The management of upper cervical spine (UCS) fractures is unclear concerning the role of fusion versus non-fusion fixation and the need for implant removal following fracture healing. This international AO Spine expert survey (Level IV study) evaluated the current trends, and practice preferences among experienced surgeons in the management of UCS fractures. A structured questionnaire was answered by AO Spine Knowledge Forum Trauma and Infection (KF T I) members (n = 24). The survey collected data regarding demographics, classification use, fixation vs. fusion preferences, and implant removal practices for UCS fractures (C1, C2 odontoid, and Hangman’s fractures). Descriptive statistics were analysed. Majority were from North America and Europe (54
STUDY DESIGN:Cross-sectional reliability study. OBJECTIVE:To propose and validate a novel biomechanical classification for high-grade spondylolisthesis (HGS) that incorporates compensatory mechanisms into the assessment of sagittal alignment patterns. BACKGROUND:Existing classifications of HGS are primarily descriptive, rely on parameters often distorted by sacral endplate dysplasia, offer limited guidance for surgical decision-making and do not completely capture the spectrum of compensation in sagittal alignment. The new classification system defines four alignment types: type 1: proportioned sagittal alignment (SVA ≤50 mm, LSA ≥90°, IP ≤T11, LL Apex ≤L3). Type 2: compensated lower lumbar hypolordosis, with cranialization of IP and/or LL Apex. Type 3: compensated lumbosacral kyphosis (LSA <90° despite SVA ≤50 mm). Type 4: sagittal malalignment with exhausted compensation (SVA >50 mm). METHODS:Fourteen spine surgeons from 12 countries evaluated 29 anonymized cases of HGS using the new classification. Each case was presented with full-spine and lumbosacral anteroposterior and lateral standing radiographs. Classifications were repeated in two separate rounds. Interobserver reliability was assessed with Fleiss' Kappa, while intraobserver reliability was evaluated with Cohen Kappa and simple percentage agreement. RESULTS:Interobserver reliability was almost perfect (Fleiss' Kappa=0.916; 95% CI: 0.888-0.945; overall concordance 82.8%). Intraobserver reliability was equally high (mean Cohen Kappa=0.958; 95% CI: 0.926-0.991; mean agreement 97.0%). CONCLUSION:This novel biomechanical classification provides a reproducible framework to describe HGS without reliance on approximated parameters. By integrating SVA, LSA, IP, and LL Apex, it captures compensated and decompensated states of malalignment with direct therapeutic implications. The system demonstrated excellent reliability and may serve as a foundation for future surgical guidelines.
The incidence of insufficiency fractures of the pelvis is rising in developed countries. The aim of this review is to summarize the current evidence regarding the classification, treatment, and surgical strategies for these fractures. Several classifications have been developed such as the AO Spine Sacral Injury Classification System, the Fragility Fractures of the Pelvis (FFP), and the OF pelvis classification. The treatment option consists of non-operative treatment, sacroplasty, ileosacral screw or rod fixation, lumbopelvic fixation and approaches to the anterior ring including fixateur externe or interne, pelvic plates or screw fixations. The advantages and disadvantages of each technique are depicted. The knowledge gap in this field is large and future directions are discussed.
Treatment of neurologically intact thoracolumbar burst fractures (AO types A3/A4) is controversial. Furthermore, the impact that concomitant posterior ligamentous complex (PLC) injuries have on patient reported outcome measures (PROMs) is not well-established. This analysis compared outcomes between patients with A3/A4 injuries with and without concomitant B1/B2 injuries and between patients treated with operative versus nonoperative management. Data from a prospective multicenter cohort study (ClinicalTrials.gov: NCT02827214) was used. Adults with AO type A3/A4 burst fractures (T10-L2), with or without concomitant B1/B2 injuries, were included. PROMs included Oswestry Disability Index (ODI), Pain NRS, EQ-5D, and AOSpine Patient Reported Outcome Spine Trauma (PROST) score. Isolated A3/A4 injuries were compared to combined A3/A4 and B1/B2 injuries—patients were then sub-analyzed by treatment. 198 patients were included (34 with combined A3/A4 and B1/B2 injuries). Patients with combined injuries had similar baseline but different 1-year postoperative (12.9 ± 12.8 vs. 7.3 ± 9.9;p = 0.024) ODI scores compared to patients with isolated injuries. After subdividing by treatment, both operatively and nonoperatively treated patients with combined injuries had higher rates of suspected/indeterminate and injured PLC statuses (p < 0.001) compared to those with isolated injuries. There were no differences in 1-year postoperative ODI scores between surgically managed patients with and without concomitant PLC injuries. Patients treated nonoperatively with combined injuries had significantly worse one-year postoperative ODI (20.8 vs. 7.6;p = 0.018) and two-year postoperative Pain NRS (3 vs. 1.1;p = 0.04), and EQ-5D (0.8 vs. 0.9;p = 0.03) scores. Patients with isolated A3/A4 injuries performed similarly compared to patients with concomitant B1/B2 injuries after surgical treatment. However, combined injuries treated nonoperatively performed worse on multiple metrics of pain and disability at final follow-up. Combined injuries were associated with a significantly higher rates of suspected/indeterminate or injured PLC status. Thus, suspicion of PLC injuries should prompt serious consideration of surgical intervention in the setting of burst fractures without neurologic deficits.
