[Cervical Spine Injuries]. / Verletzungen der oberen Halswirbelsäule.

Around a third of all cervical spine injuries occur in the upper cervical spine in the area between the occiput and the second cervical vertebra. The latter being the most common location of the injury with around 70%. But also atlas fractures, occipital condyle fractures, traumatic spondylolisthesis of C2, atypical fractures in the corpus area as well as atlantooccipital and atlantoaxial ligamentous lesions should be mentioned in connection with injuries in this area. In many cases, conservative therapy regimen is possible. In unstable or displaced injuries, however, surgical intervention is required, with various surgical procedures being used. The frequency, diagnostics, classification, and standard therapy of the individual entities are presented in detail in this continuing medical education article.

How frequently MRI modifies thoracolumbar fractures' classification or decision-making? A systematic review and meta-analysis.

PURPOSE: To provide the first meta-analysis of the impact of magnetic resonance imaging (MRI) on thoracolumbar fractures (TLFs) classification and decision-making. METHODS: A systematic review was conducted following PRISMA guidelines. We searched PubMed, Scopus, Cochrane, and Web of Science from inception to June 30, 2023 for studies evaluating the change in TLFs classification and treatment decisions after MRI. The studies extracted key findings, objectives, and patient population. A meta-analysis was performed for the pooled frequency of change in AO fracture classification or treatment decisions from surgical to conservative or vice versa after MRI. RESULTS: This meta-analysis included four studies comprising 554 patients. The pooled frequency of change in TLFs classification was 17% (95% CI 9-31%), and treatment decision was 22% (95% CI 11-40%). An upgrade from type A to type B was reported in 15.7% (95% CI 7.2-30.6%), and downgrading type B to type A in 1.2% (95% CI 0.17-8.3%). A change from conservative to surgery recommendation of 17% (95% CI 5.0-43%) was higher than a change from surgery to conservative 2% (95% CI 1-34%). CONCLUSIONS: MRI can significantly change the thoracolumbar classification and decision-making, primarily due to upgrading type A to type B fractures and changing from conservative to surgery, respectively. These findings suggest that MRI could change decision-making sufficiently to justify its use for TLFs. Type A subtypes, indeterminate PLC status, and spine regions might help to predict a change in TLFs' classification. However, more studies are needed to confirm the association of these variables with changes in treatment decisions to set the indications of MRI in neurologically intact patients with TLFs. An interactive version of our analysis can be accessed from here: https://databoard.shinyapps.io/mri_spine/ .

Vertebroplastia percutánea en fracturas vertebrales osteoporóticas / Percutaneous vertebroplasty for osteoporotic vertebral fractures

La osteoporosis es una enfermedad sistémica que deteriora la calidad del hueso y su arquitectura. Como consecuencia, predispone a fracturas por fragilidad, entre las cuales las fracturas vertebrales son frecuentes. Estas se asocian a una gran morbimortalidad. La vertebroplastia ha surgido en 1984 como alter-nativa terapéutica para tratar algunos tumores vertebrales y fracturas vertebrales osteoporóticas dolorosas. Este procedimiento consiste en la inyección de cemento guiado por imágenes, para estabilizar la vértebra fracturada y disminuir el dolor. La vertebroplastia puede ser realizada con anestesia local, sedación o anestesia general. La fuga de cemento fuera de la vértebra es una complicación común; sin embargo esto no suele tener traducción clínica y solamente se trata de un hallazgo imagenológico. En este artículo revisaremos las indicaciones, contraindicaciones, la eficacia, controversias y las complicaciones de la vertebroplastia percutánea. (AU)

Osteoporosis is a systemic disease characterized by bone quality deterioration. As a consequence of this deterioration, osteoporosis results in high fracture risk due to bone fragility. Fractures to the spine are common in this scenario, and relate to an increased morbi-mortality. Vertebroplasty emerged in 1984 as an alternative to treat painful vertebral tumors and osteoporotic vertebral fractures. This procedure relies on image guided cement injection to achieve pain relief and strengthen the vertebral body. Vertebroplasty can be performed under local anesthesia, mild sedation, or general anesthesia. Among its complications, cement leakage is common but it is rarely associated with any symptoms and it is usually an imaging finding. In this article, we will review indications and contraindications, effectiveness, controversies and complications related to percutaneous vertebroplasty. (AU)

Thoracolumbar Spine Trauma.

Thoracolumbar spine trauma can result in potentially life-threatening consequences and requires careful management to ensure good outcomes. The purpose of this chapter is to discuss the anatomy, diagnostic tools, non-operative, and operative treatments important when addressing thoracolumbar trauma.

Injury characteristics, initial clinical status, and severe injuries associated with spinal fractures in a retrospective cohort of 506 trauma patients.

BACKGROUND: Our aim was to describe the characteristics of vertebral fractures, the presence of associated injuries, and clinical status within the first days in a severe trauma population. METHODS: All patients with severe trauma admitted to our level 1 trauma center between January 2015 and December 2018 with a vertebral fracture were analyzed retrospectively. The fractures were determined by the AO Spine classification as stable (A0, A1, and A2 types) or unstable (A3, A4, B, and C types). Clinical status was defined as stable, intermediate, or unstable based on clinicobiological parameters and anatomic injuries. Severe extraspinal injuries and emergent procedures were studied. Three groups were compared: stable fracture, unstable fracture, and spinal cord injury (SCI) group. RESULTS: A total of 425 patients were included (mean ± SD age, 43.8 ± 19.6 years; median Injury Severity Score, 22 [interquartile range, 17-34]; 72% male); 72 (17%) in the SCI group, 116 (27%) in the unstable fracture group, and 237 (56%) in the stable fracture group; 62% (95% confidence interval [CI], 57-67%) had not a stable clinical status on admission (unstable, 30%; intermediate, 32%), regardless of the group (p = 0.38). This decreased to 31% (95% CI, 27-35%) on day 3 and 23% (95% CI, 19-27%) on day 5, regardless of the group (p = 0.27 and p = 0.25). Progression toward stable clinical status between D1 and D5 was 63% (95% CI, 58-68%) overall but was statistically lower in the SCI group. Severe extraspinal injuries (85% [95% CI, 82-89%]) and extraspinal emergent procedures (56% [95% CI, 52-61%]) were comparable between the three groups. Only abdominal injuries and hemostatic procedures significantly differed significantly (p = 0.003 and p = 0.009). CONCLUSION: More than the half of the patients with severe trauma had altered initial clinical status or severe extraspinal injuries that were not compatible with safe early surgical management for the vertebral fracture. These observations were independent of the stability of the fracture or the presence of an SCI. LEVEL OF EVIDENCE: Prognostic and epidemiological, level III.

Retrospective Evaluation of Thoracolumbar Injury Classification System and Thoracolumbar AO Spine Injury Scores for the Decision Treatment of Thoracolumbar Traumatic Fractures in 458 Consecutive Patients.

BACKGROUND: Thoracolumbar Injury Classification System (TLICS) score and Thoracolumbar AO Spine Injury Score (TLAOSIS) are the scores preferred to classify and treat thoracolumbar fractures. Our study evaluates the reliability of both as guidelines for treatment. METHODS: Single-center and retrospective case series of 458 patients. Clinical variables, radiology, and treatment were analyzed. We classified fractures according to the AO Spine Thoracolumbar System and retrospectively applied both scales in 2 groups (surgical and conservative). A concordance analysis and statistical measures comparing both were performed. RESULTS: The patients were divided as follows: 257 patients (56.1%) in the conservative group and 201 patients (43.9%) in the surgical group. The concordance analysis between both scales was 89.7% (95% confidence interval, 86.5%-92.3%), and the Cohen kappa coefficient was 0.68 (95% confidence interval, 59%-76%). TLAOSIS had a higher tendency to classify patients in the gray zone (10.3% vs. 2.8%, P < 0.001), whereas TLICS had a more conservative nature (85.2% vs. 78.4%, P = 0.01). In the surgical group, the matching decision ratio was 29.9% for TLICS and 42.8% for TLAOSIS, but differences were found in TLICS being more conservative (70.1% vs. 57.2%, P = 0.01). In the conservative group, the matching decision ratio was 98.1% for both scales, being the main difference in the gray zone for TLAOSIS. CONCLUSIONS: Both scales have a good concordance in general, with TLICS being more conservative overall. They had rather low coincidence when predicting surgery. Because TLAOSIS placed more patients in the gray zone, we think it might be slightly better for giving surgeons more license to decide a surgical approach on certain controversial types of fractures.

The use of Grauer classification in the management of type II odontoid fracture in elderly: Prognostic factors and outcome analysis in a single centre patient series.

OBJECTIVE: To evaluate the results of Type II odontoid fractures management in the elderly, according to the Grauer classification. METHODS: Consecutive patients with type II odontoid fracture, age > 65 years and follow-up longer than 3 months were included. Fracture management was proposed according to Grauer classification. Peri-surgical risk factors, NDI, VAS and rate of fusion were evaluated according to the treatment modality and compared between conservative and surgical groups. RESULTS: Thirty-four patients were considered eligible for the study; 2 patients showed a Type IIa fracture, 30 patients a type IIb, and 2 patients a type IIc. Type IIa patients underwent conservative treatment that resulted in failure. A conservative management was adopted in 9 cases with type IIb due to patient preference or anaesthesiologic reasons with a treatment success at 6 months of 11%. Trans-odontoid stabilization was adopted in 21 type IIb cases with an evidence of bony or fibrous union at 6 months of 95% and a median NDI of 20%. A posterior approach was reserved for 2 type IIc fracture patients and in 6 cases as rescue surgery (bony union at 6 months of 100%; median NDI 37%). Higher Lakshmanan grade, gap and displacement of the fracture were found as significant risk factor for fracture non-union (p < 0.05). CONCLUSIONS: The surgical group presented better clinical and radiological outcome and the anterior approach proved to achieve the best results in type IIb fractures. The presence of osteoporosis and fracture spatial features should be duly considered in the decision-making process.

Association Between Visit-to-Visit Fasting Plasma Glucose Variability and Osteoporotic Fractures in Nondiabetic Subjects.

CONTEXT: Although long-term glucose variability has been reported to be a risk factor associated with osteoporosis, there have been no previous studies between the relationship of glucose variability and fractures in people without diabetes. OBJECTIVE: We assessed visit-to-visit variations in fasting plasma glucose (FPG) as a prognostic factor in predicting osteoporotic fractures in individuals without diabetes. METHODS: Using a nationwide cohort database, we examined the impact of FPG on the development of osteoporotic fractures in men and women (aged ≥50 years). The primary outcomes were the number of total fractures and vertebral fractures. FPG variability was measured using standard deviation (FPG-SD), coefficient of variation (FPG-CV), and variability independent of the mean (FPG-VIM). RESULTS: Of the 92 929 participants, 5262 (5.7%) developed osteoporotic fractures during the mean follow-up of 8.4 years. Individuals in the highest quartile of FPG-SD showed an 11% and 16% increase in risk of total and vertebral fractures, respectively, compared with those in the lowest quartile after adjustment for mean FPG and other risk factors. Analyses using FPG-CV and FPG-VIM demonstrated similar results. Subgroup analyses and sensitivity analyses to explore potential heterogeneity showed consistent results. CONCLUSION: FPG variability may be a novel risk factor for osteoporotic fractures independent of risk factors in the general population without diabetes.

Proposal of New Radiological Classification and Treatment Strategy for Transverse Fractures of the C2 Axis Body.

OBJECTIVE: To investigate the characteristics of transverse fractures of the C2 axis body diagnosed on sagittal computed tomography (CT) and to propose new classification and appropriate treatment strategies. METHODS: A retrospective study was performed by enrolling 49 patients (26 men and 23 women) with transverse fractures of the C2 axis body who were treated at four national trauma centers of tertiary university hospitals from January 2000 to December 2017. The mean age of the patients was 60.8 years (ranging from 21 to 90 years). We classified 49 transverse fractures of the C2 body into three types based on fracture trajectories involving superior articular facet (SAF) and lateral cortex (LC) of the C2 body on coronal CT as follows: Type 1, involvement of C2 SAF on both sides; Type 2, unilateral involvement of C2 SAF on one side and LC on the other side; Type 3, involvement of LC on both sides. The characteristics, treatment methods, and results of 49 transverse fractures of the C2 body were analyzed. Mean follow-up was 12.6 months (ranging from 12 to 26 months). RESULTS: Twenty-six (53.1%) patients were Type 1, 21 (42.9%) were Type 2, and 2 (4.0%) were Type 3. Correlation coefficients for intra-observer and inter-observer reliabilities of classification were 0.723 and 0.598 (both, P < 0.001), respectively. About 40.8% (7 Type 1 and 13 Type 2) of the patients had fracture displacement >3 mm; Incidence of fracture displacement >3 mm was higher in Type 2 than Type 1 (61.9% vs 26.9%, P < 0.05). About 79.6% (20 Type 1, 17 Type 2 and 2 Type 3) of the patients were treated conservatively, and 20.4% (6 Type 1 and 4 Type 2) underwent surgery. At last follow-up, 47 out of 49 patients achieved fusion; overall fusion rate was 95.9%. All conservatively treated Type 1 and Type 3 patients achieved fusion. Out of 17 conservatively treated Type 2 patients, 15 achieved fusion but two developed nonunion; however, two nonunion patients opted not to undergo surgery. Subgroup analysis showed that Philadelphia brace caused nonunion significantly in fracture displacement >3 mm compared to Minerva brace/Halovest (100% vs 0%, P < 0.05). All surgically treated Type 1 and 2 patients achieved fusion. In terms of clinical outcomes, neck pain visual analog scale and neck disability index were significantly improved (both, P < 0.01). According to Odom's criteria, 93.9% (46/49) of the patients achieved satisfactory outcomes. No major complications occurred. CONCLUSIONS: The majority of transverse fractures of C2 body can be treated conservatively. However, surgery or rigid Minerva brace/Halovest should be considered for Type 2 transverse fractures of the C2 body with fracture displacement >3 mm.

Experience in surgical treatment of type â ¡ odontoid fractures: A report of two cases and review of the literature.

Two cases of type Ⅱ odontoid fractures were reported to share our experience in surgery treatment of such cases. A 33-year-old woman with comminuted type Ⅱ odontoid fracture and a 42-year-old man with fracture end hardened type Ⅱ odontoid fracture received surgical treatment in our hospital. Though imaging examination suggested that these two patients were suitable for anterior screw fixation, we encountered difficulties during the operation. The two patients eventually underwent posterior C1-C2 fusion surgery and recovered well. According to the experience of these two cases, we found that the fracture line angle and the degree of comminution are two important factors affecting surgical decision-making. Although anterior screw fixation is the ideal choice for type Ⅱ odontoid fractures with anterior superior to posterior inferior fracture line, it may not be the best choice for comminuted or fracture end hardened type Ⅱ odontoid fractures.

Progressive instability of bilateral sacral fragility fractures in osteoporotic bone: a retrospective analysis of X-ray, CT, and MRI datasets from 78 cases.

PURPOSE: The pathogenetic mechanism, progression, and instability in geriatric bilateral fragility fractures of the sacrum (BFFSs) remain poorly understood. This study investigated the hypothesis of sequential BFFS progression by analysing X-ray, computed tomography (CT), and magnetic resonance imaging (MRI) datasets. METHODS: Imaging data from 78 cases were retrospectively analysed. Fractures were categorized using the CT-based Fragility Fractures of the Pelvis classification. MRI datasets were analysed to detect relevant fracture location information. The longitudinal sacral fracture was graded as stage 1 (bone oedema) on MRI, stage 2 (recent fracture), stage 3 (healing fracture), or stage 4 (non-union) on CT. Ligamentous avulsions at the L5 transverse process and iliac crest were also captured. RESULTS: Contralateral sacral lesions were only recognized by initial bone oedema on MRI in 17/78 (22%) cases. There were 22 cases without and 56 cases with an interconnecting transverse fracture component (TFC) [between S1/S2 (n = 39) or between S2/S3 (n = 17)]. With 30/78 patients showing bilateral fracture lines at different stages (1/2: n = 13, 2/3: n = 13, 1/3: n = 4) and 38 at similar stages, Wilcoxon tests showed a significant stage difference (p < 0.001). Forty cases had a coexistent L5 transverse process avulsion, consistent with a failing iliolumbar ligament. Analysis of variance revealed significant increases in ligamentous avulsions with higher fracture stages (p < 0.001). CONCLUSION: Our results support the hypothesis of stagewise BFFS progression starting with unilateral sacral disruption followed by a contralateral lesion. Loss of sacral alar support leads to a TFC. Subsequent bone disruption causes iliolumbar ligament avulsion. MRI is recommended to detect bone oedema.

Posterior Ligament-Bone Injury Classification and Severity Score: A Novel Approach to Predict the Failure of Anterior-only Surgery for Subaxial Cervical Facet Dislocations.

STUDY DESIGN: Clinical case series. OBJECTIVE: The aim of this study was to propose a novel posterior ligament-bone injury classification and severity (PLICS) score system that can be used to reflect the severity of subaxial cervical fracture dislocations (SCFDs) and predict the failure of anterior-only surgery; and to measure the intraobserver and interobserver reliability of this system. SUMMARY OF BACKGROUND DATA: The approach selection for SCFDs is controversial. Although the anterior approach is familiar for most surgeons, postoperative hardware failure and/or delayed cervical deformity is a nonnegligible complication. METHODS: Ten patients were randomly selected for intraobserver reliability evaluation on two separate occasions, one month apart. Another 30 patients were randomly selected, and the interobserver reliability was measured by comparing results of each case between each reviewer and averaging. To analyze the difference in the PLICS score, 354 patients fulfilled the follow-up were divided into stable and unstable groups according to whether radiologically stable was observed during follow-up. RESULTS: For the intraobserver reliability, the mean intraclass correlation coefficient for the 10 reviewers was 0.931. For the interobserver reliability, the mean interobserver correlation coefficient for the three elements was 0.863. Among 16 patients with PLICS score ≥7, two patients in the stable group manifested with severe injury of the posterior ligamentous complex (PLC); extremely unstable lateral mass fractures with or without severe injury of PLC were detected in the 14 patients of the unstable group. CONCLUSION: The proposed PLICS score system showed excellent intraobserver and interobserver reliability. When a PLICS score is >7 or 7 accompanied by extremely unstable lateral mass fractures, the risk of postoperative failure after an anterior-only reconstruction is high and supplemental posterior strengthening can be considered.Level of Evidence: 4.

Thoracolumbar Burst Fracture: McCormack Load-sharing Classification: Systematic Review and Single-arm Meta-analysis.

STUDY DESIGN: A systematic review and single-arm meta-analysis of randomized clinical trials. OBJECTIVE: The aim of this study was to evaluate whether the load-sharing classification (LSC) is reliable to predict the best surgical approach for thoracolumbar burst fracture (TBF). SUMMARY OF BACKGROUND DATA: There is no previous review evaluating the efficacy of the use of LSC as a guide in the surgical treatment of burst fractures. METHODS: On April 19th, 2019, a broad search was performed in the following databases: EMBASE, PubMed, Cochrane, SCOPUS, Web of Science, LILACS, and gray literature. This study was registered on the International Prospective Register of Systematic Reviews. We included clinical trials involving patients with TBF undergoing posterior surgical treatment, classified by load-sharing score, and that enabled the analysis of the outcomes loss of segmental kyphosis and implant failure (IF). We performed random- or fixed-effects models meta-analyses depending on the data homogeneity. Heterogeneity between studies was estimated by I2 and τ2 statistics. RESULTS: The search identified 189 references, out of which nine studies were eligible for this review. All articles presenting LSC up to 6 proved to be reliable in indicating that only posterior instrumentation is necessary, without screw failures or loss of kyphosis correction. For cases where the LSC was >6, only 2.5% of the individuals presented IF upon posterior approach alone. For loss of kyphosis correction, only 5% of patients had this outcome where LSC >6. For both outcomes together, we had 6% of postoperative problems (I2 = 77%, τ2 < 0.0015, P < 0.01). CONCLUSION: Load-sharing scores up to 6 are 100% reliable, only requiring posterior instrumentation for stabilization. For scores >6, the risk of implant breakage and loss of kyphosis correction in posterior fixation alone is low. Thus, other factors should be considered to define the best surgical approach to be adopted.Level of Evidence: 1.

Fractura vertebral osteoporótica en el adulto mayor / Osteoporotic vertebral fracture in the elderly

La fractura osteoporótica es una entidad clínica que afecta seriamente la calidad y expectativa de vida del paciente, agregándose un impacto socioeconómico elevado, superando incluso a los gastos de patologías como el infarto agudo de miocardio, accidente cerebrovascular y cáncer de mama, y cuya incidencia y prevalencia va en aumento a medida que la población mundial envejece. La gran mayoría de los casos cursan inadvertidos y sub diagnosticados, dejando a tres de cuatro pacientes, sin tratamiento y expuestos a nuevos eventos. El foco mundial en los países desarrollados como estrategia de enfrentamiento de esta patología endémica ha sido el de la prevención, vale decir medicina primaria. Sin embargo, una vez diagnosticada la fractura osteoporótica, no existe consenso en el tipo de tratamiento óptimo, así como sus plazos en estos pacientes. La mayoría de las guías internacionales y los trabajos publicados, presentan diferencias en el manejo de esta lesión.

The osteoporotic fracture is a clinical entity that seriously affects the quality and life expectancy of the patient, adding a high socioeconomic impact, even exceeding the expenses of pathologies such as acute myocardial stroke, vascular cerebral stroke and breast cancer, and whose incidence and prevalence is increasing as the world population ages. The vast majority of cases are non-diagnosed, leaving three of four patients with non treatment at all. The target in developed countries as a strategy to confront this endemic pathology has been prevention, or, primary medicine. However, once the osteoporotic fracture is diagnosed, there is no consensus on the type of optimal treatment, as well as its deadlines in these patients. The majority of international guidelines and published articles show differences in the management and treatment of this fracture.

Vertebral Artery Injury in Cervical Spine Fractures: A Cohort Study and Review of the Literature.

BACKGROUND: The risk of vertebral artery injury (VAI) secondary to cervical spine fracture is increasingly recognised in the literature. The aim of this study was to determine the incidence of VAI amongst patients presenting to the Royal Victoria Hospital (Northern Ireland's regional trauma centre with emergency surgical spinal services) with acute cervical spine fractures, and to identify fracture patterns associated with the highest risk of VAI. METHODS: A retrospective review of 1,894 computed tomography (CT) reports of patients who underwent imaging of their cervical spine and/or vertebral arteries over a 12-month period, from June 2018 to June 2019, was conducted. RESULTS: Sixty-eight patients (3.59%) with a confirmed cervical spine fracture were identified. These patients had an age range of 18-97 years and included 39 males (57.4%) and 29 females (42.6%). The fractures were then classified according to the AOSpine Cervical Spine Fracture Classification. Of the 68 patients with a confirmed cervical spine fracture, five (7.35%) were diagnosed with VAI, all involving fractures of their upper cervical spine. Two involved fractures extending into the transverse foramen, two involved subluxation of the vertebrae and one involved both. In all five cases, these fractures resulted from high- energy injuries. Regarding management, the patients with VAI in this study were either monitored and given no specific treatment or treated medically with antiplatelet therapy. None underwent surgical intervention. CONCLUSIONS: Fracture patterns associated with increased risk of VAI are fractures involving the upper cervical spine, fractures with associated subluxation, and fractures of the transverse process extending into the transverse foramen - urgent CT-angiography in these cases is recommended. Further work should develop a targeted set of criteria for screening for VAI in cervical spine fractures, with consideration of high-risk fracture patterns.

Spinopelvic Dissociation: Assessment, Reduction Strategies, and Fixation Techniques.

Spinopelvic dissociation is a rare injury associated with 2% to 3% of transverse sacral fractures and 3% of sacral fractures associated with pelvic ring injuries. When spinopelvic dissociation is expediently identified and treated appropriately, patient outcomes can be maximized, highlighting the importance of early diagnosis and treatment. Because of its rarity and complexity, there remains a paucity of high-level evidence-based guidance on treating this complex issue. No consensus exists on fixation techniques or reduction maneuvers to achieve stability, allowing for early functional rehabilitation. The purpose of this article is to review the current body of literature to better understand this injury pattern to help establish a treatment algorithm that appropriately guides the treating surgeons in the surgical planning and perioperative care of these patients.

Description and Reliability of the AOSpine Sacral 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.

Reliability and application of the new morphological classification system for chronic symptomatic osteoporotic thoracolumbar fracture.

BACKGROUND: We propose a new classification system for chronic symptomatic osteoporotic thoracolumbar fracture (CSOTF) based on fracture morphology. Research on CSOTF has increased in recent years; however, the lack of a standard classification system has resulted in inconvenient communication, research, and treatment. Previous CSOTF classification studies exhibit different symptoms, with none being widely accepted. METHODS: Imaging data of 368 patients with CSOTF treated at our hospital from January 2010 to June 2017 were systematically analyzed to develop a classification system. Imaging examinations included dynamic radiography, computed tomography scans, and magnetic resonance imaging. Ten investigators methodically studied the classification system grading in 40 cases on two occasions, examined 1 month apart. Kappa coefficients (κ) were calculated to determine intraobserver and interobserver reliability. Based on the radiographic characteristics, the patients were divided into 5 types, and different treatments were suggested for each type. Clinical outcome evaluation included using the visual analog score (VAS), the Oswestry disability index (ODI), and the American Spinal Injury Association (ASIA) impairment scale. RESULTS: The new classification system for CSOTF was divided into types I-V according to whether the CSOTF exhibited dynamic instability, spinal stenosis or kyphosis deformity. Intra- and interobserver reliability were excellent for all types (κ = 0.83 and 0.85, respectively). The VAS score and ODI of each type were significantly improved at the final follow-up compared with those before surgery. In all patients with neurological impairment, the ASIA grading after surgery was significantly improved compared with that before surgery (P < 0.001). CONCLUSIONS: The new classification system for CSOTF demonstrated excellent reliability in this initial assessment. The treatment algorithm based on the classification can result in satisfactory improvement of clinical efficacy for the patients of CSOFT.

George Chance and Frank Holdsworth: Understanding Spinal Instability and the Evolution of Modern Spine Injury Classification Systems.

The concept of spinal cord injury has existed since the earliest human civilizations, with the earliest documented cases dating back to 3000 BC under the Egyptian Empire. Howevr, an understanding of this field developed slowly, with real advancements not emerging until the 20th century. Technological advancements including the dawn of modern warfare producing mass human casualties instigated revolutionary advancement in the field of spine injury and its management. Spine surgeons today encounter "Chance" and "Holdsworth" fractures commonly; however, neurosurgical literature has not explored the history of these physicians and their groundbreaking contributions to the modern understanding of spine injury. A literature search using a historical database, Cochrane, Google Scholar, and PubMed was performed. As needed, hospitals and native universities were contacted to add their original contributions to the literature. George Quentin Chance, a Manchester-based British physician, is well known to many as an eminent radiologist of his time who described the eponymous fracture in 1948. Sir Frank Wild Holdsworth (1904-1969), a renowned British orthopedic surgeon who laid a solid foundation for rehabilitation of spinal injuries under the aegis of the Miners' Welfare Commission, described in detail the management of thoraco-lumbar junctional rotational fracture. The work of these 2 men laid the foundation for today's understanding of spinal instability, which is central to modern spine injury classification and management algorithms. This historical vignette will explore the academic legacies of Sir Frank Wild Holdsworth and George Quentin Chance, and the evolution of spinal instability and spine injury classification systems that ensued from their work.

Epidemiology and Imaging Classification of Pediatric Cervical Spine Injuries: 12-Year Experience at a Level 1 Trauma Center.

OBJECTIVE. The purpose of this study was to describe the epidemiology and imaging characteristics of cervical spine injuries in children with blunt trauma. MATERIALS AND METHODS. We conducted a retrospective review of the records of all patients 16 years old or younger with a diagnosis of cervical spine injury in the trauma registry of our level 1 trauma center between July 2006 and June 2018. RESULTS. Two hundred thirty-five patients were included in the study: 125 with subaxial cervical spine injuries, 87 with upper cervical spine injuries, and 23 with both subaxial and upper cervical spine injuries. The frequency of isolated upper cervical spine injuries was 73% in patients younger than 3 years old, 48% in patients 3-8 years old, and 29% in patients older than 8 years old. Seventy-one percent of occipital condyle fractures were avulsions, and 26% of dens fractures were avulsions. Type II dens fractures were found only in patients older than 8 years old. Type I and III dens fractures were almost exclusively in patients 8 years old or younger. Injuries classified as AOSpine types A, B, and C comprised 65.6%, 17.2%, and 17.2% of subaxial injuries, respectively. Despite similar mechanism of injury distribution across age groups, the frequency of AOSpine type A injuries in patients older than 8 years old (70.6%) was significantly higher compared with patients younger than 3 years old (40.0%) and those who were 3-8 years old (45.0%). The frequency of AOSpine type B injuries in patients younger than 3 years old (40.0%) was slightly higher than patients who were 3-8 years old (30.0%) and almost three times higher than in patients older than 8 years old (13.8%). CONCLUSION. Pediatric patients have high rates of upper cervical spine injuries, which tend to be distraction injuries that are frequently associated with avulsion fractures. Injury patterns in pediatric patients vary significantly by age, with patients younger than 3 years old being particularly prone to distraction type injuries.