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Conundrum in surgical management of three-column injuries in sub-axial cervical spine: a systematic review and meta-analysis


Study design

Systematic Review and Meta-analysis.


Three-column injuries making the spine unstable require adequate fixation which can be achieved by anterior alone, posterior alone or combined anterior–posterior approach. There is no general consensus till date on a single best approach in sub-axial cervical spine trauma. This study comparing the three approaches is an attempt to establish a firmer guideline in this disputed topic.

Material and methods

The protocol was registered with PROSPERO. PubMed, Embase and Google Scholar were searched for relevant literature. For each study, pre-defined data were extracted which included correction of kyphosis, loss of correction, hospital stay, operative time, blood loss during surgery as the outcome variables. Studies were also screened for the complications.


Eleven studies were evaluated for qualitative analysis and quantitative synthesis of the data in our review. The result demonstrated significant difference with most correction achieved in combined approach subgroup. Though no significant difference was found, the anterior group was having maximum loss of correction. Combined approach showed significantly more operative time and blood loss followed by posterior approach and then anterior approach alone. The improvement in VAS was significantly more in anterior subgroup when compared to combined approach.


Cervical alignment is best restored by combined approach compared to the other two. Anterior only approach showed more correction than posterior approach. However, there is no significant difference between all three approaches in loss of correction at long-term follow-up. Anterior only approach is superior to posterior and combined approach on basis of intraoperative and perioperative parameters.

Level of Evidence I

Diagnostic: individual cross-sectional studies with the consistently applied reference standard and blinding.

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Author information

Authors and Affiliations



SS contributed to conception and design, data acquisition, analysis of data, and drafting of the manuscript. NG contributed to conception and design, data acquisition, analysis of data, and drafting of the manuscript. KA contributed to analysis of data and critical revision. SI contributed to analysis of data and critical revision. Samarth Mittal contributed to analysis of data and critical revision. GY contributed to analysis of data and critical revision. PVS contributed to analysis of data and critical revision. BS contributed to analysis of data, administrative support and supervision. PK analysis of data, administrative support, and supervision.

Corresponding author

Correspondence to Pankaj Kandwal.

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There are no study-specific conflicts of interest-associated biases to be disclosed by any of the authors.

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Sethy, S.S., Goyal, N., Ahuja, K. et al. Conundrum in surgical management of three-column injuries in sub-axial cervical spine: a systematic review and meta-analysis. Eur Spine J 31, 301–310 (2022).

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  • Cervical spine
  • Spine trauma
  • Three-column injury
  • Anterior approach
  • Posterior approach
  • Combined approach