Increased incidence of traumatic spinal injury in patients aged 65 years and older in the Netherlands.

PURPOSE: The global population is ageing rapidly. As a result, an increasing number of older patients with traumatic spine injuries are seen in hospitals worldwide. However, it is unknown how the incidence of traumatic spinal injury has developed over the past decade. Therefore, this study aimed to determine the incidence and characteristics of traumatic spinal injury in patients aged under and above 65 years. METHODS: During three time periods: 2009-2010, 2014-2015 and 2019-2020, all adult patients with traumatic spinal injury in the Netherlands were identified from the Dutch National Trauma Registry. Patient-related characteristics and 1-year mortality were collected from a subgroup of patients treated at a level-1 trauma centre, and patients aged ≥ 65 years were compared to patients aged < 65 years. RESULTS: In the Dutch National Trauma Registry 25,737 patients with traumatic spinal injury were identified. The incidence of spine injury in patients > 65 years was 49.5/100,000/yr in 2009-2010, 68.8 in 2014-2015 and 65.9 in 2019-2020. The percentage of patients ≥ 65 years increased from 37% in 2009-2010, to 43% in 2014-2015, and to 47% in 2019-2020. In the subgroup of 1054 patients treated in a level-1 trauma centre, a similar increasing incidence was seen in patients aged ≥ 65 years. In these patients low energy falls were the most common trauma mechanism and the cervical spine was the most commonly injured region. Moreover, patients ≥ 65 years had significantly higher 1-year mortality compared with patients aged < 65 years, 22.7% versus 9.2%. CONCLUSION: The incidence of traumatic spinal injury in older patients in the Netherlands has increased over the last 12 years. Almost half of the patients with traumatic spinal injury are currently aged ≥ 65 years. The increasing incidence and the high 1-year mortality highlight the need to modify existing treatment protocols for these patients.

Correction of the pelvic incidence using a bilateral extending pelvic osteotomy: a proof of concept study.

INTRODUCTION: The aim of this proof of concept human cadaver study was to quantify the effect of a bilateral extending pelvic osteotomy (BEPO) on pelvic incidence (PI) as a potential alternative for a pedicle subtraction osteotomy (PSO) in patients with severe spinal sagittal malalignment. MATERIALS AND METHODS: 10 fresh frozen human cadavers were treated with the BEPO technique. CT images were made before and after the osteotomy and pure sagittal images were created on which PI was measured. RESULTS: The mean pre-osteotomy PI was 47.9° (range 36.4-63.9) and the mean post-osteotomy PI was 36.5° (range 22.1-54.4). The mean correction was - 10.4° with a range of - 8.4° to - 17.3° (p = 0.03), which resulted in a mean decrease of 23% in the PI (range 16-42). CONCLUSIONS: There was a feasible and effective correction of PI using the BEPO technique on the os ilium. This was a preliminary cadaveric study. No conclusions could be made on global sagittal alignment. We postulate that an extending osteotomy of the ilium could be a potential alternative for a PSO reducing the complexity of spine surgery in patients with severe spinal sagittal malalignment.

N(6)-methyladenosine RNA methyltransferase like 3 inhibits extracellular matrix synthesis of endplate chondrocytes by downregulating sex-determining region Y-Box transcription factor 9 expression under tension.

OBJECTIVE: Tension stimulation is an important inducer of endplate cartilage degeneration, but the specific regulatory mechanism remains unclear. This study was the first to reveal the mechanism by which methyltransferase-like 3 (METTL3)-mediated N(6)-methyladenosine (m6A) modification affected the extracellular matrix anabolism by tension-induced endplate chondrocytes. METHOD: We examined the differences in METTL3 expression and m6A methylation levels in human endplate chondrocytes and human cartilage endplate tissues under in vitro tension. The effect on endplate cartilage degeneration was evaluated by manipulating m6A methylation mediated by METTL3 in vivo and in vitro. The effect of METTL3-mediated m6A methylation on the stability of sex-determining region Y-box transcription factor 9 (SOX9) gene expression was determined experimentally. RESULTS: METTL3 expression and m6A methylation levels were significantly increased in degenerative human endplate cartilage tissue. Similarly, tension stimulation inhibited the ability of human endplate chondrocytes to synthesize extracellular matrix, which was accompanied by an increase in METTL3-mediated m6A methylation. The ability of endplate chondrocytes to resist tension was significantly enhanced by inhibiting METTL3 expression and subsequently downregulating m6A methylation in vitro and in vivo, thereby reducing intervertebral disc degeneration. Furthermore, METTL3 mediated SOX9 RNA methylation and disrupted SOX9 mRNA stability, thereby inhibiting the gene expression of the downstream collagen type II alpha 1 chain. CONCLUSION: Tension stimulation downregulated SOX9 expression through METTL3-mediated m6A methylation, thereby inhibiting the synthesis of extracellular matrix in endplate chondrocytes.

Long-term (> 10 years) clinical outcomes of instrumented posterolateral fusion for spondylolisthesis.

PURPOSE: Despite the rapid increase in instrumented spinal fusions for a variety of indications, most studies focus on short-term fusion rates. Long-term clinical outcomes are still scarce and inconclusive. This study investigated clinical outcomes > 10 years after single-level instrumented posterolateral spinal fusion for lumbar degenerative or isthmic spondylolisthesis with neurological symptoms. METHODS: Cross-sectional long-term follow-up among the Dutch participants of an international multicenter randomized controlled trial comparing osteogenic protein-1 with autograft. Clinical outcomes were assessed using the Oswestry Disability Index (ODI), EQ-5D-3L and visual analogue scale (VAS) for leg and back pain, as well as questions on satisfaction with treatment and additional surgery. RESULTS: The follow-up rate was 73% (41 patients). At mean 11.8 (range 10.1-13.7) years after surgery, a non-significant deterioration of clinical outcomes compared to 1-year follow-up was observed. The mean ODI was 20 ± 19, mean EQ-5D-3L index score 0.784 ± 0.251 and mean VAS for leg and back pain, respectively, 34 ± 33 and 31 ± 28. Multiple regression showed that diagnosis (degenerative vs. isthmic spondylolisthesis), graft type (OP-1 vs. autograft) and 1-year fusion status (fusion vs. no fusion) were not predictive for the ODI at long-term follow-up (p = 0.389). Satisfaction with treatment was excellent and over 70% of the patients reported lasting improvement in back and/or leg pain. No revision surgeries for non-union were reported. CONCLUSION: This study showed favourable clinical outcomes > 10 years after instrumented posterolateral spinal fusion and supports spondylolisthesis with neurological symptoms as indication for fusion surgery.

The role of bacterial stimuli in inflammation-driven bone formation.

Immune cells and their soluble factors regulate skeletal cells during normal bone regeneration and pathological bone formation. Bacterial infections can trigger immune responses that activate pro-osteogenic pathways, but these are usually overshadowed by osteolysis and concerns of systemic inflammation. The aim of this study was to determine whether the transient local inflammatory reaction to non-viable bacterial immune agonists could lead to favourable new bone formation. In a series of rabbit studies, as proof-of-concept, how tibial intramedullary injection of viable or killed bacterial species affected bone remodelling and new bone formation was determined. Application of killed bacteria led to considerable new bone formation after 4 weeks, without the prolonged systemic inflammation and exaggerated bone lysis seen with active infection. The osteo-immunomodulatory effects of various species of killed bacteria and the dose response relationship were subsequently screened in ectopically-implanted ceramic scaffolds. Histomorphometry after 8 weeks showed that a relatively low dose of killed bacteria enhanced ectopic bone induction. Moreover, lipoteichoic acid - the bacterial cell-wall derived toll-like-receptor (TLR)-2 activator - was identified as an osteo-stimulatory factor. Collectively, the data indicated that bacterial stimuli could be harnessed to stimulate osteogenesis, which occurs through a synergy with osteoinductive signals. This finding holds promise for the use of non-viable bacteria, bacterial antigens, or their simplified analogues as immuno-modulatory bone regenerating tools in bone biomaterials.

Sparing the surgical area with stereotactic body radiotherapy for combined treatment of spinal metastases: a treatment planning study.

INTRODUCTION: Decreasing the radiation dose in the surgical area is important to lower the risk of wound complications when surgery and radiotherapy are combined for the treatment of spinal metastases. The purpose of this study was to compare the radiation dose in the surgical area for spinal metastases between single fraction external beam radiotherapy (EBRT), single fraction stereotactic body radiotherapy (SBRT) and single fraction SBRT with active sparing (SBRT-AS) of the posterior surgical area. METHODS: Radiotherapy treatment plans for EBRT, SBRT and SBRT-AS of the posterior surgical area were created for 13 patients with spinal metastases. A single fraction of 8Gy was prescribed to the spinal metastasis in the EBRT plan. For the SBRT treatment plans, a single fraction of 18Gy was prescribed to the metastasis and 8Gy to the rest of the vertebral body. For the SBRT plan with active sparing the dose in the designated surgical area was minimized without compromising the dose to the organs at risk. RESULTS: The median dose in the surgical area was 2.6Gy (1.6-5.3Gy) in the SBRT plan with active sparing of the surgical area compared to a median dose of 3.7Gy (1.6-6.3Gy) in the SBRT plan without sparing and 6.5Gy (3.5-9.1Gy) in the EBRT plans (p < .001). The radiation doses to the spinal metastases and organs at risk were not significantly different between the SBRT plan with and without sparing the surgical area. CONCLUSIONS: The radiation dose to the surgical area is significantly decreased with the use of SBRT compared to EBRT. Active sparing of the surgical area further decreased the mean radiation dose in the surgical area without compromising the dose to the spinal metastasis and the organs at risk.

Bone formation by heterodimers through non-viral gene delivery of BMP-2/6 and BMP-2/7.

Non-viral gene delivery is a safe technique to release sustained physiologic dosages of bone morphogenetic protein (BMP). Co-delivery of multiple BMPs can result in the formation of more potent BMP heterodimers. In this study, non-viral co-delivery of BMP-2/6 and BMP-2/7, as a mean to produce heterodimers, was assessed. Goat MSCs were non-virally transfected with plasmid DNA encoding BMP isoforms (pBMP) known to be relevant for osteogenesis: BMP-2, -6 or -7. As a result, BMP-2, -6 and -7 were produced and detectable for up to 14 d and their combined delivery (pBMP-2 with pBMP-6 or pBMP-7) was used to create BMP-2/6 and BM-2/7 heterodimers. Formation and secretion of the heterodimer proteins was validated by sandwich enzyme-linked immunosorbent assay (ELISA). Produced BMPs and heterodimers were biologically active, as confirmed by differentiation of reporter cells and MSCs. To assess bone formation, transfected MSCs were seeded on to ceramic scaffolds and implanted subcutaneously into nude mice. Bone formation was significantly enhanced in the pBMP-2/6 condition and a trend for more bone formation was observed in the pBMP-2/7 and pBMP-6 homodimer condition. No bone was found in the pBMP-2, pBMP-7 or control condition. In conclusion, simultaneous delivery of pBMP-2 with pBMP-6 or -7 resulted in the production of heterodimers that were beneficial for bone formation as compared to BMP homodimers. Combination of BMP sequences could reduce the need for high BMP protein dosages and might enhance prolonged availability of the growth factors.

Timing of surgery in traumatic spinal cord injury: a national, multidisciplinary survey.

PURPOSE: The optimal surgical timeframe for neurological recovery in traumatic spinal cord injury (tSCI) still remains unknown. Recent guidelines have recommended performing surgery within 24 h for all patients with tSCI regardless of initial neurological deficit. It remains unclear whether patients with complete, incomplete tSCI, or traumatic central cord injury (TCCI) will experience the same degree of improvement after urgent surgical intervention. We investigated if the severity of initial neurological injury influenced surgeons on their decision-making of surgical timing in tSCI. METHODS: With a web-based survey, we investigated the current opinion in The Netherlands on timing of surgical decompression and stabilization, depending on the initial degree of neurological injury. RESULTS: Surgeons prefer to perform more urgent surgery for incomplete tSCI compared to complete tSCI. In addition, 43% of patients with complete tSCI are not preferably operated within the recommended 24 h. Even though TCCI is the most common form of incomplete tSCI, these patients are preferably managed less urgently than patients with other types of incomplete tSCI. CONCLUSION: The severity of initial neurological injury seems to play an important role in the urgency of surgical timing for tSCI. A substantial number of patients with complete tSCI are not preferably treated within the recommended surgical timeframe, while patients with incomplete tSCI are preferably operated far more urgent than recommended in the current guidelines. These slides can be retrieved under Electronic Supplementary Material.

Local induction of inflammation affects bone formation.

To explore the influence of inflammatory processes on bone formation, we applied a new in vivo screening model. Confined biological pockets were first created in rabbits as a response to implanted bone cement discs. These biomembrane pockets were subsequently used to study the effects of inflammatory stimuli on ectopic bone formation within biphasic calcium phosphate (BCP) constructs loaded with TNF-α, lipopolysaccharide (LPS) or lipoteichoic acid (LTA), all with or without bone morphogenetic protein (BMP)-2. Analysis of bone formation after 12 weeks demonstrated that the inflammatory mediators were not bone-inductive in combination with the BCP alone, but inhibited or enhanced BMP-induced bone formation. LPS was associated with a strong inhibition of bone formation by BMP-2, while LTA and TNF-α showed a positive interaction with BMP-2. Since the biomembrane pockets did not interfere with bone formation and prevented the leakage of pro-inflammatory compounds to the surrounding tissue, the biomembrane model can be used for in vivo approaches to study local inflammation in conjunction with new bone formation. Using this model, it was shown that the modulation of the inflammatory response could be beneficial or detrimental to the subsequent bone formation process. The co-delivery of inflammatory factors and bone-related growth factors should be further explored as a strategy to enhance the bone-forming efficacy of bone substitutes.

Diagnosis of diffuse idiopathic skeletal hyperostosis with chest computed tomography: inter-observer agreement.

OBJECTIVE: To evaluate and improve the interobserver agreement for the CT-based diagnosis of diffuse idiopathic skeletal hyperostosis (DISH). METHODS: Six hundred participants of the CT arm of a lung cancer screening trial were randomly divided into two groups. The first 300 CTs were scored by five observers for the presence of DISH based on the original Resnick criteria for radiographs. After analysis of the data a consensus meeting was organised and the criteria were slightly modified regarding the definition of 'contiguous', the definition of 'flowing ossifications' and the viewing plane and window level. Subsequently, the second set of 300 CTs was scored by the same observers. κ ≥ 0.61 was considered good agreement. RESULTS: The 600 male participants were on average 63.5 (SD 5.3) years old and had smoked on average 38.0 pack-years. In the first round κ values ranged from 0.32 to 0.74 and 7 out of 10 values were below 0.61. After the consensus meeting the interobserver agreement ranged from 0.51 to 0.86 and 3 out of 10 values were below 0.61. The agreement improved significantly. CONCLUSIONS: This is the first study that reports interobserver agreement for the diagnosis of DISH on chest CT, showing mostly good agreement for modified Resnick criteria. KEY POINTS: • DISH is diagnosed on fluoroscopic and radiographic examinations using Resnick criteria • Evaluation of DISH on chest CT was modestly reproducible with the Resnick criteria • A consensus meeting and Resnick criteria modification improved inter-rater reliability for DISH • Reproducible CT criteria for DISH aids research into this poorly understood entity.

Extension type fracture of the ankylotic thoracic spine with gross displacement causing esophageal rupture.

PURPOSE: This study aimed at discussing the relevance of the type B3 fracture of the new AOSpine classification. METHODS: Hyperextension fractures of the spine are rare in the general population, but common in the ankylotic spine. We present a case of a severe spinal fracture with concomitant esophageal rupture, which was diagnosed early and could be treated during the initial trauma care. RESULTS: The spinal column was stabilized using a percutaneous technique after which the perforated esophagus was sutured through a thoracotomy. The spinal injury was classified a type B3 fracture using the new AOSpine classification. CONCLUSION: The B3 typification raised a lot of discussion during the development of the new classification system and may be controversial. This case, however, nicely illustrates the relevance of an intact posterior hinge as compared to C-type injuries where complete dissociation is present with inherent spinal cord damage.

Outcome of conservative and surgical treatment of pyogenic spondylodiscitis: a systematic literature review.

BACKGROUND: Spondylodiscitis is a spinal infection affecting primarily the intervertebral disk and the adjacent vertebral bodies. Currently many aspects of the treatment of pyogenic spondylodiscitis are still a matter of debate. PURPOSE: The aim of this study was to review the currently available literature systematically to determine the outcome of patients with pyogenic spondylodiscitis for conservative and surgical treatment strategies. METHODS: A systematic electronic search of MEDLINE, EMBASE, Cochrane Collaboration, and Web of Science regarding the treatment of pyogenic spondylodiscitis was performed. Included articles were assessed on risk of bias according the Cochrane Handbook for Systematic Reviews of Interventions, and the quality of evidence and strength of recommendation was evaluated according the GRADE approach. RESULTS: 25 studies were included. Five studies had a high or moderate quality of evidence. One RCT suggest that 6 weeks of antibiotic treatment of pyogenic spondylodiscitis results in a similar outcome when compared to longer treatment duration. However, microorganism-specific studies suggest that at least 8 weeks of treatment is required for S. aureus and 8 weeks of Daptomycin for MRSA. The articles that described the outcome of surgical treatment strategies show that a large variety of surgical techniques can successfully treat spondylodiscitis. No additional long-term beneficial effect of surgical treatment could be shown in the studies comparing surgical versus antibiotic only treatment. CONCLUSION: There is a strong level of recommendation for 6 weeks of antibiotic treatment in pyogenic spondylodiscitis although this has only been shown by one recent RCT. If surgical treatment is indicated, it has been suggested by two prospective studies with strong level of recommendation that an isolated anterior approach could result in a better clinical outcome.

Combination of bone morphogenetic protein-2 plasmid DNA with chemokine CXCL12 creates an additive effect on bone formation onset and volume.

Bone morphogenetic protein-2 (BMP-2) gene delivery has shown to induce bone formation in vivo in cell-based tissue engineering. In addition, the chemoattractant stromal cell-derived factor-1α (SDF-1α, also known as CXCL12) is known to recruit multipotent stromal cells towards its release site where it enhances vascularisation and possibly contributes to osteogenic differentiation. To investigate potential cooperative behaviour for bone formation, we investigated combined release of BMP-2 and SDF-1α on ectopic bone formation in mice. Multipotent stromal cell-seeded and cell-free constructs with BMP-2 plasmid DNA and /or SDF-1α loaded onto gelatin microparticles, were implanted subcutaneously in mice for a period of 6 weeks. Histological analysis and histomorphometry revealed that the onset of bone formation and the formed bone volume were both enhanced by the combination of BMP-2 and SDF-1α compared to controls in cell-seeded constructs. Samples without seeded multipotent stromal cells failed to induce any bone formation. We conclude that the addition of stromal cell-derived factor-1α to a cell-seeded alginate based bone morphogenetic protein-2 plasmid DNA construct has an additive effect on bone formation and can be considered a promising combination for bone regeneration.

Biomaterials for intervertebral disc regeneration: past performance and possible future strategies.

Intervertebral disc (IVD) degeneration is associated with most cases of cervical and lumbar spine pathologies, amongst which chronic low back pain has become the number one cause of loss of quality-adjusted life years. In search of alternatives to the current less than optimal and usually highly invasive treatments, regenerative strategies are being devised, none of which has reached clinical practice as yet. Strategies include the use of stem cells, gene therapy, growth factors and biomaterial carriers. Biomaterial carriers are an important component in musculoskeletal regenerative medicine techniques. Several biomaterials, both from natural and synthetic origin, have been used for regeneration of the IVD in vitro and in vivo. Aspects such as ease of use, mechanical properties, regenerative capacity, and their applicability as carriers for regenerative and anti-degenerative factors determine their suitability for IVD regeneration. The current review provides an overview of the biomaterials used with respect to these properties, including their drawbacks. In addition, as biomaterial application until now appears to have been based on a mix of mere availability and intuition, a more rational design is proposed for future use of biomaterials for IVD regeneration. Ideally, high-throughput screening is used to identify optimally effective materials, or alternatively medium content comparative studies should be carried out to determine an appropriate reference material for future studies on novel materials.

Growth factor-induced osteogenesis in a novel radiolucent bone chamber.

Treatment of large bone defects is currently performed using mainly autograft or allograft bone. There are important drawbacks to bone grafting, such as limited availability, donor site morbidity in the case of autograft and inferior performance of allografts. Therefore, there is a great need for a suitable bone graft substitute. In order to evaluate efficiently newly developed biomaterials and factors intended for orthopaedic surgery, the bone chamber is a very suitable model. To allow longitudinal investigation of bone growth with µCT, a new bone chamber made of radiolucent polyether ether ketone (PEEK) was developed and studied for its feasibility. Therefore, PEEK bone chambers were placed on rat tibiae, and filled with vehicle (Matrigel without growth factors, negative controls), with bone morphogenetic protein 2 (BMP-2, positive controls), or a mix of growth factors combining BMP-2, vascular endothelial growth factor and the chemokine stromal cell-derived factor 1α, all laden on gelatin microspheres for controlled release (combined growth factors). Growth factor presence led to a significant increase in bone formation after 8 weeks, which subsided after 12 weeks, underlining the importance of longitudinal analysis. We conclude that the PEEK-bone chamber is a suitable translational animal model to assess orthotopic bone formation in a longitudinal manner.

Extensive thoracolumbosacral vertebral osteomyelitis after Lemierre syndrome.

PURPOSE: To present a unique case of multilevel vertebral osteomyelitis after Lemierre syndrome. METHODS: A previously healthy 27-year-old man presented in the Emergency Department in septic shock because of Lemierre syndrome for which he was subsequently treated with intravenous benzylpenicillin for 2 months. Two and a half months later, the patient was readmitted with severe back pain without neurological deficits or fever. Imaging revealed an extensive vertebral osteomyelitis of the complete thoracic, lumbar and sacral spine. RESULTS: Although the blood cultures obtained at the initial admission for Lemierre syndrome revealed Fusobacterium species and Streptococcus milleri, the cultures from the spinal biopsies remained negative. Histology of the spinal biopsies showed a purulent sclerosing osteomyelitis. The patient was successfully treated with intravenous piperacillin and tazobactam. Despite persisting back pain, no recurrence of infection was seen at 3 years of follow-up. CONCLUSION: Lemierre syndrome and an extensive thoracolumbosacral vertebral osteomyelitis are rare but serious infections. Clinicians must maintain a high index of suspicion for infectious metastases leading to vertebral osteomyelitis when a patient presents with back pain after an episode of life-threatening septicaemia caused by Lemierre syndrome.

Complications, secondary interventions and long term morbidity after en bloc sacrectomy.

PURPOSE: En bloc sacrectomy is a demanding surgical procedure to remove tumors from the sacrum. Comprehensive data on readmissions for complications endured months to years after initial discharge are scant. The purpose of this study is to present the long-term complications, readmissions and secondary interventions for patients having undergone en bloc sacrectomy. METHODS: Patients were included if en bloc sacrectomy and follow-up were conducted in the authors institution. Correspondence from all specialties involved in the treatment of patients was retrieved. Predefined parameters were scored and assigned to five distinct phases: diagnostic phase; surgery; postoperative period to 1 year after surgery; second year after surgery until follow-up and last follow-up. RESULTS: Sixteen patients underwent anterior-posterior en bloc sacrectomy for a locally aggressive tumor (n=2); malignant tumor (n=13) or solitary metastasis (n=1). The type of resection was low (n=1); middle (n=3); high (n=4); total (n=3) and hemisacrectomy (n=5). The median surgical duration was 12.7 h and median blood lost was 12 l. A total of 73 major complications (average per patient 5; median 4; range 0-12) were recorded and 73 secondary interventions (average per patient 5; median 5; range 0-11) were performed in the first year postsurgery. From the second year until follow-up complications and secondary interventions markedly decreased. At final follow-up (65-266 months), considerable morbidity was found for the eleven patients still alive. CONCLUSIONS: En bloc sacrectomy is a procedure with a high rate of major complications, regardless of tumor histology, often necessitating readmissions and secondary interventions. Long-term survival is associated with considerable morbidity and extensive preoperative counseling should be conducted to discuss the risks and outcome of the procedure.

Giant cell tumors of the sacrum--a nationwide study on midterm results in 26 patients after intralesional excision.

PURPOSE: Evaluation of recurrences, complications and function at mid-term follow-up after curettage for sacral giant cell tumor (GCT). METHODS: We retrospectively studied all 26 patients treated for sacral GCT in the Netherlands (from 1990 to 2010). Median follow-up was 98 (6-229) months. All patients underwent intralesional excision, 21 with local adjuvants, 5 radiotherapy, 3 IFN-α, 1 bisphosphonates. Functional outcome was assessed using Musculoskeletal Tumor Society (MSTS) score. Statistics were performed with Kaplan-Meier, Cox regression, log rank and Mann-Whitney U. RESULTS: Recurrence rate was 14/26 after median 13 (3-139) months and was highest after isolated curettage (4/5). Soft tissue masses >10 cm increased recurrence risk (HR = 3.3, 95 % CI = 0.81-13, p = 0.09). Complications were reported in 12/26 patients. MSTS was superior in patients without complications (27 vs. 21; p = 0.024). CONCLUSION: Recurrence rate for sacral GCT was highest after isolated curettage, indicating that (local) adjuvant treatment is desired to obtain immediate local control. Complications were common and impaired function.

Surgeon reported treatment choices for AO type B and C thoracolumbar fractures without neurological deficits: An expert survey.

INTRODUCTION: Less invasive spine surgery (LISS) has become well-established for thoracolumbar burst fractures without neurological deficits. However, notable controversy persists regarding the adequacy of LISS for more unstable AO type B and C injuries, as it does not allow for formal open fusion. MATERIALS AND METHODS: In this cross-sectional survey experienced spine surgeons of the Dutch Spine Society were invited to participate (56 participants). They were asked to indicate the most appropriate treatment for AO type B1, B2 (L1: A1 and L1: A3), B3 and C (L1: A4) injuries at level Th12-L1. Taking into account: age, AO N0-N1, or polytrauma. Specific agreement between participants was obtained applying Variation Ratio (VR). RESULTS: A significant level of overall agreement was observed for AO type-B1 injuries with 73.8% of participants opting for percutaneous short-segment fixation (VR 0.775). For AO type-B3 injuries, 79.4% of participants favored percutaneous long-segment fixation (VR 0.794). for AO type-B2 injuries, there was less overall agreement (VR 0.571-0.657). Nonetheless, when considering all AO type-B injuries combined, percutaneous fixation emerged as the most preferred treatment option with substantial agreement (VR 0.871-0.923). Conversely, for AO type-C injuries, there was less agreement among the participants (VI 0.411), 26.5% of them chose additional open spinal fusion. CONCLUSION: For all AO type-B injuries there was substantial agreement to treat these fractures with percutaneous techniques. For AO type-C injuries, the survey results do not support a consensus. Nevertheless, the responses raise important questions about the necessity of spinal fusion for such injuries.

Term and definition of a deformity after a spine trauma: Results of an international Delphi study.

Introduction: Deformity of the spinal column after trauma could lead to pain, impaired function, and may sometimes necessitate extensive and high-risk surgery. This 'condition' has multiple terms and definitions that are used in research and clinics. A specific term and definition of this condition however is still lacking. A uniform and internationally accepted term and definition are necessary to compare cases and treatments in the future. Research question: Reach consensus on the term and definition of this deformity after spine trauma using a Delphi approach. Material and methods: An 'all-rounds invitation' Delphi process was used in this study among a group of international experts. The first round consisted of an online survey using input from preparatory studies, a typical clinical case and ICD-11 codes. The second round showed the results in-person and discussion was encouraged. Participants voted for rejection of certain terms. In the third round the final vote took place. When >80 % of the votes was for or against a term the term was rejected or accepted. Results: Response rate was high (≥84 %). The 3 Delphi rounds were completed. Unanimous voting led to the acceptance of the term and abbreviation as PSD. Deformity in any plane, pain, impaired function, and neurological deficit, were deemed important to include in the definition of PSD. Discussion and conclusion: Unanimous consensus was reached on 'Posttraumatic spinal deformity: Condition where a trauma to the spine results in a deformity in any plane and results in pain and an impaired function with or without a neurological deficit.'