A total of 272 surgeons were surveyed with 161 (59.2%) surgeons responding. A summary of surgeon demographics is presented in Table 1. The median number of spine trauma patients treated per year per surgeon was 50 (IQR 20-100). “Surgeon variation” will refer to the differences among surgeon respondents with regard to years of experience (< 5, 5–10, 11–20, > 20), surgical subspecialty (Orthopedic Spine, Neurosurgery Spine, Other), region (North/Latin/South America, Europe, Africa/Asia/Middle East), and practice setting (academic, hospital-employed, private practice). Academic practice setting includes significant time dedicated to patient care, research, and education of medical trainees, while hospital employment focuses mainly on patient care. Both academicians and hospital-employed surgeons are employees of the hospital, in contrast to private practitioners.
Preferred subaxial spine classification system
The preferred subaxial spine injury classification system for all respondents was as follows: AO Spine SCICS 71.9%, Subaxial Cervical Spine Injury Classification system (SLIC) 18.1%, and Magerl system 2.5%. Of respondents, 7.5% do not routinely use a classification system (Table 2). The AO Spine SCICS is used by the majority of respondents from all world regions except for North America, where it is used by 47.1% of surgeons and the SLIC system is used by 41.2% of surgeons (Supplemental Table 1). Academicians used the AO Spine SCICS less frequently (64.6%) compared to hospital-employed and private practice surgeons (75.4% and 87.5%, respectively) (p = 0.304). There were no statistically significant differences in the preferred subaxial cervical injury classification system based on surgeon variation.
Use of AO spine facet fracture classification system
Overall, 106 (71.6%) respondents regularly use the facet portion of the AO Spine SCICS. Significantly fewer academic respondents (61.6%) used this portion of the classification system than did hospital-employed and private practice surgeons (81.1% and 81.8%, respectively) (p = 0.029) (Table 2). There was no significant difference in the use of the facet portion of the AO Spine SCICS when grouping raters by years of experience, surgical subspecialty, or by region. Ungrouped summary of the preferred subaxial classification system and use of the facet portion of the AO Spine SCICS is presented in Supplemental Table 1.
Operative versus nonoperative management
Respondent preferences for initial management strategy regarding facet fracture subtypes with various degrees of neurologic injury are presented in Table 3. For all clinical scenarios, there was no statistically significant difference in management choice based on surgeon experience or practice setting (Table 4). When evaluated by subspecialty, the only significant difference in treatment was for F1N1 fractures where neurosurgeons were more likely to recommend surgical treatment than orthopedic spine surgeons, 20.8% vs 7.0%, respectively (p = 0.012). When evaluated by region, there was only a significant difference in management of floating lateral mass fractures, specifically F3N0 and F3N1 fractures. For F3N0 fractures, 74.1%, 59.2%, and 49.0% of North/Latin/South America, Europe, and Africa/Asia/Middle East respondents chose operative treatment, respectively (p = 0.025). And while the majority agreed on operative treatment for F3N1 fractures, significantly less surgeons from Africa/Asia/Middle East (52.0%) and Europe (63.3%) recommended surgery than respondents from North/Latin/South America (84.5%) (p = 0.001). Ungrouped summary of operative versus nonoperative management preferences for facet fracture subtypes is presented in Supplemental Table 2.
Preferred type of operative/nonoperative management
For the preferred type of operative and nonoperative management, not all participants had the possibility of answering the question depending on their response to the overlying question of operative vs nonoperative management. As a result, no statistical comparisons could be performed due to conditional probability. Ungrouped summary of the preferred nonoperative and operative method of management for fracture subtypes is presented in Supplemental Tables 3 and 4, respectively.
Preferred imaging in work-up and treatment
Summary of imaging modalities used in the work-up of F1, F2, and F3 fractures is presented in Table 5. More than 95.7% of surgeons routinely use CT imaging regardless of facet fracture subtype. Comparison of the need for MRI in the decision between operative and nonoperative treatment is presented in Table 6. There was no statistically significant difference in the use of MRI for decision making for facet fracture subtypes based on surgeon variation, with a stepwise increase in the use of MRI for F1–F3 fractures (42.2–68.7%).