Paediatric spine injuries in the thoracic and lumbar spine-results of the German multicentre CHILDSPINE study.

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

Pediatric cervical spine injuries-results of the German multicenter CHILDSPINE study.

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

Percutaneous versus open posterior stabilization in AOSpine type A3 thoracolumbar fractures.

BACKGROUND: The purpose of this retrospective cohort study was to compare treatment strategies of two level-one trauma centers regarding clinical and radiological outcomes focusing on non-osteoporotic AOSpine type A3 fractures of the thoracolumbar spine at levels T11 to L2. METHODS: Eighty-seven patients between 18 and 65 years of age that were treated operatively in either of two trauma centers were included. One treatment strategy includes open posterior stabilization whereas the other uses percutaneous posterior stabilization. Both included additional anterior fusion if necessary. Demographic data, McCormack classification, duration of surgery, hospital stay and further parameters were assessed. Owestry Disability Index (ODI), Visual Analog Scale (VAS) and SF-36 were measured for functional outcome. Bisegmental kyphosis angle, reduction loss and sagittal alignment parameters were assessed for radiological outcome. Follow up was at least 24 months. RESULTS: There was no significant difference regarding our primary functional outcome parameter (ODI) between both groups. Regarding radiological outcome kyphosis angle at time of follow up did not show a significant difference. Reduction loss at time of follow up was moderate in both groups with a significantly lower rate in the percutaneously stabilized group. Surgery time was significantly shorter for posterior stabilization and anterior fusion in the percutaneous group. Time of hospital stay was equal for posterior stabilization but shorter for anterior fusion in the open stabilized group. CONCLUSION: Both treatment strategies are safe and effective showing only minor loss of reduction. Clinical relevant differences in functional and radiographic outcome between the two surgical groups could not be demonstrated. TRIAL REGISTRATION: It was conducted according to ICMJE guidelines and has been retrospectively registered with the German Clinical Trials Registry (identification number: DRKS00015693, 07.11.2018).

[Diagnostics and treatment of cervical spine trauma in pediatric patients : Recommendations from the Pediatric Spinal Trauma Group]. / Diagnostik und Therapie von Verletzungen der Halswirbelsäule im Kindesalter : Empfehlungen der AG Wirbelsäulentrauma im Kindesalter.

BACKGROUND: Severe cervical spine injuries in children under the age of 17 years are rare. Recommendations or even guidelines for the diagnostics and treatment of such injuries in children are currently not available. OBJECTIVE: The aim of the study was to formulate recommendations for diagnostics and treatment of injuries of the cervical spine in pediatric patients. MATERIAL AND METHODS: First, a search of primary and secondary literature on the topic complex of diagnostics and treatment of cervical spine injuries in children was carried out. An appropriate internal literature database was defined and maintained. Second, within the framework of 9 meetings from April 2017 to December 2019 the members of the Pediatric Spinal Trauma Group of the Spine Section of the German Society for Orthopaedics and Trauma (DGOU) systematically formulated recommendations for the diagnostics and treatment of injuries of the cervical spine in pediatric patients by a consensus process. RESULTS: Recommendation for the diagnostics and treatment for injuries of the cervical spine could be formulated for three age groups (age group I: 0-6 years; age group II: 7-9 years; age group III: 10-16 years). The diagnostic and therapeutic principles known from adult patients suffering from injuries to the cervical spine cannot be easily transferred to pediatric patients. CONCLUSION: Injuries to the pediatric spine are rare and should be treated in specialized spine centers. Pediatric patients with a stable cardiopulmonary status should undergo magnetic resonance imaging (MRI) if a spinal trauma is suspected. Classification systems and therapeutic recommendations for injuries to the cervical spine known from adult patients could also be used for adolescent patients. This is not possible for children under the age of 10 years. Only few classification systems exist for this age group. Basic principles of the treatment of spinal trauma in children is the restoration of spinal stability and correct anatomical relationships as well as the protection of all neural structures.

[Diagnostics and treatment of thoracic and lumbar spine trauma in pediatric patients : Recommendations from the Pediatric Spinal Trauma Group]. / Diagnostik und Therapie von Verletzungen der Brust- und Lendenwirbelsäule im Kindesalter : Empfehlungen der AG Wirbelsäulentrauma im Kindesalter.

BACKGROUND: Spinal injuries in pediatric patients are overall very rare. Current reference studies including large patient numbers that enable the formulation of evidence-based recommendations on diagnostics and treatment of these injuries do not exist. OBJECTIVE: The aim of the current study was to formulate recommendations on the diagnostics and treatment for injuries of the thoracic and lumbar spine in pediatric patients. MATERIAL AND METHODS: Firstly, a search for primary and secondary literature on the topic of diagnostics and treatment of spinal injuries in children was carried out. From this, a literature database was established and maintained. Secondly, within the framework of 9 meetings in the time period from April 2017 to December 2019 the members of the Pediatric Spinal Trauma Group of the Spine Section of the German Society for Orthopaedics and Trauma (DGOU) documented recommendations on diagnostics and treatment of injuries of the thoracic and lumbar spine in pediatric patients by a consensus process. RESULTS: Recommendations on the diagnostics and treatment of injuries of the thoracic and lumbar spine could be given for 3 age groups (age group I: 0-6 years; age group II: 7-9 years; age group III: 10-16 years). Diagnostic and therapeutic principles known from adult patients suffering from injuries to the thoracic or lumbar spine cannot easily be transferred to pediatric patients. CONCLUSION: Spinal injuries in childhood are rare and should be treated in specialized spine centers. Pediatric patients with a stable cardiopulmonary status should undergo magnetic resonance imaging (MRI) if a spinal trauma is suspected. The basic principles of the treatment of spinal trauma in children is the restoration of spinal stability and correct anatomical parameters as well as the protection of all neural structures. The potential for correction and regeneration of the individual spinal sections depending on the age of the patient must be considered for deciding between operative vs. conservative treatment. Whenever operative treatment is needed, it should be performed by minimally invasive techniques as a sole instrumentation without spondylodesis. An early removal of the screw-rod-system should be performed.

[Pediatric spine trauma-Results of a German national multicenter study including 367 patients]. / Wirbelsäulenverletzungen im Kindesalter ­ Ergebnisse einer nationalen Multizenterstudie mit 367 Patienten.

BACKGROUND: In general, pediatric spinal injuries are rare. No reliable data on the epidemiology of spinal injuries in pediatric patients in Germany are available. Especially in pediatric patients, for whom the medical history, clinical examination and the performance of imaging diagnostics are difficult to obtain, all available information on a spinal injury must be taken into account. OBJECTIVE: The aim of this study was to provide epidemiological data for pediatric patients with spinal trauma in Germany in order to enhance future decision-making for the diagnostics and treatment of these patients. MATERIAL AND METHODS: Within the framework of a national multicenter study, data were retrospectively obtained from 6 German spine centers for 7 years between January 2010 and December 2016. In addition to the demographic data, the clinical databases were screened for specific trauma mechanisms, level of injury as well as accompanying injuries. Furthermore, diagnostic imaging and the treatment selected were also analyzed. RESULTS: A total of 367 children (female: male = 1:1.2) with a total of 610 spinal injuries were included in this study. The mean age was 12 years (±3.5 years). The most frequent trauma mechanisms were falls from <3 m and traffic accidents. The imaging diagnostics were only rarely carried out with the child under anesthesia. Younger children (0-9 years old) suffered more injuries to the cervical spine, whereas injuries to the thoracic and lumbar spine were more frequently found in older children (>10 years old). The children frequently showed accompanying injuries to the head and the extremities. Accompanying spinal injuries mostly occurred in adjacent regions and only rarely in other regions. Around 75% of the children were treated conservatively. CONCLUSION: The results were different from the knowledge obtained from adult patients with spinal trauma and describe the special circumstances for pediatric patients with spinal trauma. Despite certain limitations these facts may help to enhance future decision-making for the diagnostics and treatment of these patients.

Six-year outcome of thoracoscopic ventral spondylodesis after unstable incomplete cranial burst fractures of the thoracolumbar junction: ventral versus dorso-ventral strategy.

PURPOSE: The purpose of this study is to determine the long term-results after thoracoscopic spondylodesis particularly with respect to a ventral versus dorso-ventral treatment strategy. METHODS: In this prospective cohort study, a follow-up examination was performed in 19 patients (seven men, 12 women, average age: 37.7 years, follow-up rate: 79 %), six years after ventral thoracoscopic spondylodesis of unstable, incomplete burst fractures. Nine patients received a ventral monosegmental spondylodesis with iliac crest bone graft. The other ten cases were treated dorso-ventrally, five undergoing a ventral monosegmental treatment with iliac crest bone graft; the other five a ventral bisegmental treatment with expandable titanium cage. RESULTS: The complication rate was 15.7 %, the rate of revision of 10.5 %. No complication was related to the ventral thoracoscopic approach, whereas all of them were related to the iliac crest bone graft. The operative bisegmental kyphotic reduction was higher in the dorso-ventrally treated group. Afterwards, the loss of reduction was similar in both study groups. The mean VAS spine score summed up to more than 80 in both groups. The mean PCS scores were comparable to a normal healthy collective of the same age. CONCLUSIONS: The ventral thoracoscopic approach to the spine seems to be a safe therapeutic strategy. A dorso-ventral treatment concept goes along with a higher operative reduction potential.

6-Year follow-up of ventral monosegmental spondylodesis of incomplete burst fractures of the thoracolumbar spine using three cortical iliac crest bone grafts.

INTRODUCTION: Autologous bone graft is the gold standard for vertebral body replacement. Currently, after modern implants for vertebral body replacement are available, controversies exist regarding the optimal implant strategy. PATIENTS AND METHODS: Between 2002 and 2003, 17 patients were included in this study, all suffering from incomplete burst fractures of the thoracolumbar spine. All of them were treated by ventral monosegmental spondylodesis using iliac crest bone graft. The individual treatment strategy depended on the fracture situation and patient's condition. After an average of 74 months (range 66-84) a clinical and computer tomographic follow-up examination was performed in 14 patients (average age, 35.2 years) including VAS spine score and SF 36 score. Nine patients were treated ventral only five patients dorsoventrally. RESULTS: Complete osseous consolidation was visible in nine, partial consolidation (>30 %) in four, and lysis in one patient, without any significant differences between ventral only or dorsoventral approach. After removal of the fixateur interne the level of consolidation improved in all patients, treated dorsoventrally. There was no significant correlation between percentage of osseous consolidation and the clinical follow-up parameters. After 6 years, 71 % of the patients suffered from persistent pain associated with the approach to the iliac crest. Two revision surgeries have been necessary. CONCLUSION: High rates of osseous consolidation are visible 6 years after ventral spondylodesis by iliac crest bone grafts. A further improvement of consolidation can be expected after dorsal implant removal. But the surgical approach to the iliac crest is accompanied with a relevant complication rate.

Multicenter evaluation of therapeutic strategies of inpatients with osteoporotic vertebral fractures in Germany.

PURPOSE: The aim of this study was to assess therapeutic strategies of inpatients with osteoporotic thoracolumbar fractures (OTF) in Germany. METHODS: Prospective multi-center study including 16 German-speaking trauma centers over a period of 7 months. All inpatients with OTF were included. Radiological and clinical data on admission and treatment modalities were assessed. RESULTS: Seven hundred and seven (99.3%) out of 712 included patients (73.3% female) could be evaluated. Mean age was 75 years (30-103). 51.3% could not remember any traumatic incident. Fracture distribution was from T2 to L5 with L1 (19%) most commonly affected. According to the Magerl classification type A1 (52.1%) and A3 (42.7%) were most common. B and C type injuries (2.6%) and neurological deficits (3.1%) were rare. Previous progression of vertebral deformation was evident in 34.4% of patients and related to t score below - 3 (Odds ratio 1.9661). Patients presented with anticoagulation medication (15.4%), dementia (13%), and ASA score > 3 (12.4%) frequently. 82.3% of patients complained of pain > 4 on VAS, 37% could not be mobilized despite pain medication according to grade II WHO pain ladder. 81.6% received operative treatment. Kyphoplasty (63.8%) and hybrid stabilization including kyphoplasty with (14.4%) or without screw augmentation (7.6%) were the techniques most frequently used. Invasiveness of treatment increased with degree of instability. CONCLUSIONS: OTF are mostly type A compression fractures. Patients suffer from severe pain and immobilization frequently. Progression of deformity is correlated to t score below - 3. Treatment of inpatients is mainly surgical, with kyphoplasty followed by hybrid stabilization as commonly used techniques.

Biomechanical comparison of the end plate design of three vertebral body replacement systems.

INTRODUCTION: Compression fractures at the thoracolumbar junction are frequently treated by reconstruction with vertebral body replacement systems. Modern cage implants have been developed which respect the anatomy and angulation of the adjacent bony endplates. The objective of this study was to investigate the biomechanical performance of anatomic endplate design and variable endplate angulation. MATERIALS AND METHODS: Three cage systems [Hydrolift (HYL), Aesculap; Synex II (SYN), Synthes; Obelisc (OBC), Ulrich] were compared employing a composite bone substitute material at two levels of endplate angulation (0°, 3°). Their load-bearing capacity was assessed in a physiologic test with human vertebral specimens in a misalignment situation (3°). The HYL and SYN offered anatomically shaped endplates. The endplates of the HYL had variable angulation during insertion and were then mechanically fixated. The OBC had fixed and circular endplates. The load to failure and system stiffness were evaluated by an axial compression test. The bone mineral density (BMD) and the area of the bony endplates were measured via CT. RESULTS: None of the mechanical properties differed between 0° and 3° for the HYL cage using bone substitute material, while the OBC lost 19% of the failure load (p = 0.001) and 55% of stiffness (p = 0.001) in case of misalignment. In human bone specimens, failure loads were comparable among all implants (p > 0.1) with the HYL showing the largest system stiffness (p < 0.05). Furthermore, a strong correlation between stiffness and BMD (R(2) = 0.82) and failure load and BMD (R(2) = 0.87) was found. CONCLUSION: Anatomically shaped and continuously variable endplates provide mechanical advantages under imperfect alignment and may thus reduce secondary dislocation and the loss of correction. This is achieved by retaining an optimal contact area between the implant and the bony endplates. Conventional cage design with circular endplates offer adequate stability in optimal contact situations.

Clinical and radiological evaluation of thoracic spine fractures with or without sternal fracture: is there a need for ventral stabilization?

OBJECTIVE: The treatment of thoracic spine (TS) fractures with additional sternal fractures compared to TS fractures without sternal fractures is discussed controversionally, because in some studies it was stated that sternal fractures decrease the thoracic stability. We hypothesized that both types of fractures can be treated the same way by posterior stabilization alone. METHODS: A total number of 69 patients with thoracic fractures, with or without additional sternal fractures, were examined, regarding the angle of kyphosis after fracture, postoperatively and after 6 and 12 months. We also recorded the outcome using the Odom's score and the time until patients returned to work and the activity level. RESULTS: It was found that the angle of kyphosis was nearly physiological after stabilization in both groups and a loss of reduction after 1 year was also comparable, either in the patients suffering from the additional sternal fracture or not. In addition, the Odom's score and the time until return to work and the activity level were comparable in both groups. CONCLUSION: We did not find any arguments to preserve additional anterior stabilization or reasons for different treatment strategies either additional sternal fractures occur in thoracic spine fractures or not.

Long-term results after thoracoscopic anterior spondylodesis with or without posterior stabilization of unstable incomplete burst fractures of the thoracolumbar junction: a prospective cohort study.

BACKGROUND: Minimally invasive, thoracoscopic anterior spondylodesis (MIAS) is an established treatment for burst fractures of the thoracolumbar spine. Good restoration of the local sagittal alignment and good functional results have been reported. The aim of this study was to evaluate long-term results of MIAS in patients with incomplete burst fractures and to analyze the influence on global sagittal alignment, clinical outcomes, and adjacent segment degeneration. METHODS: From 2002 to 2003, 18 patients were treated with MIAS for incomplete thoracolumbar burst fractures. Mono-segmental spondylodesis was performed with an iliac crest bone graft and bisegmental spondylodesis with a titanium cage. In this single-center prospective cohort study, 15 patients were available for follow-up (FU) after an average of 12.9 years (12.1-14.4). Seven patients were treated with a combined anterior and posterior instrumentation and eight patients with anterior spondylodesis only. The primary clinical outcome parameter was the Oswestry Disability Index (ODI); secondary parameters were the Short Form 36 (SF36) and the visual analog scale (VAS spine). Full spine radiographs were assessed for bisegmental Cobb angle, alignment parameters, and signs of adjacent segment degeneration (ASD). RESULTS: ODI evaluation showed a mean impairment of 11.7% with minimal limitations in 13 patients. Neither a significant deterioration over time nor significant differences between both therapy strategies were found in the clinical scores at the latest follow-up. The mean bisegmental increase of regional malalignment of reduction was 8.8° (± 7.3°) with no significant correlation to any clinical outcome scores. The majority of patients had no signs of adjacent segment degeneration. Two patients showed minor radiologic changes. All patients had a balanced sagittal spine profile. CONCLUSIONS: In conclusion, MIAS leads to good clinical results with-in majority-minimal spine-related impairment at the latest follow-up. No significant deterioration at 12-year FU was detectable compared to the 6-year results for the SF36 and VAS spine scores. There was no association between sagittal alignment, clinical outcome scores, and ASD. TRIAL REGISTRATION: The study was retrospectively registered in the German Clinical Trials Register ( Nr.00015656 ).

Influence of Preoperative Magnetic Resonance Imaging on Surgical Decision Making for Patients with Acute Traumatic Cervical Spinal Cord Injury: A Survey Among Experienced Spine Surgeons.

OBJECTIVE: Early decompression after acute spinal cord injury (SCI) is recommended. Acute care is crucial, but optimal management is unclear. The aim of this study was to investigate the role of preoperative magnetic resonance imaging (MRI) in addition to computed tomography (CT) in surgical decision making for acute cervical SCI. METHODS: All patients with cervical SCI between 2008 and 2016 who had preoperative CT and MRI (n = 63) at the Trauma Center Murnau, Germany, were included. We administered a survey to 10 experienced spine surgeons (5 neurosurgeons, 5 trauma surgeons) regarding the surgical management. First, the surgeons were shown clinical information and CT scans. Two months later, the survey was repeated with additional MRI. Corresponding percentages of change and agreement were obtained for each rater and survey item. Finally, results from both parts of the survey were compared with the definitive treatment option (i.e., real-world decision). RESULTS: MRI modified surgical timing in a median of 41% of patients (interquartile range 38%-56%). In almost every fifth patient (17%), no surgery would have been indicated with CT alone. The advocated surgical approach was changed in almost half of patients (median 48%, interquartile range 33%-49%). Surgically addressed levels were changed in a median of 57% of patients (interquartile range 56%-60%). MRI led to higher agreement with the real-world decision concerning addressed levels (median 35% vs. 73%), timing (median 51% vs. 57%), and approach (median 44% vs. 65%). CONCLUSIONS: Preoperative MRI influenced surgical decision making substantially in our cohort and has become a new standard for patients with cervical SCI in our institution if medically possible.

Recommendations for the Diagnostic Testing and Therapy of Atlas Fractures. / Empfehlungen zur Diagnostik und Therapie oberer Halswirbelsäulenverletzungen: Atlasfrakturen.

In a consensus process with four sessions in 2017, the working group on "the upper cervical spine" of the German Society for Orthopaedic and Trauma Surgery (DGOU) formulated "Therapeutic Recommendations for the Diagnosis and Treatment of Fractures to the Upper Cervical Spine", incorporating their own experience and current literature. The following article describes the recommendations for the atlas vertebra. About 10% of all cervical spine injuries include the axis vertebra. The diagnostic process primarily aims to detect the injury and to determine joint incongruency and integrity of the atlas ring. For classification purposes, the Gehweiler classification and the Dickman classification are suitable. The Canadian c-spine rule is recommended for clinical screening for c-spine injuries. CT is the preferred imaging modality; MRI is needed to determine the integrity of the Lig. transversum atlantis in complete atlas ring fractures. Conservative treatment is appropriate in very many atlas fractures. Surgical treatment is recommended in existing or potential joint incongruity or instability, which are frequently seen in Gehweiler IIIB or Gehweiler IV fractures. Posterior atlanto-axial stabilisation and fusion using transarticular screws or an internal fixator are regarded as a gold standard in the majority of surgical cases. Especially in young patients, the possibility of isolated atlas osteosynthesis should be checked. A possible option for Gehweiler IV fractures is halo-fixation with mild distraction for ligamentotaxis. Secondary dislocation should be checked for frequently. Involvement of the occipito-atlantal joint complex requires stabilisation of the occiput as well.

Treatment of Odontoid Fractures: Recommendations of the Spine Section of the German Society for Orthopaedics and Trauma (DGOU).

STUDY DESIGN: Narrative review. OBJECTIVE: To establish recommendations for the treatment of odontoid fractures based on current literature and the knowledge of the experts of the Spine Section of the German Society for Orthopaedics and Trauma (DGOU). METHODS: Narrative review of the literature. Analyzing treatment algorithms of German trauma and spine centers as members of the Spine Section of the German Society for Orthopaedics and Trauma (DGOU). RESULTS: There are many influencing factors leading to appropriate treatment of odontoid fractures such as age, bone quality, arthrosis, classification, and type of the fracture. Conservative nonoperative treatment is appropriate for stable undislocated displaced odontoid fractures. Anterior osteosynthesis with 1 or 2 screws leads to good results in the classical unstable type II odontoid fracture in patients with good bone quality. However, modifiers have been identified by the working group leading to higher complication and failure rates. For these cases, more stable constructs and/or posterior approaches are indicated. CONCLUSIONS: Operation seems to be standard treatment for odontoid fractures. However, in the aged population, conservative treatment should be considered as morbidity and mortality rise significantly in the group of >75 years. Conservative treatment may also be started within stable nondislocated fractures, but then regular controls have to be performed. If operation is indicated, many influencing factors have to be considered for appropriate approach and technique. The classification of Anderson and D'Alonzo is still standard. To create an adequate treatment algorithm, dislocation displacement and instability have to be identified. Stable odontoid fractures are treated conservatively non-operatively, but if so regular controls have to be performed. Unstable and/or dislocated displaced odontoid fractures are treated by anterior osteosynthesis with 1 or 2 screws. The technique is demanding and leads to elevated complication and failure rates if modifiers are apparent. In these cases, posterior instrumentation or fusion of C1 and C2 is favorable. In the aged population (>80 years), operative therapy is critical as postoperative morbidity complication and mortality rates rise significantly. As there is still some bias in the treatment algorithms, the working group recommends establishment of a prospective study to result in more objective statements.

Nonsurgical and Surgical Management of Osteoporotic Vertebral Body Fractures: Recommendations of the Spine Section of the German Society for Orthopaedics and Trauma (DGOU).

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

Classification of Osteoporotic Thoracolumbar Spine Fractures: Recommendations of the Spine Section of the German Society for Orthopaedics and Trauma (DGOU).

STUDY DESIGN: Expert opinion. OBJECTIVES: Osteoporotic vertebral fractures are of increasing medical importance. For an adequate treatment strategy, an easy and reliable classification is needed. METHODS: The working group "Osteoporotic Fractures" of the Spine Section of the German Society for Orthopaedics and Trauma (DGOU) has developed a classification system (OF classification) for osteoporotic thoracolumbar fractures. The consensus decision followed an established pathway including review of the current literature. RESULTS: The OF classification consists of 5 groups: OF 1, no vertebral deformation (vertebral edema); OF 2, deformation with no or minor (<1/5) involvement of the posterior wall; OF 3, deformation with distinct involvement (>1/5) of the posterior wall; OF 4, loss of integrity of the vertebral frame or vertebral body collapse or pincer-type fracture; OF 5, injuries with distraction or rotation. The interobserver reliability was substantial (κ = .63). CONCLUSIONS: The proposed OF classification is easy to use and provides superior clinical differentiation of the typical osteoporotic fracture morphologies.

Recommendations for Diagnosis and Treatment of Fractures of the Ring of Axis. / Empfehlungen zur Diagnostik und Therapie oberer Halswirbelsäulenverletzungen: Axisringfrakturen.

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.

Antispastic therapy with botulinum toxin type A in patients with traumatic spinal cord lesion.

OBJECTIVES: The purpose of this study was to determine the effect of botulinum toxin injections for the treatment of spasticity after traumatic spinal cord injury. METHODS: 9 patients were included in this prospective designed study, with a follow-up of at least 2 years. All patients suffered from a massive spasticity after traumatic spinal cord lesion. Conservative treatment options did not show satisfying results. All patients were injected a maximal dose of 2,000 units of botulinum toxin A in no more than 6 skeletal muscle groups. Clinical control examinations were performed after 2 weeks and after at least 2 years. RESULTS: 6 patients reported a good or very good result. One patient offered increasing difficulty in walking for a short time after injection. 2 patients showed no beneficial effects. One patient experienced a modest temporary general weakness for 3 days. After 2 years, 3 patients showed improved function with persistent reduction of spasticity. In the other cases, the beneficial effect lasted for an average of 9 months. CONCLUSION: Botulinum toxin A injection seems to be an effective complementary therapy option in the treatment of spasticity of paraplegic patients with complete deficit of their motor function (ASIA A and B) and a spastic distribution pattern, effecting only a limited number of muscle groups. Caution has to be recommended for incomplete paretic patients, who are able to walk.