AOSpine Members Research Articles

Research Practices and Needs Among Spine Surgeons Worldwide.

Resource allocation to research activities is challenging and there is limited evidence to justify decisions. Members of AO Spine were surveyed to understand the research practices and needs of spine surgeons worldwide. An 84-item survey was distributed to the AO Spine community in September of 2020. Respondent demographics and insights regarding research registries, training and education, mentorship, grants and financial support, and future directions were collected. Responses were anonymous and compared among regions. A total of 333 spine surgeons representing all geographic regions responded; 52.3% were affiliated with an academic/university hospital, 91.0% conducted clinical research, and 60.9% had 5+ years of research experience. There was heterogeneity among research practices and needs across regions. North American respondents had more research experience (P = .023), began conducting research early on (P < .001), had an undergraduate science degree (P < .001), and were more likely to have access to a research coordinator or support staff (P = .042) compared to other regions. While all regions expressed having the same challenges in conducting research, Latin America, and Middle East/Northern Africa respondents were less encouraged to do research (P < .001). Despite regional differences, there was global support for research registries and research training and education. To advance spine care worldwide, spine societies should establish guidelines, conduct studies on pain management, and support predictive analytic modeling. Tailoring local/regional programs according to regional needs is advised. These results can assist spine societies in developing long-term research strategies and provide justified rationale to governments and funding agencies.

Spine Surgeons Burnout and Quality of Life: Results of a Worldwide Survey.

Cross-sectional survey study. To evaluate the prevalence of burnout, assess the personal and professional characteristics associated with burnout in spine surgeons and determine their quality of life. Burnout is a syndrome characterized by emotional exhaustion, depersonalization, and decreased sense of accomplishment that leads to decreased effectiveness at work. To date, there has been a lack of information on the prevalence of burnout among spine surgeons worldwide and the risk factors associated with this condition. An electronic survey with members of AO Spine was performed in May 2018. The survey evaluated demographic variables, practice characteristics, burnout, and quality of life. Maslach Burnout Inventory (MBI) and EuroQol 5-dimensions (EQ5D) were used to evaluate burnout and quality of life, respectively. A total of 818 surgeons from 86 countries completed the survey. The prevalence of burnout was 30.6%. In the multiple linear model, emotional fatigue was independently associated with younger age (B = -0.17, CI95% = -0.26 to -0.07, P < 0.0001), and longer working hours per week (B = -2.71, CI95% = -4.34 to -1.07, P = 0.001); depersonalization was independently associated with younger age (B = -0.13, CI95% = -0.19 to -0.07, P < 0.0001), practicing outside Latin America (LA) (B = 0.71, CI95% = 0.41-1.01, P < 0.0001) and currently being a fellow (B = 0.54, CI95% = 0.06-1.02, P = 0.02); and higher scores of personal fulfilment was associated with practicing in LA (B = -1.27, CI95% = -1.69 to -0.85, P < 0.0001). Burnout is a common condition among spine surgeons worldwide. There is a significant association between burnout scores and decreased general quality of life. These results highlight the need to develop interventional programs to better identify, prevent, and manage this condition among practicing spine surgeons.Level of Evidence: 4.

Attitude of Spine Surgeons Towards the Application of 3D Technologies – A Survey of AOSpine Members

3D technologies (3D virtual and physical model, 3D printing, computer aided engineering, finite element analysis based simulations) play an important role in personalized spine surgery. Objective - In collaboration with AOSpine a global, online survey-based study was performed in order to determine the acceptance rate and the factors which stand against the wider spread of 3D technologies. A survey containing 21 questions was developed and divided into five pages, every page corresponding to one chapter. Our analysis is based on the responses of 282 spine surgeons from 57 countries. To interpret our results in a global context, we used the Human Development Index of the respondent's countries in comparisons. Significant difference between the AOSpine regions (p ≤ 0.05) was found, with the highest acceptance in Asia-Pacific region. There was no significant difference in acceptance score according to the field of spine surgery, or the surgical experience in years (p=0.77, and p=0.19). In the case of public practice, we found significantly higher acceptance compared to private and mixed (public and private) surgical practice (p ≤ 0.05). The acceptance of the technology varied based on the respondent's resident country's Human Development Index and was significantly different between "Medium" vs "Very high" (p = 0.0005) and "High" vs "Very high" (p=0.019) category. Significant positive correlation was found between the acceptance score and the HDI score (Spearman test, ρ = 0.37, p = 0.007). The main limitation factor was identified as the lack of information. There is high interest among spine surgeons towards the incorporation of 3D technologies into the clinical practice. Education, the healthcare system, and the economic environment plays a major role in acceptance. Our results provide the basis of a strategy to promote the application of 3D technologies.

Worldwide Steroid Prescription for Acute Spinal Cord Injury.

Study Design:Cross-sectional study.Objectives:To continue the line of a previous publication using steroid for acute spinal cord injury (SCI) by spine surgeons from Latin America (LA) and assess the current status of methylprednisolone (MP) prescription in Europe (EU), Asia Pacific (AP), North America (NA), and Middle East (ME) to determine targets for educational activities suitable for each region.Methods:The English version of a previously published questionnaire was used to evaluate opinions about MP administration in acute SCI in LA, EU, AP, NA, and ME. This Internet-based survey was conducted by members of AOSpine. The questionnaire asked about demographic features, background with management of spine trauma patients, routine administration of MP in acute SCI, and reasons for MP administration.Results:A total of 2659 responses were obtained for the electronic questionnaire from LA, EU, AP, NA, and ME. The number of spine surgeons that treat SCI was 2206 (83%). The steroid was used by 1198 (52.9%) surgeons. The uses of MP were based predominantly on the National Acute Spinal Cord Injury Study III study (n = 595, 50%). The answers were most frequently given by spine surgeons from AP, ME, and LA. These regions presented a statistically significant difference from North America (P < .001). The number of SCI patients treated per year inversely influenced the use of MP. The higher the number of patients treated, the lower the administration rates of MP observed.Conclusions:The study identified potential targets for educational campaigns, aiming to reduce inappropriate practices of MP administration.

Current Status of Worldwide Use of Patient-Reported Outcome Measures (PROMs) in Spine Care.

Patient-reported outcome measures (PROMs) are the most widely accepted means of measuring outcomes after spine procedures. We sought to determine the current status of worldwide use of PROMs in Latin America (LA), Europe (EU), Asia Pacific (AP), North America (NA), and Middle East (ME) to determine the barrier to its full implementation. A questionnaire survey was sent by e-mail to members of AOSpine to evaluate their familiarity and use of PROMs instruments and to assess the barriers to their use in spine care practice in LA, EU, AP, NA, and ME. A total of 1634 AOSpine members from LA, EU, AP, NA, and ME answered the electronic questionnaire. The percentage of spine surgeons who were familiar with the generic health-related quality of life questionnaire was 71.7%. In addition, 31.9% of respondents did not use any PROMs routinely. The main barriers to implementing PROMs were lack of time to administer the questionnaires (57%) followed by lack of staff to assist in data collection (55%), and the long time to fill out the questionnaires (46%). The routine use of questionnaires was more frequent in NA and EU and less common in LA and ME (P < 0.001). We found that 31.9% of spine surgeons do not use the PROMs questionnaire routinely. This appears to occur because of lack of knowledge regarding their importance, absence of reimbursement for this extra work, minimal financial support for clinical research, the cost of implementation, and lack of concern among physicians.

ACDF Graft Selection by Surgeons: Survey of AOSpine Members.

Study Design:Cross-sectional survey study.Objective:To determine what are the most commonly used graft materials in anterior cervical discectomy and fusion and whether the choice of graft is affected by surgeon’s training, years in practice, geographic location, practice setting, or surgeon’s perceived difficulty in achieving fusion.Methods:A 23-question survey was sent out to 5334 surgeons using the Global AO Spine database. Response data was then stratified into surgeon training, years of practice, practice type, and global region.Results:Overall, surgeons believe that graft selection affects fusion rates (89.3% of surgeons) and affects time to fusion (86.0% of surgeons). The use of a cage is currently the most common structural graft component used worldwide at 64.1%. Of surgeons that use cages, the PEEK Cage makes up 84%. North American surgeons differ from this global trend and use composite allograft more commonly. The choice to add a nonstructural graft component was reported at 74%. This result was similar for performing multilevel fusions at 72.8%. The selection of nonstructural graft material depends on whether the type of surgery is considered simple or complex. Most surgeons are not satisfied with available literature comparing effectiveness of grafts but believed that there was sufficient evidence to support the use of their chosen graft.Conclusion:Almost all surgeons believe that fusion is important to anterior cervical discectomy and fusion surgery outcomes and that most surgeons believe graft choice affects fusion. However, this survey indicates that there is great variability in the type of graft material used by spine surgeons across the world.

Updates from Global Spine Congress.

Global Spine Journal (GSJ) and many of its editorial board attended Global Spine Congress in Dubai this April. GSJ hosted two successful AOSpine members only sessions on “How to Write, Publish, and Review a Paper.” The sessions were led by the Editors-in-Chief of GSJ, and during this session, the key points to writing a paper were addressed, from study results to submission. The key points in reviewing papers were also addressed, which gave the potential authors great insight into the process. We were very excited to share these sessions with the AOSpine community, and based on the success of these sessions, we will be continuing and expanding this programming at next year's Global Spine Congress in Milan. GSJ also presented its annual best paper and best reviewer awards at the GSC closing ceremony. All of the winners received a certificate along with a cash prize. GSJ would like to congratulate the winners. The Best Clinical Paper Award went to “A Randomized Controlled Trial Comparing Transforaminal Lumbar Interbody Fusion and Uninstrumented Posterolateral Fusion in the Degenerative Lumbar Spine” by Kourosh Jalalpour, Pavel Neumann, Christer Johansson, Rune Hedlund. The Best Basic Science Award went to “Annulus Fibrosus Can Strip Hyaline Cartilage End Plate from Subchondral Bone: A Study of the Intervertebral Disk in Tension” by Christian Balkovec, Michael A. Adams, Patricia Dolan, Stuart M. McGill. The Best Reviewer Awards went to John Devine, Andrei Joaquim, Justin Smith, and Christof Birkenmaier. The Best Paper Awards are awarded based on the following criteria: Original Research papers the total number of downloads, the total number of citations, the highest rated papers, the originality of the paper's topic, and paper rankings. All Original Research papers submitted in 2016 will be eligible for the 2016 Best Paper Awards. The Best Reviewer Awards are awarded based on the number of reviews completed during the year as well as the reviewer's average score/ranking. All reviewers who review articles in 2016 will be eligible to receive the 2016 Best Reviewer Award. If you would like to become a reviewer for GSJ, please e-mail Managing Editor Danielle Lieberman at globalspinejournal@aospine.org. Please send her your CV along with your areas of expertise. If you would like to submit a manuscript to GSJ, please go to www.editorialmanager.com/gsj. There you can also find instructions for authors. GSJ looks forward to receiving more excellent papers and reviews from you in the future and would like to thank all of its current authors and reviewers.

Key Preoperative Clinical Factors Predicting Outcome in Surgically Treated Patients with Metastatic Epidural Spinal Cord Compression: Results from a Survey of 438 AOSpine International Members

Accurate prediction of surgical outcomes in patients suffering from metastatic epidural spinal cord compression (MESCC) is challenging. This survey aims to obtain expert opinion on which preoperative clinical factors are the most relevant predictors of survival, neurologic, functional, and health-related quality of life (HRQoL). Members of AOSpine International were invited to participate in a 15-question electronic survey. Results from the entire sample and differences across geographic regions and between neurosurgeons and orthopedic surgeons were analyzed. Factors endorsed by over 50% of the respondents were considered key predictors. Among AOSpine members, 438 responded. The absence of visceral metastasis (n= 335; 76.48%) and the site of primary tumor (n= 228; 52.05%) were identified as important predictors for survival. Frankel/American Spinal Injury Association grade D or E and the ability to walk were common to neurologic (n= 344; 78.54% and n= 238; 54.34%, respectively); functional (n= 269; 61.42% and n= 243; 55.48%, respectively); and HRQoL outcomes (n= 241; 55.02% and n= 242; 55.25%, respectively). While the absence of bowel/bladder/sexual dysfunction was common to neurologic (n= 260; 59.36%) and HRQoL (n= 229; 52.28%) outcomes, a high Karnofsky/Eastern Cooperative Oncology Group performance status was common to functional (n= 237; 54.11%) and HRQoL (n= 221; 50.46%) outcomes. There was overall consistency across specialities and geographic regions. Neurosurgeons and orthopedic surgeons and respondents from different geographic regions generally identified similar preoperative clinical factors as key predictors of survival, neurologic, functional, and HRQoL outcomes in surgical MESCC patients. The results of this survey will inform the development of clinical prediction rules for survival and HRQoL in MESCC patients selected for surgery to maximize their clinical relevance.

Paperless Journals: The Future of the Global Spine Journal.

As technology is expanding and changing, people are moving away from newspapers, books, and paper journals. People are instead opting to use tablets and/or smartphones as their platform for reading books, newspapers, and journals. Global Spine Journal is one of the few journals left that still prints and distributes paper copies of every issue. GSJ is happy to distribute paper copies to those who still enjoy reading a physical journal. We recently surveyed all AOSpine members to ask them if they prefer to read paper journals because we greatly value the opinions of our readership. In the future, for those of you who still prefer to read GSJ on paper, you can opt-in to receive it. GSJ also understands that paperless journals are the future of journals, and we want to keep up with the changing times. We will continue to publish a paper copy of the journal for now, but may consider a paperless situation in the future. We do want to ensure that we offer the best paperless options for our readers to ensure a seamless reading process. We will ensure that our online journal is optimized for all smart devices including phones and tablets. We also are exploring the opportunity to develop a full purpose GSJ app where you can download and read full issues offline. Another important thing that GSJ puts into consideration is the impact that paper journals have on the environment. Printing and distributing paper journals each year takes its toll on the environment and GSJ would like to play its part in reducing our carbon footprint. Again GSJ prides itself on valuing the needs of all of its readers. For those of you who still prefer to read a paper copy of the journal, we are more than happy to provide this to you at this time. For those of you who enjoy reading the journal online, our online journal is optimized for viewing on smart devices. We will of course keep all of our readers updated on any changes we make to the journal.

The AOSpine Sacral Fracture Classification

Introduction Sacral fractures are complex and heterogeneous injuries that often include involvement of the lumbar spine and/or pelvis. Due to their complex nature, no comprehensive classification system has been accepted. Material and Methods The AOSpine Trauma Knowledge Forum partnered with orthopaedic traumatologists from AOTrauma to develop a straightforward, hierarchical classification system for sacral fractures. The classification was developed via a consensus process of clinical experts, and, prior to finalizing the classification system, a survey was sent to all members of AOSpine and AOTrauma asking for their input on key parts of the classification. Results The new AOSpine Sacral Classification is a hierarchical classification that follows the same structure as the subaxial and thoracolumbar classifications. First injuries are broadly divided into three types: Type A—Lower Sacro-coccygeal Injuries; Type B—Posterior Pelvic Injuries and Type C—Spino-Pelvic Injuries. Type A injuries have no impact on posterior pelvic or spinopelvic instability, however higher grade injuries may be associated with neurologic injuries. Type A injuries are divided into three subtypes; A1—Coccygeal or compression injuries as well as ligamentous avulsion fractures; A2—Non-displaced transverse fractures below the Sacroiliac (SI) joint, and A3—Displaced transverse fractures below the SI joint. Type B injuries are unilateral longitudinal sacral fractures in which the ipsilateral superior S1 facet is not discontinuous with medial portion of the sacrum. These injuries primarily impact posterior pelvic stability and have minimal impact on spino-pelvic stability. Type B injuries are divided into three subtypes based on the likelihood of neurologic injury, and while this is similar to the Denis classification, because B-type injuries exclude fractures with a transverse component, there is little risk of a neurologic injury with an injury medial to the foramen. The three sub-types of B injuries are: B1—Longitudinal fracture medial to the foramen; B2—Longitudinal fracture lateral to the foramen and B3—Longitudinal injury thought the foramen. Type C injuries are Injuries that result in spino-pelvic instability. They are divided into four subtypes: C0—Non displaced sacral U fracture (commonly seen in low energy insufficiency fractures); C1—Any unilateral B-subtype where the ipsilateral superior S1 facet is discontinuous with the medial portion of the sacrum; C2—Bilateral complete B type fracture without a transverse component, and C3—Displaced sacral U type fracture. In addition to the fracture morphology, the new classification also formally considers the neurologic status of the patient: Nx—The patient cannot be examined; N0—No neurological deficits; N1—Transient neurological injury; N2—Nerve root injury and N3—Cauda Equina Syndrome. Lastly there are four patient specific modifiers that may alter the treatment of these fractures: M1—Significant soft tissue injury; M2—Metabolic bone disease; M3—High-energy injury that may be associated with an anterior pelvic ring injury, acetabular fracture or vascular injury, and M4—Altered anatomy of the lumbosacral junction (may be due to a prior fusion or transitional anatomy). Conclusion The AOSpine sacral fracture classification is the first comprehensive sacral classification to consider posterior pelvic and spino-pelvic instability patterns, and validation studies are ongoing.

The Development of a Universally Accepted Sacral Fracture Classification: A Survey of AOSpine and AOTrauma Members

Introduction Sacral fractures are complex injuries that pose diagnostic and technical challenges for surgeons. While multiple classifications have been proposed, there is not a comprehensive, universally accepted classification. The AOSpine Trauma Knowledge Forum partnered with orthopaedic traumatologists from AOTrauma to develop a straightforward, hierarchical classification system for sacral fractures. While the classification was developed via a consensus process of clinical experts, the authors solicited input from the global community to ensure that the proposed classification could achieve global acceptance. Material and Methods Prior to finalizing the new AOSpine Sacral Injury Classification System, a survey was sent to all members of AOSpine and AOTrauma. The survey included the preliminary sacral classification as well as questions asking for their input on key parts of the classification. Along with demographic information, the following four questions were asked: (1) Since type B injuries in the new AOSpine sacral classification refer only to vertical fracture patterns and exclude injuries with a transverse component, do you agree that there is an increase in the risk of neurologic injury as the B subtype increase: B1—an injury medial to the foramen; B2—an injury lateral to the foramen and B3 an injury through the foramen. (2) Do you think the hierarchical nature of the sacral classification is appropriate with: A = transverse; B = Unilateral vertical fracture; C = Any fracture that leads to spinopelvic instability. (3) Do you think the integrity of the L5/S1 facet is adequately considered in this classification system? (4) Do you think C0 (a non-displaced sacral U fracture that may be seen in low energy insufficiency fractures) is a clinically relevant entity that deserves its own spot in the classification? Results A total of 596 surgeons from all six AO regions of the world responded to the survey. 70.9% of respondents were orthopaedic trauma surgeons, 18.5% were orthopaedic spine surgeons and 4.7% were neurosurgeons. Overall 78.1% of respondents agreed that the B subtypes were correctly ordered for an increase in the risk of a neurologic injury. 86.1% of respondents felt that the hierarchical nature of the classification was appropriate. 82.9% of respondents felt that the L5/S1 facet was adequately considered in the classification, and 84.1% of surgeons felt that C0 is clinically relevant entity that deserves its own spot in the classification. When surgeons were stratified as either a trauma surgeon or a spine surgeon (orthopaedic or neurosurgeon), significantly more spine surgeons than trauma surgeons agreed with the organization of B type injuries (84.7% versus 75.4%, respectively, p = 0.03); however, still more than 3 in 4 trauma surgeons agreed with the organization of B type injuries. No other significant difference was identified by specialty. Additionally, no significant difference (p &gt; 0.39) was found when respondents were grouped by years in practice (0–10 years, 11–20 years and &gt;20 years). Conclusion While validation studies are ongoing for the new AOSpine sacral fracture classification, the classification is designed such that worldwide acceptance from both spine surgeons and trauma surgeons may be possible.

The Development of a Universally Accepted Sacral Fracture Classification: A Survey of AOSpine and AOTrauma Members.

Study Design Survey study. Objective To determine the global perspective on controversial aspects of sacral fracture classifications. Methods While developing the AOSpine Sacral Injury Classification System, a survey was sent to all members of AOSpine and AOTrauma. The survey asked four yes-or-no questions to help determine the best way to handle controversial aspects of sacral fractures in future classifications. Chi-square tests were initially used to compare surgeons' answers to the four key questions of the survey, and then the data was modeled through multivariable logistic regression analysis. Results A total of 474 surgeons answered all questions in the survey. Overall 86.9% of respondents felt that the proposed hierarchical nature of injuries was appropriate, and 77.8% of respondents agreed that that the risk of neurologic injury is highest in a vertical fracture through the foramen. Almost 80% of respondents felt that the separation of injuries based on the integrity of L5–S1 facet was appropriate, and 83.8% of surgeons agreed that a nondisplaced sacral U fracture is a clinically relevant entity. Conclusion This study determines the global perspective on controversial areas in the injury patterns of sacral fractures and demonstrates that the development of a comprehensive and universally accepted sacral classification is possible.

Is there a regional difference in morphology interpretation of A3 and A4 fractures among different cultures?

OBJECT The aim of this study was to determine if the ability of a surgeon to correctly classify A3 (burst fractures with a single endplate involved) and A4 (burst fractures with both endplates involved) fractures is affected by either the region or the experience of the surgeon. METHODS A survey was sent to 100 AOSpine members from all 6 AO regions of the world (North America, South America, Europe, Africa, Asia, and the Middle East) who had no prior knowledge of the new AOSpine Thoracolumbar Spine Injury Classification System. Respondents were asked to classify 25 cases, including 6 thoracolumbar burst fractures (A3 or A4). This study focuses on the effect of region and experience on surgeons' ability to properly classify these 2 controversial fracture variants. RESULTS All 100 surveyed surgeons completed the survey, and no significant regional (p > 0.50) or experiential (p > 0.21) variability in the ability to correctly classify burst fractures was identified; however, surgeons from all regions and with all levels of experience were more likely to correctly classify A3 fractures than A4 fractures (p < 0.01). Further analysis demonstrated that no region predisposed surgeons to increasing their assessment of severity of burst fractures. CONCLUSIONS A3 and A4 fractures are the most difficult 2 fractures to correctly classify, but this is not affected by the region or experience of the surgeon; therefore, regional variations in the treatment of thoracolumbar burst fractures (A3 and A4) is not due to differing radiographic interpretation of the fractures.

The surgical algorithm for the AOSpine thoracolumbar spine injury classification system.

The goal of the current study is to establish a surgical algorithm to accompany the AOSpine thoracolumbar spine injury classification system. A survey was sent to AOSpine members from the six AO regions of the world, and surgeons were asked if a patient should undergo an initial trial of conservative management or if surgical management was warranted. The survey consisted of controversial injury patterns. Using the results of the survey, a surgical algorithm was developed. The AOSpine Trauma Knowledge forum defined that the injuries in which less than 30% of surgeons would recommend surgical intervention should undergo a trial of non-operative care, and injuries in which 70% of surgeons would recommend surgery should undergo surgical intervention. Using these thresholds, it was determined that injuries with a thoracolumbar AOSpine injury score (TL AOSIS) of three or less should undergo a trial of conservative treatment, and injuries with a TL AOSIS of more than five should undergo surgical intervention. Operative or non-operative treatment is acceptable for injuries with a TL AOSIS of four or five. The current algorithm uses a meaningful injury classification and worldwide surgeon input to determine the initial treatment recommendation for thoracolumbar injuries. This allows for a globally accepted surgical algorithm for the treatment of thoracolumbar trauma.

Establishing the Injury Severity of Thoracolumbar Trauma: Confirmation of the Hierarchical Structure of the AOSpine Thoracolumbar Spine Injury Classification System

Introduction The AOSpine Thoracolumbar Spine Injury Classification System was recently published and combines elements of both the Magerl system and the Thoracolumbar Injury Classification System (TLICS); however, the injury severity of each fracture has yet to be established. The objective of this study is to develop a validated regional and global injury severity scoring system for thoracolumbar trauma. Material and Methods A survey was sent to 100 AOSpine members from all six AO regions of the world (North America, South America, Europe, Africa, Asia, and the Middle East). Each respondent was asked to numerically grade the severity of each variable of the AOSpine Thoracolumbar Spine Injury Classification System including the morphology, neurologic grade, and patient-specific modifiers. A grade of zero was considered to be not severe at all, and a grade of 100 was the most severe injury possible. Results A total of 74 AOSpine surgeons from all six AO regions of the world numerically graded the severity of each variable of the AOSpine Thoracolumbar Spine Injury Classification System to establish the injury severity score. The reported fracture severity increased significantly ( p &lt; 0.0001) as the subtypes of fracture type A and type B increased, and a significant difference ( p &lt; 0.0001) in severity was established for burst fractures with involvement of two versus one end plates. Finally, no regional or experiential difference in severity or classification was identified. Conclusion Development of a globally applicable injury severity scoring system for thoracolumbar trauma is possible. This study demonstrates no regional or experiential difference in perceived severity or thoracolumbar spine trauma. The AOSpine Thoracolumbar Spine Injury Classification System provides a logical approach to assessing these injuries and enables rational strategies for treatment.

Is there a Regional Difference in Morphology Interpretation of A3/A4 Fractures among Different Cultures?

Introduction The AOSpine Thoracolumbar Spine Injury Classification System was recently published, but before establishing a treatment algorithm to accompany the classification, further investigation on the cause of current regional treatment variations is required. The objective of this study is to determine if the ability of a surgeon to correctly classify A3 (burst fractures with a single endplate involved) and A4 (burst fractures with both end plates involved) fractures were affected by either the region or the experience of the surgeon. Material and Methods A survey was sent to 100 AOSpine members from all six AO regions of the world (North America, South America, Europe, Africa, Asia, and the Middle East) that had no prior knowledge of the new AOSpine Thoracolumbar Spine Injury Classification System. Respondents were asked to classify 25 cases, including 6 thoracolumbar burst fractures (A3 or A4). The current analysis focuses on the effect of region and experience on surgeons' ability to properly classify these controversial fractures. Results All 100 surveyed surgeons completed the survey, and no significant regional variability in the ability to correctly classify burst fractures was identified ( p &gt; 0.50). Further analysis demonstrated that no region predisposed surgeons increasing the severity of burst fractures. Similarly, experience did not affect surgeons' ability to correctly classify burst fracture ( p &gt; 0.21). Conclusion Regional variation in the treatment of thoracolumbar burst fractures (A3 and A4) is not because of the differing radiographic interpretation of the fractures.

ACDF Graft Selection by Surgeons: Survey of AOSpine Members

Introduction The choice of graft material for anterior cervical disc fusion (ACDF) surgery is presumed to be very important in achieving fusion. Worldwide, a large diversity of graft options exists but no published data exist on actual use. Our objective is to determine the most commonly used graft materials in ACDF, whether the choice is affected by surgeon's training, years in practice, geographical location of practice setting, or surgeon's perceived difficulty in achieving fusion for a particular case. We also want to confirm our previous assumption that surgeons feel that the choice of graft material is important for outcome and that there is sufficiently good comparative and safety data on the most common grafts. Materials and Methods A 23-question survey was sent out to 5,334 surgeons using the Global AOSpine database. Response data were then stratified into surgeon training, years of practice, practice type, and global region. To further characterize type of ACDF graft, we classified common graft materials into structural and nonstructural components. Results Nearly all surgeons, 94.6%, performing ACDF believe that cervical disc fusion is important for a successful patient outcome. Overall, 89.3% of the surgeons believe that graft impacts fusion rates and 86.0% affect time to fusion. The use of a cage is currently the most common structural graft component used worldwide at 64.1%. Of the surgeons who use cages, the PEEK cage makes up for 84% of them. North American surgeons have stopped this trend and use composite allograft more commonly. Surgeon experience seems to be positively related to the use of a cage because surgeons with a greater number of years of practice are more likely to select a cage. The choice to add a nonstructural graft component was reported at 74%. This result was similar for performing multilevel fusions at 72.8%. The most common nonstructural graft material depends on the type of surgery, simple or complex. For simple cases, local autograft is most common and for multilevel fusions, allograft iliac cancellous is most widely used. Most surgeons are not satisfied with the available literature comparing the effectiveness of grafts, but believed there was sufficient evidence to support the use of their chosen graft. Conclusion Almost all surgeons believe that fusion is important to ACDF surgery outcomes and that most surgeons believe choice of graft impacts fusion. However, this survey indicates that there is great variability in the type of graft material used by spine surgeons across the world and surgeons feel that there is insufficient comparative data to help choose between graft types. This variability in surgeon practice and gap in the literature indicate an important opportunity to change surgeon practice with well-conducted comparative studies.

Establishing the injury severity of thoracolumbar trauma: confirmation of the hierarchical structure of the AOSpine Thoracolumbar Spine Injury Classification System.

Survey of spine surgeons. To develop a validated regional and global injury severity scoring system for thoracolumbar trauma. The AOSpine Thoracolumbar Spine Injury Classification System was recently published and combines elements of both the Magerl system and the Thoracolumbar Injury Classification System; however, the injury severity of each fracture has yet to be established. A survey was sent to 100 AOSpine members from all 6 AO regions of the world (North America, South America, Europe, Africa, Asia, and the Middle East). Each respondent was asked to numerically grade the severity of each variable of the AOSpine Thoracolumbar Spine Injury Classification System including the morphology, neurological grade, and patient specific modifiers. A grade of zero was considered to be not severe at all, and a grade of 100 was the most severe injury possible. Seventy-four AOSpine surgeons from all 6 AO regions of the world numerically graded the severity of each variable of the AOSpine Thoracolumbar Spine Injury Classification System to establish the injury severity score. The reported fracture severity increased significantly (P < 0.0001) as the subtypes of fracture type A and type B increased, and a significant difference (P < 0.0001) in severity was established for burst fractures with involvement of 2 versus 1 endplates. Finally, no regional or experiential difference in severity or classification was identified. Development of a globally applicable injury severity scoring system for thoracolumbar trauma is possible. This study demonstrates no regional or experiential difference in perceived severity or thoracolumbar spine trauma. The AOSpine Thoracolumbar Spine Injury Classification System provides a logical approach to assessing these injuries and enables rational strategies for treatment. 4.

A Worldwide Analysis of the Reliability and Perceived Importance of an Injury to the Posterior Ligamentous Complex in AO Type A Fractures.

Study Design Survey of spine surgeons. Objective To determine the reliability with which international spine surgeons identify a posterior ligamentous complex (PLC) injury in a patient with a compression-type vertebral body fracture (type A). Methods A survey was sent to all AOSpine members from the six AO regions of the world. The survey consisted of 10 cases of type A fractures (2 subtype A1, 2 subtype A2, 3 subtype A3, and 3 subtype A4 fractures) with appropriate imaging (plain radiographs, computed tomography, and/or magnetic resonance imaging), and the respondent was asked to identify fractures with a PLC disruption, as well as to indicate if the integrity of the PLC would affect their treatment recommendation. Results Five hundred twenty-nine spine surgeons from all six AO regions of the world completed the survey. The overall interobserver reliability in determining the integrity of the PLC was slight (kappa = 0.11). No substantial regional or experiential difference was identified in determining PLC integrity or its absence; however, a regional difference was identified (p < 0.001) in how PLC integrity influenced the treatment of type A fractures. Conclusion The results of this survey indicate that there is only slight international reliability in determining the integrity of the PLC in type A fractures. Although the biomechanical importance of the PLC is not in doubt, the inability to reliably determine the integrity of the PLC may limit the utility of the M1 modifier in the AOSpine Thoracolumbar Spine Injury Classification System.

Diagnostic criteria of traumatic central cord syndrome. Part 2: A Questionnaire Survey among Spine Specialists

A questionnaire survey. To evaluate the need for the introduction of quantitative diagnostic criteria for the traumatic central cord syndrome (TCCS). An online questionnaire survey with participants from all over the world. An invitation to participate in an eight-item online survey questionnaire was sent to surgeon members of AOSpine International. Out of 3340 invited professionals, 157 surgeons (5%) from 41 countries completed the survey. Whereas most of the respondents (75%) described greater impairment of the upper extremities than of the lower extremities in their own TCCS definitions, symptoms such as sensory deficit (39%) and bladder dysfunctions (24%) were reported less frequently. Initially, any difference in motor strength between the upper and lower extremities was considered most frequently (23%) as a 'disproportionate' difference in power. However, after presenting literature review findings, the majority of surgeons (61%) considered a proposed difference of at least 10 points of power (based on the Medical Research Council scale) in favor of the lower extremities as an acceptable cutoff criterion for a diagnosis of TCCS. Most of the participants (40%) felt that applying a single criterion to the diagnosis of TCCS is insufficient for research purposes. Various definitions of TCCS were used by physicians involved in the spinal trauma care. The authors consider a difference of at least 10 motor score points between upper and lower extremity power a clear diagnostic criterion. For clinical research purposes, this diagnostic criterion can be considered as a face valid addendum to the commonly applied TCCS definition as introduced by Schneider et al.