgung sowie die OP-Verfahren und soll auf diesem Wege die Therapieentscheidungen erleichtern.

Die optimale Behandlung von Verletzungen des thorakolumbalen Ubergangs basiert auf einem guten Verstandnis der Wirbelsaulenverletzung unter Berucksichtigung der Frakturmorphologie, der ligamentaren Integritat und der neurologischen Ausfallsymptomatik. Ein Klassifikationssystem hilft dabei, diese Analyse zu strukturieren und sollte einen Leitfaden fur die Behandlung offerieren. Die gebrauchlichen Klassifikationssysteme, wie z. B. die Magerl-Klassifikation oder die TLICS-Klassifikation sind entweder sehr komplex, berucksichtigen nicht den neurologischen Status oder vereinfachen die Frakturmorphologie als Indikator der Instabilitat zu sehr. Die „AOSpine Classification Group“ hat daher eine neue Klassifikation entwickelt, die sowohl auf der Magerl- als auch auf der TLICS-Klassifikation basiert, und die Schwachen dieser beiden Klassifikationen uberwinden soll. Dabei bietet sie auch eine Quantifizierung des Verletzungsschweregrads und lasst damit eine Vergleichbarkeit von Wirbelsaulenverletzungen zu. Wie in der bisherigen AO-Klassifikation unterscheidet sie dabei 3 Grundtypen der Verletzung: Typ-A-Verletzungen sind knocherne Kompressionsverletzungen der Wirbelsaule. Typ-B-Verletzungen zeigen Zerreisungen entweder der hinteren oder der vorderen Zuggurtung und Typ-C-Verletzungen sind translatorisch instabile Verletzungen. Nur Typ-A- und Typ-B-Verletzungen werden in weitere Untergruppen unterteilt. Eine begleitende neurologische Lasion wird vom transienten neurologischen Defizit bis zur kompletten Querschnittslahmung in 5 Schweregrade unterteilt. Weitere Modifikatoren berucksichtigen Erkrankungen, welche die Therapie masgeblich beeinflussen, z. B. eine signifikante Osteoporose oder eine ankylosierende Wirbelsaulenerkrankung. Bisherige Untersuchungen zur Intra- und Interbegutachterkonsistenz haben vielversprechende Ergebnisse gezeigt, sodass die Einfuhrung der AOSpine-Klassifikation fur thorakolumbale Verletzungen in einer deutschen Ubersetzung gerechtfertigt sinnvoll ist.

Study Design. Empirical cross-sectional multicenter study.Objective. To identify the most commonly experienced problems by patients with traumatic spinal column injuries, excluding patients with complete paralysis.Summary of Background Data. There is no disease or condition-specific outcome instrument available that is designed or validated for patients with spine trauma, contributing to the present lack of consensus and ongoing controversies in the optimal treatment and evaluation of many types of spine injuries. Therefore, AOSpine Knowledge Forum Trauma started a project to develop such an instrument using the International Classification of Functioning, Disability and Health (ICF) as its basis.Methods. Patients with traumatic spinal column injuries, within 13 months after discharge from hospital were recruited from 9 trauma centers in 7 countries, representing 4 AOSpine International world regions. Health professionals collected the data using the general ICF Checklist. The responses were analyzed using frequency analysis. Possible differences between the world regions and also between the subgroups of potential modifiers were analyzed using descriptive statistics and Fisher exact test.Results. In total, 187 patients were enrolled. A total of 38 (29.7%) ICF categories were identified as relevant for at least 20% of the patients. Categories experienced as a difficulty/impairment were most frequently related to activities and participation (n = 15), followed by body functions (n = 6), and body structures (n = 5). Furthermore, 12 environmental factors were considered to be a facilitator in at least 20% of the patients.Conclusion. Of 128 ICF categories of the general ICF Checklist, 38 ICF categories were identified as relevant. Loss of functioning and limitations in daily living seem to be more relevant for patients with traumatic spinal column injuries rather than pain during this time frame. This study creates an evidence base to define a core set of ICF categories for outcome measurement in adult spine trauma patients. Level of Evidence: 4

Study Design Narrative review. Objective To elucidate the current concepts in diagnosis and treatment of traumatic spondylolisthesis of the axis. Methods Literature review using PubMed, Google Scholar, and Cochrane databases. Results The traumatic spondylolisthesis of the axis accounts to 5% of all cervical spine injuries and is defined by a bilateral separation of the C2 vertebral body from the neural arch. The precise location of the fracture line may vary widely. For understanding the pathobiomechanics, the involvement of the C2–C3 disk is essential. Although its synonym “hangman's fracture” suggests an extension moment as primary injury mechanism, flexion moments are also proven to cause such fracture morphology. The axial force vector (distraction versus compression) is thought to have a significant effect on the neurologic involvement. The most widely accepted classifications, according to Effendi and modified by Levine, regard the displacement of the C2 vertebral body and possible locking of the facet joints. For decisions on conservative versus surgical therapy, a definitive statement about the stability is essential. The stability is determined by involvement of the C2–C3 disk and longitudinal ligaments, which frequently cannot be assessed by X-ray or computed tomography alone. The assessment of this soft tissue injury therefore requires additional imaging either by magnetic resonance imaging to display the disk and longitudinal ligaments or dynamic fluoroscopy to assess functional behavior of the C2–C3 motion segment. If stability is proven, an immobilization of the cervical spine in a semirigid cervical collar is sufficient. Unstable lesions require surgical stabilization. The standard procedure is an anterior C2–C3 diskectomy and fusion, because of the lower morbidity of the anterior approach and the motion preservation between C1 and C2. In rare cases (irreducible locked facet joints, the necessity of decompression of the vertebral artery, contraindication for anterior approach), a posterior approach is sometimes necessary. Isolated direct screw osteosynthesis is of little value, because it only makes sense in cases with an intact C2–C3 disk, which is usually regarded as stable and therefore might be treated conservatively. Conclusions Overall, the clinical evidence regarding traumatic spondylolisthesis of the axis is very low and mainly based on small case series, expert opinion, laboratory findings, and theoretical considerations.

Study Design Survey of spine surgeons. Objective To determine the reliability with which international spine surgeons identify a posterior ligamentous complex (PLC) injury in a patient with a compression-type vertebral body fracture (type A). Methods A survey was sent to all AOSpine members from the six AO regions of the world. The survey consisted of 10 cases of type A fractures (2 subtype A1, 2 subtype A2, 3 subtype A3, and 3 subtype A4 fractures) with appropriate imaging (plain radiographs, computed tomography, and/or magnetic resonance imaging), and the respondent was asked to identify fractures with a PLC disruption, as well as to indicate if the integrity of the PLC would affect their treatment recommendation. Results Five hundred twenty-nine spine surgeons from all six AO regions of the world completed the survey. The overall interobserver reliability in determining the integrity of the PLC was slight (kappa = 0.11). No substantial regional or experiential difference was identified in determining PLC integrity or its absence; however, a regional difference was identified ( p Conclusion The results of this survey indicate that there is only slight international reliability in determining the integrity of the PLC in type A fractures. Although the biomechanical importance of the PLC is not in doubt, the inability to reliably determine the integrity of the PLC may limit the utility of the M1 modifier in the AOSpine Thoracolumbar Spine Injury Classification System.

Study Design Literature review. Objective The aim of this review is to highlight challenges in the development of a comprehensive surgical algorithm to accompany the AOSpine Thoracolumbar Spine Injury Classification System. Methods A narrative review of the relevant spine trauma literature was undertaken with input from the multidisciplinary AOSpine International Trauma Knowledge Forum. Results The transitional areas of the spine, in particular the cervicothoracic junction, pose unique challenges. The upper thoracic vertebrae have a transitional anatomy with elements similar to the subaxial cervical spine. When treating these fractures, the surgeon must be aware of the instability due to the junctional location of these fractures. Additionally, although the narrow spinal canal makes neurologic injuries common, the small pedicles and the inability to perform an anterior exposure make decompression surgery challenging. Similarly, low lumbar fractures and fractures at the lumbosacral junction cannot always be treated in the same manner as fractures in the more cephalad thoracolumbar spine. Although the unique biomechanical environment of the low lumbar spine makes a progressive kyphotic deformity less likely because of the substantial lordosis normally present in the low lumbar spine, even a fracture leading to a neutral alignment may dramatically alter the patient's sagittal balance. Conclusion Although the new AOSpine Thoracolumbar Spine Injury Classification System was designed to be a comprehensive thoracolumbar classification, fractures at the cervicothoracic junction and the lumbosacral junction have properties unique to these junctional locations. The specific characteristics of injuries in these regions may alter the most appropriate treatment, and so surgeons must use clinical judgment to determine the optimal treatment of these complex fractures.

Aim To compare four different atlantoaxial stabilization techniques. Material and methods Eight human cervical spines (segments C0-C3) were tested in flexion/extension, lateral bending and axial rotation. Range of Motion (ROM) at a 1.5 Nm load was recorded. After native testing, the Harms (HARMS), pars screw (PARS), intralaminar screw (INTRA) and anterior transarticular screw (ATA) constructs were applied in a random order. Results FLEXION/EXTENSION: mean ROM (±SD) in native state was 15.9° (± 7.6°); HARMS 3.6° (± 2.0°); INTRA 5.5° (± 2.7°); PARS 2.8° (± 1.6°); ATA 3.7° (± 1.3°). A significant difference was found for all techniques compared to the native spine. Lateral bending ROM in native state was 3.2° (± 1.9°); HARMS 1.4° (± 0.4°); INTRA 2.5° (± 1.4°); PARS 1.3° (± 0.7°); ATA 0.9° (± 0.6°). There were no significant differences compared to native spine, although ATA and PARS showed a strong tendency. INTRA had a significantly higher ROM than ATA. Axial rotation ROM in native state was 15.7° (± 6.6°); HARMS 1.5° (± 0.7); INTRA 2.7° (± 2.1°); PARS 1.7° (± 0.7); ATA 1.1° (± 0.3°). All instrumentation techniques significantly reduced ROM; there was no significant difference between the techniques. All instrumentation techniques were able to reduce ROM for most of the motions. The differences between the techniques were small. Nevertheless, the intralaminar screw showed deficits in lateral bending. Conclusion Screw positioning seems to be of minor influence on stability in atlantoaxial stabilization. Therefore, the pars screw is a sound alternative to the established techniques from a biomechanical point of view. Anatomical considerations for screw placement should be kept in mind as a superior priority.

The aims of this study were (1) to demonstrate the AOSpine thoracolumbar spine injury classification system can be reliably applied by an international group of surgeons and (2) to delineate those injury types which are difficult for spine surgeons to classify reliably.A previously described classification system of thoracolumbar injuries which consists of a morphologic classification of the fracture, a grading system for the neurologic status and relevant patient-specific modifiers was applied to 25 cases by 100 spinal surgeons from across the world twice independently, in grading sessions 1 month apart. The results were analyzed for classification reliability using the Kappa coefficient (κ).The overall Kappa coefficient for all cases was 0.56, which represents moderate reliability. Kappa values describing interobserver agreement were 0.80 for type A injuries, 0.68 for type B injuries and 0.72 for type C injuries, all representing substantial reliability. The lowest level of agreement for specific subtypes was for fracture subtype A4 (Kappa = 0.19). Intraobserver analysis demonstrated overall average Kappa statistic for subtype grading of 0.68 also representing substantial reproducibility.In a worldwide sample of spinal surgeons without previous exposure to the recently described AOSpine Thoracolumbar Spine Injury Classification System, we demonstrated moderate interobserver and substantial intraobserver reliability. These results suggest that most spine surgeons can reliably apply this system to spine trauma patients as or more reliably than previously described systems.

BACKGROUND Traumatic spondylolisthesis of the axis, is a common cervical spine fracture; however, to date there is limited data available to guide the treatment of these injuries. The purpose of this review is to provide an evidence-based analysis of the literature and clinical outcomes associated with the surgical and nonsurgical management of hangman's fractures. METHODS A systematic literature search was conducted using PubMed (MEDLINE) and Scopus (EMBASE, MEDLINE, COMPENDEX) for all articles describing the treatment of hangman's fractures in 2 or more patients. Risk of nonunion, mortality, complications, and treatment failure (defined as the need for surgery in the nonsurgically managed patients and the need for revision surgery for any reason in the surgically managed patients) was compared for operative and nonoperative treatment methods using a generalized linear mixed model and odds ratio analysis. RESULTS Overall, 25 studies met the inclusion criteria and were included in our quantitative analysis. Bony union was the principal outcome measure used to assess successful treatment. All studies included documented fracture union and were included in statistical analyses. The overall union rate for 131 fractures treated nonsurgically was 94.14% [95% confidence interval (CI), 76.15-98.78]. The overall union rate for 417 fractures treated surgically was 99.35% (95% CI, 96.81-99.87). Chance of nonunion was lower in those patients treated surgically (odds ratio, 0.12; 95% CI, 0.02-0.71). There was not a significant difference in mortality between patients treated surgically (0.16%; 95% CI, 0.01%-2.89%) and nonsurgically (1.04%; 95% CI, 0.08%-11.4%) (odds ratio, 0.15; 95% CI, 0.01-2.11). Treatment failure was less likely in the surgical treatment group (0.12%; 95% CI, 0.01%-2.45%) than the nonsurgical treatment group (0.71%; 95% CI, 0.28%-15.75%) (odds ratio 0.07; 95% CI, 0.01-0.56). CONCLUSION Hangman's fractures are common injuries, and surgical treatment leads to an increase in the rate of osteosynthesis/fusion without significantly increasing the rate of complication. Both an anterior and a posterior approach result in a high rate of fusion, and neither approach seems to be superior.

Study Design: Systematic literature review with meta-analysis. Objective: Thoracolumbar (TL) fractures can be treated conservatively or surgically. Especially, the treatment strategy for incomplete and complete TL burst fractures (A3 and A4, AOSpine classification) in neurologically intact patients remains controversial. The aim of this work was to collate the clinical evidence on the respective treatment modalities. Methods: Searches were performed in PubMed and the Web of Science. Clinical and radiological outcome data were collected. For studies comparing operative with nonoperative treatment, the standardized mean differences (SMD) for disability and pain were calculated and methodological quality and risk of bias were assessed. Results: From 1929 initial matches, 12 were eligible. Four of these compared surgical with conservative treatment. A comparative analysis of radiological results was not possible due to a lack of uniform reporting. Differences in clinical outcomes at follow-up were small, both between studies and between treatment groups. The SMD was 0.00 (95% CI −0.072, 0.72) for disability and −0.05 (95% CI −0.91, 0.81) for pain. Methodological quality was high in most studies and no evidence of publication bias was revealed. Conclusions: We did not find differences in disability or pain outcomes between operative and nonoperative treatment of A3 and A4 TL fractures in neurologically intact patients. Notwithstanding, the available scores have been developed and validated for degenerative diseases; thus, their suitability in trauma may be questionable. Specific and uniform outcome parameters need to be defined and enforced for the evaluation of TL trauma.

Injuries to the upper cervical spine represent a diagnostic and therapeutic challenge to the treating surgeon due to the complex anatomical relationships and biomechanical features. In this further education article the diagnostic principles, established classifications and therapeutic recommendations as well as injury-specific characteristics of bony and ligamentous injuries to the upper cervical spine (C0-C2) are presented.

In a consensus process during four sessions in 2016, the working group "lower cervical spine" of the German Society for Orthopedic and Trauma Surgery (DGOU), formulated "Therapeutic Recommendations for the Lower Cervical Spine", taking into consideration the current literature. Therapeutic goals are a permanently stable, painless cervical spine and the protection against secondary neurologic damage while retaining the greatest possible amount of motion and spinal profile. Due to its ease of use and its proven good reliability, the AOSpine classification for subaxial cervical injuries should be used. The Canadian C-Spine Rule is recommended as a clinical decision rule whether to perform imaging or not. If a structural or unstable injury is suspected by patient history or clinical findings, a spiral CT scan of the cervical spine is the favoured diagnostic modality. Conventional X-ray is reserved for patients in whom there is no "dangerous mechanism of injury". MR imaging is recommended in case of unexplained neurologic deficit, prior to closed reduction and open posterior surgery and to exclude disco-ligamentous injuries. Urgency of MR imaging depends on the specific findings. CT angiography is recommended in higher-grade facet joint injuries or in the presence of vertebra-basilar symptoms. Flexion-extension imaging is recommended only as a physician-guided dynamic fluoroscopy, when an unstable lesion is still suspected. The therapeutic strategy is mainly dependent on morphologic criteria, which are described using the AOSpine classification. A0-injuries are treated conservatively. A1- and A2-injuries are treated conservatively in the majority of cases, and in single cases a gross kyphotic deformity might indicate surgical stabilisation. A3-injuries do indicate a surgical therapy in the majority of cases, but certain cases might be treated conservatively. A4-fractures as well as B- and C-type injuries are to be treated surgically. Most injuries can be treated by anterior plate stabilisation with interbody support; when a complete burst fracture is present, corpectomy and vertebral body replacement is necessary. In certain cases, an additive posterior or pure posterior instrumentation might be possible or even mandatory. In most of these cases, lateral mass screws are sufficient; when pedicle screws are applied in C3 to C6, a 3D-navigation system is recommended. Injuries in an ankylosing spine (M3-modifier) should be treated preferably from posterior with long-segment instrumentation.Im Rahmen eines Konsensusprozesses der Arbeitsgruppe „subaxiale HWS-Verletzungen“ der Sektion Wirbelsäule der DGOU erfolgte in 4 Sitzungen im Jahre 2016 die Erstellung der vorliegenden Therapieempfehlungen unter Berücksichtigung der vorhandenen Literatur. Therapieziele sind eine dauerhaft stabile, schmerzfreie Halswirbelsäule und der Schutz vor sekundären neurologischen Schäden unter größtmöglicher Berücksichtigung der Beweglichkeit und des Wirbelsäulenprofils. Aufgrund der Praktikabilität und der guten Evaluation hinsichtlich Reliabilität sollte die AOSpine-Klassifikation für subaxiale HWS-Verletzungen für die Klassifikation zur Anwendung kommen. Es wird die Canadian C-Spine Rule als klinischer Algorithmus zur Entscheidung hinsichtlich der Notwendigkeit einer bildgebenden Diagnostik empfohlen. Bei gemäß dieser Regel anamnestisch oder klinisch hohem Verdacht auf eine strukturelle, instabile Verletzung ist die Spiral-CT der HWS Verfahren der Wahl. Die konventionelle Röntgendiagnostik in 2 Ebenen bleibt Fällen vorbehalten, in denen kein „gefährlicher Unfallmechanismus“ vorliegt. Die Indikation für die MRT der HWS wird vor allem bei nicht erklärbaren neurologischen Symptomen, bei geplanter geschlossener Reposition und dorsaler Stabilisierung und zum Ausschluss vermuteter diskoligamentärer Verletzungen empfohlen, wobei hier je nach Befundkonstellation eine abgestufte Dringlichkeit gilt. Die CT-Angiografie wird bei höhergradigen Facettengelenkverletzungen oder bei Vorliegen vertebrobasilärer Symptome empfohlen. Die konventionelle Funktionsdiagnostik wird ausschließlich in Form der ärztlich geführten dynamischen Bildwandlerdurchleuchtung bei persistierendem Verdacht auf eine instabile Verletzung empfohlen. Die therapeutische Strategie richtet sich primär nach der Verletzungsmorphologie, die in der AOSpine-Klassifikation beschrieben wird. A0-Frakturen sollten konservativ behandelt werden. A1- und A2-Frakturen sollten meistens konservativ behandelt werden, wobei die segmentale Kyphose in Einzelfällen eine OP-Indikation bedingen kann. A3-Frakturen stellen in den meisten Fällen eine OP-Indikation dar, in Einzelfällen ist eine konservative Behandlung möglich. A4-Frakturen sowie die B- und C-Verletzungen bedürfen einer operativen Therapie. Die ventrale Plattenspondylodese mit interkorporeller Abstützung (bei Berstungskomponente durch Korporektomie und Wirbelkörperersatz) wird für die meisten Verletzungen empfohlen, eine rein dorsale oder zusätzlich dorsale Stabilisierung kann bei besonderer Befundkonstellation möglich oder sogar notwendig sein. In diesen Fällen ist die Instrumentierung mit Massa-lateralis-Schrauben zumeist ausreichend; bei Anwendung von Pedikelschrauben in Höhe C III – C VI wird ein Navigationssystem empfohlen. Bei Vorliegen einer ankylosierenden Grunderkrankung (M3-Modifikator) wird hingegen die dorsale, langstreckige Stabilisierung favorisiert.

Das intraoperative CT (iCT) ist ein modernes bildgebendes Verfahren in der Wirbelsäulen- und Unfallchirurgie. Eingriffe, die eine hohe Präzision erfordern, sind für den Einsatz der spinalen Navigation auf Grundlage intraoperativer CT-Bildgebung besonders geeignet. Hierzu zählen die korrekte transpedikuläre Schraubenplatzierung bei schmalen Pedikeln, intraossäre Tumoren, ausgeprägte Deformitäten, Revisionseingriffe und myelonnahe bzw. intramedulläre Operationen im Bereich der Wirbelsäulenchirurgie. Unfallchirurgische Indikationen bestehen v. a. bei Beckeneingriffen sowie bei der operativen Versorgung komplexer Gelenkverletzungen. Das intraoperative CT ermöglicht eine zeitnahe Kontrolle des Operationsergebnisses mit einer höheren Bildqualität sowie einem wesentlich größeren Field of View im Vergleich zur intraoperativen 3D-Fluoroskopie. Die Strahlenbelastung ist für den Patienten höher als beim fluoroskopischen Verfahren, für den Operateur jedoch geringer. Die Kosteneffektivität des iCTs sowie der iCT-gestützten Navigation ist aufgrund der noch immer hohen Investitionskosten niedrig, unter medizinischen Aspekten ist das iCT-gestützte Navigieren jedoch gegenüber anderen Monitoringverfahren klinisch oftmals vorteilhaft.

Object Despite promising early clinical results, the long-term outcome of the use of expandable titanium cages to reconstruct the anterior column after traumatic burst fractures is still unknown. The purpose of this prospective study was to assess the clinical and radiological outcomes of the use of expandable titanium cages 5 years postoperatively. Methods Eighty patients with traumatic thoracolumbar burst fractures (T4–L5) underwent posterior stabilization followed by anterior corpectomy and reconstruction using expandable titanium cages with or without additional anterior plating. After 5 years, fusion was evaluated by means of plain radiographs and CT scans, and the patients' scores on the Oswestry Disability Index (ODI), their neurological status, and clinical results were assessed. Results Forty-five (56%) of the 80 patients could be examined after 5 years. There was a relatively high rate of complications related to thoracotomy (26%), but there were no complications directly related to the cages. Revision surgery was required in 1 case. The average postoperative loss of correction was only 2.4° due to minimal subsidence of the cages. No cage showed a radiolucent line or instability in flexion-extension views. Bony fusion, as assessed by CT scan, was achieved in 41 patients (91%). On clinical examination, 96% of all patients were ambulatory and showed minimal restriction of spinal range of motion; 71% did not need analgesic medication at all; and 67% were able to work. The average ODI score was 12. Thirty-one percent of patients complained of some kind of anterior approach–related complications. Conclusions Combined anteroposterior stabilization of thoracolumbar burst fractures with expandable titanium cages is a relative safe procedure with satisfactory radiological and clinical long-term outcome. High fusion rates can be achieved, with only minor loss of correction, typically occurring in the 1st year. However, open thoracotomy carries the risks of additional complications and development of post-thoracotomy syndrome.

To prospectively evaluate the potential radiological and clinical effect of the additional application of an anterior plate in anteroposteriorly stabilized thoracolumbar fractures.75 consecutive patients with unstable thoracolumbar fractures underwent posterior (internal fixator) and anterior stabilization (corpectomy cage with local autologous bone grafting). 40 (53.3%) patients received an additional anterior plate (Group A), while 35 (46.6%) (Group B) did not. Plain X-rays and CT-scans were obtained pre- and postoperatively, after 12 months and at the last follow-up (mean 32 months, range 22-72). Loss of reduction, cage subsidence to adjacent vertebrae, fusion rates and clinical results were evaluated.66 (87%) patients (36 Group A; 30 Group B) were available for follow-up. Patients in both groups were comparable regarding age, gender, comorbidities, localization and classification of fracture. Average loss of reduction was 2.4° in Group A, and 3.1° in Group B (not significant). Cage subsidence did not differ significantly between both groups, too. However, after 12 months the rate of continuous osseous bridging between endplates was significantly higher in Group A (63% vs. 25%) (p0.05). After 32 months this difference was even higher (81% vs. 33%) (p0.001). The bony fusion mass was located beneath or around the anterior plate in 94% of patients. There was no significant difference in clinical outcome.Additional anterior plating in anteroposteriorly stabilized thoracolumbar fractures leads to significant faster fusion but does neither influence reduction loss nor cage subsidence. The anterior plate serves as a pathway for bone growth and increases biomechanical stability, resulting in a higher fusion rate.

STUDY DESIGN: A post-test design biological experiment. OBJECTIVE: The aim of this study was to evaluate the osteogenic effects of riluzole on human mesenchymal stromal cells and osteoblasts. SUMMARY OF BACKGROUND DATA: Riluzole may benefit patients with spinal cord injury (SCI) from a neurologic perspective, but little is known about riluzole's effect on bone formation, fracture healing, or osteogenesis. METHODS: Human mesenchymal stromal cells (hMSCs) and human osteoblasts (hOB) were obtained and isolated from healthy donors and cultured. The cells were treated with riluzole of different concentrations (50, 150, 450 ng/mL) for 1, 2, 3, and 4 weeks. Cytotoxicity was evaluated as was the induction of osteogenic differentiation of hMSCs. Differentiation was evaluated by measuring alkaline phosphatase (ALP) activity and with Alizarin red staining. Osteogenic gene expression of type I collagen (Col1), ALP, osteocalcin (Ocn), Runx2, Sox9, Runx2/Sox9 ratio were measured by qRT-PCR. RESULTS: No cytotoxicity or increased proliferation was observed in bone marrow derived hMSCs and primary hOBs cultured with riluzole over 7 days. ALP activity was slightly increased in hMSCs after treatment for 2 weeks with riluzole 150 ng/mL and slightly upregulated by 150% (150 ng/mL) and 90% (450 ng/mL) in hMSCs at 3 weeks. In hOBs, ALP activity almost doubled after 2 weeks of culture with riluzole 150 ng/mL (P

STUDY DESIGN Reliability and agreement study, retrospective case series. OBJECTIVE To develop a widely accepted, comprehensive yet simple classification system with clinically acceptable intra- and interobserver reliability for use in both clinical practice and research. SUMMARY OF BACKGROUND DATA Although the Magerl classification and thoracolumbar injury classification system (TLICS) are both well-known schemes to describe thoracolumbar (TL) fractures, no TL injury classification system has achieved universal international adoption. This lack of consensus limits communication between clinicians and researchers complicating the study of these injuries and the development of treatment algorithms. METHODS A simple and reproducible classification system of TL injuries was developed using a structured international consensus process. This classification system consists of a morphologic classification of the fracture, a grading system for the neurological status, and description of relevant patient-specific modifiers. Forty cases with a broad range of injuries were classified independently twice by group members 1 month apart and analyzed for classification reliability using the Kappa coefficient (κ). RESULTS The morphologic classification is based on 3 main injury patterns: type A (compression), type B (tension band disruption), and type C (displacement/translation) injuries. Reliability in the identification of a morphologic injury type was substantial (κ= 0.72). CONCLUSION The AOSpine TL injury classification system is clinically relevant according to the consensus agreement of our international team of spine trauma experts. Final evaluation data showed reasonable reliability and accuracy, but further clinical validation of the proposed system requires prospective observational data collection documenting use of the classification system, therapeutic decision making, and clinical follow-up evaluation by a large number of surgeons from different countries.

Osteoblastoma is a rare, benign bone tumor that accounts for approximately 1 % of all primary bone tumors and 5 % of spinal tumors, mostly arising within the posterior elements of the spine within the second and third decades of life. Nonspecific initial symptoms mainly neck or back pain and stiffness of the spine remain often undiagnosed and the destructive nature of the expanding tumor can cause even neurological deficits. CT and MRI scans constitute the basic imaging modalities employed in diagnosis and preoperative planning with the former delineating the location and osseous involvement of the mass and the latter providing appreciation of the effect on soft tissues and neural elements. In our case a 23-year-old male presented with persisting head and neck pain, after being involved in a car collision a month ago. Although the initial diagnostic imaging, including plain X-rays and MRI scan failed to reveal any pathological findings, the persistence of the symptoms led to repeating imaging (CT and MRI) that showed the existence of a benign osseous tumor of the C2 lamina that was destructing the surrounding osseous structures and encompassing the right vertebral artery. The suspicion of an osteoblastoma was raised and the decision for surgical removal of the tumor was made for treating the persistent symptoms and preventing a possible neurological deficit or vascular lesion. A marginal tumor resection was performed through a posterior approach, followed by an anterior instrumented fusion. Histological examination confirmed the diagnosis of an osteoblastoma. The recovery of the patient was uneventful and a significant symptom subsidence was reported following surgery. Eighteen months postoperatively the patient remains pain free without any indications for tumor recurrence. This case delineates the difficulties in diagnosing this tumor, as well as the challenges and problems encountered in its surgical management, and also the favorable prognosis when adequately treated.

If surgery for thoracolumbar incomplete cranial burst fractures (Magerl A3.1.1) is necessary, the ideal stabilization strategy still remains undetermined. To justify posterior–anterior stabilization, which generates higher costs and potentially higher morbidity vs. posterior-only stabilization, clinical trials with sufficient power and adequate methodology are required. This prospective randomized single-centre pilot trial was designed to enable sufficient sample-size calculation for a randomized multicentre clinical trial (RASPUTHINE). Patients with a traumatic thoracolumbar (Th11–L2) incomplete burst fracture (Magerl A3.1.1) were randomly assigned either to the interventional group (posterior–anterior) or to the control group (posterior-only). Primary endpoint of the study was the clinical outcome measured using the Oswestry Disability Index (ODI) at 24 months. Radiological outcome was assessed as secondary endpoint by evaluation of mono- and bisegmental kyphotic angulation and monosegmental fusion. 21 patients were randomly assigned to interventional group (n = 9) or control group (n = 12). One posterior-only treated patient showed a severe initial loss of correction resulting in a crossover to additional anterior bisegmental fusion. The ODI measures at the primary study endpoint showed less but insignificant (p = 0.67) disability for the interventional group over the control group (13.3 vs. 19.3%). Comparison of preoperative bisegmental kyphosis in supine position with the bisegmental kyphosis at 24-month FU in upright position showed a worsened kyphosis for the control group (10.7° → 15.6°), whereas an improved kyphosis (11° → 8.3°) was detectable for the interventional group. The results of this pilot RCT showed less disability for the posterior–anterior group linked with a significant better restoration of the sagittal profile in comparison with the posterior-only group. To detect a clinically significant difference using the ODI and assuming a 20% loss of FU rate, a total of 266 patients have to be studied in the multicentre trial.

Der zervikale Bandscheibenvorfall ist durch einen Austritt von Gewebe des Nucleus pulposus durch den Anulus fibrosus in den Spinalkanal gekennzeichnet. Dort fuhrt die mechanische oder chemische Irritation neuraler Strukturen zu Symptomen einer Radikulopathie, Zervikozephalgie oder Myelopathie. Ausgepragte sensomotorische Defizite oder konservativ nicht zu beherrschende Schmerzen stellen eine Operationsindikation dar. Ansonsten ist die Therapie des zervikalen Bandscheibenvorfalls konservativ mittels Analgetika, aktiver und passiver Physiotherapie und lokalen Infiltrationen. Die anteriore zervikale Diskektomie und Fusion (ACDF) stellt das operative Standardverfahren dar. Es werden uberwiegend Cages mit oder ohne additive Platten verwendet. Alternativ besteht die Moglichkeit der Implantation einer Bandscheibenprothese, sofern keine Kontraindikationen vorliegen. Andere chirurgische Techniken konnen in geeigneten Fallen ebenfalls angewandt werden. Die klinischen und radiologischen Ergebnisse operativer und konservativer Masnahmen sind insgesamt als gut zu bezeichnen.

Objective Computer-assisted surgery (CAS) can improve the accuracy of screw placement and decrease radiation exposure, yet this is not widely accepted among spine surgeons. The current viewpoint of spine surgeons on navigation in their everyday practice is an important issue that has not been studied. A survey-based study assessed opinions on CAS to describe the current global attitudes of surgeons on the use of navigation in spine surgery. Methods A 12-item questionnaire focusing on the number and type of surgical cases, the type of equipment available, and general opinions toward CAS was distributed to 3348 AOSpine surgeons (a specialty group within the AO [Arbeitsgemeinschaft fur Osteosynthesefragen] Foundation). Latent class analysis was used to investigate the existence of specific groups based on the respondent opinion profiles. Results A response rate of 20% was recorded. Despite a widespread distribution of navigation systems in North America and Europe, only 11% of surgeons use it routinely. High-volume procedure surgeons, neurological surgeons, and surgeons with a busy minimal invasive surgery practice are more likely to use CAS. “Routine users” consider the accuracy, potential of facilitating complex surgery, and reduction in radiation exposure as the main advantages. The lack of equipment, inadequate training, and high costs are the main reasons that “nonusers” do not use CAS. Conclusions Spine surgeons acknowledge the value of CAS, yet current systems do not meet their expectations in terms of ease of use and integration into the surgical work flow. To increase its use, CAS has to become more cost efficient and scientific data are needed to clarify its potential benefits.

STUDY DESIGN Radiological and histological assessment of fusion status after anterior cervical discectomy and fusion (ACDF) procedure in a sheep spinal fusion model. OBJECTIVE To evaluate the efficacy of cyclic arginine-glycine-aspartic (cRGD) in comparison with recombinant human bone morphogenetic protein-2 (rhBMP-2) on a mineralized collagen matrix (MCM). SUMMARY OF BACKGROUND DATA A previous evaluation of MCM alone in comparison with autologous bone graft alone was not able to show an advantage on spinal fusion. The cRGD peptide sequence plays a major role in mediating cell adhesion. Studies have demonstrated enhances osteoblasts adhesion resulting in increased periimplant bone formation after implantcoating with cRGD. rhBMP-2 has already proven its ability to enhance spinal fusion. To date, no comparative in vivo evaluation of cRGD and rhBMP-2 in combination with a MCM for spinal fusion has been performed. METHODS Twenty-four sheep (N = 8/group) underwent C3-C4 fusion. Implants: group 1: titanium cage with MCM and rhBMP-2; group 2: titanium cage with MCM and cRGD; control group: titanium cage with MCM alone. After 12 weeks fusion sites were evaluated by computed tomography to assess fusion status, bone mineral density as well as bony callus volume. Furthermore, histomorphological and histomorphometrical analysis of the fusion sites were performed. RESULTS In comparison with the control group, cRGD, and rhBMP-2 groups showed a higher fusion rate in radiographical findings and a higher degree of interbody fusion in histomorphometrical analysis (P < 0.05). There was no significant difference in radiographical and histological parameters between the rhBMP-2 and the cRGD group. Although rhBMP-2 demonstrated ectopic prevertebral bone formations, this effect was less prominent in the cRGD group. CONCLUSION In this animal model the combination of cRGD and a mineralized collagen matrix showed superior fusion results in comparison with the mineralized collagen alone. Further, cRGD was comparably effective to rhBMP-2 in promoting interbody fusion by demonstrating less ectopic bone formations.

STUDY DESIGN.: International web-based survey OBJECTIVE.: To identify clinical and radiological parameters that spine surgeons consider most relevant when evaluating clinical and functional outcomes of subaxial cervical spine trauma patients. SUMMARY OF BACKGROUND DATA.: While an outcome instrument that reflects the patients’ perspective is imperative, there is also a need for a surgeon reported outcome measure (SROM) to reflect the clinicians’ perspective adequately. METHODS.: A cross-sectional online survey was conducted among a selected number of spine surgeons from all five AOSpine International world regions. They were asked to indicate the relevance of a compilation of 21 parameters, both for the short term (3 months - 2 years) and long term (≥2 years), on a five-point scale. The responses were analyzed using descriptive statistics, frequency analysis and Kruskal-Wallis test. RESULTS.: Of the 279 AOSpine International and International Spinal Cord Society members who received the survey, 108 (38.7%) participated in the study. Ten parameters were identified as relevant both for short term and long term by at least 70% of the participants. Neurological status, implant failure within 3 months, and patient satisfaction were most relevant. Bony fusion was the only parameter for the long term, while 5 parameters were identified for the short term. The remaining 6 parameters were not deemed relevant. Minor differences were observed when analyzing the responses according to each world region, or spine surgeons’ degree of experience. CONCLUSIONS.: The perspective of an international sample of highly experienced spine surgeons was explored on the most relevant parameters to evaluate and predict outcomes of subaxial cervical spine trauma patients. These results form the basis for the development of a disease-specific SROM, which will be a helpful tool in research and clinical practice.Level of Evidence: 4

Purpose: This project describes a morphology-based subaxial cervical spine traumatic injury classification system. Using the same approach as the thoracolumbar system, the goal was to develop a comprehensive yet simple classification system with high intra- and interobserver reliability to be used for clinical and research purposes. Methods: A subaxial cervical spine injury classification system was developed using a consensus process among clinical experts. All investigators were required to successfully grade 10 cases to demonstrate comprehension of the system before grading 30 additional cases on two occasions, 1 month apart. Kappa coefficients (κ) were calculated for intraobserver and interobserver reliability. Results: The classification system is based on three injury morphology types similar to the TL system: compression injuries (A), tension band injuries (B), and translational injuries (C), with additional descriptions for facet injuries, as well as patient-specific modifiers and neurologic status. Intraobserver and interobserver reliability was substantial for all injury subtypes (κ = 0.75 and 0.64, respectively). Conclusions: The AOSpine subaxial cervical spine injury classification system demonstrated substantial reliability in this initial assessment, and could be a valuable tool for communication, patient care and for research purposes.

To investigate whether wide variations are seen in the measurement techniques preferred by spine surgeons around the world to assess traumatic fracture kyphosis and vertebral body height loss (VBHL). An online survey was conducted at two time points among an international community of spine trauma experts from all world regions. The first survey (TL-survey) focused on the thoracic, thoracolumbar and lumbar spine, the second survey (C-survey) on the subaxial cervical spine. Participants were asked to indicate which measurement technique(s) they used for measuring kyphosis and VBHL. Descriptive statistics, frequency analysis and the Fisher exact test were used to analyze the responses. Of the 279 invited experts, 107 (38.4 %) participated in the TL-survey, and 108 (38.7 %) in the C-survey. The Cobb angle was the most frequently used for all spine regions to assess kyphosis (55.6–75.7 %), followed by the wedge angle and adjacent endplates method. Concerning VBHL, the majority of the experts used the vertebral body compression ratio in all spine regions (51.4–54.6 %). The most frequently used combination for kyphosis was the Cobb and wedge angles. Considerable differences were observed between the world regions, while fewer differences were seen between surgeons with different degrees of experience. This study identified worldwide variations in measurement techniques preferred by treating spine surgeons to assess fracture kyphosis and VBHL in spine trauma patients. These results establish the importance of standardizing assessment parameters in spine trauma care, and can be taken into account to further investigate these radiographic parameters.