Study Design.: Global cross-sectional survey. Objective.: To determine the classification accuracy, interobserver reliability, and intraobserver reproducibility of the AO Spine Upper Cervical Injury Classification System based on an international group of AO Spine members. Summary of Background Data.: Previous upper cervical spine injury classifications have primarily been descriptive without incorporating a hierarchical injury progression within the classification system. Further, upper cervical spine injury classifications have focused on distinct anatomical segments within the upper cervical spine. The AO Spine Upper Cervical Injury Classification System incorporates all injuries of the upper cervical spine into a single classification system focused on a hierarchical progression from isolated bony injuries (type A) to fracture dislocations (type C). Methods.: A total of 275 AO Spine members participated in a validation aimed at classifying 25 upper cervical spine injuries through computed tomography scans according to the AO Spine Upper Cervical Classification System. The validation occurred on two separate occasions, three weeks apart. Descriptive statistics for percent agreement with the gold-standard were calculated and the Pearson χ² test evaluated significance between validation groups. Kappa coefficients (κ) determined the interobserver reliability and intraobserver reproducibility. Results.: The accuracy of AO Spine members to appropriately classify upper cervical spine injuries was 79.7% on assessment 1 (AS1) and 78.7% on assessment 2 (AS2). The overall intraobserver reproducibility was substantial (κ=0.70), while the overall interobserver reliability for AS1 and AS2 was substantial (κ=0.63 and κ=0.61, respectively). Injury location had higher interobserver reliability (AS1: κ = 0.85 and AS2: κ=0.83) than the injury type (AS1: κ=0.59 and AS2: 0.57) on both assessments. Conclusion.: The global validation of the AO Spine Upper Cervical Injury Classification System demonstrated substantial interobserver agreement and intraobserver reproducibility. These results support the universal applicability of the AO Spine Upper Cervical Injury Classification System. Level of Evidence: 4

Lumbar disc herniation (LDH) is a leading cause of low back pain (LBP) and leg pain and may require surgical treatment in case of persistent pain and/or neurological deficits. Conventional discectomy involves removing the herniated fragment and additional material from the disc space, potentially accelerating disc degeneration and contributing to chronic LBP. Conversely, by resecting the herniated fragment only, sequestrectomy may reduce postoperative LBP while increasing the risk of LDH recurrence. To compare discectomy versus sequestrectomy in terms of risk of reherniation, reoperation rate, complications, pain, satisfaction, and perioperative outcomes (operative time, blood loss, length of stay [LOS]). Systematic review and meta-analysis. A systematic search of PubMed/MEDLINE and Scopus databases was performed through May 1, 2024 for both randomized and nonrandomized studies. The search was conducted according to PRISMA guidelines. The RoB-2 and MINORS tools were utilized to assess the risk of bias in included studies. The quality of the evidence was evaluated according to the GRADE approach. Relevant outcomes were pooled for meta-analysis. A total of 16 articles (1 randomized controlled trial with 2 follow-up studies, 6 prospective studies, and 7 retrospective studies) published between 1991 and 2020 involving 2009 patients were included for analysis. No significant differences were noted between discectomy versus sequestrectomy in terms of risk of reherniation (OR: 0.85, 95% CI: 0.57 to 1.26, p=.42), reoperation rate (OR: 0.95, 95% CI: 0.64 to 1.40, p=.78), and complications (OR: 1.03, 95% CI: 0.50 to 2.11, p=.94). Although LBP (MD: -0.06, 95% CI: -0.39 to 0.28, p=.74) and leg pain intensity (MD: 0.11, 95% CI: -0.21 to 0.42, p=.50) were similar postoperatively, significantly better outcomes were reported by patients treated with sequestrectomy at 1 year (leg pain: MD: 0.37, 95% CI: 0.19 to 0.54, p<.0001) and 2 years (LBP: MD: 0.19, 95% CI: 0.03 to 0.34, p=.02; leg pain: MD: 0.20, 95% CI: 0.09 to 0.31, p=.0005). Sequestrectomy also resulted in a higher patient satisfaction (OR: 0.60, 95% CI: 0.40 to 0.90, p=.01) and shorter operative time (MD: 8.71, 95% CI: 1.66 to 15.75, p=.02), while blood loss (MD: 0.18, 95% CI: -2.31 to 2.67, p=.89) and LOS (MD: 0.02 days, 95% CI: -0.07 to 0.12, p=.60) did not significantly differ compared to discectomy. Based on the current evidence, discectomy and sequestrectomy do not significantly differ in terms of risk of reherniation, reoperation rate, and postoperative complications. Patients treated with sequestrectomy may benefit from a marginally higher pain improvement, better satisfaction outcomes, and a shorter operative time, although the clinical relevance of these differences needs to be validated in larger, prospective, randomized studies.

The aim of this study was to assess nurses’ and physicians’ ethical dilemmas in clinical practice. Nurses and physicians of the Clinical Hospital Centre Rijeka were surveyed (N = 364). A questionnaire was used to identify recent ethical dilemma, primary ethical issue in the situation, satisfaction with the resolution, perceived usefulness of help, and usage of clinical ethics consultations in practice. Recent ethical dilemmas include professional conduct for nurses (8%), and near-the-end-of-life decisions for physicians (27%). The main ethical issue is limiting life-sustaining therapy (nurses 15%, physicians 24%) and euthanasia and physician-assisted suicide (nurses 16%, physicians 9%). The types of help available are similar for nurses and physicians: obtaining complete information about the patient (37% vs. 50%) and clarifying ethical issues (31% vs. 39%). Nurses and physicians experience similar ethical dilemmas in clinical practice. The usage of clinical ethics consultations is low. It is recommended that the individual and team consultations should be introduced in Croatian clinical ethics consultations services.

Study Type: Systematic Scoping Review. Introduction: Radiographic assessment is crucial for diagnosing symptomatic pseudarthrosis and evaluating spinal fusion outcomes, yet no consensus exists on defining successful lumbar fusion. This scoping review presents criteria for imaging-based assessment after posterolateral and interbody lumbar fusion, aiming to guide consistent evaluation methods. Methods: Following PRISMA guidelines, a comprehensive search of Medline, Embase, and Scopus identified eligible randomized controlled trials and Federal Drug Administration clinical trials involving lumbar fusion. Studies on revision surgeries, non-lumbar fusions, adult spinal deformity, traumatic fractures, tumors, infections, or lacking defined fusion assessment methods were excluded. Data extraction focused on classification and descriptive systems of fusion evaluation, analyzing parameters such as bony bridging, angular motion, translation, hardware failure, cage migration, radiolucency, and cleft within the fusion mass. Results: A total of 142 articles (1995-2024) were reviewed. Computerized tomography was the most common imaging modality (102, 71.8%), followed by static (96, 67.6%) and dynamic radiographs (88, 62%). Descriptive criteria were used in 108 studies (76.1%) and classification systems in 47 (33.1%). Interbody fusion was assessed in 90 articles (63.4%) and posterolateral fusion in 68 (47.9%). Bony bridging continuity was the most reported descriptive criterion (105, 73.9%), followed by angular motion (72, 50.7%) and translation (43, 30.3%). Radiolucency was reported around the cage (31, 21.8%), pedicle screws (17, 11.9%), and within the fusion mass (36, 25.4%) to describe nonunion. Common classification systems included Bridwell (10 studies), Brantigan (9), and Lenke (9). Conclusions: This scoping review highlights the variability in lumbar fusion assessment across RCTs and FDA trials. Over time, assessment methods have evolved from static radiographs to greater use of dynamic imaging and classification systems in the mid-2000s, with CT emerging as the dominant modality in the past decade. Despite these advancements, fusion assessment criteria remain inconsistent across studies.

Enhanced Recovery After Surgery (ERAS) protocols aim to improve recovery, reduce complications, and optimise surgical outcomes. Despite increasing use in spinal surgery, no standardised ERAS for spinal surgery (ERASS) exists and evidence synthesis is limited. This umbrella review consolidates findings from systematic reviews (SRs) and meta-analyses (MAs) to evaluate the clinical and economic impact of ERASS and identify research gaps. A systematic search of MEDLINE, Embase, Cochrane Database of Systematic Reviews, and Web of Science (1990-2024) identified SRs and MAs on ERASS. Data extraction followed Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) and Preferred Reporting Items for Overviews of Reviews (PRIOR), with quality assessed using AMSTAR-2 and ROBIS. Overlapping primary studies were removed before recalculating pooled estimates using fixed or random-effects models based on heterogeneity. Primary outcomes included length of stay, postoperative complications, readmission rates, healthcare costs, pain scores, and opioid consumption. Seventeen SRs and 55 MAs (319 primary studies; n=221 605 participants) were included. ERASS significantly reduced length of stay (-1.55 days; 95% confidence interval [CI] -1.83 to -1.27 days; P<0.01), postoperative complications (relative risk=0.61; 95% CI 0.52-0.72; P<0.01), opioid consumption (-7.26 mg morphine equivalents; 95% CI -10.82 to -3.70 mg; P<0.01), and healthcare costs (-$1029.41 per patient; 95% CI -$1630.17 to -$428.65; P<0.01). Readmission rates were not significantly impacted (relative risk=0.91; P=0.38). Pain scores showed a modest, non-significant reduction (-0.27; 95% CI -0.66 to 0.13; P=0.19). High heterogeneity was observed, reflecting protocol and design variation. ERASS protocols significantly improve surgical efficiency and safety. Standardised guidelines and future research addressing heterogeneity, under-represented ERASS elements, and long-term outcomes are needed. PROSPERO (CRD42024578786).

Study design: Guideline Objectives: To develop an international guideline (AOGO) about the use of osteobiologics in anterior cervical discectomy and fusion (ACDF) for treating degenerative spine conditions. Methods: The guideline development process was guided by AO Spine Knowledge Forum Degenerative (KF Degen) and followed the Guideline International Network McMaster Guideline Development Checklist. The process involved 73 participants with expertise in degenerative spine diseases and surgery from 22 countries. Fifteen systematic reviews were conducted addressing respective key topics and evidence was collected. The methodologist compiled the evidence into GRADE Evidence-to-Decision frameworks. Guideline panel members judged the outcomes and other criteria and made the final recommendations through consensus. Results: Five conditional recommendations were created. A conditional recommendation is about the use of allograft, autograft or a cage with an osteobiologic in primary ACDF surgery. Other conditional recommendations are about the use of osteobiologic for single- or multi-level ACDF, and for hybrid construct surgery. It is suggested that surgeons use other osteobiologics rather than human bone morphogenetic protein-2 (BMP-2) in common clinical situations. Surgeons are recommended to choose 1 graft over another or 1 osteobiologic over another primarily based on clinical situation, and the costs and availability of the materials. Conclusion: This AOGO guideline is the first to provide recommendations for the use of osteobiologics in ACDF. Despite the comprehensive searches for evidence, there were few studies completed with small sample sizes and primarily as case series with inherent risks of bias. Therefore, high-quality clinical evidence is demanded to improve the guideline.