Subaxial Cervical Spine Trauma Research Articles

Validation of the Subaxial Cervical Spine Injury Classification score in children: a single-institution experience at a level 1 pediatric trauma center.

The Subaxial Cervical Spine Injury Classification (SLIC) score has not been previously validated for a pediatric population. The authors compared the SLIC treatment recommendations for pediatric subaxial cervical spine trauma with real-world pediatric spine surgery practice. A retrospective cohort study at a pediatric level 1 trauma center was conducted in patients < 18 years of age evaluated for trauma from 2012 to 2021. An SLIC score was calculated for each patient, and the subsequent recommendations were compared with actual treatment delivered. Percentage misclassification, sensitivity, specificity, positive (PPV) and negative predictive value (NPV), and area under the receiver operating characteristic (ROC) curve (AUC) were calculated. Two hundred forty-three pediatric patients with trauma were included. Twenty-five patients (10.3%) underwent surgery and 218 were managed conservatively. The median SLIC score was 2 (interquartile range = 2). Sixteen patients (6.6%) had an SLIC score of 4, for which either conservative or surgical treatment is recommended; 27 children had an SLIC score ≥ 5, indicating a recommendation for surgical treatment; and 200 children had an SLIC score ≤ 3, indicating a recommendation for conservative treatment. Of the 243 patients, 227 received treatment consistent with SLIC score recommendations (p < 0.001). SLIC sensitivity in determining surgically treated patients was 79.2% and the specificity for accurately determining who underwent conservative treatment was 96.1%. The PPV was 70.3% and the NPV was 97.5%. There was a 5.7% misclassification rate (n = 13) using SLIC. Among patients for whom surgical treatment would be recommended by the SLIC, 29.6% (n = 8) did not undergo surgery; similarly, 2.5% (n = 5) of patients for whom conservative management would be recommended by the SLIC had surgery. The ROC curve for determining treatment received demonstrated excellent discriminative ability, with an AUC of 0.96 (OR 3.12, p < 0.001). Sensitivity decreased when the cohort was split by age (< 10 and ≥ 10 years old) to 0.5 and 0.82, respectively; specificity remained high at 0.98 and 0.94. The SLIC scoring system recommended similar treatment when compared with the actual treatment delivered for traumatic subaxial cervical spine injuries in children, with a low misclassification rate and a specificity of 96%. These findings demonstrate that the SLIC can be useful in guiding treatment for pediatric patients with subaxial cervical spine injuries. Further investigation into the score in young children (< 10 years) using a multicenter cohort is warranted.

Comparison of Anterior versus Posterior Fixation in Traumatic Subaxial Cervical Spine Subluxation in Terms of Intraoperative Blood Loss, Surgical Time, and Length of Hospital Stay: A Prospective Observational Study

Abstract Objective The aim of this study was to compare the outcome of anterior versus posterior fixation for traumatic subaxial cervical spine subluxation in terms of mean intraoperative blood loss, surgical time, and length of hospital stay. Materials and Methods A prospective observational study was conducted from August 25, 2022 to August 24, 2023 at the Department of Neurosurgery, Punjab Institute of Neurosciences, Lahore, Pakistan, including 60 patients (30 in each group) fulfilling the inclusion criteria. Group A had anterior cervical fixation, while group B underwent posterior cervical fixation. Patients were monitored for intraoperative blood loss, surgical time, and length of hospital stay. All the results were collected and recorded on a proforma. Results The mean age of the patients in group A was 45.40 ± 3.75 years and that in group B was 45.50 ± 4.13 years. In all, 48.8% (n = 21) were males and 52.9% (n = 9) were females in group A, while 51.2% (n = 22) were males and 47.1% (n = 8) were females in group B. The mean intraoperative blood loss was 71.60 ± 0.77 mL in group A and 101.76 ± 0.85 mL in group B. The mean surgical time was 72.73 ± 0.98 minutes in group A and 94.73 ± 0.58 minutes in group B. The mean length of hospital stay was 7.63 ± 0.55 days in group A and 12.80 ± 0.71 days in group B. Conclusion It was concluded that the anterior approach is better than the posterior approach for traumatic subaxial cervical subluxation spine in terms of low blood loss, less surgical time, and reduced hospital stay.

Predictors of failure after primary anterior cervical discectomy and fusion for subaxial traumatic spine injuries

IntroductionTraumatic subaxial fractures account for more than half of all cervical spine injuries. The optimal surgical approach is a matter of debate and may include anterior, posterior or a combined anteroposterior (360º) approach. Analyzing a cohort of patients initially treated with anterior cervical discectomy and fusion (ACDF) for traumatic subaxial injuries, the study aimed to identify predictors for treatment failure and the subsequent need for supplementary posterior fusion (PF).MethodsA retrospective, single center, consecutive cohort study of all adult patients undergoing primary ACDF for traumatic subaxial cervical spine fractures between 2006 and 2018 was undertaken and 341 patients were included. Baseline clinical and radiological data for all included patients were analyzed and 11 cases of supplementary posterior fixation were identified.ResultsPatients were operated at a median of 2.0 days from the trauma, undergoing 1-level (78%), 2-levels (16%) and ≥ 3-levels (6.2%) ACDF. A delayed supplementary PF was performed in 11 cases, due to ACDF failure. On univariable regression analysis, older age (p = 0.017), shorter stature (p = 0.031), posterior longitudinal ligament (PLL) injury (p = 0.004), injury to ligamentum flavum (p = 0.005), bilateral facet joint dislocation (p < 0.001) and traumatic cervical spondylolisthesis (p = 0.003) predicted ACDF failure. On the multivariable regression model, older age (p = 0.015), PLL injury (p = 0.048), and bilateral facet joint dislocation (p = 0.010) remained as independent predictors of ACDF failure.ConclusionsACDF is safe and effective for the treatment of subaxial cervical spine fractures. High age, bilateral facet joint dislocation and traumatic PLL disruption are independent predictors of failure. We suggest increased vigilance regarding these cases.

The Effect of Concomitant Spinal Cord Injury on Postoperative Health-related Quality of Life After Traumatic Subaxial Cervical Spine Injuries: A Nationwide Registry Study

ObjectiveTo evaluate the effect of spinal cord injury (SCI) on the health-related quality of life (HRQoL) in patients surgically treated for traumatic subaxial cervical spine injuries and investigate the agreement between objective neurologic outcomes and patient reported outcome measures (PROMs) in that context. Study DesignObservational study on prospectively collected multi-institutional registry data. SettingSweden. ParticipantsPatients with traumatic subaxial spine injuries identified in the Swedish Spine Registry (Swespine) between 2006 and 2016. InterventionsAnterior, posterior, or anteroposterior cervical fixation surgery. Main OutcomesPatient-reported outcome measures (PROMs) consisting of EQ-5D-3Lindex and Neck Disability Index (NDI). ResultsAmong the 418 identified patients, 93 (22%) had a concomitant SCI. In this group, 30 (32%) had a complete SCI (Frankel A), and the remainder had incomplete SCIs (17%) Frankel B; 25 (27%) Frankel C; 22 (24%) Frankel D. PROMs significantly correlated with the Frankel grade (P<.001). However, post hoc analysis revealed that the differences between adjacent Frankel grades failed to reach both statistical and clinical significance. On univariable linear regression, the Frankel grade was a significant predictor of a specific index derived from the EQ-5D-3L questionnaire (EQ-5D-3Lindex) at 1, 2, and 5 years postoperatively as well as the NDI at 1 and 2 years postoperatively (P<.001). Changes of PROMs over time from 1, to 2, and 5 years postoperatively did not reach statistical significance, regardless of the presence and degree of SCI (P>.05). ConclusionOverall, the Frankel grade significantly correlated with the EQ-5D-3Lindex and NDI and was a significant predictor of PROMs at 1, 2, and 5 years. PROMs were stable beyond 1 year postoperatively regardless of the severity of the SCI.

Is it true that treatment in patients with Subaxial Cervical Spine Injury Classification System (SLICS) 4 is the surgeon's choice?

The Subaxial Cervical Spine Injury Classification System (SLICS) is a commonly used algorithm for diagnosing and managing subaxial cervical spine trauma. A SLIC score 4 suggests either surgery or non-surgically treatment depending on the surgeon's experience and patient's conditions. Prognosis and treatment results were analyzed in patients with SLIC score 4. The patients with SLIC score 4 were retrospectively reviewed from 2012 to 2019. Forty-one patients were included and divided into two groups: non-surgically treated and surgically treated. Demographic data and radiographs were analyzed. Statistical analysis was performed to determine the difference between the two clinical groups. Twenty-two patients were non-surgically treated, and nineteen patients were surgically treated. There was no neurological deterioration in both groups. However, there was no statistically significant difference in the last follow-up AISA and Nurick grade (p> 0.05). There was no significant difference in the number of patients who showed improvement when comparing the initial and the last follow-up neurological status (p> 0.05). Regardless of the treatment method, the spinal cord injury patients with SLICS point 4 showed a relatively good prognosis. Patients with SLIC score 4 could be treated non-surgically or surgically based on the surgeon's experience and factors associated with the patient's acute health status and chronic comorbidities.

Timing of Surgery and Pre-operative Physiological Parameters as Clinical Predictors of Surgical Outcomes in Traumatic Subaxial Cervical Spine Fractures and Dislocations.

Objective To evaluate the risk factors and outcomes in patients surgically treated for subaxial cervical spine injuries with respect of the timing of surgery and preoperative physiological parameters of the patient. Methods 26 patients with sub-axial cervical spine fractures and dislocations were enrolled. Demographic data of patients, appropriate radiological investigation, and physiological parameters like respiratory rate, blood pressure, heart rate, PaO2 and ASIA impairment scale were documented. They were divided pre-operatively into 2 groups. Group U with patients having abnormal physiological parameters and Group S including patients having physiological parameters within normal range. They were further subdivided into early and late groups according to the timing of surgery as U early , U late, S early and S late . All the patients were called for follow-up at 1, 6 and 12 months. Results 56 percent of patients in Group S had neurological improvement by one ASIA grade and a good outcome irrespective of the timing of surgery. Patients in Group U having unstable physiological parameters and undergoing early surgical intervention had poor outcomes. Conclusion This study concludes that early surgical intervention in physiologically unstable patients had a strong association as a risk factor in the final outcome of the patients in terms of mortality and morbidity. Also, no positive association of improvement in physiologically stable patients with respect to the timing of surgery could be established.

Socio-Demographic Profile of Patients Victims of Subaxial Cervical Spine Trauma at the University Hospital of Brazzaville (Congo)

Socio-Demographic Profile of Patients Victims of Subaxial Cervical Spine Trauma at the University Hospital of Brazzaville (Congo)

Epidemiology and Surgical Outcome of Traumatic Sub Axial Cervical Spine Injuries in a Tertiary Care Hospital of KPK, Pakistan

Objective: The purpose of this study was to characterize the epidemiologic characteristics, a pattern of traumatic subaxial cervical spine injuries, and their surgical outcomes in a tertiary care hospital in Khyber Pakhtunkhwa, Pakistan. Materials and Methods: This retrospective descriptive study was conducted at the Department of Neurosurgery at Lady Reading Hospital Peshawar. The records of 40 patients between the ages of 15 and 60 who had cervical spine injuries were evaluated to characterize the injuries and surgical outcomes. We employed the anterior route for surgery regularly and the posterior method only when the reduction failed or substantial instability. We used a tricortical bone graft or titanium cages with autologous bone and secured them through titanium plates to achieve fusion. Results: 80% of patients presented with sub axial cervical injury. Regarding the etiology of injury, 37.5 % had motor vehicle accidents, 28.12% had a history of height falls, and the remaining had sustained injuries due to other causes. The majority of the patients, 68.75% (n = 22), had isolated subluxation injury.87.5% (n = 28) underwent surgical intervention; surgical outcomes such as pain relief were measured using the VAS, which was 6.09 ± 1.42 preoperatively while 4.5 ± 1.29 postoperatively with a difference of means of 1.59. There was a significant improvement in neurological functions as measured through the ASIA impairment scale. Conclusion: Most cervical spine injuries occurred in young male patients, motor vehicle accidents were the most prevalent cause, and isolated subluxation was the most frequent injury pattern.

Observational retrospective study of subaxial cervical spine trauma at tertiary care centre

The aim of this study is to compare between various treatment modalities available for treatment of subaxial cervical spine injuries due to trauma A total of 172 patients of subaxial cervical spine injuries were assessed retrospectively about their mode of injury, clinical course, definitive treatment given and its outcome. As the study was Descriptive and retrospective in nature involving only patient case files, statistical test is not applied to the study In our study 44 patients suffered from vertebral body fracture while 108 patients had spinal canal compromise due to other injuries. 16 patients had quadriplegia, 24 patients had grade 4 power in upper and lower extremities, and roots were involved in 46 patients. In 44 patients complete corpectomy was performed with placement of tricorticate graft taken from fibula, this graft was fixed in place with titanium plate and four screws.From this study it can be concluded that Patients treated with anterior approach had better outcome in relation to the fixation and fusion of the spine, reconstruction is more better in anterior approach.

Variations in management of A3 and A4 cervical spine fractures as designated by the AO Spine Subaxial Injury Classification System.

Optimal management of A3 and A4 cervical spine fractures, as defined by the AO Spine Subaxial Injury Classification System, remains controversial. The objectives of this study were to determine whether significant management variations exist with respect to 1) fracture location across the upper, middle, and lower subaxial cervical spine and 2) geographic region, experience, or specialty. A survey was internationally distributed to 272 AO Spine members across six geographic regions (North America, South America, Europe, Africa, Asia, and the Middle East). Participants' management of A3 and A4 subaxial cervical fractures across cervical regions was assessed in four clinical scenarios. Key characteristics considered in the vignettes included degree of neurological deficit, pain severity, cervical spine stability, presence of comorbidities, and fitness for surgery. Respondents were also directly asked about their preferences for operative management and misalignment acceptance across the subaxial cervical spine. In total, 155 (57.0%) participants completed the survey. Pooled analysis demonstrated that surgeons were more likely to offer operative intervention for both A3 (p < 0.001) and A4 (p < 0.001) fractures located at the cervicothoracic junction compared with fractures at the upper or middle subaxial cervical regions. There were no significant variations in management for junctional incomplete (p = 0.116) or complete (p = 0.342) burst fractures between geographic regions. Surgeons with more than 10 years of experience were more likely to operatively manage A3 (p < 0.001) and A4 (p < 0.001) fractures than their younger counterparts. Neurosurgeons were more likely to offer surgical stabilization of A3 (p < 0.001) and A4 (p < 0.001) fractures than their orthopedic colleagues. Clinicians from both specialties agreed regarding their preference for fixation of lower junctional A3 (p = 0.866) and A4 (p = 0.368) fractures. Overall, surgical fixation was recommended more often for A4 than A3 fractures in all four scenarios (p < 0.001). The subaxial cervical spine should not be considered a single unified entity. Both A3 and A4 fracture subtypes were more likely to be surgically managed at the cervicothoracic junction than the upper or middle subaxial cervical regions. The authors also determined that treatment strategies for A3 and A4 subaxial cervical spine fractures varied significantly, with the latter demonstrating a greater likelihood of operative management. These findings should be reflected in future subaxial cervical spine trauma algorithms.

Contiguous-Level Unilateral Cervical Spine Facet Dislocation-A Report of a Less Discussed Subtype.

Unilateral facet dislocation of subaxial cervical spine trauma is characterized by dislocation of inferior facet of superior vertebra over the superior facet of inferior vertebra. The injury is due to high-velocity trauma and associated with instability of spinal column. Such unilateral facet dislocations occurring at multiple adjacent levels for some reason are not reported or studied frequently. We have reported two cases of multiple-level dislocation of unilateral facets managed in our hospital with a review of available literature. The injury occurs as one side of the motion segment translates and rotates around an intact facet on the contralateral side. The major mechanism of injury is distractive flexion injury with axial rotation component. The injury is associated with instability secondary to loss of the discoligamentous complex. In cases with multiple-level dislocations of unilateral cervical facets, there are multiple mechanisms associated with significant neurological injury and most of them succumb at the site of injury. Only three other cases are available in English language literature. The neurological outcome is invariably poor. Multiple-level facet dislocations of subaxial cervical spine are reported sparsely in literature. We suspect that due to high-velocity nature of these injuries, most of them succumb soon after injury and not often reported. This article reports two cases of contiguous-level unilateral facet dislocation of subaxial cervical spine with associated injuries and the outcomes with review of literature.

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

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

260. Comparing outcomes and mortality of upper cervical and subaxial cervical spine trauma in elderly patients

<h3>BACKGROUND CONTEXT</h3> In contrast to younger patients, the elderly are more likely to sustain severe cervical spine trauma from relatively low energy mechanisms of injury. The presence of preexisting spine pathology such as osteoporosis, cervical stenosis, ankylosis, spondylosis, and degenerative changes can predispose elderly patients to fractures and neurologic injury in both the upper and subaxial cervical spine. <h3>PURPOSE</h3> To date, there has been little research comparing outcomes and mortality rates of patients with upper cervical (occiput-C2) versus subaxial (C3-C7) cervical spine injuries. Given the paucity of data on this subject, this current study compares mortality rates and outcomes between elderly patients with upper cervical and subaxial cervical spine injuries using our prospective trauma database. <h3>STUDY DESIGN/SETTING</h3> Using data extracted from our clinical trauma registry, we conducted a single center retrospective cohort study. Retrospective chart review was performed to assess treatment rendered, complications, and outcome measures and then stored in a deidentified database. <h3>PATIENT SAMPLE</h3> All elderly (65+) trauma patients with cervical spine injuries who presented to a single, high-volume, level I trauma center between 2010-2019 were identified. <h3>OUTCOME MEASURES</h3> Outcomes such as medical and surgical complication rates, length of hospitalization, and mortality at various time points were collected. <h3>METHODS</h3> Imaging characteristics of patients including psoas index (a marker for sarcopenia) and L3 Hounsfield Unit (an indicator of osteoporosis) were calculated using standard technique and recorded into the database. Patients with cervical spine trauma were sorted into upper cervical (occipital condyle, C1, and C2 vertebral fractures and ligamentous injuries) and subaxial (C3-7) cohorts and by treatment (operative vs nonoperative management). Surgical and medical morbidity variables recorded include surgical site infection, pneumonia, STEMI, DVT/PE and stroke. Pearson's Chi-squared tests were used to compare rates of mortality and complications between groups. <h3>RESULTS</h3> A total of 922 patients were identified, with 545 upper cervical (59%), and 377 subaxial (41%) trauma patients. Patients with upper cervical spine trauma were significantly older (p<0.001), more sarcopenic (p=0.002), osteoporotic (p=0.002), and had higher rates of dementia (p=0.003). There was no significant difference in cardiac or pulmonary comorbidities between the two groups (p=0.7). Patients with subaxial injuries had a higher injury burden, with significantly higher Injury Severity Scale (ISS) scores (p=0.008), non-contiguous spine injuries (p=0.016), closed head injury (p=0.04), and pelvic fractures (p=0.04). Comparing operative cohorts, there was a statistically significant higher proportion of medical and surgical complications in the upper cervical group (p=0.006), and specifically a higher incidence of pneumonia (p=0.009). There was also found to be higher overall mortality in all upper cervical injuries both operative and nonoperatively managed as compared to the subaxial cohort (p=0.015). There was no significant difference in in-hospital mortality between the two groups (p=0.25). <h3>CONCLUSIONS</h3> Although patients with subaxial injuries were found to be more severely traumatized with higher energy mechanisms and more severe associated injuries, our data demonstrate that patients with upper cervical trauma are at higher risk for medical and surgical complication and mortality, regardless of need for operative intervention. This is likely secondary to poor reserve given their older age, advanced sarcopenia, and the increased morbidity associated with both operative management and nonoperative immobilization. In conclusion, we have demonstrated in the largest study to date that patients with upper cervical injuries, although less severely traumatized, should be more critically evaluated given their increased risk for morbidity and mortality, which can help guide discussions with the patient and family about expected outcomes and functional status. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

Traumatic subaxial cervical spine injury - Improving initial evaluation through correlation of diffusion tensor imaging and subaxial cervical spine injury classification SLIC score.

Background: Traumatic injury to spine and spinal cord represents a devastating condition, with a huge risk for permanent severe disabilities. Predicting the long-term outcome in this type of trauma is a very difficult task being under the influence of a wide spectrum of biomechanical and pathophysiological factors. The advent of magnetic resonance imaging (MRI) structural evaluation of the spinal cord brought critical supplementary data in the initial evaluation of these cases. Although edema and hemorrhage proved to be valuable in predicting the outcome, there is a well-documented discrepancy between MRI findings and clinical status.Methods: We performed diffusion tensor imaging (DTI) MR in 22 symptomatic patients with traumatic cervical spine injuries (mean age 49.6 ± 16, range from 17 to 74 years, 20 males and 2 females). DTI parameters were computed in 15 patients. Regional apparent diffusion coefficient, fractional anisotropy (FA), and fiber length (FL) were calculated in the region of interest defined as the region of maximum structural MR alterations and in the normal cord (above or below the level of the injury). The values for normal and pathological cord were compared. The clinical deficit was assessed with ASIA and subaxial cervical spine injury classification (SLIC) scores. We looked at the correlation between the DTI measures and clinical scores.Results: There is a highly significant difference between normal and pathological spinal cord for all DTI properties measured. There is also a strong correlation between DTI measures and SLIC clinical score, especially for FA. Significant results were obtained for CDA and FL as well although with lesser statistical power.Conclusion: Our results suggest that DTI measures, especially FA, represent a strong indicator of the severity of the traumatic cervical cord injury. It correlates very well with SLCI score and can be used as an additional confirmation of the real degree of level lesioning and as a prognostic factor for the neurological outcome regardless of the choice of treatment.

Cervical spine trauma: impact of different imaging classification systems in the clinical decision-making.

Background and aim:Considering the high rate of mortality and permanent disability related to vertebral traumas, an early and detailed diagnosis of the trauma and subsequently an immediate and effective intervention are crucial. Cervical vertebral injury classifications guide treatment choice through a severity grade based on radiological information. The purpose of the present study was to define which imaging classification system could provide the best morphological and clinical-surgical correlations for cervical spine traumas.Methods:We retrospectively analyzed patients evaluated for cervical spine trauma at our Institution in the period 2015-2020. Information regarding the morphological examination (using CT and MRI), the neurological evaluation, and the therapeutic management were collected. C3-C7 fractures were classified according to the SLIC and AOSpine criteria; axial lesions were classified according to the modified AOSpine for the C1-C2 compartment and through the Roy-Camille and the Anderson D’Alonzo system for the odontoid process of the axis.Results:29 patients were included in the final study population. Nine patients with axial spine trauma and 21 with subaxial cervical spine trauma. A conservative approach was applied in 16 patients while nine patients underwent neurosurgery. Considering the therapeutical indications provided by the SLIC system, a 76.9% accordance was found for patients with a <4 score, while a 100% concordance was calculated for patients with a >4 score undergoing neurosurgery. Regarding the AOSspine classification, a 28.6% concordance was observed for patients classified group B being treated with a posterior neurosurgical approach, while for patients belonging to subgroup C, considered for anterior neurosurgical approach, a 66.7% accordance was calculated.Conclusions:The study demonstrated a better morphological correlation for the AOSpine classification in subaxial trauma and the AOSpine and Anderson D’Alonzo in axial trauma. The therapeutic indication found a better correlation in the SLIC classification for subaxial trauma and the Anderson D’Alonzo for axial ones. (www.actabiomedica.it)

Management of subaxial cervical spine trauma: Clinical results of early surgical decompression

Traumatic injuries of the subaxial cervical spine (C3-7); considered among the most common and most damaging injuries to the axial skeleton. Decompression of the spine is standard approach after cervical spinal cord injury.In this study, 72 patients who underwent early decompression with the decision of surgery according to the classification system with the Subaxial Injury Classification and Severity Scale (SLICS) among 212 patients who developed spine fractures as a result of acute traumatic subaxial cervical trauma were examined.ASIA scoring system was used for neurological examination evaluation.Patients were included in the rehabilitation program, which lasted at least six months after the operation.Neurological recovery results were evaluated with ASIA scores obtained after the rehabilitation program.It has been shown that early surgery for subaxial cervical spine fractures contributes significantly to the patient's neurological recovery.

Can Injury Type/ Subtype of the New Aospine Subaxial Cervical Trauma Classification Dictate Patient’s Treatment?

Aim: The AOSpine Subaxial Cervical Classification (AOSCC) was proposed in 2015 to review and improve morphology aspects of cervical fractures classification. The main objective of this paper is evaluate if the new AOSCC can predict non-surgical versus surgical management of traumatic cervical injuries. Materials and Methods: The AOSCC was retrospectively applied in a retrospective case series of 51 patients with subaxial cervical spine trauma (C3-7) treated according to the SLICS system by a single surgeon. The type, subtype and facet modifier were correlated with non-surgical versus surgical treatment using the t-student and Chi-Square tests. Results: Most of these patients were men (88.2%), suffered car accidents (33.3%) with a median SLIC score of 4.52 points. There was no neurological deterioration in this series. In the non-surgery group, nineteen patients (95%) were classified as type A fractures, whereas only one patient (5%)had a type C injury not surgically treated due to severe concomitant clinical complications and traumatic brain injury. In the surgically treated group, fifteen patients (48.3%) were classified as type C. The A0 group was associated to non-surgery group (p = 0.0005) and the B-C groups was significantly associated to surgery group (p = 0.0006). The F1-2-3 was associated to non-surgery group (p = 0.0102) and F4 modifier to surgery group (p = 0.0006). Conclusion: Some injury patterns may predict surgical treatment, such as type C characterized by cervical dislocations. Type A injuries, despite a potential for bone healing, may requiring additional radiological investigation in the setting of neurological deficits, to define the best treatment modality.

Establishing the Injury Severity of Subaxial Cervical Spine Trauma: Validating the Hierarchical Nature of the AO Spine Subaxial Cervical Spine Injury Classification System.

Study Design.Global cross-sectional survey.Objective.The aim of this study was to validate the AO Spine Subaxial Cervical Spine Injury Classification by examining the perceived injury severity by surgeon across AO geographical regions and practice experience.Summary of Background Data.Previous subaxial cervical spine injury classifications have been limited by subpar interobserver reliability and clinical applicability. In an attempt to create a universally validated scheme with prognostic value, AO Spine established a subaxial cervical spine injury classification involving four elements: injury morphology, facet injury involvement, neurologic status, and case-specific modifiers.Methods.A survey was sent to 272 AO Spine members across all geographic regions and with a variety of practice experience. Respondents graded the severity of each variable of the classification system on a scale from zero (low severity) to 100 (high severity). Primary outcome was to assess differences in perceived injury severity for each injury type over geographic regions and level of practice experience.Results.A total of 189 responses were received. Overall, the classification system exhibited a hierarchical progression in subtype injury severity scores. Only three subtypes showed a significant difference in injury severity score among geographic regions: F3 (floating lateral mass fracture, P = 0.04), N3 (incomplete spinal cord injury, P = 0.03), and M2 (critical disk herniation, P = 0.04). When stratified by surgeon experience, pairwise comparison showed only two morphological subtypes, B1 (bony posterior tension band injury, P = 0.02) and F2 (unstable facet fracture, P = 0.03), and one neurologic subtype (N3, P = 0.02) exhibited a significant difference in injury severity score.Conclusion.The AO Spine Subaxial Cervical Spine Injury Classification System has shown to be reliable and suitable for proper patient management. The study shows this classification is substantially generalizable by geographic region and surgeon experience, and provides a consistent method of communication among physicians while covering the majority of subaxial cervical spine traumatic injuries.Level of Evidence: 4

Anterior Cervical Reduction Decompression Fusion With Plating for Management of Traumatic Subaxial Cervical Spine Dislocations

Study Design:Prospective case series.Objective:To evaluate the efficacy of anterior-only approach, for treatment of type C F4 (AO classification) traumatic subaxial cervical spine injuries.Methods:Patients with type C F4 traumatic cervical injuries presenting to a tertiary center between June 2017 and July 2018 were included. Outcome measures included self-reported measures (Neck Disability Index, visual analogue scale, and return to work), radiological measures (local segmental angle, Ishihara curvature index, cervical lordosis angle, and step-off distance), fusion state, and neurological state according to American Spinal Injury Association (ASIA) Impairment Scale (AIS).Results:Twenty-one cases were operated by anterior approach with mean age 39.1 ± 13.8 years. The most common injury was at C4-5 (47.6%). Six out of 7 cases (85.7%) with preoperative neurological impairment showed late follow-up improvement by one or more grade in AIS. Complete anatomical reduction and imaging measures did not correlate significantly to the self-reported outcome measures. Median value of local segmental angle improved from −16° (−11° to −20) preoperatively to 0° (−7°) to 8°) at late follow-up. The cervical lordotic angle and Ishihara curvature index improved from 35° (29° to 43°) and 6.92 (−2.7 to 28.9) preoperatively, to 44° (33° to 51°) and 18.7 (−3.5 to 26.9) at the late follow-up, respectively. Step-off distance decreased postoperatively, however; complete reduction could not be achieved.Conclusion:Surgical treatment of lower cervical traumatic instability by anterior decompression and fusion is efficient regarding fusion state and patients’ satisfaction. The anterior approach can be recommended in cases with neurological impairment and in patients with medical comorbidities or when a short operative time—compared with combined approach—is preferred.

Subaxial Cervical Spine Injury in the Elderly and Treatment-Related Mortality - Anterior or Posterior Approach.

Subaxial cervical spine injury especially in the elderly can be associated to severe complications and disability. Until today there is no consensus concerning the best operative treatment. A potential superiority of anterior or posterior fixation is the subject of controversial discussions. The aim of this study was to compare the outcome of anterior and posterior fixation after subaxial cervical spine trauma in the elderly focussing on the postoperative mortality. A retrospective cohort analysis was performed to analyse the data of 43 patients. Especially mortality data were collected. A total of 43 patients was identified. Anterior fixation was performed in 21 patients, posterior fixation was performed in 22 patients. There were no significant differences between these groups. Although statistical significance was not reached, a slightly higher mortality was found among patients undergoing anterior fixation (52,4 vs. 31,8%). Furthermore the male sex, a higher age, translation injuries, long duration of operation and hospitalisation as well as postoperative complications were slightly associated to a higher mortality. Subaxial cervical spine trauma is associated to a high mortality in the elderly. Although neither anterior nor posterior fixation could show a significant superiority, every surgical decision making should be performed individually for each patient balancing the advantages and disadvantages of each method.