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Purpose The AO Spine PROST (Patient Reported Outcome Spine Trauma) was developed for people with spine trauma and minor or no neurological impairment. The purpose is to investigate health professionals’ perspective on the applicability of the AO Spine PROST for people with motor-complete traumatic or non-traumatic spinal cord injury (SCI), using a discussion meeting and international survey study. Methods A discussion meeting with SCI rehabilitation physicians in the Netherlands was performed, followed by a worldwide online survey among the AO Spine International community, involved in the care of people with SCI. Participants rated the comprehensibility, relevance, acceptability, feasibility and completeness of the AO Spine PROST on a 1–5 point scale (5 most positive). Comments could be provided per question. Results The discussion meeting was attended by 13 SCI rehabilitation physicians. The survey was completed by 196 participants. Comprehensibility (mean ± SD: 4.1 ± 0.8), acceptability (4.0 ± 0.8), relevance (3.9 ± 0.8), completeness (3.9 ± 0.8), and feasibility (4.1 ± 0.7) of the AO Spine PROST were rated positively for use in people with motor-complete traumatic or non-traumatic SCI. Only a few participants questioned the relevance of items on the lower extremities (e.g., walking) or missed items on pulmonary functioning and complications. Some recommendations were made for improvement in instructions, terminology and examples of the tool. Conclusion Health professionals found the AO Spine PROST generally applicable for people with motor-complete traumatic or non-traumatic SCI. This study provides further evidence for the use of the AO Spine PROST in spine trauma care, rehabilitation and research, as well as suggestions for its further development.

OBJECTIVE The purpose of this study was to describe the genesis of the AO Spine Sacral and Pelvic Classification System in the context of historical sacral and pelvic grading systems. METHODS A systematic search of MEDLINE, EMBASE, Google Scholar, and Cochrane databases was performed consistent with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to identify all existing sacral and pelvic fracture classification systems. RESULTS A total of 49 articles were included in this review, comprising 23 pelvic classification systems and 17 sacral grading schemes. The AO Spine Sacral and Pelvic Classification System represents both the evolutionary product of these historical systems and a reinvention of classic concepts in 5 ways. First, the classification introduces fracture types in a graduated order of biomechanical stability while also taking into consideration the neurological status of patients. Second, the traditional belief that Denis central zone III fractures have the highest rate of neurological deficit is not supported because this subgroup often includes a broad spectrum of injuries ranging from a benign sagittally oriented undisplaced fracture to an unstable “U-type” fracture. Third, the 1990 Isler lumbosacral system is adopted in its original format to divide injuries based on their likelihood of affecting posterior pelvic or spinopelvic stability. Fourth, new discrete fracture subtypes are introduced and the importance of bilateral injuries is acknowledged. Last, this is the first integrated sacral and pelvic classification to date. CONCLUSIONS The AO Spine Sacral and Pelvic Classification is a universally applicable system that redefines and reorders historical fracture morphologies into a rational hierarchy. This is the first classification to simultaneously address the biomechanical stability of the posterior pelvic complex and spinopelvic stability, while also taking into consideration neurological status. Further high-quality controlled trials are required prior to the inclusion of this novel classification within a validated scoring system to guide the management of sacral and pelvic injuries.

Survey among spine experts.To investigate the different views and opinions of clinically relevant spinal post-traumatic deformity (SPTD).There is no clear definition of clinically relevant SPTD. This leads to a wide variation in characteristics used for diagnosis and treatment indications of SPTD. To understand the current concepts of SPTD a survey was conducted among spine trauma surgeons.Members of the AO Spine Knowledge Forum Trauma participated in an online survey. The survey was divided in 4 domains: Demographics, criteria to define SPTD, risk factors, and management. The data were collected anonymously and analyzed using descriptive statistics, absolute, and relative frequencies. Consensus on dichotomous outcomes was set to 80% of agreement.Fifteen members with extensive experience in treatment of spinal trauma participated, representing the 5 AO Spine Regions. Back pain was the only criterion for definition of SPTD with complete agreement. Consensus (≥80%) was reached for kyphotic angulation outside normative ranges and impaired function. Eighty-seven percent and 100% agreed that a full-spine conventional radiograph was necessary in diagnosing and treating SPTD, respectively. The "missed B-type injury" was rated at most important by all but 1 participant. There was no agreement on other risk factors leading to clinically relevant SPTD. Concerning the management, all participants agreed that an asymptomatic patient should not undergo surgical treatment and that neurological deficit is an absolute surgical indication. For most of the participants the preferred surgical treatment of acute injury in all spine regions but the subaxial region is posterior fixation.Some consensus exists among leading experts in the field of spine trauma care concerning the definition, diagnosis, risk factors, and management of SPTD. This study acts as the foundation for a Delphi study among the global spine community.

Introduction Procedures like kyphoplasty or vertebroplasty have become an established treatment option for vertebral compression fractures (VCF). The transpedicular approach used during these procedures allows to take biopsies from the affected vertebral body. The aim of this study was to systematically summarize the existing knowledge on the value of routine transpedicular biopsies during kyphoplasty or vertebroplasty for vertebral compression fractures. Methods A systematic review of the literature using PubMed/Medline databases with the goal of finding all articles describing the value trans-pedicular biopsies for detecting primary bone tumors, metastases, bone diseases, or spondylitis in patients with vertebral compression fractures was performed. Search terms were (*biopsy/ OR biops*.ti,ab.) AND (vertebral compression fracture*.ti,ab.). Results Sixteen articles met the inclusion criteria, among these were six prospective and ten retrospective case series. Publication dates ranged from 2005 to 2020. A total of 3083 patients with 3667 transpedicular biopsies performed were included. Most biopsies confirmed osteoporosis as the dominant underlying pathology of VCFs. Transpedicular biopsies revealed an unexpected malignant diagnosis in 0.4–6% of the cases. Conclusion Routine transpedicular biopsies during kyphoplasty or vertebroplasty detect unexpected malignant lesions in 0.4–6% of the patients, even though the definition of “unexpected” varies among the analyzed studies. The evidence to support a routine biopsy is inconsistent. Nevertheless, routine biopsies can be considered, especially when sufficient preoperatvie imaging is not available or radiological findings are unclear.

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.

Background Anxiety in combination with osteoporotic vertebral compression fractures (OVCFs) of the spine remains understudied. The purpose of this study was to analyze whetheranxiety has an impact on the short-term functional outcome of patients with an OVCF. Furthermore, a direct impact of the fracture on the patient’s anxiety during hospitalization should be recognized. Methods A prospective multicentric study in a German-speaking area was performed. All inpatients with an OVCF of the thoracolumbar spine from 2017 to 2020 were included. Trauma mechanism, analgetic medication, anti-osteoporotic therapy, timed-up-and-go test (TuG), mobility, Barthel index, Oswestry-Disability Index (ODI) and EQ5D-5L were documented. For statistical analysis, the U test, chi-square independence test, Spearman correlation, General Linear Model for repeated measures, Bonferroni analysis and Wilcoxon test were used. The item anxiety/depression of the EQ5D-5L was analyzed to describe the patients’ anxiousness. Results Data from 518 patients from 17 different hospitals were evaluated. Fracture severity showed a significant correlation (r=0.087, p=0.0496) with anxiety. During the hospital stay, pain medication (pConclusions Higher anxiety is associated with lower functional outcome after OVCF. The item anxiety/depression of the EQ5D-5L provides an easily accessible, quick and simple tool that can be used to screen for poor outcomes and may also offer the opportunity for a specific anxiety intervention.

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.

Transpedicular cement augmentation is an established therapeutic option in the treatment of pathologic compression fractures of the spine. In addition to osteoporosis, underlying metastatic diseases or, more rarely, a primary bone tumor are recurrent causes of vertebral compression fractures without adequate trauma.To obtain a current opinion among spine surgeons in Germany, Switzerland, and Austria on the value of transpedicular biopsy during kyphoplasty and vertebroplasty of vertebral body fractures.A web-based (UmfrageOnline®) questionnaire with 11 questions was created and sent to the email distribution lists of the German Spine Society (DWG), the Austrian Society for Spine Surgery (spine.at), and the Swiss Society for Spinal Surgery (SGS), as well as to the email distribution list of the Spine Section of the German Society for Orthopedics and Trauma Surgery (DGOU).Of a total of 2675 spine surgeons contacted 250 (9.3%) responded to the survey. Approximately one third (29.8%) of respondents regularly perform a transpedicular biopsy with each kyphoplasty or vertebroplasty. Reasons cited for biopsy were image morphology (79.7%) or history of suspected (66.0%) or present (71.4%) tumor disease. Reasons cited against routine biopsy were the associated costs and the limited informative value of the biopsies obtained.Nearly one third of the spine surgeons surveyed regularly perform a transpedicular biopsy with each kyphoplasty or vertebroplasty. Almost all respondents perform biopsies at least when there is an imaging morphologic suspicion of tumor disease or tumor disease is known or suspected based on risk factors. Future studies need to further clarify the cost-effectiveness of transpedicular biopsy.HINTERGRUND: Transpedikuläre Zementaugmentationen sind eine etablierte Therapieoption in der Behandlung pathologischer Kompressionsfrakturen der Wirbelsäule. Neben der Osteoporose sind auch immer wieder metastasierte Grundleiden oder seltener ein primärer Knochentumor Ursache für Wirbelkompressionsfrakturen ohne adäquates Trauma. ZIEL: Erstellung eines aktuellen Meinungsbildes unter Wirbelsäulenchirurgen in Deutschland, der Schweiz und Österreich zum Stellenwert der transpedikulären Biopsie während Kypho- und Vertebroplastien von Wirbelkörperfrakturen.Es wurde ein webbasierter UmfrageOnline®-Fragebogen mit 11 Fragen erstellt und an die E‑Mail-Verteiler der Deutschen Wirbelsäulengesellschaft (DWG), der Österreichischen Gesellschaft für Wirbelsäulenchirurgie (spine.at) und der Schweizerischen Gesellschaft für spinale Chirurgie (SGS) sowie an den E‑Mail-Verteiler der Sektion Wirbelsäule der Deutschen Gesellschaft für Orthopädie und Unfallchirurgie (DGOU) versendet.Von insgesamt kontaktierten 2675 Wirbelsäulenchirurgen beantworteten 250 (9,3 %) die Umfrage. Rund ein Drittel (29,8 %) der Befragten führt regelhaft bei jeder Kypho- oder Vertebroplastie eine transpedikuläre Biopsie durch. Genannte Gründe für eine Biopsie waren ein bildmorphologischer (79,7 %) oder anamnestischer Verdacht auf eine Tumorerkrankung (66,0 %) oder das Vorliegen einer solchen (71,4 %). Als Gründe gegen eine routinemäßige Biopsie wurden die damit verbundenen Kosten und die limitierte Aussagekraft der gewonnenen Biopsate genannt.Fast ein Drittel der befragten Wirbelsäulenchirurgen führt regelhaft bei jeder Kypho- oder Vertebroplastie eine transpedikuläre Biopsie durch. Fast alle Befragten führen Biopsien zumindest dann durch, wenn eine Tumorerkrankung bekannt ist bzw. aufgrund von Risikofaktoren vermutet wird. Zukünftige Studien müssen die Kosteneffizienz der transpedikulären Biopsie weiter abklären.

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.

Study design Prospective randomized placebo controlled double blind trial. Objective To examine the effect of ESP block after minimally invasive posterior stabilization for vertebral fractures on opioid consumption, pain, blood loss, disability level, and wound healing complications. Methodology Patients indicated for minimal invasive posterior stabilisation were included to the study. Our primary outcome was the opioid consumption and Visual Analogue Scale (VAS) measured during the first 48 hours. Secondary outcomes used to measure the short-term outcome included Oswestry Disability Index (ODI) and Patient Reported Outcome Spine Trauma (PROST). Results In total, 60 patients were included with a 93.3% follow-up. Average morphine consumption during the PACU (Post Anaesthesia Care Unit) period was 5.357 mg in ESP group and 8.607 mg in placebo group ( P = .004). Average VAS during first 24 hour was 3.944 in ESP group and 5.193 in placebo group ( P = .046). Blood loss was 14.8 g per screw in ESP group and 15.4 g in placebo group ( P = .387). The day2 PROST value was 33.9 in ESP group and 28.8 in placebo group ( P = .008) and after 4 weeks 55.2 in ESP group and 49.9 in placebo group ( P = .036). No significant differences in ODI were detected. Conclusion The use of ESP block in minimally invasive spinal surgery for posterior fracture stabilization leads to a significant reduction of opioid consumption during PACU stay by 37.7%. Reduction of opioid consumption was accompanied with lower pain (VAS). We found positive effect of the ESP block on short term outcome scores, but no effect on perioperative blood loss and wound healing.

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.

Procedures like kyphoplasty or vertebroplasty have become an established treatment option for vertebral compression fractures (VCF). The transpedicular approach used during these procedures allows to take biopsies from the affected vertebral body. The aim of this study was to systematically summarize the existing knowledge on the value of routine transpedicular biopsies during kyphoplasty or vertebroplasty for vertebral compression fractures.A systematic review of the literature using PubMed/Medline databases with the goal of finding all articles describing the value trans-pedicular biopsies for detecting primary bone tumors, metastases, bone diseases, or spondylitis in patients with vertebral compression fractures was performed. Search terms were (*biopsy/ OR biops*.ti,ab.) AND (vertebral compression fracture*.ti,ab.).Sixteen articles met the inclusion criteria, among these were six prospective and ten retrospective case series. Publication dates ranged from 2005 to 2020. A total of 3083 patients with 3667 transpedicular biopsies performed were included. Most biopsies confirmed osteoporosis as the dominant underlying pathology of VCFs. Transpedicular biopsies revealed an unexpected malignant diagnosis in 0.4-6% of the cases.Routine transpedicular biopsies during kyphoplasty or vertebroplasty detect unexpected malignant lesions in 0.4-6% of the patients, even though the definition of "unexpected" varies among the analyzed studies. The evidence to support a routine biopsy is inconsistent. Nevertheless, routine biopsies can be considered, especially when sufficient preoperatvie imaging is not available or radiological findings are unclear.

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.

To determine the variation in the global treatment practices for subaxial unilateral cervical spine facet fractures based on surgeon experience, practice setting, and surgical subspecialty.A survey was sent to 272 members of the AO Spine Subaxial Injury Classification System Validation Group worldwide. Questions surveyed surgeon preferences with regard to diagnostic work-up and treatment of fracture types F1-F3, according to the AO Spine Subaxial Cervical Spine Injury Classification System, with various associated neurologic injuries.A total of 161 responses were received. Academic surgeons use the facet portion of the AO Spine classification system less frequently (61.6%) compared to hospital-employed and private practice surgeons (81.1% and 81.8%, respectively) (p = 0.029). The overall consensus was in favor of operative treatment for any facet fracture with radicular symptoms (N2) and for any fractures categorized as F2N2 and above. For F3N0 fractures, significantly less surgeons from Africa/Asia/Middle East (49%) and Europe (59.2%) chose operative treatment than from North/Latin/South America (74.1%) (p = 0.025). For F3N1 fractures, significantly less surgeons from Africa/Asia/Middle East (52%) and Europe (63.3%) recommended operative treatment than from North/Latin/South America (84.5%) (p = 0.001). More than 95% of surgeons included CT in their work-up of facet fractures, regardless of the type. No statistically significant differences were seen in the need for MRI to decide treatment.Considerable agreement exists between surgeon preferences with regard to unilateral facet fracture management with few exceptions. F2N2 fracture subtypes and subtypes with radiculopathy (N2) appear to be the threshold for operative treatment.

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.