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.

Risk Factors for Neurologic Deficits in Patients With Spinal Epidural Abscess: An Analysis of One-Hundred-Forty Cases.

STUDY DESIGN: retrospective study. OBJECTIVES: In addition to surgical treatment of spinal epidural abscesses (SEA), a conservative, medical treatment for patients without acute neurologic deficits has been proposed. However, the risk factors for neurologic deficits are unclear. This study aims to identify factors predisposing patients with SEA to neurological impairment. METHODS: All patients treated for SEA between 2008 and 2021 were identified from a prospective vertebral-osteomyelitis registry of a tertiary referral centre. Patient demographics, comorbidities, pathogens, degree of osseous destruction, location of SEA and preoperative neurologic status were retrospectively collected. Differences between patients with (Group 1) and without (Group 2) pretreatment neurologic deficits were assessed by univariate and logistic regression analysis. RESULTS: A total of 140 patients with SEA were included. Forty-three patients (31%) had a neurologic deficit and 97 patients (69%) had no neurologic deficit prior to therapy. The prevalence of diabetes mellitus (35% vs 19%, P = .03), median visual analogue scale leg pain (8 vs 5, P = .01), median American Society of Anesthesiologists (ASA) Score (3 vs 2.6, P = .003) and mean Body-Mass-Index (29 vs 26, P = .02) differed between Group 1 and 2 in univariate analysis. In multivariable analysis, diabetes mellitus (odds ratio = 2.7), female sex (odds ratio = 2.5) and ASA-Score (odds ratio = 2.4) were significant contributors for neurologic deficits. CONCLUSIONS: In patients with a SEA without neurologic deficits, the ASA score and diabetes mellitus should be considered, especially in female patients. These patients may be at a higher risk for developing a neurologic deficit and may benefit from an early surgical treatment.

Spondylodiscitis in Geriatric Patients: What Are the Issues?

STUDY DESIGN: Review article. OBJECTIVES: A review of literature on the treatment of pyogenic spondylodiscitis in geriatric patients was performed with the aim to give an overview about these special patients and a recommendation on necessary diagnostics as well as conservative and operative treatment options. METHODS: A systematic computerized literature search was done by the spondylodiscitis working group of the German Society for Orthopedics and Trauma Surgery. RESULTS: Spondylodiscitis has an increasing incidence by age with a peak at 75 years or older. The 1-year mortality without an appropriate treatment is with 15 to 20% extremely high. Pathogen detection is the essential diagnostic step and the basis for a sufficient antibiotic treatment. Geriatric patients have initially less elevated inflammatory parameters. Compared to younger patients. They have a longer length of hospital stay and take longer for CRP normalization. Even the outcome between conservative and operative treatment is comparable after one year. Patients with spinal instability, immobilizing pain, epidural abscess, and newly emerged neurological deficits should be considered for operative treatment. CONCLUSIONS: The treatment of geriatric patients with pyogenic spondylodiscitis must take into account that these patients usually have multiple comorbidities. The main goals are resistance-based antibiotics and the shortest possible time of immobilization of the patient.

Evaluation of Classification Systems and Their Correlation With Clinical and Quality-of-life Parameters in Patients With Surgically Treated Spondylodiskitis.

INTRODUCTION: Surgical classifications for spondylodiscitis (SD) typically include radiologic features and the status of neurologic impairment. Clinical factors such as preoperative pain, function/disability, overall quality of life (QoL), and risk of recurrence and mortality, which are necessary for a comprehensive assessment of SD and measurement of treatment success, are not considered. There is a lack of external validation of SD classifications. The aim of this study was to validate classifications of SD and to correlate these classifications with the above clinical factors. METHODS: One hundred fourteen patients from a prospective SD register (2008-2020) with available imaging, preoperative neurologic status, backpain, function/disability data (Oswestry Disability Index and Core Outcome Measures Index), QoL data (Short Form 36, European Quality-of-life Questionnaire), and a 1-year follow-up were retrospectively classified according to Akbar, Homagk, and Pola classifications. Interrater reliability, correlation among classifications, and correlation between classifications and QoL were calculated. RESULTS: Interrater reliability was κ = 0.83 for Akbar, κ = 0.94 for Homagk, and κ = 0.99 for Pola. The correlation of Akbar with Pola and Homagk was moderate (ρ s = 0.47; ρ s = 0.46) and high between Pola and Homagk (ρ s = 0.7). No notable correlation was observed between any of the classifications and preoperative Oswestry Disability Index, Core Outcome Measures Index, QoL, mortality, and recurrence within 1 year. Only a weak correlation was observed between Homagk and preoperative leg pain and back pain. CONCLUSION: Available SD classifications have a very good interrater reliability and moderate-to-high correlation with each other but lack correlation with preoperative pain, function/disability, and overall QoL. Because these factors are important for a comprehensive assessment of SD in severity, decision making, and prognosis, they should be included in future SD classifications. This could allow for more comprehensive treatment algorithms. LEVEL OF EVIDENCE: Level II. Diagnostic study = prospective cohort study; development of diagnostic criteria. DATA AVAILABILITY: The data sets used and analyzed during this study are available from the corresponding author on reasonable request.

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.

Transosseous suture versus suture anchor fixation for inferior pole fractures of the patella in osteoporotic bone: a biomechanical study.

BACKGROUND: The surgical treatment of inferior patellar pole fractures can be a challenge, especially in geriatric patients, who are particularly frequently affected by osteoporosis. The objective of this biomechanical study was to compare the performance of suture anchor and transosseous suture fixation in fractures of the inferior patellar pole in context of bone mineral density. METHODS: Twelve fresh-frozen human cadaveric knees received a transverse osteotomy, simulating an AO/OTA 34C1.3 inferior pole fracture of the patella. These fractures were fixated with either suture anchors (SA; Corkscrew® FT 4.5 mm) or transosseous suture (TS; #2 FiberWire®). Cyclic loading tests were performed by pulling the quadriceps tendon against gravity from 90° flexion to almost full extension (5°) for 1000 cycles. Motion and fracture gap displacement were tracked until failure occurred. Subsequently, loading to failure tests followed. Differences between groups were compared using unpaired t-tests, and correlations were calculated with Pearson's correlation coefficient. RESULTS: The suture anchor group showed significantly fewer cycles to failure than the transosseous suture group (SA: 539.0 ± 465.6 cycles, TS: 1000 ± 0 cycles, P = 0.04). Bone mineral density correlated positively with cycles to failure in the suture anchor group (Pearson's r = 0.60, P = 0.02). No differences in fracture gap displacement could be proven after 100 cycles (SA: 4.1 ± 2.6 mm, TS: 6.5 ± 2.6 mm, P = 0.19); 500 cycles (SA: 6.4 ± 6.1 mm, TS: 9.6 ± 3.8 mm, P = 0.39); and 1000 cycles (SA: 4.0 ± 0.4 mm, TS: 11.0 ± 4.5 mm, P = 0.08). Furthermore, the mean destructive load to failure in the suture anchor group was also significantly lower than in the transosseous suture group (SA: 422.4 ± 212.2 N, TS: 825.7 ± 189.3 N, P = 0.04). CONCLUSIONS: Suture anchors may be a viable alternative to transosseous suture in younger patients for clinical advantages, but in osteoporotic bone, the more stable osteosynthesis with transosseous suture continues to prove superior. Therefore, trauma surgeons might consider the use of transosseous suture in elderly patients, especially in those presenting with low bone mineral density values.

Polytrauma scoring revisited: prognostic validity and usability in daily clinical practice.

PURPOSE: Scores are widely used for the assessment of injury severity and therapy guidance in severely injured patients. They differ vastly regarding complexity, applicability, and prognostic accuracy. The objective of this study was to compare well-established with more recently developed trauma scores as well as intensive care unit (ICU) scores. METHODS: Retrospective analysis of severely injured patients treated at a level I trauma centre from 2010 to 2015. INCLUSION CRITERIA: Age ≥ 18 years, Injury Severity Score ≥ 16 and ICU treatment. Primary endpoint was in-hospital mortality. Several scores (ISS, APACHE II, RTS, Marshall Score, SOFA, NISS, RISC II, EAC and PTGS) were assessed to determine their predictive quality for mortality. Statistical analysis included correlation analysis and receiver operating characteristic (ROC). RESULTS: 444 patients were included. 71.8% were males, mean age was 51 ± 20.26 years. 97.4% sustained a blunt trauma. The area under the ROC curve (AUROC) revealed RISC II (0.92) as strongest predictor regarding mortality, followed by APACHE II (0.81), Marshall score (0.69), SOFA (0.70), RTS (0.66), NISS (0.62), PTGS (0.61) and EAC (0.60). ISS did not reach statistical significance. CONCLUSIONS: RISC II provided the strongest predictive capability for mortality. In comparison, more simple scores focusing on injury pattern (ISS, NISS), physiological abnormalities (RTS, EAC), or a combination of both (PTGS) only provided inferior mortality prediction. Established ICU scores like APACHE II, SOFA and Marshall score were proven to be helpful tools in severely injured trauma patients.

Interobserver reliability of the Gehweiler classification and treatment strategies of isolated atlas fractures: an internet-based multicenter survey among spine surgeons.

PURPOSE: Atlas (C1) fractures are commonly rated according to the Gehweiler classification, but literature on its reliability is scarce. In addition, evaluation of fracture stability and choosing the most appropriate treatment regime for C1-injuries are challenging. This study aimed to investigate the interobserver reliability of the Gehweiler classification and to identify whether evaluation of fracture stability as well as the treatment of C1-fractures are consistent among spine surgeons. METHODS: Computed tomography images of 34 C1-fractures and case-specific information were presented to six experienced spine surgeons. C1-fractures were graded according to the Gehweiler classification, and the suggested treatment regime was recorded in a questionnaire. For data analyses, SPSS was used, and interobserver reliability was calculated using Fleiss' kappa (κ) statistics. RESULTS: We observed a moderate reliability for the Gehweiler classification (κ = 0.50), the evaluation of fracture stability (κ = 0.50), and whether a surgical or non-surgical therapy was indicated (κ = 0.53). Type 1, 2, 3a, and 5 fractures were rated stable and treated non-surgically. Type 3b fractures were rated unstable in 86.7% of cases and treated by surgery in 90% of cases. Atlas osteosynthesis was most frequently recommended (65.4%). Overall, 25.8% of type 4 fractures were rated unstable, and surgery was favoured in 25.8%. CONCLUSION: We found a moderate reliability for the Gehweiler classification and for the evaluation of fracture stability. In particular, diverging treatment strategies for type 3b fractures emphasise the necessity of further clinical and biomechanical investigations to determine the optimal treatment of unstable C1-fractures.

Surgical Treatment Strategies for Pyogenic Spondylodiscitis of the Thoracolumbar Spine. / Operative Behandlungsstrategien der pyogenen Spondylodiszitis der thorakolumbalen Wirbelsäule.

BACKGROUND: Despite advances, the morbidity and mortality rates of patients with spondylodiscitis remains high, with an increasing incidence worldwide. Although conservative therapy has progressed, several cases require surgical intervention. However, the indication and opportunities for surgical treatment are still disputable. METHODS: In a joint consensus, the members of the 'Spondylodiscitis' working group of the Spine Section of the German Society for Orthopaedics and Trauma Surgery considered current literature, particularly the newly published S2k guideline of the AWMF, and examined the surgical indications and treatment strategies for thoracolumbar spondylodiscitis. RESULTS: Surgical intervention for spondylodiscitis is only required in a small percentage of patients. In studies comparing conservative and surgical therapies, most patients benefitted from surgery, regardless of the surgical technique selected. Presently, the standard procedure is a combined dorsoventral approach, in which a monolateral attempt should always be made. The choice of material (PEEK, titanium) for ventral support does not influence the clinical result.

Biomechanical In Vitro and Finite Element Study on Different Sagittal Alignment Postures of the Lumbar Spine During Multiaxial Daily Motion.

Lumbar lordotic correction (LLC), the gold standard treatment for sagittal spinal malalignment (SMA), and its effect on sagittal balance have been critically discussed in recent studies. This paper assesses the biomechanical response of the spinal components to LLC as an additional factor for the evaluation of LLC. Human lumbar spines (L2L5) were loaded with combined bending moments in flexion (Flex)/extension (Ex) or lateral bending (LatBend) and axial rotation (AxRot) in a physiological environment. We examined the dependency of AxRot range of motion (RoM) on the applied bending moment. The results were used to validate a finite element (FE) model of the lumbar spine. With this model, the biomechanical response of the intervertebral discs (IVD) and facet joints under daily motion was studied for different sagittal alignment postures, simulated by a motion in Flex/Ex direction. Applied bending moments decreased AxRot RoM significantly (all P < 0.001). A stronger decline of AxRot RoM for Ex than for Flex direction was observed (all P < 0.0001). Our simulated results largely agreed with the experimental data (all R2 > 0.79). During the daily motion, the IVD was loaded higher with increasing lumbar lordosis (LL) for all evaluated values at L2L3 and L3L4 and posterior annulus stress (AS) at L4L5 (all P < 0.0476). The results of this study indicate that LLC with large extensions of LL may not always be advantageous regarding the biomechanical loading of the IVD. This finding may be used to improve the planning process of LLC treatments.

Intraoperative Computed Tomography-Assisted Spinal Navigation in Dorsal Cervical Instrumentation: A Prospective Study on Accuracy Regarding Different Pathologies and Screw Types.

BACKGROUND: Intraoperative computed tomography (iCT) navigated dorsal instrumentation has been successfully introduced as a new clinical standard. The proximity of vital anatomic structures makes cervical spine instrumentation an especially delicate task. Therefore, navigated approaches might prove to be beneficial. In this study, the accuracy of conventional instrumentation was compared with iCT navigated dorsal cervical spine instrumentation with focus on cervical pedicle screws (CPSs) versus lateral mass screws (LMSs) and pathologies. METHODS: We analyzed a prospective consecutive series of patients undergoing cervical dorsal instrumentation with iCT and spinal navigation and retrospectively analyzed a cohort that received conventional cervical instrumentation with C-arm fluoroscopy (control group). Accuracy was assessed with a modified Gertzbein-Robbins classification. Underlying pathologies were taken into account regarding accuracy in different entities. RESULTS: Fifty-nine patients were treated using iCT (357 screws: 238 CPSs, 119 LMSs), and 98 patients underwent conventional instrumentation (632 screws: 69 CPSs, 563 LMSs). We achieved an initial accuracy of 93.28% (n = 220 screws) in the iCT group and 80.9% (n = 511 screws) in the control group (P < 0.001). Significant differences were found regarding the accuracy of CPS placement in cases of degenerative disorders (iCT vs. control; 94% vs. 63%; P < 0.001) and trauma (iCT vs. control; 88% vs. 72%; P < 0.05). iCT yielded favorable precision rates in regard to LMS placement (iCT vs. control; 94.2% vs. 82%; P < 0.05). CONCLUSIONS: Accuracy of iCT navigated instrumentation was significantly higher than conventional instrumentation. An overall tendency toward the use of CPSs with iCT navigation is evident, increasing the mechanical properties of the construct. iCT appears to be especially beneficial in elective surgery cases of degenerative spinal disorders.

Impact of Chest Trauma and Overweight on Mortality and Outcome in Severely Injured Patients.

The morbidity and mortality of severely injured patients are commonly affected by multiple factors. Especially, severe chest trauma has been shown to be a significant factor in considering outcome. Contemporaneously, weight-associated endocrinological, haematological, and metabolic deviations from the norm seem to have an impact on the posttraumatic course. Therefore, the aim of this study was to determine the influence of body weight on severely injured patients by emphasizing chest trauma. A total of 338 severely injured patients were included. Multivariate regression analyses were performed on patients with severe chest trauma (AIS ≥ 3) and patients with minor chest trauma (AIS < 3). The influence of body weight on in-hospital mortality was evaluated. Of all the patients, 70.4% were male, the median age was 52 years (IQR 36-68), the overall Injury Severity Score (ISS) was 24 points (IQR 17-29), and a median BMI of 25.1 points (IQR 23-28) was determined. In general, chest trauma was associated with prolonged ventilation, prolonged ICU treatment, and increased mortality. For overweight patients with severe chest trauma, an independent survival benefit was found (OR 0.158; p = 0.037). Overweight seems to have an impact on the mortality of severely injured patients with combined chest trauma. Potentially, a nutritive advantage or still-unknown immunological aspects in these patients affecting the intensive treatment course could be argued.

Biomechanical effects of posterior pedicle screw-based instrumentation using titanium versus carbon fiber reinforced PEEK in an osteoporotic spine human cadaver model.

BACKGROUND: Aim of this biomechanical investigation was to compare the biomechanical effects of a carbon fiber reinforced PEEK and titanium pedicle screw/rod device in osteoporotic human cadaveric spine. METHODS: Ten human fresh-frozen cadaveric lumbar spines (L1-L5) have been used and were randomized into two groups according to the bone mineral density. A monosegmental posterior instrumentation (L3-L4) using titanium pedicle screws and rods was carried out in group A and using carbon fiber reinforced PEEK in group B. A cyclic loading test was performed at a frequency of 3 Hz, starting with a peak of 500 N for the first 2000 cycles, up to 950 N for 100,000 cycles under a general preload with 100 N. All specimens were evaluated with regard to a potential collapse of the implanted pedicle screws. A CT supported digital measurement of cavities around the pedicle at 3 defined measuring points was performed. Finally, the maximum zero-time failure load of all specimens was determined using a universal testing machine (80% Fmax). FINDINGS: Regarding maximum axial force (group A: 2835 N, group B: 3006 N, p = 0.595) and maximum compression (group A: 11.67 mm, group B: 15.15 mm, p = 0.174) no statistical difference could be shown between the two groups. However, significant smaller cavity formation around the pedicle screws could be observed in group B (p = 0.007), especially around the screw tip (p < 0.001). INTERPRETATION: Carbon fiber reinforced PEEK devices seem to be advantageous in terms of microscopic screw loosening compared to titanium devices.

Early Spinal Injury Stabilization in Multiple-Injured Patients: Do All Patients Benefit?

BACKGROUND: Thoracolumbar spine fractures in multiple-injured patients are a common injury pattern. The appropriate timing for the surgical stabilization of vertebral fractures is still controversial. The purpose of this study was to analyse the impact of the timing of spinal surgery in multiple-injured patients both in general and in respect to spinal injury severity. METHODS: A retrospective analysis of multiple-injured patients with an associated spinal trauma within the thoracic or lumbar spine (injury severity score (ISS) >16, age >16 years) was performed from January 2012 to December 2016 in two Level I trauma centres. Demographic data, circumstances of the accident, and ISS, as well as time to spinal surgery were documented. The evaluated outcome parameters were length of stay in the intensive care unit (ICU) (iLOS) and length of stay (LOS) in the hospital, duration of mechanical ventilation, onset of sepsis, and multiple organ dysfunction syndrome (MODS), as well as mortality. Statistical analysis was performed using SPSS. RESULTS: A total of 113 multiple-injured patients with spinal stabilization and a complete dataset were included in the study. Of these, 71 multiple-injured patients (63%) presented with an AOSpine A-type spinal injury, whereas 42 (37%) had an AOSpine B-/C-type spinal injury. Forty-nine multiple-injured patients (43.4%) were surgically treated for their spinal injury within 24 h after trauma, and showed a significantly reduced length of stay in the ICU (7.31 vs. 14.56 days; p < 0.001) and hospital stay (23.85 vs. 33.95 days; p = 0.048), as well as a significantly reduced prevalence of sepsis compared to those surgically treated later than 24 h (3 vs. 7; p = 0.023). These adverse effects were even more pronounced in the case where cutoffs were increased to either 72 h or 96 h. Independent risk factors for a delay in spinal surgery were a higher ISS (p = 0.036), a thoracic spine injury (p = 0.001), an AOSpine A-type spinal injury (p = 0.048), and an intact neurological status (p < 0.001). In multiple-injured patients with AOSpine A-type spinal injuries, an increased time to spinal surgery was only an independent risk factor for an increased LOS; however, in multiple-injured patients with B-/C-type spinal injuries, an increased time to spinal surgery was an independent risk factor for increased iLOS, LOS, and the development of sepsis. CONCLUSION: Our data support the concept of early spinal stabilization in multiple-injured patients with AOSpine B-/C-type injuries, especially of the thoracic spine. However, in multiple-injured patients with AOSpine A-type injuries, the beneficial impact of early spinal stabilization has been overemphasized in former studies, and the benefit should be weighed out against the risk of patients' deterioration during early spinal stabilization.

[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.

[Posttraumatic deformity of the thoracolumbar spine]. / Posttraumatische Fehlstellungen der Brust- und Lendenwirbelsäule.

Posttraumatic kyphotic deformities of the thoracolumbar spine may result in significant clinical complaints. If conservative treatment is not successful, surgical correction of the kyphosis becomes an option. In contrast to degenerative deformities, posttraumatic kyphotic deformities are usual limited to few segments and can be treated with shorter constructs. The surgical strategy depends on the rigidity and the localization of the posttraumatic kyphotic deformity. In this respect purely posterior approaches and combined posteroanterior surgical approaches are available each with different advantages and disadvantages.

Biomechanical In Vitro Test of a Novel Dynamic Spinal Stabilization System Incorporating Polycarbonate Urethane Material Under Physiological Conditions.

Posterior dynamic stabilization systems (PDSS) were developed to provide stabilization to pathologic or hypermobile spinal segments while maintaining the healthy biomechanics of the spine. Numerous novel dynamic devices incorporate the temperature and moisture dependent material polycarbonate urethane (PCU) due to its mechanical properties and biocompatibility. In this study, standardized pure moment in vitro tests were carried out on human lumbar spines to evaluate the performance of a device containing PCU. An environmental chamber with controlled moisture and temperature was included in the setup to meet the requirements of testing under physiological conditions. Three test conditions were compared: (1) native spine, (2) dynamic instrumentation, and (3) dynamic instrumentation with decompression. The ranges of motion, centers of rotation, and relative pedicle screw motions were evaluated. The device displayed significant stiffening in flexion-extension, lateral bending, and axial rotation load directions. A reduction of the native range of motion diminished the stiffening effect along the spinal column and has the potential to reduce the risk of the onset of degeneration of an adjacent segment. In combination with decompression, the implant decreased the native range of motion for flexion-extension and skew bending, but not for lateral bending and axial rotation. Curve fittings using the sigmoid function were performed to parameterize all load-deflection curves in order to enhance accurate numerical model calibrations and comparisons. The device caused a shift of the center of rotation (COR) in the posterior and caudal direction during flexion-extension loading.