Subaxial cervical spine trauma
- 389 Downloads
Subaxial cervical spine trauma is common and an often missed diagnosis. Accurate and efficient diagnosis and management is necessary to avoid devastating complications such as spinal cord injury. Several classification schemes have been devised to help categorize fractures of the subaxial spine and define treatment algorithms. The Subaxial Cervical Spine Injury Classification System (SLIC) is widely used and evaluates not only fracture morphology but also considers ligamentous injury and neurological status in surgical decision making. However, interobserver reliability is poor, which proves to be the defining pitfall of this tool. More modern classification systems have been developed, which aim to improve the interobserver reliability; however, further large-scale studies are needed for more definitive evaluation. Overall, treatment of subaxial cervical spine injuries should include a protocol with initial trauma evaluation, leading to expedient operative intervention if indicated. Surgical techniques include both anterior and posterior approaches to the cervical spine depending on fracture classification.
KeywordsSubaxial cervical spine trauma Fracture Ligamentous injury Classification system
Compliance with ethical standards
Conflict of interest
Eric Feuchtbaum declares that he has no conflict of interest.
Jacob Buchowski reports personal fees from Advance Medical, personal fees from CoreLink Inc., personal fees from DePuy Synthes, personal fees from Gerson Lehrman Group (GLG), personal fees from Globus Medical Inc., personal fees from K2M Inc., personal fees from Medtronic Inc., personal fees from Stryker Inc., personal fees from Broadwater/Vertical Health, personal fees from DePuy Synthes, personal fees from Globus Medical Inc., personal fees from Orthofix, personal fees from Stryker Inc., personal fees from Wolters Kluwer Health Inc., and personal fees from Globus Medical Inc., outside the submitted work. In addition, Dr. Buchowski has a patent CAPRI (spinal fixation device) with royalties paid to K2M Inc. and AO Foundation (parent organization to AOSpine), “other,” “teaching,” and “not for profit organization.”
Lukas Zebala reports personal fees from K2M, personal fees from Ulrich Medical USA, personal fees from Broadwater, personal fees from K2M, non-financial support from Scoliosis Research Society, non-financial support from Depuy Synthes Spine, non-financial support from Medtronic, and non-financial support from Nuvasive, outside the submitted work.
Human and animal rights and informed consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
Papers of particular interest, published recently, have been highlighted as: • Of importance
- 11.• Bush L, Brookshire R, Roche B, Johnson A, Cole F, Karmy-Jones R, Long W, Martin MJ. Evaluation of cervical spine clearance by computed tomographic scan alone in intoxicated patients with blunt trauma. JAMA Surg. 2016;151(9):807–13. This prospective observational study has high potential to change medical decision making processes not only for spine surgeons but also for emergency room physicians. It provides sound evidence that CT scan can be used to clear cervical spine injuries in the intoxicated patient therefore preventing a delay in clearance and unnecessary cervical immobilization.Google Scholar
- 12.• Chew BG, Swartz C, Quigley MR, Altman DT, Daffner RH, Wilberger JE. Cervical spine clearance in the traumatically injured patient: is multidetector CT scanning sufficient alone? Clinical article. J Neurosurg Spine. 2013;19(5):576–81. This study may provide guidance on the use of CT scan to clear cervical of injuries in polytrauma patients in which many distracting variable exist. The results of this study can have meaningful impact in cutting down on the use of unnecessary and costly additional imaging tools such as magnetic resonance imaging.CrossRefPubMedGoogle Scholar
- 13.• Mascarenhas D, Dreizin D, Bodanapally UK, Stein DM. Parsing the utility of CT and MRI in the Subaxial Cervical Spine Injury Classification (SLIC) System: is CT SLIC enough? AJR Am J Roentgenol. 2016;206(6):1292–7. This study helps define the role of MRI for evaluation of cervical spine injuries. It demonstrates that CT scan alone may be accurate enough for the initial triage of trauma patients to evaluate for cervical spine injury. MRI provides little benefit in conjunction with CT scan for the initial evaluation of the patient and may be reserved for surgical planning. Overall this study will help decrease the number of unnecessary and costly MRI studies orders.CrossRefPubMedGoogle Scholar
- 14.• Pourtaheri S, Emami A, Sinha K, Faloon M, Hwang K, Shafa E, et al. The role of magnetic resonance imaging in acute cervical spine fractures. Spine J. 2014;14(11):2546–53. This study better defines the role of MRI in evaluating for potential cervical spine injuries which can help decrease the number of MR orders that are not only unnecessary but cost-inefficient.CrossRefPubMedGoogle Scholar
- 23.Kepler CK, Vaccaro AR, Koerner JD, et al. Reliability analysis of the AOSpine Thoracolumbar Spine Injury Classification System by a worldwide group of naive spinal surgeons. Eur Spine J. 2015.Google Scholar
- 24.• Vaccaro AR, Koerner JD, Radcliff KE, Oner FC, Reinhold M, Schnake KJ, et al. AOSpine Subaxial Cervical Spine Injury Classification System. Eur Spine J. 2016;25(7):2173–84. Previously, several cervical spine injury classification systems existed however now were universally accepted, validated and reliable. This study outlines a new comprehensive classification system for cervical spine injuries that includes a high intra- and interobserver reliability that allows for appropriate diagnosis, decision making and use as a research tool.CrossRefPubMedGoogle Scholar
- 25.Urrutia J, Zamora T, Yurac R, Campos M, Palma J, Mobarec S, Prada C. An independent inter- and intra-observer agreement evaluation of the AOSpine Subaxial Cervical Spine Injury Classification. Spine (Phila Pa 1976). 2015.Google Scholar
- 26.Silva OT, Sabba MF, Lira HI, Ghizoni E, Tedeschi H, Patel AA, Joaquim AF. Evaluation of the reliability and validity of the newer AOSpine Subaxial Cervical Injury Classification (C-3 to C-7). J Neurosurg Spine. 2016: 1-6.Google Scholar
- 32.• Furlan JC, Craven BC, Massicotte EM, Fehlings MG. Early versus delayed surgical decompression of spinal cord after traumatic cervical spinal cord injury: a cost-utility analysis. World Neurosurg. 2016;88:166–74. It is imperative to make cost conscious decisions in our current medical environment given the rising cost of healthcare and limited available resources. This study provides data that can impact spine surgeon decision making that not only provides optimal patient outcomes but also provides a service in a cost effective manner.CrossRefPubMedGoogle Scholar