Subaxial Cervical Spine Trauma Research Articles

The Development and Evaluation of the Subaxial Injury Classification Scoring System for Cervical Spine Trauma

Fractures and dislocations of the subaxial cervical spine may give rise to devastating consequences. Previous algorithms for describing cervical trauma largely depend on retrospective reconstructions of injury mechanism and utilize nonspecific terminology which thus diminish their clinical relevance add to the difficulty of educating doctors and performing prospective research. We characterized the potential benefits of the Subaxial Injury Classification (SLIC) scale which considers three major variables that influence spinal stability: morphology, integrity of the discoligamentous complex, and neurologic status. Each category was assigned a certain number of points based on the severity of the injury which are added together to generate a total score; this value provides prognostic information and may also be useful for directing subsequent management (ie, nonoperative treatment versus operative intervention). We examined the individual components that comprise the SLIC paradigm and reviewed the manner in which cervical injuries are scored and stratified. We also critically assessed the preliminary data comparing the SLIC scheme to preexisting classification systems. The results of a preliminary analysis demonstrate that the intraclass coefficients (ICC) for the three primary components range between 0.49 and 0.90, suggesting that the overall reliability of the SLIC system appears to be at least as good as that of other conventional schemes for classifying subaxial cervical spine trauma (ICC between 0.41 and 0.53). This scheme will hopefully facilitate the development of evidence-based guidelines that may influence other aspects of the therapeutic decision-making process (eg, which operative approach is most appropriate for a particular injury). We anticipate its accuracy and reproducibility will increase over time as surgeons become more familiar with the protocol.

Subaxial cervical spine trauma classification: the Subaxial Injury Classification system and case examples

Object The authors review a novel subaxial cervical trauma classification system and demonstrate its application through a series of cervical trauma cases. Methods The Spine Trauma Study Group collaborated to create the Subaxial Injury Classification (SLIC) and Severity score. The SLIC system is reviewed and is applied to 3 cases of subaxial cervical trauma. Results The SLIC system identifies 3 major injury characteristics to describe subaxial cervical injuries: injury morphology, discoligamentous complex integrity, and neurological status. Minor injury characteristics include injury level and osseous fractures. Each major characteristic is assigned a numerical score based upon injury severity. The sum of these scores constitutes the injury severity score. Conclusions By addressing both discoligamentous integrity and neurological status, the SLIC system may overcome major limitations of earlier classification systems. The system incorporates a number of critical clinical variables-including neurological status, absent in earlier systems-and is simple to apply and may provide both diagnostic and prognostic information.

Letters

Study design Systematic review of literature and expert clinical opinions of the members of the Spine Trauma Study Group were combined to develop and refine this algorithm. Objective To develop an evidence-based algorithm for surgical approaches to manage subaxial cervical injuries using a systematic review of the literature, expert opinion, and anticipated patient preferences. Summary of background data There is lack of consensus in the management of subaxial cervical spine trauma, in part, because of the lack of a clinically relevant system for classifying these injuries. The newly developed Subaxial Injury Classification scoring system categorizes injury morphology into 3 broad groups, includes an assessment of the integrity of the discoligamentous soft tissue structures and the patient's neurologic status, and thus guides surgical or nonsurgical treatment. The choice of a specific surgical technique and approach is currently not evidence based, and this gap in knowledge is one which the current article seeks to address. Methods A literature review followed by a consensus of experts approach was used to develop the algorithm and to ensure face and content validity. Results An algorithm is presented to guide the choice of surgical approach in cervical subaxial burst fractures, distraction injuries, and translation or rotation injuries. The burst or compression injuries and distraction injuries are more likely to be treated with a single anterior approach, whereas the more severe translation or rotation injuries may more commonly be approached posteriorly or with combined anterior and posterior surgery. Conclusion This algorithm; derived from the Subaxial Injury Classification scoring system, will assist surgeons in answering the 2 most common questions they face when managing subaxial cervical spine trauma: "Should I operate?" and "Which surgical approach should I select?"

The Surgical Approach to Subaxial Cervical Spine Injuries

Systematic review of literature and expert clinical opinions of the members of the Spine Trauma Study Group were combined to develop and refine this algorithm. To develop an evidence-based algorithm for surgical approaches to manage subaxial cervical injuries using a systematic review of the literature, expert opinion, and anticipated patient preferences. There is lack of consensus in the management of subaxial cervical spine trauma, in part, because of the lack of a clinically relevant system for classifying these injuries. The newly developed Subaxial Injury Classification scoring system categorizes injury morphology into 3 broad groups, includes an assessment of the integrity of the discoligamentous soft tissue structures and the patient's neurologic status, and thus guides surgical or nonsurgical treatment. The choice of a specific surgical technique and approach is currently not evidence based, and this gap in knowledge is one which the current article seeks to address. A literature review followed by a consensus of experts approach was used to develop the algorithm and to ensure face and content validity. An algorithm is presented to guide the choice of surgical approach in cervical subaxial burst fractures, distraction injuries, and translation or rotation injuries. The burst or compression injuries and distraction injuries are more likely to be treated with a single anterior approach, whereas the more severe translation or rotation injuries may more commonly be approached posteriorly or with combined anterior and posterior surgery. This algorithm; derived from the Subaxial Injury Classification scoring system, will assist surgeons in answering the 2 most common questions they face when managing subaxial cervical spine trauma: "Should I operate?" and "Which surgical approach should I select?"

The Subaxial Cervical Spine Injury Classification System

The classification system was derived through a literature review and expert opinion of experienced spine surgeons. In addition, a multicenter reliability and validity study of the system was conducted on a collection of trauma cases. To define a novel classification system for subaxial cervical spine trauma that conveys information about injury pattern, severity, treatment considerations, and prognosis. To evaluate reliability and validity of this system. Classification of subaxial cervical spine injuries remains largely descriptive, lacking standardization and prognostic information. Clinical and radiographic variables encountered in subaxial cervical trauma were identified by a working section of the Spine Trauma Study Group. Significant limitations of existing systems were defined and addressed within the new system. This system, as well as the Harris and Ferguson & Allen systems, was applied by 20 spine surgeons to 11 cervical trauma cases. Six weeks later, the cases were randomly reordered and again scored. Interrater reliability, intrarater reliability, and validity were assessed. Each of 3 main categories (injury morphology, disco-ligamentous complex, and neurologic status) identified as integrally important to injury classification was assigned a weighted score; the injury severity score was obtained by summing the scores from each category. Treatment options were assigned based on threshold values of the severity score. Interrater agreement as assessed by intraclass correlation coefficient of the DLC, morphology, and neurologic status scores was 0.49, 0.57, and 0.87, respectively. Intrarater agreement as assessed by intraclass correlation coefficient of the DLC, morphology, and neurologic status scores was 0.66, 0.75, and 0.90, respectively. Raters agreed with treatment recommendations of the algorithm in 93.3% of cases, suggesting high construct validity. The reliability compared favorably to the Harris and Ferguson & Allen systems. The Sub-axial Injury Classification and Severity Scale provides a comprehensive classification system for subaxial cervical trauma. Early validity and reliability data are encouraging.

Posterior stabilization of subaxial cervical spine trauma: indications and techniques

The use of instrumentation for stabilization following cervical trauma has evolved rapidly in the past few decades. Nonoperative maneuvers, including traction, extended bed rest, and cast immobilization, have given way to wiring or screw rod constructs that allow immediate fixation and early mobilization of the patient. These procedures can be performed soon after trauma and with a minimum of surgical risk. They offer immediate stability of the injured spine, and can prevent the sequelae of acute cervical spinal cord injury that may accompany prolonged bed rest, thus allowing early rehabilitation and the potential for improved recovery. Current techniques for posterior cervical spine stabilization following trauma include spinous process or facet wiring [1-9], lateral mass plating [10-18], and cervical pedicle screws [19-27]. Several radiological tools, including MRI [28] and reformatted CT, yield precise details of the injured spine and allow the treating physician to determine which, if any, fixation technique offers the best chance of recovery with the least amount of risk. The goals of surgery following acute cervical spine injury include decompressing the injured spinal cord or nerve root, maintaining alignment, providing stability to the spine, promoting healing and fusion, and allowing early mobilization. This article will review indications for posterior cervical spine surgery, as well as the techniques that are currently available to help achieve the above-noted goals. We also report a recent retrospective review of 5-year data in treating posterior cervical trauma with lateral mass and pedicle screw fixation.