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.

STUDY DESIGN:Prospective observational multicenter cohort study. OBJECTIVE:To evaluate and compare functional outcomes, as measured by AO Spine Patient Reported Outcome Spine Trauma (PROST), in neurologically intact patients with thoracolumbar (TL) burst fractures treated operatively or nonoperatively. SUMMARY OF BACKGROUND DATA:The optimal management of these patients remains debated. METHODS:This investigation was part of a prospective observational international multicenter cohort study. Neurologically intact adults (18-65 y) with acute (≤10 d) TL burst fractures were included from various sites across the world. Provided treatment was determined by the local standard of care. PROST was administered at multiple prospective timepoints from baseline up to 2-years post-injury. Descriptive statistics were used to analyze patient and clinical characteristics. Multivariable mixed models for repeated measures were used to assess differences in treatment groups and between the fracture types. RESULTS:A total of 93 patients were included (mean age 41 y, 57% male). Most sustained high-energy trauma (73.1%) and had type A3 fractures (63.4%), with 61.3% treated nonoperatively. Both nonsurgical (34.2 to 86.0) and surgical (39.9 to 85.6), as well as fracture types (A4: 38.4 to 85.6; A3: 36.4 to 87.3) demonstrated significant improvements in PROST scores over time (P<0.001). No statistically significant differences in PROST scores were found between treatment groups or fracture types. Although, surgically treated patients showed higher PROST scores within the first 3 months, and nonsurgical patients had marginally higher scores hereafter, these differences were not statistically significant and converged by 2 years. CONCLUSION:Both surgical and nonsurgical treatment of neurologically intact TL burst fracture patients resulted in comparable long-term functional outcomes as measured by AO Spine PROST. A descriptive trend was observed with surgically treated patients showing higher mean PROST scores up to 3 months post-treatment, however, between-group differences were not statistically significant and equalized by two years.

Study Design: Retrospective review of prospectively collected data. Objective: The objective of this study is to compare the clinical outcomes of patients treated with or without a stabilizing brace for neurologically intact thoracolumbar burst fractures. Summary of Background Data: The role of bracing in the nonoperative management of thoracolumbar burst fractures remains controversial. Methods: This post hoc subanalysis of a prospective, multicenter study examined patients with type A3 or A4 thoracolumbar burst fractures without neurologic deficit who were treated nonoperatively with either a stabilizing brace or no brace. The primary outcomes were achieving the minimal clinically important difference (MCID) and patient acceptable symptom state (PASS) in the Oswestry Disability Index (ODI). Secondary outcomes included return to work, mental health, pain, and overall patient satisfaction with treatment. Results: In total, 76 patients met inclusion criteria for the study including 48 patients (63%) treated with bracing and 28 (37%) patients treated without bracing. Time-to-event analyses indicated no differences in achieving MCID or PASS in ODI between patients with and without a stabilizing brace (all P >0.05). Significantly better scores were seen in the bracing group when compared with the non-bracing group at 3 months in terms of pain and overall satisfaction with care (both P <0.05). Anxiety/depression scores were better in the bracing group at all follow-up visits except the 3-month follow-up visit when compared with the non-bracing group (all P <0.05). Conclusions: We found no statistically significant differences in PROMs, return to work, or satisfaction at 1 year between patients treated with or without bracing. However, bracing was associated with improved pain, anxiety/depression scores, and satisfaction in the early period after injury. Bracing may offer advantages in terms of patient comfort and mental health in the short term but likely has no bearing on longer-term outcome in neurologically intact patients with thoracolumbar burst fractures. Level of Evidence: Level III.

Study designProspective observational multicenter cohort study.ObjectivesTo determine Minimal Clinically Important Difference (MCID) of AO Spine PROST (Patient Reported Outcome Spine Trauma) and conducting a long-term prospective validation.MethodsData were collected from a prospective observational international multicenter cohort study. Adults (18-65) with acute thoracolumbar (TL) burst fractures without neurologic deficits were enrolled, and followed for up to 2 years. Patients completed the AO Spine PROST, Oswestry Disability Index (ODI), EQ-5D, and Pain NRS. Characteristics were analyzed using descriptive statistics, MCID for PROST with distribution-based approach using the standard deviation (SD) of change in scores. Floor and ceiling effects were also evaluated. Internal consistency (Cronbach's alpha, item-total correlation coefficient (ITCC) and pairwise Spearman correlation), construct validity (Pearson correlations (rs) with ODI, EQ-5D, Pain NRS), and responsiveness (effect sizes (ES) and standardized response mean (SRM)) were assessed.ResultsNinety-three patients were included. MCID for a moderate change (0.5*SD) in PROST score was 10.6. No floor or ceiling effects were observed. Internal consistency was high (Cronbach's α = 0.9-1.0 and acceptable ITCC). PROST scores strongly correlated with ODI (rs = -0.67 to -0.89; P < .001), but correlations with EQ-5D were weak (rs = -0.29 to 0.05; P > .005), except at 1-year follow-up. No consistent pattern was found with Pain NRS. Responsiveness was very good (ES = 3.2, SRM = 3.1; P < .001).ConclusionsThe AO Spine PROST identified an MCID of 10.6 as indicative of a moderate clinically meaningful change. The instrument also showed strong internal consistency, construct validity, and excellent responsiveness in long-term follow-up.

Surgeons are often faced with complex decision-making when deciding on the optimum surgical management of thoracolumbar (TL) burst fractures. The magnitude of surgical techniques is vast from standard open techniques to minimally invasive surgery (MIS). In recent years, the application of MIS has grown in popularity in parallel to impressive technological advances. In this narrative review, we discuss the available literature focusing on minimally invasive surgical techniques for TL burst fractures. The aim of this article is to help guide spinal surgeons who wish to include MIS as part of their surgical portfolio and to identify remaining knowledge gaps. We aimed to present a review on the choice of long vs short construct, cement augmentation techniques, reduction and realignment techniques, surgical nuances in incomplete (A3) versus complete (A4) burst fractures, as well as discuss the role of implant removal. Percutaneous pedicle screw fixation including the index fracture level and subsequent implant removal has shown promise for the surgical treatment of TL AO Type A3 fractures, and A4 fractures. This technique may be best considered as internal bracing while fracture heals with the prototypical patient being a young active individual without severe kyphotic deformity. These techniques can be enhanced with cement augmentation as well as reduction and realignment techniques. With ongoing technological advancement, the armentarium of MIS surgical techniques applicable to TL burst fractures will certainly continue to expand. Despite rapid technological advances, a comprehensive understanding of optimal application of those techniques is lacking creating knowledge gaps.

BACKGROUND CONTEXT:Many efforts have been made to determine what is the best treatment strategy for neurologically intact patients with TL burst fractures: surgery or nonoperative management. Studies comparing clinical outcomes have produced mixed and inconclusive results creating lack of consensus in the expert community. PURPOSE:Therefore, it is necessary to explore other important components of healthcare such as economics to settle this controversial debate. The goal of the current study was to perform a cost-utility analysis comparing surgical treatment to nonoperative treatment for neurologically intact TL burst fractures (AOSpine classification types A3 and A4) from a societal perspective in a multicenter and international setting. STUDY DESIGN/SETTING:We performed a cost-utility analysis from a societal perspective comparing the cost-utility of surgical treatment versus nonsurgical treatment of thoracolumbar (TL) burst fractures in neurologically intact patients. PATIENT SAMPLE:Patient demographics and all clinical and outcome data were taken from an observational, prospective multicenter cohort study comparing surgical versus nonsurgical treatment of TL burst fractures in neurological intact patients. OUTCOME MEASURES:The ICER was calculated comparing surgical versus nonsurgical treatment for the full analysis population with a 1-year time horizon, two-year time horizon as well as the working-life time horizon. Costs were taken from the clinical study, patient diaries with productivity loss documented, current scientific literature in addition to national and international healthcare costing guidelines and databases. METHODS:The mean difference in cost between the two treatment groups were calculated, firstly by applying the central limit theorem, and secondly by using bootstrapping. To calculate the average cost per patient in each treatment group, the Kaplan-Meier Sample Average (KMSA) estimator was used in order to take account of the censored patients. To evaluate the derived models and to explore uncertainty, sensitivity analysis was used. RESULTS:Eleven sites from different regions (North America, Europe, Middle east, and Asia) completed the recruitment and follow-up for 213 patients. One hundred and thirty patients were treated surgically (61.0%) and eighty-three patients (39.0%) were treated nonsurgically. At 1-year, the ICER for surgical treatment was $191,648.00 USD per QALY. Compared to a willingness to pay threshold of $100,000, surgical treatment was not cost-effective within the 1-year timeframe. At 2-years, the nonsurgical group had visited the surgeon or general practitioner more often (0.31 vs 0.25). The nonsurgical group had visited physiotherapist and other allied health more often (3.68 vs 1.68). The utilization of NSAIDs and opioids remained higher in the nonsurgical group (2.66 vs 2.39) (1.52 vs 0.75). The average workdays lost remained higher in the nonsurgical group (143.12 vs 114.78). The caregiver days taken off work remained higher in the nonsurgical group (29.86 vs 2.39). At 2 years, surgical treatment showed to be a dominant strategy with a $28,978.50 savings per QALY. At lifetime horizon, surgical treatment remained the cost-effective strategy at $25,530.18 savings per QALY. CONCLUSION:Our cost-utility analysis showed surgical management to be cost-effective at 2 years compared to nonoperative management in neurologically intact TL burst fractures from a societal perspective. This finding was maintained through the working-lifetime horizon. Surgical treatment became cost-effective largely due to the greater productivity loss of patients and caregivers within the nonsurgical group. This investigation highlights the viability for surgical management of TL burst fractures to provide societal benefit especially when productivity is valued.

Study designProspective multicentric study.ObjectiveThoracolumbar fractures without neurologic deficit are challenging situations in terms of treatment decision making. We aimed to analyze the occurrence of adverse events (AEs) after surgical and nonsurgical treatment and its impact on functional outcomes.Methods198 patients from a prospective multicentric database were included. The occurrence of adverse events and treatment failure within 2 years of follow up were recorded. ODI was compared between patients with and without adverse events at six months, 1 year and 2 years follow up. Multivariable regression analysis was conducted to assess the association between post-treatment adverse events and ODI at 1-year follow-up.Results46 adverse events were recorded (23.2%). Higher categories of the Charlson Comorbidity Index (CCI) (P = 0.006), unemployment or retirement (P = 0.027), and current smoking (P = 0.008) were significantly associated with the occurrence of adverse events whereas no significant differences were observed in terms of treatment decision (conservative vs surgical). ODI values were significantly higher in patients with adverse events at the 6-month and 1-year follow-up visits without significant differences at 2 years follow up. Treatment failure was observed in only 5 patients.ConclusionWe found association between the occurrence of AE and higher ODI at 6-months and one-year follow up. Additionally, a higher CCI and smoking status were associated with higher likelihood to develop adverse events in our cohort.

Osteoporosis is a widespread disease with an increasing incidence. In 2018, the “Osteoporotic Fracture working group” affiliated with the German Society for Orthopaedic and Trauma Surgery (DGOU), introduced a novel classification system specifically for osteoporotic thoracolumbar vertebral body fractures. To evaluate the influence of geographic region on the reliability and reproducibility of the AO Spine-DGOU Osteoporotic Fracture Classification System. This study included 320 participants from various global regions who classified 27 cases of osteoporotic vertebral fractures using the AO Spine-DGOU system which categorizes the fractures to 5 subtypes (OF 1 – OF 5). Participants underwent training via an online webinar. Interobserver reliability and intraobserver reproducibility were assessed using Fleiss' kappa coefficient, and agreement with a gold-standard committee was evaluated. The classification system showed moderate to substantial agreement with the gold standard globally (initial kappa 0.58, improving to 0.61). European participants had the highest agreement (kappa 0.64 and 0.66). OF4 fractures were most accurately classified, while OF3 fractures showed the least agreement. Intraobserver reliability was highest among European participants. Post-hoc analysis indicated significantly better reliability among German-speaking participants compared to other Europeans (kappa 0.79 vs. 0.70, p=0.0026). The AO Spine-DGOU Osteoporotic Fracture Classification System demonstrates moderate to substantial reliability and reproducibility, with regional differences influenced by factors such as training and clinical experience. This underlines the necessity of proper education adapted to the regional particularities.

BACKGROUND:Recent research has demonstrated the potential of implant load monitoring to assess posterolateral spinal fusion in a sheep model. This study investigated whether such a system could monitor bone fusion after interbody fusion surgery by biomechanically testing of human cadaveric lumbar spines in two states: following a transforaminal lumbar interbody fusion (TLIF) procedure and after simulating bone fusion. METHODS:Eight human cadaveric spines underwent a TLIF procedure at L4-L5. An implantable sensor system was attached to one rod, while two strain gauges were attached to the contralateral rod (dorsally and ventrally) to derive implant load changes during unconstrained flexion-extension (FE), lateral bending (LB) and axial rotation (AR) motion. The specimens were retested after simulating bone fusion at L4-L5. Range of motion (ROM) of L4-L5 was measured during each loading mode. RESULTS:ROM decreased in the simulated bone fusion state in all loading directions (p ≤ 0.002). Compared to the TLIF motion, the remnant motion after simulated fusion was 53 ± 21 % in FE, 40 ± 12 % in LB, and 49 ± 16 % in AR. In both states, measured strain on the posterior instrumentation was highest during LB motion. All sensors detected a significant decrease in load-induced rod strain after simulated bone fusion in LB (p ≤ 0.002). The strain measured by the implantable strain sensor, the dorsal strain gauge, and the ventral strain gauge decreased to 49 ± 12 %, 49 ± 17 %, and 54 ± 17 %, respectively. CONCLUSION:Rod load measured via strain sensors can monitor fusion progression after a TLIF procedure when measured during isolated LB of the lumbar spine. This study provides the basis for further development and understanding of in vivo implant load data.

To present and evaluate the safety and efficacy of our new procedure for treating thoracolumbar burst-split fractures without neurological injury. Our new surgical technique for the treatment of thoracolumbar burst-split fractures (AO type A4, Magerl classification A3.2.1) involving (1) posterior reduction and bisegmental instrumention, (2) anterior screw fixation of the caudal sagittal split, (3) anterior one-level fusion of the cranial segment, and (4) interval posterior implant removal was presented. In an initial cohort of patients, demographic information, surgical specifics and imaging data were evaluated. Twenty-one patients (mean age 29.5 ± 11.8 years, 38

BACKGROUND:Anterior lumbar interbody fusion (ALIF) surgery can damage nerve fibers and has been linked to retrograde ejaculation in men. In women, sexual dysfunction following ALIF is rarely investigated. The aim of this study was to investigate the frequency of postoperative changes in sexual function and incontinence in women following ALIF. METHODS:For this study, 173 female patients aged 18 to 60 years who had undergone a primary ALIF surgery in 2015 to 2022 in a large spine center to retrospectively answer a questionnaire about sexual function and incontinence pre- and postoperatively; they were also asked to rate their satisfaction with the surgery. McNemar tests were used to compare the prevalence of specific problems pre- vs postoperatively. RESULTS:Of all respondents (n = 84), 23 (27%) reported a worsening of sexual function following ALIF surgery, and these changes were persistent in 83% of those patients. Among individual symptoms of sexual dysfunction, the highest increase was observed for the prevalence of vaginal dryness, which increased from 12% preoperatively to 32% postoperatively (P < 0.001), followed by dyspareunia, which increased from 8% to 21% (P = 0.001). Urinary incontinence increased from 25% to 41% (P < 0.001). Patient age, level of surgery, and fusion material were not associated with worsening of sexual function. However, worsening of sexual function was associated with a lower level of satisfaction with the surgery outcome and a lower proportion of patients who would have the surgery again. CONCLUSIONS:Female patients undergoing ALIF should receive adequate preoperative information about potential changes in sexual function to enable them to make an informed decision. CLINICAL RELEVANCE:An improved understanding among patients will lead to more realistic patient expectations and higher patient satisfaction. LEVEL OF EVIDENCE: 4:

Study Design.Global cross-sectional survey.Objective.To validate the hierarchical nature of the AO Spine Upper Cervical Spine Injury Classification (UCIC) across AO geographical regions/practice experience.Summary of Background Data.To create a universally validated scheme with prognostic value, AO Spine established an upper cervical spine injury classification involving three elements: injury morphology (region: I-occipital condyle and craniocervical junction; II-C1 ring and C1-2 joint; III-C2 and C2-3 joint), and (subtype: A-isolated bony injury; B-bony/ligamentous injury; C-displaced/translational injury), neurological status [N0-intact; N1-transient deficit; N2-radiculopathy; N3-incomplete spinal cord injury (SCI); N4-complete SCI, and NX-unable to examine], and case-specific modifiers (M1-injuries at risk of nonunion; M2-injuries at risk of instability; M3-patient specific factors; M4-vascular injury).Materials and Methods.Totally, 151 AO Spine members (orthopaedic and neurosurgery) were surveyed globally regarding the severity (zero-low severity to 100-high severity) of each UCIC variable. Primary outcomes were differences in perceived injury severity score (ISS) over various geographic/practice settings, level of experience, and subspecialty.Results.One hundred forty-eight responses were received. There was an increase in median perceived severity as each anatomic region (I-III) progressed from types A to B to C. Neurological status progressed similarly, except N1 and N2 were perceived similarly. Modifier M2 was perceived more severely than M3. There were no differences in ISS among levels of surgeon experience. There were small geographic differences with respondents from North and Central and South America perceiving types IC (P=0.003), IIB (P=0.003), and IIIB (P=0.003) somewhat more severely than other regions. Neurosurgeons perceived types IB (P=0.002) and IIIB (P=0.026) as more severe than orthopaedic spine surgeons.Conclusions.The AO Spine UCIC has overall excellent hierarchical progression in subtype ISS. These findings are consistent across geographic regions, spine subspecialty training and experience levels.

Background: Carbon-fiber-reinforced polyetheretherketone (CFR-PEEK) vertebral-body replacements (VBRs) aim to mitigate subsidence, minimize imaging artifacts, and facilitate radiation planning while preserving fusion potential. We assessed the safety and efficacy of a novel modular, titanium-coated CFR-PEEK VBR (Kong®) for anterior column reconstruction (ACR) in the thoracolumbar spine. Primary question: Does the implant safely and effectively achieve and maintain kyphosis correction after ACR for trauma and neoplasms? Methods: A single-center retrospective case series was performed on 28 patients who underwent thoracolumbar ACR with the Kong® VBR for fractures or tumors (2020–2021). The primary outcome was the bi-segmental kyphotic angle (BKA). Secondary outcomes were screw loosening, cage height loss, fusion rate, subsidence, and tilting. Clinical status was recorded with Odom criteria, Karnofsky Performance Status (KPS), and AOSpine PROST. Results: Twenty-eight patients (mean age, 61 yr; 33% female; mean follow-up, 17.7 mts) were studied. Mean postoperative BKA correction was 16.5° (p = 0.006) and remained 14.5° at final follow-up (p = 0.008); loss of correction was 2.0° (p = 0.568). Subsidence, cage height, and sagittal tilt were unchanged. Fusion (Bridwell grade I/II) was observed in 95% on CT. One deep surgical-site infection occurred. At final follow-up, 91% of patients were graded “excellent” or “good” by Odom. KPS improved by 20 points (p = 0.031), and mean AOSpine PROST was 56.9. Conclusions: Single-center early results indicate that the modular titanium-coated CFR-PEEK VBR is a safe, effective adjunct for thoracolumbar ACR in trauma and neoplasm, providing durable kyphosis correction, mechanical stability and high fusion rates and grants for improved follow-up imaging quality.

Study Design Cross-sectional survey. Objectives A cornerstone of classification systems is good reliability amongst different groups of classification users. Thus, the aim of this international validation study was to assess the reliability of the new AO Spine DGOU Osteoporotic Fracture Classification (OF classification) stratified by surgical specialty, work-setting, work-experience, and trauma center level. Methods 320 spine surgeons were asked to rate 27 cases according to the OF classification at 2 time points, 4 weeks apart (assessment 1 and 2) in this online-webinar based validation process. The kappa statistic (κ) was calculated to assess the inter-observer reliability and the intra-rater reproducibility. Results A total of 7798 (90.3%) ratings were recorded in assessment 1 and 6621 (76.6%) ratings in assessment 2. Global inter-rater reliability was moderate in both assessments (κ = 0.57; κ = 0.58). Participants with a work-experience of >20 years showed the highest inter-rater agreement in both assessments globally (κ = 0.65; κ = 0.67). Participants from a level-1 trauma center showed the highest agreement (κ = 0.58), whereas participants working at a tertiary trauma center showed higher grade of agreement in the second assessment (κ = 0.66). Participants working in academia showed the highest agreement in assessment 2 (κ = 0.6). Surgeons with academic background and surgeons employed by a hospital showed substantial intra-rater agreement in the second assessment. Conclusions The AO Spine-DGOU Osteoporotic Fracture Classification showed moderate to substantial inter-rater agreement as well as intra-rater reproducibility regardless of work-setting, surgical experience, level of trauma center and surgical specialty.

OBJECTIVE:The objective was to compare incomplete (A3) versus complete (A4) thoracolumbar burst fractures managed nonoperatively or operatively with respect to reaching minimal clinically important difference (MCID) in Oswestry Disability Index (ODI) score. METHODS:A prospective observational international multicenter cohort study was conducted. After stratification using the AO Spine Thoracolumbar Injury Classification System, A3 and A4 outcomes were analyzed separately within nonoperative and operative management groups. Outcomes included absolute and relative improvement in ODI scores between discharge and 12-month follow-up. Kaplan-Meier curves were generated and compared with the log-rank test. Multivariable Cox regression models were constructed. The Cox regression models were adjusted using the key covariates of age, sex, thoracolumbar injury classification and severity (TLICS) score, and the interaction between fracture type and treatment type. Additional adjustment was performed for discharge ODI scores to compare relative improvement. RESULTS:In total, 198 neurologically intact patients were identified, with incomplete fractures (58.6%) being more common than complete burst fractures (41.4%). The rate of nonoperative management was significantly higher among A3 than A4 fractures (48.3% vs 24.4%, p < 0.01). A4 fractures demonstrated a higher mean TLICS score than A3 fractures (2.8 vs 2.4, p = 0.04). There were no significant functional differences in MCID in ODI scores, defined as an improvement in 12.8 points within 1 year after treatment (HR 1.21, 95% CI 0.86-1.70, p = 0.28). Examination of only the surgically treated cohort of patients also revealed no significant difference in achieving relative ODI score improvement within 1 year after treatment between those with A4 and those with A3 fractures (HR 1.19, 95% CI 0.78-1.82, p = 0.43). A similar finding was demonstrated for the nonoperative cohort, with no difference between the incomplete or complete burst fracture morphologies (HR 1.24, 95% CI 0.68-2.27, p = 0.48). Odds of achieving an absolute ODI score of 20 or less were also similar between patients with A4 and A3 fractures, regardless of whether operative (HR 0.81, 95% CI 0.52-1.25, p = 0.34) or nonoperative (HR 0.72, 95% CI 0.38-1.35, p = 0.30) management was pursued. CONCLUSIONS:Patients with A3 and A4 fractures had similar odds to reach MCID in ODI score at 1 year. Even when exclusively considering the nonoperative cohort of patients who sustained A4 fractures with perceived increased biomechanical stability, there was no difference in functional improvement compared to patients with A3 fractures. Further large prospective multicenter studies are required to specifically assess radiographic outcomes and compare surgical approaches in the management of A3 and A4 fractures.

Study design Prospective cohort study.Objectives Treatment for thoracolumbar (TL) burst fractures in neurologically intact patients remains controversial. The goal of this study was to utilize the international equipoise to determine whether surgery leads to a more rapid improvement of disability measured by minimal clinically important difference (MCID) in Oswestry Disability Index (ODI).Methods The primary endpoint was time to achieve an improvement in ODI of more than 12.8 points within 1 year after baseline (MCID). A post hoc analysis was conducted to assess time to minimal disability (ODI of <20). Time-to-event analyses were applied, including log rank test for equality of survivor functions, Kaplan Meier survival curves and Cox proportional hazard models.Results One hundred and ninety-eight patients were included (122 surgical and 76 non-surgical patients). Median time to achieve MCID in ODI (12.8 points) from baseline was similar between the two groups (25.0 days vs 25.5 days, P = 0.517). Post hoc analysis showed a potential trend towards a short time to achieve minimal disability for the surgical group (69.0 days vs 82.0 days, P = 0.057). Similar results were obtained when excluding all patients with suspected PLC injury.Conclusion Surgically and non-surgically treated patients with thoracolumbar burst fractures without neurological injury were similar in terms of time to reaching MCID in ODI at 1 year. Surgical patients may reach minimal disability faster than nonsurgical patients, but additional large scale studies are warranted.Level of Evidence Therapeutic Prospective Comparative Cohort Study Level II.

This study aimed to evaluate the safety and efficacy of a novel Poly-Ether-Ether-Ketone (PEEK) expandable vertebral body replacement (VBR) for anterior cervico-thoracic vertebral column reconstruction in patients with metastatic, traumatic, or degenerative diseases. Radiographic and clinical outcomes, as well as complication rates, were analyzed in a retrospective analysis of 28 patients (61 ± 13 years; 64% female) who underwent an anterior cervical corpectomy and fusion (ACCF) with the Expandable Corpectomy Device (ECD) from DePuy/Synthes (2011–2020). Correction of the bisegmental kyphotic angle (BKA) was chosen as the primary outcome. Bony fusion, loss of device height, and implant subsidence were evaluated additionally. Clinical outcome was assessed using Odom’s criteria, the numerical pain rating scale (NRS), the American Spinal Injury Association Impairment Scale (AIS), and the Karnofsky Performance Status Scale (KPSS). Our study found a significant improvement in the BKA (12.3° ± 9.6°; p = 0.0002) at the last follow-up with no statistically relevant loss of device height (p = 0.96) or implant subsidence (p = 0.99). Successful bony fusion was observed in all patients. The KPSS significantly improved in patients with a tumorous disease at the time of discharge (p = 0.0009), and the sensation of pain showed significant improvement at six months post-operatively and at the final follow-up (p = 0.004; p = 0.021). However, four patients needed further secondary posterior stabilization, and one ECD was explanted due to a severe surgical site infection after an accidental esophageal lesion. In conclusion, the ECD proofed the radiographic stability for the anterior column reconstruction of the cervico-thoracic spine with significantly improved clinical outcome.