Retrospective Cohort Study. To evaluate risk factors for adverse outcome and complications of elderly patients with upper cervical spine fracture following conservative or surgical treatment. 141 cases of elderly patients (≥ 65 years) admitted between 01/2013 and 12/2015 with upper cervical spine injuries were retrospectively analyzed through our prospectively collected database. Median follow-up was 113.5 days (IQR: 21–393). With a collective median age of 79, operatively treated patients (41

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.

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.

Background Minimally invasive, thoracoscopic anterior spondylodesis (MIAS) is an established treatment for burst fractures of the thoracolumbar spine. Good restoration of the local sagittal alignment and good functional results have been reported. The aim of this study was to evaluate long-term results of MIAS in patients with incomplete burst fractures and to analyze the influence on global sagittal alignment, clinical outcomes, and adjacent segment degeneration. Methods From 2002 to 2003, 18 patients were treated with MIAS for incomplete thoracolumbar burst fractures. Mono-segmental spondylodesis was performed with an iliac crest bone graft and bisegmental spondylodesis with a titanium cage. In this single-center prospective cohort study, 15 patients were available for follow-up (FU) after an average of 12.9 years (12.1–14.4). Seven patients were treated with a combined anterior and posterior instrumentation and eight patients with anterior spondylodesis only. The primary clinical outcome parameter was the Oswestry Disability Index (ODI); secondary parameters were the Short Form 36 (SF36) and the visual analog scale (VAS spine). Full spine radiographs were assessed for bisegmental Cobb angle, alignment parameters, and signs of adjacent segment degeneration (ASD). Results ODI evaluation showed a mean impairment of 11.7% with minimal limitations in 13 patients. Neither a significant deterioration over time nor significant differences between both therapy strategies were found in the clinical scores at the latest follow-up. The mean bisegmental increase of regional malalignment of reduction was 8.8° (± 7.3°) with no significant correlation to any clinical outcome scores. The majority of patients had no signs of adjacent segment degeneration. Two patients showed minor radiologic changes. All patients had a balanced sagittal spine profile. Conclusions In conclusion, MIAS leads to good clinical results with—in majority—minimal spine-related impairment at the latest follow-up. No significant deterioration at 12-year FU was detectable compared to the 6-year results for the SF36 and VAS spine scores. There was no association between sagittal alignment, clinical outcome scores, and ASD. Trial registration The study was retrospectively registered in the German Clinical Trials Register ( Nr.00015656 ).

Objective The treatment of thoracic spine (TS) fractures with additional sternal fractures compared to TS fractures without sternal fractures is discussed controversionally, because in some studies it was stated that sternal fractures decrease the thoracic stability. We hypothesized that both types of fractures can be treated the same way by posterior stabilization alone. Methods A total number of 69 patients with thoracic fractures, with or without additional sternal fractures, were examined, regarding the angle of kyphosis after fracture, postoperatively and after 6 and 12 months. We also recorded the outcome using the Odom's score and the time until patients returned to work and the activity level. Results It was found that the angle of kyphosis was nearly physiological after stabilization in both groups and a loss of reduction after 1 year was also comparable, either in the patients suffering from the additional sternal fracture or not. In addition, the Odom's score and the time until return to work and the activity level were comparable in both groups. Conclusion We did not find any arguments to preserve additional anterior stabilization or reasons for different treatment strategies either additional sternal fractures occur in thoracic spine fractures or not.

Generell stellen Wirbelsäulenverletzungen bei Kindern im Alter unter 16 Jahren eine seltene Verletzungsentität dar. Für Deutschland liegen keine belastbaren Daten bezüglich der Epidemiologie von Verletzungen der Wirbelsäule im Kindesalter vor. Gerade bei pädiatrischen Patienten, bei denen sowohl die Anamnese, die klinische Untersuchung, aber auch die Durchführung der bildgebenden Diagnostik häufig erschwert sind, müssen sämtliche Hinweise auf eine Verletzung der Wirbelsäule mitberücksichtigt werden. Das Ziel der vorliegenden Studie war die Bereitstellung epidemiologischer Daten von pädiatrischen Patienten mit Wirbelsäulenverletzungen in Deutschland, um diese zukünftig in die Entscheidungsfindung bei der Diagnostik und Therapie dieser Patienten einfließen lassen zu können. Im Rahmen einer nationalen Multizenterstudie wurden retrospektiv Patientendaten innerhalb eines Zeitraums von 7 Jahren aus 6 Wirbelsäulenzentren erhoben. Neben den demografischen Daten wurden der Unfallmechanismus, die betroffene Wirbelsäulenregion und auch die Begleitverletzungen erhoben. Zudem erfolgte die Erfassung der bildgebenden Diagnostik sowie der jeweiligen Therapie. Es konnten 367 Kinder (weiblich: männlich = 1:1,2) mit insgesamt 610 Verletzungen an der Wirbelsäule in die Studie eingeschlossen werden. Das mittlere Alter betrug 12 (±3,5) Jahre. Die häufigsten Unfallmechanismen in allen Altersgruppen waren ein Sturz aus unter 3 m Höhe sowie Verkehrsunfälle. Die bildgebende Diagnostik musste nur in Ausnahmefällen in Narkose durchgeführt werden. Während jüngere Kinder (0 bis 9 Jahre) eher Verletzungen im Bereich der Halswirbelsäule erlitten, zeigten sich Verletzungen der thorakolumbalen Wirbelsäule eher bei Kindern >10 Jahren. Die Kinder wiesen häufige Begleitverletzungen an Kopf und Extremitäten auf. Im Bereich der Wirbelsäule befanden sich weitere Verletzungen meist benachbart und nur selten in anderen Regionen. Rund 75 % der Kinder wurden konservativ behandelt. Die Ergebnisse unterscheiden sich von den Erkenntnissen aus der Erwachsenenmedizin und beschreiben spezielle Gegebenheiten für pädiatrische Patienten mit Wirbelsäulenverletzungen. Trotz gewisser Limitationen können sie so bei der Entscheidungsfindung über die durchzuführende Diagnostik und Therapie dieser Patienten helfen.

STUDY DESIGN:Expert consensus. OBJECTIVES:To establish treatment recommendations for subaxial cervical spine injuries based on current literature and the knowledge of the Spine Section of the German Society for Orthopaedics and Trauma. METHODS:This recommendation summarizes the knowledge of the Spine Section of the German Society for Orthopaedics and Trauma. RESULTS:Therapeutic goals are a stable, painless cervical spine and protection against secondary neurologic damage while retaining maximum possible motion and spinal profile. The AOSpine classification for subaxial cervical injuries is recommended. The Canadian C-Spine Rule is recommended to decide on the need for imaging. Computed tomography is the favoured modality. Conventional x-ray is preserved for cases lacking a "dangerous mechanism of injury." Magnetic resonance imaging is recommended in case of unexplained neurologic deficit, prior to closed reduction and to exclude disco-ligamentous injuries. Computed tomography angiography is recommended in high-grade facet joint injuries or in the presence of vertebra-basilar symptoms. A0-, A1- and A2-injuries are treated conservatively, but have to be monitored for progressive kyphosis. A3 injuries are operated in the majority of cases. A4- and B- and C-type injuries are treated surgically. Most injuries can be treated with anterior plate stabilization and interbody support; A4 fractures need vertebral body replacement. In certain cases, additive or pure posterior instrumentation is needed. Usually, lateral mass screws suffice. A navigation system is advised for pedicle screws from C3 to C6. CONCLUSIONS:These recommendations provide a framework for the treatment of subaxial cervical spine Injuries. They give advice about diagnostic measures and the therapeutic strategy.

In a consensus process during four sessions in 2016, the working group "lower cervical spine" of the German Society for Orthopedic and Trauma Surgery (DGOU), formulated "Therapeutic Recommendations for the Lower Cervical Spine", taking into consideration the current literature. Therapeutic goals are a permanently stable, painless cervical spine and the protection against secondary neurologic damage while retaining the greatest possible amount of motion and spinal profile. Due to its ease of use and its proven good reliability, the AOSpine classification for subaxial cervical injuries should be used. The Canadian C-Spine Rule is recommended as a clinical decision rule whether to perform imaging or not. If a structural or unstable injury is suspected by patient history or clinical findings, a spiral CT scan of the cervical spine is the favoured diagnosticmodality. Conventional X-ray is reserved for patients in whom there is no "dangerous mechanism of injury". MR imaging is recommended in case of unexplained neurologic deficit, prior to closed reduction and open posterior surgery and to exclude disco-ligamentous injuries. Urgency of MR imaging depends on the specific findings. CT angiography is recommended in higher-grade facet joint injuries or in the presence of vertebra-basilar symptoms. Flexion-extension imaging is recommended only as a physician-guided dynamic fluoroscopy, when an unstable lesion is still suspected. The therapeutic strategy is mainly dependent on morphologic criteria, which are described using the AOSpine classification. A0-injuries are treated conservatively. A1- and A2-injuries are treated conservatively in the majority of cases, and in single cases a gross kyphotic deformity might indicate surgical stabilisation. A3-injuries do indicate a surgical therapy in the majority of cases, but certain cases might be treated conservatively. A4-fractures as well as B- and C-type injuries are to be treated surgically. Most injuries can be treated by anterior plate stabilisation with interbody support; when a complete burst fracture is present, corpectomy and vertebral body replacement is necessary. In certain cases, an additive posterior or pure posterior instrumentation might be possible or even mandatory. In most of these cases, lateral mass screws are sufficient; when pedicle screws are applied in C3 to C6, a 3D-navigation system is recommended. Injuries in an ankylosing spine (M3-modifier) should be treated preferably from posterior with long-segment instrumentation.

Zusammenfassung Die Planung und Vorbereitung von operativen Eingriffen an der HWS muss präzise und exakt indiziert werden. Die Schwierigkeit besteht dabei in der Vielzahl an Verletzungsmustern, die insbesondere an der oberen HWS auftreten. Der 1. Schritt im Rahmen der Vorbereitung ist zunächst eine adäquate Bildgebung, meist durch schnittbildgebende Verfahren. Bei Unklarheiten werden diese durch eine Funktionsdiagnostik ergänzt. Die korrekte Klassifikation und somit die Zuordnung zu einer instabilen, hoch instabilen bzw. stabilen Verletzung sollte damit ermöglicht werden. Die Entscheidung zur weiteren Versorgung, ob operativ oder konservativ, resultiert aus weiteren Kofaktoren, die das Alter, die Knochenqualität, den Anspruch des Patienten sowie das Komplikationsrisiko, insbesondere von Schraubenfehllagen berücksichtigen müssen. Wird der Entschluss zur operativen Versorgung gefasst, muss eine sinnvolle Lagerung und Repositionsmöglichkeit im Vorfeld geplant werden. Hierzu zählen verschiedene Tools, die im Folgenden dargestellt werden. Die besondere Anatomie der HWS mit der Nähe zum Rückenmark, den Gefäßen sowie den Halsorganen und ihrer grazilen Struktur erfordert exakte anatomische Kenntisse sowie eine präzise handwerkliche Ausführung. Ein großer Fortschritt sind hier neue bildgebende Verfahren, die eine bisher nicht bekannte intraoperative Sicherheit und Kontrolle bieten. Hierzu zählt die intraoperative Schnittbilddiagnostik mit sagittalen und koronaren Rekonstruktionen, weiterhin die Möglichkeit zur Navigation mit optoelektronisch gesteuerten Instrumenten auf der Grundlage der CT-Darstellung mit Trackern. Die intraoperative Kontrolle wird weiterhin erhöht durch mikrochirurgische und minimalinvasive Verfahren sowie die Verwendung eines Operationsmikroskops.