We review the international experience of placing monitoring probes intrathecally at the injury site in patients with acute, severe traumatic spinal cord injuries. The aims are to assess the types of probes used, their placement, signal quality, and safety. We analyzed data from 109 adult patients managed in intensive care units in Aarhus, Leuven, Ljubljana, London, and Madrid. A questionnaire was distributed to all participating sites and data were retrospectively collected from each patient’s medical record. Admission American Spinal Injury Association (AIS) grade was A (58.7

Thoracolumbar spine injuries can result from various traumatic events such as falls, motor vehicle accidents, and sports injuries. While surgical intervention is often indicated for complex fractures and in case of neurological deficits, non-operative treatment remains a viable option for certain types of injuries. This manuscript aims to provide a comprehensive overview of the specific indications and treatment options of non-operative thoracolumbar spine injuries. It seeks to provide evidence-based recommendations for selecting patients suitable for conservative management based on fracture type and stability, absence of neurological deficits, spine deformity, integrity of the posterior ligament complex and patient specific factors.

The operative treatment of thoracolumbar fractures is a rapidly evolving improvement in the care of patients with this injury after trauma. This article describes the different techniques and principles. Considerations and methods of treatment are scientifically addressed and illustrated according to the classification and severity of the fracture pattern. The use of computer navigation and optimisation of minimally invasive techniques is inevitable. The timing of surgery as well the removal of the material after fracture healing are also discussed. The operative treatment of spinal fractures is emerging and there is still much more knowledge to gain.

Acute traumatic spinal cord injury (tSCI) is a complex and heterogeneous injury, where the level of injury, injury severity, duration and degree of spinal cord compression, and blood pressure management seem to influence neurologic outcome. Although data in the literature seem to be inconsistent regarding the effectiveness of surgical decompression and spinal fixation in patients with thoracic and thoracolumbar tSCI, some single-center studies suggest that early surgical decompression may lead to a superior neurologic outcome, especially in patients with incomplete tSCI, suggesting surgical decompression to be performed as soon as possible. However, high energy injuries, especially to the upper thoracic levels, may be too severe to be influenced by surgical decompression, which may represent a critical second hit for the polytraumatized patient. Therefore, the surgeon first needs to critically evaluate the potential for neurologic recovery in each patient before determining the ideal timing of surgery. Circulatory stabilization must be achieved before surgical intervention, and minimally invasive procedures should be preferred. Invasive blood pressure monitoring should be started on admission, and maintenance of a MAP between 85 and 90 mmHg is recommended for a duration of 5–7 days, with special attention to the prevention of hypoxia, fever, acidosis and deep venous thrombosis. The role of a 24-hour infusion of high-dose MPSS is still controversial, but it may be offered at the discretion of the treating surgeon to adult patients within 8 h of acute tSCI as a treatment option, especially in the case of very early decompression or incomplete tSCI.

Thoracolumbar fractures are common injuries that usually result from high energy trauma. They can lead to significant morbidity due to neurologic impair - or mortality - if not managed according to strict and rapid intervention rules in terms of decompression of the spinal cord, and rigid fixation of the fracture. This manuscript reviews emergency treatment protocols, imaging modalities, and classification systems used for thoracolumbar fractures. The emergency treatment is discussed, specific classifications are compared and indications for surgeries are compared.

Due to increasing life expectancy, the prevalence of fractures caused by osteoporosis is raising. These fractures significantly reduce the quality of life in the elderly population. They represent both a disease and an injury simultaneously. While they were once treated solely with conservative methods, new techniques and implants are expanding the indications for surgical treatment. This article presents the current treatment options.

Spinal trauma is less common than other musculoskeletal injuries, yet leads to more disability and costs.In recent decades reliable classification and injury assessment systems have been published and surgical techniques have greatly improved.There are many new insights into the principles and timing of the treatment of thoracolumbar injuries, but many unsolved problems remain:1. Role and timing of medical and surgical interventions for patients with associated neurological injury.2. Timing of surgical intervention in patients with multiple injuries.3. Wide variation in practice between operative versus nonoperative management, without clear reasons.4. The role of different surgical approaches and techniques in certain injury types is not clarified yet.5. Methods of non-operative management.6.No consensus is found yet for the care of elderly patients with concurrent complex disorders [1].After initial assessment and management, a decision about the definitive treatment has to be made.There are two possibilities: conservative or operative treatment.The decision depends on the severity of the fracture (classification), spinal cord injury and possible comorbidity, and must be made together with the patient (shared decisionmaking).There are many different ways to treat a patient, both conservative and operative.Because of the impact of thoracolumbar injuries and the many options for treating these injuries, the European Society of Trauma and Emergency Surgery established a working group on this topic.

Zlomi prsno-ledvene hrbtenice (PLH) predstavljajo širok spekter poškodb. Zdravljenje je odvisno od vrste poškodbe, splošnega stanja poškodovanca ter morebitnih pridruženih bolezni hrbtenice. Skupna ocena teh dejavnikov narekuje strategijo zdravljenja, ki je zaradi nejasnih in včasih nasprotujočih si podatkov v literaturi nemalokrat težavna. Kljub številnim odprtim vprašanjem pa v mnogih primerih lahko le hitra in usklajena veriga postopkov od začetne oskrbe na terenu do končne rehabilitacije zagotovi dober izid zdravljenja. Prispevek zato predstavi priporočila Vertebrološkega združenja Slovenije za obravnavo bolnikov z zlomom PLH. Zajemajo celotno verigo oskrbe, od oskrbe na terenu in v urgentnem centru do diagnostičnih postopkov in klasifikacije ter kirurškega zdravljenja, končno po do rehabilitacije in ambulantnega spremljanja zdravstvenega stanja poškodovanca. Posebna pozornost se posveča poškodbam z nevrološko prizadetostjo, osteoporotičnim zlomom in zlomom pri ankilozirajočih boleznih hrbtenice, ki so zaradi starajočega se prebivalstva v porastu. Namen priporočil je postaviti minimalne standarde oskrbe zlomov PLH v slovenskem prostoru. Zato priporočila temeljijo na empiričnih znanjih, upoštevajo pa tudi regionalne posebnosti slovenskega prostora.

BACKGROUND:Instrumentation of the pediatric spine is challenging due to anatomical constraints and the absence of specific instrumentation, which may result in iatrogenic injury and implant failure, especially in occipito-cervical constructs. Therefore, preoperative planning and in vitro testing of instrumentation may be necessary.METHODS:In this paper, we present a technical note on the use of 1:1 scale patient-specific 3D printed spinal models for preoperative assessment of feasibility of spinal instrumentation with conventional spinal implants in pediatric spinal pathologies.RESULTS:The printed 3D models fully matched the intraoperative anatomy and allowed a preoperative confirmation of the feasibility of the planned instrumentation with conventional screws for adult patients. In addition, the possibility of intraoperative model assessment resulted in better intraoperative sense of spinal anatomy and easier freehand screw insertion, thereby reducing the potential for iatrogenic injury. All 3D models were printed at the surgical department at a very low cost, and the direct communication between the surgeon and the dedicated specialist allowed for multiple models or special spinal segments to be printed for more detailed consideration.CONCLUSIONS:Our technical note highlights the critical steps for preoperative virtual planning and in vitro testing of spinal instrumentation on patient-specific 3D printed models at 1:1 scale. The simple and affordable method helps to better visualize pediatric spinal anatomy and confirm the suitability of preplanned conventional spinal instrumentation, thereby reducing X-ray exposure and intraoperative complications in freehand screw insertion without navigation.

INTRODUCTION:In the case of tumor resection in the upper cervical spine, a multilevel laminectomy with instrumented fixation is required to prevent kyphotic deformity and myelopathy. Nevertheless, instrumentation of the cervical spine in children under the age of 8 years is challenging due to anatomical considerations and unavailability of specific instrumentation.CASE PRESENTATION:We present a case of 3D-printed model-assisted cervical spine instrumentation in a 4-year-old child with post-laminectomy kyphotic decompensation of the cervical spine and spinal cord injury 1 year after medulloblastoma metastasis resection in the upper cervical spine. Due to unavailability of specific instrumentation, 3D virtual planning was used to assess and plan posterior cervical fixation. Fixation with 3.5 mm lateral mass and isthmic screws was suggested and the feasibility of fixation was confirmed "in vitro" in a 3D-printed model preoperatively to reduce the possibility of intraoperative implant-spine mismatch. Intraoperative conditions completely resembled the preoperative plan and 3.5 mm polyaxial screws were successfully used as planned. Postoperatively the child made a complete neurological recovery and 2 years after the instrumented fusion is still disease free with no signs of spinal decompensation.DISCUSSION/CONCLUSION:Our case shows that posterior cervical fixation with the conventional screw-rod technique in a 4-year-old child is feasible, but we suggest that suitability and positioning of the chosen implants are preoperatively assessed in a printed 3D model. In addition, a printed 3D model offers the possibility to better visualize and sense spinal anatomy "in vivo," thereby helping screw placement and reducing the chance for intraoperative complications, especially in the absence of intraoperative spinal navigation.

Purpose The aim of this article is to present history, state of the art, and future trends in the treatment of acetabular fractures. Methods Review of recent and historical literature. Results Acetabular fractures are difficult to treat. The first descriptions of this injury already appeared in ancient Greek history, but intensive development started in the second half of the twentieth century after Judet and Letournel’s seminal work. Their classification is still the gold standard today. It is actually a pre-operative planning system and is used to determine the most appropriate surgical approach. The therapy of choice for dislocated fractures is open reduction and internal fixation. Recent modern techniques based on high-tech computerized planning systems and 3D printing have been successfully integrated into orthopaedic trauma practice. Conclusion There is no ideal surgical approach for acetabulum fracture treatment, so new approaches have been developed in recent decades. The best outcome series have shown good or excellent results, between 70 and 80%.

Purpose The aim of this article is to present history, state of the art, and future trends in the treatment of acetabular fractures. Methods Review of recent and historical literature. Results Acetabular fractures are difficult to treat. The first descriptions of this injury already appeared in ancient Greek history, but intensive development started in the second half of the twentieth century after Judet and Letournel’s seminal work. Their classification is still the gold standard today. It is actually a pre-operative planning system and is used to determine the most appropriate surgical approach. The therapy of choice for dislocated fractures is open reduction and internal fixation. Recent modern techniques based on high-tech computerized planning systems and 3D printing have been successfully integrated into orthopaedic trauma practice. Conclusion There is no ideal surgical approach for acetabulum fracture treatment, so new approaches have been developed in recent decades. The best outcome series have shown good or excellent results, between 70 and 80%.

OBJECTIVE:The objective of this prospective study was to determine the optimal timing for surgical decompression (SD) in patients with acute traumatic cervical spinal cord injury (tSCI) within the first 24 hours of injury. METHODS:In successive patients with fracture and/or dislocation of the subaxial cervical spine and American Spinal Injury Association Impairment Scale (AIS) grades A-C, receiver operating characteristic curve analysis was used to determine the optimal timing for SD within the first 24 hours of cervical tSCI to obtain a neurological recovery of at least two AIS grades. Multivariate logistic regression was used to model significant neurological recovery with time to SD, degree of spinal canal compromise (SCC), and severity of injury. RESULTS:In this cohort of 64 patients, the optimal timing for SD to obtain a significant neurological improvement was within 4 hours of injury (95% confidence interval 4-9 hours). Increasing the delay from injury to SD or the degree of SCC significantly reduced the likelihood of significant neurological improvement. Due to the strong correlation with SCC, the severity of injury was a marginally significant predictor of neurological recovery. CONCLUSIONS:These findings indicate that in patients with acute cervical tSCI and AIS grades A-C, the optimal timing for SD is within the first 4-9 hours of injury, depending on the degree of SCC and the severity of injury. Further studies are required to better understand the interrelationships among the timing of SD, injury severity, and degree of SCC in these patients.

Travmatska poškodba hrbtenjače (PH) je nepričakovan dogodek, ki lahko trajno zaznamuje bolnika in predstavlja veliko obremenitev moderne družbe. Kljub napredkom v razumevanju patofiziologije poškodbe in obetavnim napredkom na predkliničnem nivoju, je uspešnost prenosa različnih modelov zdravljenja v klinično prakso izredno omejena in prevladuje napačno prepričanje, da je zdravnik v borbi s tovrstno poškodbo nemočen. Novejše raziskave so namreč pokazale, da takojšnja dekompresija hrbtenjače in zagotavljanje ustrezne perfuzije hrbtenjače izboljšata nevrološki izid zdravljenja. Dodatni terapevtski ukrepi zaenkrat ostajajo še ekperimentalne narave, vendar pričakovati je, da bodo nadaljnje raziskave in poglobljeno razumevanje vseh patofizioloških procesov vodilo v nadgradnjo terapevtskih ukrepov. V preglednem članku so zato predstavljene osnove patofiziologije poškodbe, ki predstavljajo temelj razumevanja akutnega zdravljenja, ter moderni pristopi k zdravljenju PH, ki se uveljavljajo v klinični praksi.

Introduction Traumatic spinal cord injury (tSCI) is a catastrophic event with enormous personal, social and economic impact. Despite recent progress in understanding the pathophysiology of acute tSCI and the positive effects of acute spinal cord decompression on neurological recovery reported in standardized preclinical studies, neurological benefits of early surgical decompression (SD) remain elusive in the clinical setting. Material and Methods A prospective study was performed to evaluate the impact of SD and instrumented fusion within 8 hour versus 8–24 hour after injury on neurological recovery after cervical tSCI in patients operated on in the UMC Ljubljana, Slovenia. Only patients with the ASIA Impairment Scale (AIS) grades of A through C and with MRI-confirmed spinal cord compression were enrolled. The primary outcome was the change in AIS grade at the six-month follow-up. Results Of the 48 enrolled patients, 22 patients who underwent surgery within 8h (Group-8h) and 20 patients who underwent surgery between 8 and 24h (Group-8–24h) after injury concluded the study. At admission, there was no statistically significant difference in AIS grade between the study groups. At the six-month follow-up, an improvement of at least two AIS grades was found in 45.5% of patients in Group-8h and in 10% of patients in Group-8–24h ( p = 0.017). In a multivariate analysis, adjusted for the preoperative AIS grade and the degree of spinal canal compromise, the odds of an at least two-grade AIS improvement were at least 106% higher for patients in Group-8h than for patients in Group-8–24h (OR = 11.08, p = 0.004). No statistically significant difference was found in the rate of pneumonia, the number of ventilator-dependent days or the mortality between the groups. Conclusion Our results suggest that the patients with tSCI who undergo SD within 8h after injury have superior neurological outcomes than patients who undergo SD 8 to 24h after injury, without any increase in the rate of adverse effects.

A prospective study was performed to evaluate the impact of surgical decompression (SD) and instrumented fusion within 8 h versus 8-24 h after injury on neurological recovery after cervical traumatic spinal cord injury (tSCI) in patients operated on in the UMC Ljubljana, Slovenia. Only patients with the American Spinal Injury Association (ASIA) Impairment Scale (AIS) grades of A through C and with MRI-confirmed spinal cord compression were enrolled. The primary outcome was the change in AIS grade at the 6-month follow-up. Of the 48 enrolled patients, 22 patients who underwent surgery within 8 h (group 8 h) and 20 patients who underwent surgery between 8 and 24 h (Group 8-24 h) after injury concluded the study. At admission, there was no statistically significant difference in AIS grade between the study groups. At the 6-month follow-up, an improvement of at least two AIS grades was found in 45.5% of patients in group 8 h and in 10% of patients in group 8-24 h (p=0.017). The median improvement in the ASIA motor score was 38.5 (10.0-61.0) motor points in group 8 h and 15.0 (8.8-34.0) motor points in group 8-24 h (p=0.0468). In a multivariate analysis, adjusted for the preoperative AIS grade and the degree of spinal canal compromise, the odds of an at least two-grade AIS improvement were at least 106% higher for patients in group 8 h than for patients in group 8-24 h (odds ratio=11.08, p=0.004). No statistically significant difference was found in the rate of perioperative complications, pneumonia, and the number of ventilator-dependent days or the mortality between the groups. Our results suggest that the patients with tSCI who undergo SD within 8 h after injury have superior neurological outcomes than patients who undergo SD 8-24 h after injury, without any increase in the rate of adverse effects.

The effect of hyperbaric oxygen treatment (HBO) on sensory axon regeneration was examined in the rat. The sciatic nerve was crushed in both legs. In addition, the distal stump of the sural nerve on one side was made acellular and its blood perfusion was compromised by freezing and thawing. Two experimental groups received hyperbaric exposures (2.5 ATA) to either compressed air (pO(2) = 0.5 ATA) or 100% oxygen (pO(2) = 2.5 ATA) 90 minutes per day for 6 days. Sensory axon regeneration in the sural nerve was thereafter assessed by the nerve pinch test and immunohistochemical reaction to neurofilament. HBO treatment increased the distances reached by the fastest regenerating sensory axons by about 15% in the distal nerve segments with preserved and with compromised blood perfusion. There was no significant difference between the rats treated with different oxygen tensions. The total number of regenerated axons in the distal sural nerve segments after a simple crush injury was not affected, whereas in the nerve segments with compromised blood perfusion treated by the higher pO(2), the axon number was about 30% lower than that in the control group. It is concluded that the beneficial effect of HBO on sensory axon regeneration is not dose-dependent between 0.5 and 2.5 ATA pO(2). Although the exposure to 2.5 ATA of pO(2) moderately enhanced early regeneration of the fastest sensory axons, it decreased the number of regenerating axons in the injured nerves with compromised blood perfusion of the distal nerve stump.