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Supplemental Digital Content is Available in the Text., Objectives: To (1) demonstrate that the AO Spine Sacral Classification System can be reliably applied by general orthopaedic surgeons and subspecialists universally around the world and (2) delineate those injury subtypes that are most difficult to classify reliably to refine the classification before evaluating clinical outcomes. Design: Agreement study. Setting: All-level trauma centers, worldwide. Participants: One hundred seventy-two members of the AO Trauma and AO Spine community. Intervention: The AO Sacral Classification System was applied by each surgeon to 26 cases in 2 independent assessments performed 3 weeks apart. Main Outcome Measurements: Interobserver reliability and intraobserver reproducibility. Results: A total of 8097 case assessments were performed. The kappa coefficient for interobserver agreement for all cases was 0.72/0.75 (assessment 1/assessment 2), representing substantial reliability. When comparing classification grading (A/B/C) regardless of subtype, the kappa coefficient was 0.84/0.85, corresponding to excellent reliability. The kappa coefficients for interobserver reliability were 0.95/0.93 for type A fractures, 0.78/0.79 for type B fractures, and 0.80/0.83 for type C fractures. The overall kappa statistic for intraobserver reliability was 0.82 (range 0.18–1.00), representing excellent reproducibility. When only evaluating morphology type (A/B/C), the average kappa value was 0.87 (range 0.18–1.00), representing excellent reproducibility. Conclusion: The AO Spine Sacral Classification System is universally reliable among general orthopaedic surgeons and subspecialists worldwide, with substantial interobserver and excellent intraobserver reliability.

Purpose To validate the Dutch version of AOSpine PROST (Patient Reported Outcome Spine Trauma). Methods Patients were recruited from two level-1 trauma centers from the Netherlands. Next to the AOSpine PROST, patients also filled out SF-36 for concurrent validity. Descriptive statistics were used to analyze the characteristics. Content validity was assessed by evaluating the number of inapplicable or missing questions. Also floor and ceiling effects were analyzed. Internal consistency was assessed by calculating Cronbach’s α and item-total correlation coefficients (itcc). Spearman correlation tests were performed within AOSpine PROST items and in correlation with SF-36. Test–retest reliability was analyzed using Intraclass Correlation Coefficients (ICC). Responsiveness was assessed by calculating effect sizes (ES) and standardized response mean (SRM). Factor analysis was performed to explore any dimensions within AOSpine PROST. Results Out of 179 enrolled patients, 163 (91.1%) were included. Good results were obtained for content validity. No floor or ceiling effects were seen. Internal consistency was excellent (Cronbach’s α = 0.96, itcc 0.50–0.86), with also good Spearman correlations (0.25–0.79). Compared to SF-36, the strongest correlation was seen for physical functioning (0.79; p p 1), explaining 65.4% of variance. Conclusions Very satisfactory results were obtained for reliability, validity and responsiveness of the Dutch version of AOSpine PROST. Treating surgeons are encouraged to use this novel and validated tool in clinical setting and research to contribute to evidence-based and patient-centered care.

STUDY DESIGN Cross-sectional survey. OBJECTIVE To determine the influence of surgeons' level of experience and subspeciality training on the reliability, reproducibility, and accuracy of sacral fracture classification using the Arbeitsgemeinschaft f��r Osteosynthesefragen Spine Sacral Classification System. SUMMARY OF BACKGROUND DATA A surgeons' level of experience or subspecialty may have a significant effect on the reliability and accuracy of sacral classification given various levels of comfort with imaging assessment required for accurate diagnosis and classification. METHODS High-resolution computerized tomography (CT) images from 26 cases were assessed on two separate occasions by 172 investigators representing a diverse array of surgical subspecialities (general orthopedics, neurosurgery, orthopedic spine, orthopedic trauma) and experience (20���yrs). Reliability and reproducibility were calculated with Cohen kappa coefficient (k) and gold standard classification agreement was determined for each fracture morphology and subtype and stratified by experience and subspeciality. RESULTS Respondents achieved an overall k���=���0.87 for morphology and k���=���0.77 for subtype classification, representing excellent and substantial intraobserver reproducibility, respectively. Respondents from all four practice experience groups demonstrated excellent interobserver reliability when classifying overall morphology (k���=���0.842/0.850, Assessment 1/Assessment 2) and substantial interobserver reliability in overall subtype (k���=���0.719/0.751) in both assessments. General orthopedists, neurosurgeons, and orthopedic spine surgeons exhibited excellent interobserver reliability in overall morphology classification and substantial interobserver reliability in overall subtype classification. Surgeons in each experience category and subspecialty correctly classified fracture morphology in over 90% of cases and fracture subtype in over 80% of cases according to the gold standard. Correct overall classification of fracture morphology (Assessment 1: P���=���0.024, Assessment 2: P���=���0.006) and subtype (P2���

The upper cervical spine accounts for the largest proportion of cervical range of motion afforded by a complex system of bony morphology and ligamentous stability. Its unique anatomy, however, also makes it particularly vulnerable during both low and high energy trauma. Trauma to this area, referred to as upper cervical spine trauma, can disrupt the stability of the upper cervical spine and result in a wide spectrum of injury. Numerous upper cervical injury classification systems have been proposed, each of which have distinct limitations and drawbacks that have prevented their universal adoption. In this article, we provide an overview of previous classifications, with an emphasis on the development of the new AO Spine Upper Cervical Classification System (AO Spine UCCS).

Study Design: Systematic review. Objectives: Postoperative spinal implant infections (PSII) are an increasing challenge in the daily clinical routine. This review summarizes existing knowledge in the field of PSII, including definitions, epidemiology, classifications, risk factors, pathogenesis, symptoms, diagnosis, and treatment. Methods: A systematic review was performed using a structured PubMed analysis, based on the PRISMA criteria. The search terminology was set as: “spinal implant associated infection OR spinal implant infection OR spinal instrumentation infection OR peri spinal implant infection.” PubMed search was limited to the categories randomized controlled trials (RCT), clinical trials, meta-analysis and (systematic) reviews, whereas case reports were excluded. Studies from January 2000 to December 2020 were considered eligible. A total of 572 studies were identified, 82 references included for qualitative synthesis, and 19 for detailed sub analysis (12 meta-analysis, 7 prospective RCT). Results: Structural problems in the field of PSII were revealed, including (1) limited level of evidence in clinical studies (missing prospective RCT, metanalyzes), (2) small patient numbers, (3) missing standardized definitions, (4) heterogeneity in patient groups, and (5) redundancy in cited literature. Conclusion: Evidence-based knowledge about spinal implant-associated infections is lacking. All involved medical fields should come together to define the term PSII and to combine their approaches toward research, training, and patient care.

Purpose The aim of this study was to give a systematic overview over the rate and location of concomitant injuries, the probability of suffering from neurological deficits, and to give evidence of the timing of surgery in severely injured patients with unstable thoracic vertebral body fractures. Methods This review is based on articles retrieved by a systematic search in the PubMed and Web of Science database for publications up to November 2020 dealing with unstable fractures of the mid-thoracic spine. Results Altogether, 1109 articles were retrieved from the literature search. A total of 1095 articles were excluded. Thus, 16 remaining original articles were included in this systematic review depicting the topics timing of surgery in polytraumatized patients, outcome neurologic deficits, and impact of concomitant injuries. The overall level of evidence of the vast majority of studies is low. Conclusion The evidence of the available literature is low. The cited studies reveal that thoracic spinal fractures are associated with a high number of neurological deficits and concomitant injuries, particularly of the thoracic cage and the lung. Thereby, diagnostic algorithm should include computer tomography of the whole thoracic cage if there is any clinical sign of concomitant injuries. Patients with incomplete neurologic deficits benefit from early surgery consisting of decompression and long-segmental stabilization.

Study Design: Retrospective cohort study. Objectives: The OF classification is a new classification for osteoporotic vertebral fractures. The aim of this study was to clarify the relationship between preoperative OF subgroups and the postoperative outcome after kyphoplasty in patients with such fractures. Methods: Patients who underwent kyphoplasty of a single osteoporotic vertebral fracture were included and divided into groups according to the OF subgroups. Pre- and postoperative plain radiographs were analyzed in regard to the restoration of vertebral body height and local kyphotic angle (LKA). Additionally, clinical data including pre- and postoperative Visual Analogue Scale pain scores was documented. The clinical and radiological results were compared pre- and postoperatively within groups and between groups. Results: A total of 156 patients from OF subgroups 2 to 4 were included (OF 2: n = 58; OF 3: n = 36; OF 4: n = 62). Patients from all groups experienced significant pain relief postoperatively ( P < .001). Patients with OF 2 fractures showed a repositioning of the vertebral body height in the anterior and middle portions (both P < .001), but no significant improvement in LKA. For OF 3 and 4 fractures, there was a significant restoration of vertebral body height ( P < .001 for both) and a significant improvement of LKA ( P < .001 for both). The highest average restoration was noted in the OF 4 group. Conclusions: A higher OF subgroup is related to a higher radiological benefit from kyphoplasty. This confirms that the OF classification is an appropriate tool for the preoperative assessment of osteoporotic fractures.

Als Spondylolisthese wird eine Instabilität der Wirbelsäule mit Gleiten zweier Wirbelkörper zueinander bezeichnet. Aufgrund der unterschiedlichen Ursachen – angeboren oder erworben – unterscheidet sich die Klinik stark. Die Spondylolyse ist die Spaltbildung in der Pars interarticularis eines Wirbelbogens, d. h. im Bereich zwischen dem oberen und unteren Gelenkfortsatz des Wirbelbogens. Die Folge davon kann ein Gleiten des lytischen Wirbels nach ventral sein.

ZusammenfassungDie Möglichkeiten der orthetischen Therapie von Pathologien an der Wirbelsäule sind umfangreich und können unübersichtlich sein. Zunächst muss der betroffenen Lokalisation an der Wirbelsäule Rechnung getragen werden. Darüber hinaus muss das Behandlungsziel, das durch die Orthesenanwendung erreicht werden soll, klar definiert sein. Das Wirkprinzip der verwendeten Orthese sollte daran ausgerichtet sein. Insgesamt sind die therapeutischen Mittel- und Langzeiteffekte der Orthesentherapie für die meisten Pathologien an der Wirbelsäule überwiegend unzureichend. Lediglich bei osteoporotischen Frakturen von älteren Frauen ist ein muskelstimulierender Effekt bei der Verwendung von Aktivorthesen nachgewiesen. Demgegenüber weist eine deutschsprachige Umfrage über die nationale Orthesenanwendung an der Wirbelsäule eine heterogene Anwenderhäufigkeit auf. Insbesondere die häufige Anwendung im Rahmen der konservativen Therapie von traumatischen Wirbelkörperfrakturen als auch die häufige postoperative Orthesenverwendung basiert nicht auf der Grundlage der aktuellen Literatur.

The majority of traumatic vertebral fractures occur at the thoracolumbar junction and the lumbar spine and less commonly at the mid-thoracic and upper thoracic spine. In accordance, a high number of articles are dealing with thoracolumbar fractures focusing on the thoracolumbar junction. Nonetheless, the biomechanics of the thoracic spine differ from the thoracolumbar junction and the lumbar vertebral spine. The aim of this review is to screen the literature dealing with acute traumatic thoracic vertebral fractures in patients with normal bone quality. Thereby, the diagnostic of thoracic vertebral body fractures should include a CT examination. Ideally, the CT should include the whole thoracic cage particularly in patients suffering high energy accidents or in those with clinical suspicion of concomitant thoracic injuries. Generally, concomitant thoracic injuries are frequently seen in patients with thoracic spine fractures. Particularly sternal fractures cause an increase in fracture instability. In case of doubt, long segment stabilization is recommended in patients with unstable mid- und upper thoracic fractures, particularly in those patients with a high grade of instability.

BACKGROUND: The prevalence of osteoporotic vertebral body fractures in Europe is 18–26%. Although most of these injuries can be treated conservatively, the underlying concepts have not been defined clearly or uniformly. In this article, we present the current state of the evidence on the diagnosis and conservative treatment of osteoporotic fractures of the thoracic and lumbar vertebrae. METHODS: A systematic review of the literature up to May 2020 was carried out in the PubMed and Web of Science Core Collection databases. 549 articles were identified, of which 36 were suitable for inclusion in the review. Articles were sought in the areas of diagnosis, provision of physical aids, pharmacotherapy, physiotherapy, and treatments from the realm of alternative medicine. RESULTS: The primary diagnostic technique was conventional x-ray in two planes (with the patient standing, if possible), which had 51.3% sensitivity and 75% specificity. If a fracture was suspected, magnetic resonance imaging (MRI) of the entire spine and regional computed tomography (CT) were carried out. The overall state of the evidence on treatment is poor; the best available evidence is for exercise therapy and physiotherapy, which are supported by three level I and four level II studies. Improvements were seen mainly in mobility and a reduced fear of falling. The use of an active orthosis can be useful as well. No evidence was found on the use of drugs or alternative medicine exclusively in the conservative treatment of osteoporotic vertebral body fractures. CONCLUSION: It is reasonable to evaluate instability with imaging repeatedly, at regular intervals, over a period of six months. There is still a lack of reliable data on the optimal intensity and duration of physiotherapy, and on the use of orthoses.

Purpose To report on the development of AOSpine CROST (Clinician Reported Outcome Spine Trauma) and results of an initial reliability study. Methods The AOSpine CROST was developed using an iterative approach of multiple cycles of development, review, and revision including an expert clinician panel. Subsequently, a reliability study was performed among an expert panel who were provided with 20 spine trauma cases, administered twice with 4-week interval. The results of the developmental process were analyzed using descriptive statistics, the reliability per parameter using Kappa statistics, inter-rater rater agreement using intraclass correlation coefficient (ICC), and internal consistency using Cronbach’s α. Results The AOSpine CROST was developed and consisted of 10 parameters, 2 of which are only applicable for surgically treated patents (‘Wound healing’ and ‘Implants’). A dichotomous scoring system (‘yes’ or ‘no’ response) was incorporated to express expected problems for the short term and long term. In the reliability study, 16 (84.2%) participated in the first round and 14 (73.7%) in the second. Intra-rater reliability was fair to good for both time points (κ = 0.40–0.80 and κ = 0.31–0.67). Results of inter-rater reliability were lower (κ = 0.18–0.60 and κ = 0.16–0.46). Inter-rater agreement for total scores showed moderate results (ICC = 0.52–0.60), and the internal consistency was acceptable (α = 0.76–0.82). Conclusions The AOSpine CROST, an outcome tool for the surgeons, was developed using an iterative process. An initial reliability analysis showed fair to moderate results and acceptable internal consistency. Further clinical validation studies will be performed to further validate the tool.

Odontoid fractures in geriatric patients represent an entity of increasing incidence with a high rate of morbidity and mortality. The optimal diagnostic and therapeutic management is being controversially discussed in the literature.In a consensus process and based on the current literature, the members of the working groups "Osteoporotic Fractures" and "Upper Cervical Spine" of the German Society for Orthopaedics and Trauma Surgery (DGOU) defined recommendations for the diagnostics and treatment of odontoid fractures in geriatric patients.For the diagnosis of odontoid fractures in symptomatic patients, computed tomography represents the gold standard, along with conventional radiographs. Magnetic resonance and dynamic imaging can be used as ancillary imaging modalities. With regard to fracture classification, the systems described by Anderson/D'Alonzo and by Eysel/Roosen have proved to be of value. A treatment algorithm was developed based on these classifications. Anderson/D'Alonzo type 1, type 3, and non-displaced type 2 fractures usually can be treated non-operatively. However, a close clinical and radiological follow-up is essential. In Anderson/D'Alonzo type 2 fractures, operative treatment is associated with better fracture healing. Displaced type 2 and type 3 fractures should be stabilized operatively. Type 2 fractures with suitable fracture patterns (Eysel/Roosen 2A/B) can be stabilized anteriorly. Posterior C I/II-stabilization procedures are well established and suitable for all fracture patterns.Frakturen des Dens axis beim geriatrischen Patienten stellen eine wachsende Entität mit hoher Morbidität und Mortalität dar. Die optimale Diagnostik und Behandlung der Verletzung in diesem Patientenkollektiv werden in der Literatur kontrovers diskutiert.In einem gemeinsamen Konsensusprozess erstellten die Mitglieder der Arbeitsgemeinschaft „Osteoporotische Frakturen“ und der Arbeitsgemeinschaft „Obere Halswirbelsäule“ der Sektion Wirbelsäule der Deutschen Gesellschaft für Orthopädie und Unfallchirurgie (DGOU) unter Berücksichtigung aktueller Literatur Empfehlungen zu Diagnostik und Behandlung von Frakturen des Dens axis bei geriatrischen Patienten.In der Diagnostik der Densfrakturen stellt beim symptomatischen Patienten neben der konventionellen Bildgebung die Computertomografie den Goldstandard dar. Kernspintomografie und Funktionsaufnahmen können ergänzende Informationen liefern. Zur Klassifikation haben sich die Systeme nach Anderson/DʼAlonzo und Eysel/Roosen bewährt. Anhand der genannten Klassifikationen wurde ein Behandlungsalgorithmus entwickelt: Anderson/DʼAlonzo Typ 1, Typ 3 und nicht dislozierte Frakturen vom Typ 2 können i. d. R. unter engmaschigen Verlaufskontrollen konservativ behandelt werden. Bei Frakturen vom Typ 2 nach Anderson/DʼAlonzo bietet die operative Behandlung den Vorteil höherer knöcherner Heilungsraten. Dislozierte Typ-2- und Typ-3-Frakturen sollten operativ stabilisiert werden. Bei geeignetem Frakturverlauf (Eysel/Roosen 2A/B) sind anteriore Verfahren möglich. Posteriore Verfahren zur C I/II-Stabilisation sind etabliert und bei allen Frakturtypen durchführbar.

An increasing incidence of sacral insufficiency fractures in geriatric patients has been documented, representing a major challenge to our healthcare system. Determining the accurate diagnosis requires the use of sectional imaging, including computed tomography and magnetic resonance imaging. Initially, non-surgical treatment is indicated for the majority of patients. If non-surgical treatment fails, several minimally invasive therapeutic strategies can be used, which have shown promising results in small case series. These approaches are sacroplasty, percutaneous iliosacral screw fixation (S1 with or without S2), trans-sacral screw fixation or implantation of a trans-sacral bar, transiliac internal fixator stabilisation, and spinopelvic stabilisation. These surgical strategies and their indications are reported in detail. Generally, treatment-related decision making depends on the clinical presentation, fracture morphology, and attending surgeon's experience.Insuffizienzfrakturen des hinteren Beckenrings nehmen an Häufigkeit zu und stellen eine relevante Herausforderung für unser Gesundheitssystem dar. Zur Sicherung der Diagnose sollte ergänzend zu den konventionellen Röntgenaufnahmen eine Computertomografie und ggf. eine Magnetresonanztomografie erfolgen. Bei Versagen konservativer Therapieregime zeigen kleinere Serien minimalinvasiver operativer Therapieansätze vielversprechende Ergebnisse. Ziel dieser Übersichtsarbeit ist es, die aktuell eingesetzten Techniken der minimalinvasiven operativen Versorgung von Insuffizienzfrakturen des Sakrums aufzuführen und die jeweiligen Vor- und Nachteile darzulegen. Dies sind aktuell die Sakroplastie, die perkutane iliosakrale Verschraubung S I oder S I/S II, die transsakrale Verschraubung u. a. mithilfe des transsakralen „bar“ und von posterior horizontalen sowie lumbopelvinen Stabilisierungen. Im Allgemeinen hängt die Entscheidungsfindung zur Therapie vom klinischen Erscheinungsbild, der Frakturmorphologie und den Erfahrungen der behandelnden Chirurgen ab.

BACKGROUND Osteoporotic vertebral fractures (OVFs) have become increasingly common, and previous nonrandomized and randomized controlled trials (RCTs) have compared the effects of cement augmentation versus nonoperative management on the clinical outcome. This meta-analysis focuses on RCTs and the calculated differences between cement augmentation techniques and nonsurgical management in outcome (e.g., pain reduction, adjacent-level fractures, and quality of life [QOL]). METHODS A systematic review was performed according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines, and the following scientific search engines were used: MEDLINE, Embase, Cochrane, Web of Science, and Scopus. The inclusion criteria included RCTs that addressed different treatment strategies for OVF. The primary outcome was pain, which was determined by a visual analog scale (VAS) score; the secondary outcomes were the risk of adjacent-level fractures and QOL (as determined by the EuroQol-5 Dimension [EQ-5D] questionnaire, the Oswestry Disability Index [ODI], the Quality of Life Questionnaire of the European Foundation for Osteoporosis [QUALEFFO], and the Roland-Morris Disability Questionnaire [RDQ]). Patients were assigned to 3 groups according to their treatment: vertebroplasty (VP), kyphoplasty (KP), and nonoperative management (NOM). The short-term (weeks), midterm (months), and long-term (>1 year) effects were compared. A random effects model was used to summarize the treatment effect, including I2 for assessing heterogeneity and the revised Cochrane risk-of-bias 2 (RoB 2) tool for assessment of ROB. Funnel plots were used to assess risk of publication bias. The log of the odds ratio (OR) between treatments is reported. RESULTS After screening of 1,861 references, 53 underwent full-text analysis and 16 trials (30.2%) were included. Eleven trials (68.8%) compared VP and NOM, 1 (6.3%) compared KP and NOM, and 4 (25.0%) compared KP and VP. Improvement of pain was better by 1.31 points (95% confidence interval [CI], 0.41 to 2.21; p < 0.001) after VP when compared with NOM in short-term follow-up. Pain effects were similar after VP and KP (midterm difference of 0.0 points; 95% CI, -0.25 to 0.25). The risk of adjacent-level fractures was not increased after any treatment (log OR, -0.16; 95% CI, -0.83 to 0.5; NOM vs. VP or KP). QOL did not differ significantly between the VP or KP and NOM groups except in the short term when measured by the RDQ. CONCLUSIONS This meta-analysis provides evidence in favor of the surgical treatment of OVFs. Surgery was associated with greater improvement of pain and was unrelated to the development of adjacent-level fractures or QOL. Although improvements in sagittal balance after surgery were poorly documented, surgical treatment may be warranted if pain is a relevant problem. LEVEL OF EVIDENCE Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Die minimal-invasive Stabilisation thorakolumbaler osteoporotischer Frakturen (OF) bei Patienten ohne neurologisches Defizit hat sich weitestgehend etabliert. Verschiedene dorsale und ventrale Techniken stehen zur Verfugung. Die OF-Klassifikation und der OF-Score stellen Hilfen bei der Indikation und Auswahl der operativen Technik dar. Die Arbeit gibt einen Uberblick uber die minimal-invasiven Stabilisationstechniken sowie uber deren Komplikationen und Ergebnisse. Selektive Literaturrecherche und Beschreibung der operativen Techniken. Die alleinige Wirbelkorperaugmentation kann bei schmerzhaften, aber stabilen Frakturen der Typen OF 1 und 2, seltener bei Typ OF 3 indiziert sein. Die Kyphoplastie stellt ein gut untersuchtes, effektives und sicheres Verfahren dar. Instabile Frakturen und kyphotische Fehlstellungen (Typen OF 3–5) sollten perkutan dorsal stabilisiert werden. Die Lange des Konstrukts richtet sich nach dem Grad der Instabilitat und der Fehlstellung. Die Zementaugmentation der Schrauben kann bei ausgepragter Osteoporose indiziert sein, erhoht jedoch die Komplikationsrate. Die Wiederherstellung der Stabilitat der ventralen Saule kann uber eine Wirbelkorperaugmentation, seltener uber eine minimal-invasive ventrale Stabilisation erfolgen. Die klinisch-radiologischen kurz- und mittelfristigen Ergebnisse der Stabilisationstechniken sind gut, jedoch steigt mit zunehmender Invasivitat auch die Komplikationsrate an. Die minimal-invasiven Stabilisationstechniken sind sicher und effektiv. Die Indikationen fur die einzelnen Verfahren richten sich nach der OF-Klasse und der individuellen klinischen Situation des Patienten.

Purpose The aim of this review is to systematically screen the literature for clinical and biomechanical studies dealing with posterior stabilization of acute traumatic mid-thoracic vertebral fractures in patients with normal bone quality. Methods This review is based on articles retrieved by a systematic search in the PubMed and Web of Science database for publications up to December 2018 dealing with the posterior stabilization of fractures of the mid-thoracic spine. Results Altogether, 1012 articles were retrieved from the literature search. A total of 960 articles were excluded. A total of 16 articles were dealing with the timing of surgery in polytraumatized patients, patients suffering of neurologic deficits after midthoracic fractures, and the impact of concomitant thoracic injuries and were excluded. Thus, 36 remaining original articles were included in this systematic review depicting the topics biomechanics, screw insertion, and outcome after posterior stabilization. The overall level of evidence of the vast majority of studies is low. Conclusion High quality studies are lacking. Long-segmental stabilization is indicated in unstable midthoracic fractures with concomitant sternal fractures. Generally, long-segmental constructs seem to be the safer treatment strategy considering the relative high penetration rate of pedicle screws in this region. Thereby, navigated insertion techniques and intraoperative 3D-imaging help to improve pedicle screw placement accuracy.

This study aimed to compare clinical results and fusion rates of uncoated polyetheretherketone (PEEK) cages with titanium-coated PEEK cages in posterior lumbar interbody fusion (PLIF) surgery. A prospective randomised study including 60 patients with one- or two-segment lumbar degenerative diseases. Patients received either titanium-coated PEEK cages (group A) or uncoated PEEK cages (group B). Fusion rates were evaluated on plain X-rays and CT scans after 6 and 12 months. Clinical follow-up (visual analogue scale, VAS; Oswestry Disability Index score, ODI; EQ-5D) was performed for 24 months. Fifty-five patients (92%) (36 female, 19 male) had a complete follow-up. There were no statistically significant differences in demographic, peri- or intraoperative data between groups A and B. ODI, VAS and EQ-5D improved significantly (p

The AOSpine PROST (Patient Reported Outcome Spine Trauma) is a new disease-specific outcome instrument for spine trauma patients. Very good results were obtained for reliability and validity of the English version. It has the potential to contribute to the reduction of ongoing controversies in spine trauma care., Study Design. Multicenter validation study. Objective. The aim of this study was to translate and adapt the AOSpine PROST (Patient Reported Outcome Spine Trauma) into English, and test its psychometric properties among North-American spine trauma patients. Summary of Background Data. In the absence of an outcome instrument specifically designed and validated for traumatic spinal column injury patients, it is difficult to measure the effect size of various treatment options. The AOSpine Knowledge Forum Trauma initiated a project and developed the AOSpine PROST consisting of 19 items. Methods. Patients were recruited from two level-1 North-American trauma centers. For concurrent validity, next to AOSpine PROST also 36-item Short-Form Health Survey (SF-36) was filled out by patients. Patient characteristics were analyzed using descriptive statistics. Floor and ceiling effects as well as the number of inapplicable and missing questions were analyzed for content validity. Cronbach α and item-total correlation coefficients (ITCCs) were calculated for internal consistency. Spearman correlation tests were performed within AOSpine PROST items and in correlation to SF-36. Test-retest reliability was assessed using intraclass correlation coefficients (ICCs). Factor analysis was performed to explore any dimensions within AOSpine PROST. Results. The AOSpine PROST was translated adapted into English using established guidelines. Of 196 enrolled patients, 162 (82.7%) met the inclusion criteria and provided sufficient data. Content validity showed good results, and no floor and ceiling effects were seen. The internal consistency was excellent (Cronbach α = 0.97; ITCC 0.50–0.90) as well as test–retest reliability (ICC = 0.97). Spearman correlations were good (0.29–0.85). The strongest correlations of AOSpine PROST with SF-36 were seen with the physical components (0.69–0.82; P 1), explaining 75.7% of variance. Conclusion. The English version of AOSpine PROST showed very good validity and reliability. It is considered as a valuable tool, and has the potential to contribute to the reduction of ongoing controversies in spine trauma care. Level of Evidence: 2

Prospektive klinische Kohortenstudie (Datensammlung), Expertenmeinung (Erstellung von Empfehlungen) Behandlungsstrategien fur die nicht-operative und operative Therapie osteoporotischer Wirbelkorperfrakturen gehen haufig weit auseinander. Auf Grundlage der existierenden Literatur, dem Wissen von Experten und deren Klassifikation osteoporotischer Wirbelkorperfrakturen (OF-Klassifikation) hat die Sektion Wirbelsaule der Deutschen Gesellschaft fur Orthopadie und Unfallchirurgie nun allgemeine Behandlungsempfehlungen herausgegeben. Insgesamt wurden 707 klinische Falle aus 16 Krankenhausern ausgewertet. Ein auf der OF-Klassifikation basierender Score wurde entwickelt, der die Therapiefestlegung nicht-operativ versus operativ erleichtert. Fur jeden Klassifikationstyp werden differenzierte Behandlungsempfehlungen gegeben. Diagnostische Anforderungen werden definiert, um die Reproduzierbarkeit der Empfehlungen zu gewahrleisten: Konventionelle Rontgenbilder einschlieslich entsprechender Nachuntersuchungen (wann immer moglich in stehender Position), Kernspintomographie und Computertomographie. Die OF-Klassifikation ermoglicht grundsatzlich eine Hoherstufung der initial festgelegten Frakturschwere im Fall von Veranderungen im Rahmen der radiologischen Kontrolluntersuchungen. In den Score geht der jeweils aktuelle Klassifikationstyp ein. Ein Score mit weniger als 6 Punkten empfiehlt ein nicht-operatives Vorgehen. Werden mehr als 6 Punkte erzielt, wird ein operatives Therapieregime empfohlen. Oberstes Behandlungsziel ist die schnelle und schmerzfreie Mobilisierung. Aufgrund der in dieser Altersgruppe zu erwartenden Komorbiditaten wird minimalinvasiven Verfahren der Vorzug gegeben. Als allgemeiner Behandlungsgrundsatz gilt, dass Stabilitat wichtiger ist als der Erhalt von Bewegungssegmenten. Es ist erforderlich, die physiologische Belastbarkeit der Wirbelsaule wiederherzustellen. Wenn vor dem Frakturereignis eine kompensierte Dysbalance vorlag, genugt die Wiederherstellung des individuellen Ausgangszustandes. Die gewahlte Instrumentierungstechnik muss die zu erwartende Minderung der Knochendichte berucksichtigen. Wir empfehlen daher die Verwendung von Zement-Augmentationstechniken oder den Einsatz spezieller Schraubendesigns mit erhohter Haltekraft. Fur besondere Situationen, wie Verletzungen mit neurologischem Defizit, Notwendigkeit einer Fusion, Vorliegen multipler Frakturen, Nachbarsegment- und Anschlussfrakturen sowie Frakturen bei ankylosierender Spondylitis, werden eigene Therapieempfehlungen gegeben. Die hier vorgestellten Behandlungsempfehlungen stellen eine verlassliche und reproduzierbare Basis dar, um sich zwischen den verfugbaren Therapiemoglichkeiten zu entscheiden. Unentschiedene klinische Situationen, bei denen keine klare Empfehlung fur ein entweder nicht-operatives oder operatives Vorgehen ausgesprochen werden, kommen bei einem OF-Score von 6 jedoch weiterhin vor. Daher konnen individualisierte Behandlungsentscheidungen nach wie vor notwendig sein. In einem nachsten Schritt werden die vorliegenden Behandlungsempfehlungen im Rahmen einer kontrollierten klinischen Multizenterstudie weiter evaluiert werden.

Study Design: Narrative review and expert recommendation. Objectives: To establish treatment recommendations for atlas fractures based on the knowledge of the experts of the Spine Section of the German Society for Orthopaedics and Trauma. Methods: Neither high-level evidence studies comparing conservative and operative management nor studies matching different operative treatment strategies exist. This recommendation summarizes the knowledge of the experts of the Spine Section of the German Society for Orthopaedics and Trauma with regard to the treatment of atlas fractures. Results: Most atlas fractures are the result of compression forces. A valuable morphological classification system has been described by Gehweiler. For an adequate diagnosis, a computed tomography is mandatory. To distinguish between stable and unstable type 3 injuries, it is necessary to evaluate the integrity of the transverse atlantal ligament (TAL) with magnetic resonance imaging and to classify the TAL lesions. The majority of atlas fractures are stable and will be successfully managed conservatively. Unstable atlas fractures (type 3b and sagittal split type 4 fractures) should be treated by surgical stabilization. Unstable atlas fractures (type 3b) with a midsubstance ligamentous disruption or severely dislocated ligamentous bony avulsions of the TAL can successfully be treated by a C1/2 fusion. Unstable atlas fractures (type 3b) with a moderately dislocated ligamentous bony avulsion of the TAL and sagittal split type 4 fractures may be treated by atlas osteosynthesis only. Conclusions: Whereas the majority of atlas fractures can be managed conservatively, in specific fracture patterns surgical treatment strategies have become the standard of care.

Study Design: Expert consensus. Objectives: To establish treatment recommendations for subaxial cervical spine injuries based on current literature and the knowledge of the Spine Section of the German Society for Orthopaedics and Trauma. Methods: This recommendation summarizes the knowledge of the Spine Section of the German Society for Orthopaedics and Trauma. Results: Therapeutic goals are a stable, painless cervical spine and protection against secondary neurologic damage while retaining maximum possible motion and spinal profile. The AOSpine classification for subaxial cervical injuries is recommended. The Canadian C-Spine Rule is recommended to decide on the need for imaging. Computed tomography is the favoured modality. Conventional x-ray is preserved for cases lacking a “dangerous mechanism of injury.” Magnetic resonance imaging is recommended in case of unexplained neurologic deficit, prior to closed reduction and to exclude disco-ligamentous injuries. Computed tomography angiography is recommended in high-grade facet joint injuries or in the presence of vertebra-basilar symptoms. A0-, A1- and A2-injuries are treated conservatively, but have to be monitored for progressive kyphosis. A3 injuries are operated in the majority of cases. A4- and B- and C-type injuries are treated surgically. Most injuries can be treated with anterior plate stabilization and interbody support; A4 fractures need vertebral body replacement. In certain cases, additive or pure posterior instrumentation is needed. Usually, lateral mass screws suffice. A navigation system is advised for pedicle screws from C3 to C6. Conclusions: These recommendations provide a framework for the treatment of subaxial cervical spine Injuries. They give advice about diagnostic measures and the therapeutic strategy.

Fractures of the os sacrum without relevant trauma history are defined as stress or insufficiency fractures and often affect the anterior pelvis. Sacral insufficiency fractures are associated with osteoporosis and occur under physiological load. In contrast, sacral stress fractures are caused by mechanical overloading. Diagnostic confirmation is delayed in many of these patients. Thus, MRI and/or CT should be performed early. Fracture stability should be evaluated by CT. MRI is the better approach to rule out fractures and is highly sensitive. It is indicated in young patients and in patients with non-specific lumbosacral pain. Nuclear imaging techniques are viable alternatives in patients with a contraindication for MRI.Sakrumfrakturen, die ohne adäquates Trauma entstanden sind, werden in Insuffizienzfrakturen und Stressfrakturen eingeteilt. Während Insuffizienzfrakturen bei physiologischer Belastung meist auf dem Boden einer relevanten Osteoporose entstehen, beruhen Stressfrakturen auf einer mechanischen Überlastung. Der vordere Beckenring ist regelmäßig beteiligt. Aufgrund des fehlenden bzw. niederenergetischen Unfallhergangs wird die korrekte Diagnose oft verspätet gestellt. Demzufolge war es das Ziel der AG Osteoporotische Frakturen der Sektion Wirbelsäule der DGOU, die einzelnen bildgebenden Verfahren zur korrekten, schnellen und kosteneffektiven Diagnostik vorzustellen. Zur Diagnosesicherung sollte neben der konventionell radiologischen Diagnostik zeitnah eine Schnittbildgebung in die Wege geleitet werden. Mittels CT kann die Frakturmorphologie am besten beurteilt werden, wodurch potenzielle Instabilitätszeichen der Verletzung erkannt werden können. Die MRT kann aufgrund der hohen Sensitivität bei fehlendem Frakturnachweis im CT, bei jungen Patienten und unklaren Situationen zusätzliche wichtige Informationen liefern. Im Falle einer Kontraindikation für das MRT stellen nuklearmedizinische Untersuchungen eine gute Alternative dar.

In a consensus process with four sessions in 2017, the working group "upper cervical spine" of the German Society for Orthopaedics and Trauma Surgery (DGOU) formulated "Therapeutic Recommendations for the Diagnosis and Treatment of Upper Cervical Fractures", taking their own experience and the current literature into consideration. The following article describes the recommendations for axis ring fractures (traumatic spondylolysis C2). About 19 to 49% of all cervical spine injuries include the axis vertebra. Traumatic spondylolysis of C2 may include potential discoligamentous instability C2/3. The primary aim of the diagnostic process is to detect the injury and to determine potential disco-ligamentous instability C2/3. For classification purposes, the Josten classification or the modified Effendi classification may be used. The Canadian C-spine rule is recommended for clinical screening for C-spine injuries. CT is the preferred imaging modality and an MRI is needed to determine the integrity of the discoligamentous complex C2/3. Conservative treatment is appropriate in case of stable fractures with intact C2/3 motion segment (Josten type 2 and 2). Patients should be closely monitored, in order to detect secondary dislocation as early as possible. Surgical treatment is recommended in cases of primary severe fracture dislocation or discoligamentous instability C2/3 (Josten 3 and 4) and/or secondary fracture dislocation. Anterior cervical decompression and fusion (ACDF) C2/3 is the treatment of choice. However, in case of facet joint luxation C2/3 with looked facet (Josten 4), a primary posterior approach may be necessary.Im Jahr 2017 wurde die Arbeitsgruppe „obere HWS“ in der Sektion Wirbelsäulenchirurgie der DGOU etabliert. Die Mitglieder der AG erstellten in einem formalen Konsensverfahren im nominalem Gruppenprozess mit 4 Präsenzveranstaltungen, Empfehlungen zur Diagnostik und Therapie von Axisringfrakturen unter Berücksichtigung der aktuellen Literatur. Der folgende Artikel beschreibt die Empfehlung für Frakturen des Axisrings (traumatische Spondylolyse HWK II). Axisfrakturen werden mit einer Häufigkeit von 19 – 41% bei Nachweis einer HWS-Verletzung detektiert. Insbesondere besteht bei Frakturen des Axisrings eine potenzielle diskoligamentäre Instabilität. Daher zielt die Diagnostik auf die Detektion der Verletzung sowie die Beurteilung einer möglichen diskoligamentären Instabilität ab. Zur Klassifikation wird die Klassifikation nach Josten oder auch die von Levine modifizierte Effendi-Klassifikation empfohlen. Zum primären klinischen Screening hat sich die Canadian C-Spine Rule bewährt. Bildgebendes Verfahren der Wahl bei klinischem Verdacht auf eine Axisringverletzung ist die Computertomografie. Die MRT dient der Beurteilung der Integrität des diskoligamentären Komplexes HWK II/III. Stabile Axisringfrakturen können konservativ in einer Zervikalorthese behandelt werden, wobei eine engmaschige Dislokationskontrolle obligat ist. Im Falle einer sekundären Dislokation ist eine operative Stabilisierung indiziert. Eine OP-Indikation besteht bei ausgeprägter Dislokation und/oder diskoligamentärer Instabilität HWK II/III, die am häufigsten bei Josten-Typ-3- und -4-Frakturen vorliegt. Operative Standardtherapie ist die ventrale Fusion HWK II/III wobei insbesondere bei Typ-4-Frakturen ein primär dorsales Vorgehen zur Frakturreposition und ggf. Stabilisation notwendig werden kann.

Geriatrische Sakrumfrakturen stellen eine eigenstandige Frakturentitat mit wachsender Inzidenz und von steigender gesundheitsokonomischer Relevanz dar. Die Ziele der Behandlung sind sehr unterschiedlich zu denen bei jungeren Patienten mit Hochenergiebeckenverletzungen. Um den Erfolg der Behandlung geriatrischer Sakrumfrakturen beurteilen zu konnen, mussen daher andere, vielleicht auch neue Messinstrumente zur Anwendung kommen. Literaturubersicht zu den vorhandenen Konzepten und Messinstrumenten der Outcome-Messung nach geriatrischen Sakrumfrakturen. Narrativer Ubersichtsartikel basierend auf einer Recherche der relevanten deutsch- und englischsprachigen Literatur der letzten 10 Jahre. Geriatrische Sakrumfrakturen fuhren zu einer verminderten Mobilitat, einer erhohten korperlichen und sozialen Abhangigkeit und einer hohen Morbiditats- und Mortalitatsrate. Standardisierte spezifische Beurteilungsverfahren zur Beurteilung des funktionellen Ergebnisses nach geriatrischen Sakrumfrakturen fehlen. Bis diese entwickelt werden, scheint die parallele Erfassung von Mortalitat, Timed „Up and Go“ Test, Oswestry Disability Index und einem generischen Gesundheitsfragebogen (Short Form-36, EurQul-5D) am sinnvollsten. Unser Wissen uber den naturlichen Verlauf nach geriatrischen Sakrumfrakturen ist derzeit limitiert, durch das Fehlen gut validierter Instrumente zur Messung des radiologischen und funktionellen Outcome. Dies gilt es zu beachten, wenn der Erfolg neuer Therapien fur diese Patienten beurteilen werden muss. Zukunftige Studien sollten existierende Scores fur diese Patientengruppe validieren und neue spezifische Messinstrumente entwickeln.

Thorakolumbale Frakturen des alten Menschen sind regelmasig mit einer Osteoporose assoziiert. Diese kann Ursache der Fraktur oder wichtige Komorbiditat bei einem Trauma sein. Die OF-Klassifikation erlaubt eine einfache und fur die Therapie relevante Einteilung der Frakturen und basiert auf Rontgenaufnahmen, Computer- (CT) und Magnetresonanztomographie (MRT). Die Therapie richtet sich nach dem klinischen und dem radiologischen Erscheinungsbild und kann mithilfe des OF-Scores bestimmt werden. Dieser berucksichtigt die aktuelle klinische Situation, aber auch Komorbiditaten des Patienten. Die Therapieempfehlungen basieren auf einem Expertenkonsens und beinhalten konservative und operative Optionen. Sofern eine chirurgische Therapie indiziert ist, kommen Wirbelkorperaugmentationen, perkutane Stabilisationen, aber auch offene Verfahren zur Anwendung.

ZusammenfassungIm 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.

Study Design: Prospective survey-based study. Objectives: The AO Spine thoracolumbar injury classification has been shown to have good reproducibility among clinicians. However, the influence of spine surgeons’ clinical experience on fracture classification, stability assessment, and decision on management based on this classification has not been studied. Furthermore, the usefulness of varying imaging modalities including radiographs, computed tomography (CT) and magnetic resonance imaging (MRI) in the decision process was also studied. Methods: Forty-one spine surgeons from different regions, acquainted with the AOSpine classification system, were provided with 30 thoracolumbar fractures in a 3-step assessment: first radiographs, followed by CT and MRI. Surgeons classified the fracture, evaluated stability, chose management, and identified reasons for any changes. The surgeons were divided into 2 groups based on years of clinical experience as 10 years (n = 29). Results: There were no significant differences between the 2 groups in correctly classifying A1, B2, and C type fractures. Surgeons with less experience had more correct diagnosis in classifying A3 (47.2% vs 38.5% in step 1, 73.6% vs 60.3% in step 2 and 77.8% vs 65.5% in step 3), A4 (16.7% vs 24.1% in step 1, 72.9% vs 57.8% in step 2 and 70.8% vs 56.0% in step3) and B1 injuries (31.9% vs 20.7% in step 1, 41.7% vs 36.8% in step 2 and 38.9% vs 33.9% in step 3). In the assessment of fracture stability and decision on treatment, the less and more experienced surgeons performed equally. The selection of a particular treatment plan varied in all subtypes except in A1 and C type injuries. Conclusion: Surgeons’ experience did not significantly affect overall fracture classification, evaluating stability and planning the treatment. Surgeons with less experience had a higher percentage of correct classification in A3 and A4 injuries. Despite variations between them in classification, the assessment of overall stability and management decisions were similar between the 2 groups.

PURPOSE: To report on the multi-phase process used in developing the AOSpine Patient Reported Outcome Spine Trauma (AOSpine PROST), as well as the results of its application in a pilot study. METHODS: The International Classification of Functioning, Disability and Health (ICF) methodology was used as the basis for the development of this tool. Four preparatory studies and a consensus conference were performed, and resulted in the selection of 25 core ICF categories as well as the scale for use. The first draft of the Dutch version of AOSpine PROST was pilot tested among a consecutively selected representative sample of 25 spine trauma patients, using the 'think aloud' and 'probing' methods. RESULTS: Of the 25 core ICF categories, 9 related to body functions, 14 activities and participation, and 2 environmental factors. Those 25 core categories were implemented into the selected response scale, and resulted in a draft version of AOSpine PROST consisting of 19 items. From the pilot study, very satisfactory results were obtained for comprehensibility, relevance, acceptability, feasibility and completeness, as well as high internal consistency (Cronbach's α = 0.926). CONCLUSIONS: Following the ICF methodology and including the results of 4 different preparatory studies and a consensus conference, the AOSpine PROST is developed. Taking the results from the subsequent pilot study into account, a definite version to be further validated will be developed. The AOSpine PROST has the potential to be a helpful tool in clinical practice and research to compare various treatments and improve the quality of health care.

Study Design: Global cross-sectional survey. Objective: To develop an injury score for the AO Spine Subaxial Cervical Spine Injury Classification System. Methods: Respondents numerically graded each variable within the classification system for severity. Based on the results, and with input from the AO Spine Trauma Knowledge Forum, the Subaxial Cervical AO Spine Injury Score was developed. Results: An A0 injury was assigned an injury score of 0, A1 a score of 1, and A2 a score of 2. Given the significant increase in severity, A3 was given a score of 4. Based on equal severity assessment, A4 and B1 were both assigned a score of 5. B2 and B3 injuries were assigned a score of 6. Unstable C-type injuries were given a score of 7. Stable F1 injuries were assigned a score of 2, with a 2-point increase for F2 injuries. Likewise, F3 injuries received a score of 5, whereas more unstable F4 injuries a score of 7. Neurologic status severity rating scores increased stepwise, with scores of 0 for N0, 1 for N1, and 2 for N2. Consistent with the Thoracolumbar AO Spine Injury Score, N3 (incomplete) and N4 (complete) injuries were given a score of 4. Finally, case-specific modifiers M1 (PLC injury) received a score of 1, while M2 (critical disc herniation) and M3 (spine stiffening disease) received a score of 4. Conclusions: The Subaxial Cervical AO Spine Injury Score is an easy-to-use metric that can help develop a surgical algorithm to supplement the AO Spine Subaxial Cervical Spine Injury Classification System.

BACKGROUND Several classification systems exist for sacral fractures; however, these systems are primarily descriptive, are not uniformly used, have not been validated, and have not been associated with a treatment algorithm or prognosis. The goal of the present study was to demonstrate the reliability of the AOSpine Sacral Classification System among a group of international spine and trauma surgeons. METHODS A total of 38 sacral fractures were reviewed independently by 18 surgeons selected from an expert panel of AOSpine and AOTrauma members. Each case was graded by each surgeon on 2 separate occasions, 4 weeks apart. Intrarater reproducibility and interrater agreement were analyzed with use of the kappa statistic (κ) for fracture severity (i.e., A, B, and C) and fracture subtype (e.g., A1, A2, and A3). RESULTS Seventeen reviewers were included in the final analysis, and a total of 1,292 assessments were performed (646 assessments performed twice). Overall intrarater reproducibility was excellent (κ = 0.83) for fracture severity and substantial (κ = 0.71) for all fracture subtypes. When comparing fracture severity, overall interrater agreement was substantial (κ = 0.75), with the highest agreement for type-A fractures (κ = 0.95) and the lowest for type-C fractures (κ = 0.70). Overall interrater agreement was moderate (κ = 0.58) when comparing fracture subtype, with the highest agreement seen for A2 subtypes (κ = 0.81) and the lowest for A1 subtypes (κ = 0.20). CONCLUSIONS To our knowledge, the present study is the first to describe the reliability of the AOSpine Sacral Classification System among a worldwide group of expert spine and trauma surgeons, with substantial to excellent intrarater reproducibility and moderate to substantial interrater agreement for the majority of fracture subtypes. These results suggest that this classification system can be reliably applied to sacral injuries, providing an important step toward standardization of treatment.

Trotz der heutigen guten diagnostischen und therapeutischen Moglichkeiten ist die Dunkelziffer der an Osteoporose erkrankten Patienten weiterhin sehr hoch und die Therapie folglich meist unzureichend. Haufig wird die Diagnose erst nach Auftreten einer Fraktur gestellt. Ursachlich hierfur ist sicherlich neben den anfallenden Kosten wie auch der zusatzlichen Strahlenexposition die nur eingeschrankte Verfugbarkeit der Dual-energy-Rontgenabsorptiometrie (DEXA) als auch der quantitativen Computertomographie (q-CT). Auf der Suche nach einer alternativen Technik erwiesen sich die „Hounsfield units“ (HU) der klinischen CT-Untersuchung als richtungsweisend. So zeigte sich eine signifikante Korrelation zwischen den T‑Werten der DEXA-Messung und den HU des gleichen Wirbelkorpers. Aufgrund der weiten Verbreitung klinischer CT-Untersuchungen des Thorax und des Abdomens kann durch diese Methode die Dunkelziffer der Erkrankung im Rahmen des Osteoporosescreenings sicherlich deutlich reduziert werden – ohne zusatzliche Kosten, Strahlenexposition oder Mehraufwand fur den Patienten. Neben der Osteoporosediagnostik ermoglichen die berechneten HU auch eine bessere praoperative Planung als auch Vorhersage des weiteren Krankheitsverlaufs. So lasst sich das Risiko fur Wirbelkorperfrakturen, Schraubenlockerungen und Cagesinterungen nach ventralen Fusionsoperationen suffizient vorhersagen. Auf diese Weise lassen sich bereits praoperativ Modifikationen des chirurgischen Vorgehens treffen, um den Schraubenhalt und die Cageverankerung zu verbessern und Anschlussfrakturen zu vermeiden.

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 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: Prospective clinical cohort study (data collection); expert opinion (recommendation development). Objectives: Treatment options for nonsurgical and surgical management of osteoporotic vertebral body fractures are widely differing. Based on current literature, the knowledge of the experts, and their classification for osteoporotic fractures (OF classification) the Spine Section of the German Society for Orthopaedics and Trauma has now introduced general treatment recommendations. Methods: a total of 707 clinical cases from 16 hospitals were evaluated. An OF classification–based score was developed to guide in the option of nonsurgical versus surgical management. For every classification type, differentiated treatment recommendations were deduced. Diagnostic prerequisites for reproducible treatment recommendations were defined: conventional X-rays with consecutive follow-up images (standing position whenever possible), magnetic resonance imaging, and computed tomography scan. OF classification allows for upgrading of fracture severity during the course of radiographic follow-up. The actual classification type is decisive for the score. Results: A score of less than 6 points advocates nonsurgical management; more than 6 points recommend surgical management. The primary goal of treatment is fast and painless mobilization. Because of expected comorbidities in this age group, minimally invasive procedures are being preferred. As a general rule, stability is more important than motion preservation. It is mandatory to restore the physiological loading capacity of the spine. If the patient was in a compensated unbalanced state at the time of fracture, reconstruction of the individual prefracture sagittal profile is sufficient. Instrumentation technique has to account for compromised bone quality. We recommend the use of cement augmentation or high purchase screws. The particular situations of injuries with neurological impairment; necessity to fuse; multiple level fractures; consecutive and adjacent fractures; fractures in ankylosing spondylitis are being addressed separately. Conclusions: The therapeutic recommendations presented here provide a reliable and reproducible basis to decide for treatment choices available. However, intermediate clinical situations remain with a score of 6 points allowing for both nonsurgical and surgical options. As a result, individualized treatment decisions may still be necessary. In the next step, the recommendations presented will be further evaluated in a multicenter controlled clinical trial.

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.

Background Alterations in the activity of the lumbar erector spinae (LES) muscles on both sides of the spine have been inconsistently reported in patients with specific low back pain (sLBP) after measuring the muscular activity with surface electromyography (sEMG). It also remains unclear whether these alterations in LES activity can be related to the functional level of patients with sLBP. Research question This study investigated the LES activity in patients with sLBP during activities of daily living (ADL) which included dynamic and static movement tasks. Moreover, the alterations in LES activity were correlated with the first seven questions of the Zurich Claudication Questionnaire (ZCQ-SS). Methods Thirty patients with specific LBP and twenty healthy subjects were recruited to perform five ADLs including ‘static waist flexion’, ‘sit to stand’,’ 30-seconds standing’, ‘6-minutes walking’ and ‘climbing stairs’. sEMG sensors were mounted on the left and right LES muscles. The integrated EMG (IEMG) was calculated from the preprocessed sEMG data as statistical comparison criteria. Results LES activity was significantly higher in patients during ‘sit to stand’,’ 30-seconds standing’ and ‘climbing stairs’ and significantly lower during ‘static waist flexion’ compared to healthy controls. All tasks showed a significant correlation with the ZCQ-SS score except for ‘6-minutes walking’, whereby LES activity and ZCQ-SS score correspondingly increased during ‘sit to stand’ and ‘climbing stairs’ and the LES activity decreased with an increasing ZCQ-SS score during ‘static waist flexion’ and’ 30-seconds standing’. Significance There was a high correlation between alterations in LES activity and the level of functionality in LBP patients. However, the LES activity showed an opposite behavior during static and dynamic movement tasks. The methodology presented can be a useful tool for quantifying improvements in functionality after rehabilitation processes.

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.

Background context Prior studies have demonstrated the superiority of decompression and fusion over decompression alone for the treatment of lumbar degenerative spondylolisthesis with spinal stenosis. More recent studies have investigated whether nonfusion stabilization could provide durable clinical improvement after decompression and fusion. Purpose To examine the clinical safety and effectiveness of decompression and implantation of a novel flexion restricting paraspinous tension band (PTB) for patients with degenerative spondylolisthesis. Study design A prospective clinical study. Patient sample Forty-one patients (7 men and 34 women) aged 45 to 83 years (68.2±9.0) were recruited with symptomatic spinal stenosis and Meyerding Grade 1 or 2 degenerative spondylolisthesis at L3–L4 (8) or L4–L5 (33). Outcome measures Self-reported measures included visual analog scale (VAS) for leg, back, and hip pain and the Oswestry Disability Index (ODI). Physiologic measures included quantitative and qualitative radiographic analysis performed by an independent core laboratory. Methods Patients with lumbar degenerative spondylolisthesis and stenosis were prospectively enrolled at four European spine centers with independent monitoring of data. Clinical and radiographic outcome data collected preoperatively were compared with data collected at 3, 6, 12, and 24 months after surgery. This study was sponsored by the PTB manufacturer (Simpirica Spine, Inc., San Carlos, CA, USA), including institutional research support grants to the participating centers totaling approximately US $172,000. Results Statistically significant improvements and clinically important effect sizes were seen for all pain and disability measurements. At 24 months follow-up, ODI scores were reduced by an average of 25.4 points (59%) and maximum leg pain on VAS by 48.1 mm (65%). Back pain VAS scores improved from 54.1 by an average of 28.5 points (53%). There was one postoperative wound infection (2.4%) and an overall reoperation rate of 12%. Eighty-two percent patients available for 24 months follow-up with a PTB in situ had a reduction in ODI of greater than 15 points and 74% had a reduction in maximum leg pain VAS of greater than 20 mm. According to Odom criteria, most of these patients (82%) had an excellent or good outcome with all except one patient satisfied with surgery. As measured by the independent core laboratory, there was no significant increase in spondylolisthesis, segmental flexion-extension range of motion, or translation and no loss of lordosis in the patients with PTB at the 2 years follow-up. Conclusions Patients with degenerative spondylolisthesis and spinal stenosis treated with decompression and PTB demonstrated no progressive instability at 2 years follow-up. Excellent/good outcomes and significant improvements in patient-reported pain and disability scores were still observed at 2 years, with no evidence of implant failure or migration. Further study of this treatment method is warranted to validate these findings.

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.

Stabilization of unstable thoracic fractures with transpedicular screws is widely accepted. However, placement of transpedicular screws can cause complications, particularly in the thoracic spine with physiologically small pedicles. Hybrid stabilization, a combination of sublaminar bands and pedicle screws, might reduce the rate of misplaced screws and can be helpful in special anatomic circumstances, such as preexisting scoliosis and osteoporosis. We report about two patients suffering from unstable thoracic fractures, of T5 in one case and T3, T4, and T5 in the other case, with preexisting scoliosis and extremely small pedicles. Additionally, one patient had osteoporosis. Patients received hybrid stabilization with pedicle screws adjacent to the fractured vertebral bodies and sublaminar bands at the level above and below the pedicle screws. No complications occurred. Follow-up was 12 months with clinically uneventful postoperative courses. No signs of implant failure or loss of reduction could be detected. In patients with very small thoracic pedicles, scoliosis, and/or osteoporosis, hybrid stabilization with sublaminar bands and pedicle screws can be a viable alternative to long pedicle screw constructs.

Numerous classification systems for subaxial and thoracolumbar spine injuries were proposed in the past with the attempt to facilitate communication between physicians. The AO-Magerl, thoracolumbar system, and Subaxial Cervical Spine Injury Classification systems are all well known, but did not achieve universal international adoption. A group of international experienced spine trauma surgeons were brought together by AOSpine with the goal to develop a comprehensive yet simple classification system for spinal trauma. This article is a synopsis of the proposed subaxial and thoracolumbar classification systems. In several studies, this classification system was developed using an iterative consensus process among the clinical experts in sufficient number and quality of DICOM images of real cases searching for meaningful and reproducible patterns. Both systems are based on 3 injury morphology types: compression injuries (A), tension band injuries (B), and translational injuries (C) with a total of 9 subgroups. In the subaxial cervical spine 4 additional subtypes for facet injuries exist. Patient-specific modifiers and neurologic status were also included to aid surgeons in therapeutic decision making. The proposed classification systems for subaxial and thoracolumbar injuries showed substantial intraobserver and interobserver reliability (κ = 0.64-0.85) for grading fracture type. Grading for the subtypes varied considerably due to the low frequency of certain injury subtypes among other reasons. In summary, the AOSpine thoracolumbar and subaxial cervical spine injury systems show substantial reliability, thus being valuable tools for clinical and research purposes.

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