Global Spine Journal Review Article 63

Subaxial Cervical Spine Trauma: Evaluation and

Surgical Decision-Making
Andrei F. Joaquim1 Alpesh A. Patel2

1 Department of Neurosurgery, State University of Campinas Address for correspondence Alpesh A. Patel, MD, Department of
(UNICAMP), Campinas, SP, Brazil Orthopaedic Surgery, Northwestern University, 676 North St. Clair
2 Department of Orthopaedic Surgery, Northwestern University, Street, Suite 1350, Chicago, IL 60611, United States
Chicago, Illinois, United States (e-mail: [email protected]).

Global Spine J 2014;4:63–70.

Abstract Study Design Literature review.

Objective To discuss the evaluation and management of subaxial cervical spine
trauma (C3–7).
Methods A literature review of the main imaging modalities, classification systems,
and nonsurgical and surgical treatment performed.
Results Computed tomography and reconstructions allow for accurate radiologic
identification of subaxial cervical spine trauma in most cases. Magnetic resonance
imaging can be utilized to evaluate the stabilizing discoligamentous complex, the
nerves, and the spinal cord. The Subaxial Injury Classification (SLIC) is a new system that
aids in injury classification and helps guide the decision-making process of conservative
versus surgical treatment. Though promising, the SLIC system requires further valida-
tion. When the decision for surgical treatment is made, early decompression (less than
Keywords 24 hours) has been associated with better neurologic recovery. Surgical treatment
► subaxial cervical spine should be individualized based on the injury characteristics and surgeon’s preferences.
trauma Conclusions The current state of subaxial cervical spine trauma is one of great
► diagnosis progress. However, many questions remain unanswered. We need to continue to
► classification account for the individual patient, surgeon, and hospital circumstances that effect
► treatment decision making and care.

Introduction Diagnostic Imaging

Cervical spine trauma is one of the most common sites of After hemodynamic stabilization, all injured patients should
spinal cord injury (SCI). Anatomically, subaxial cervical spine be screened for subaxial cervical injuries. Today, computed
trauma consists of injuries from C3 to C7,1,2 with more than tomography (CT) scans with coronal and sagittal reconstruc-
50% of the cervical spine injuries located between C5 and C7.3 tions are available in almost all trauma centers and provide
The potential catastrophic events associated with subaxial rich and detailed information about the status of the cervical
cervical spine trauma, including tetraplegia and severe per- spine.4–6 A sensitivity of 99% and specificity of 100% have
manent disability, require a consistent and evidence-based been reported with multiplanar CT scan screening of cervical
diagnosis and treatment plan. In this article, we review injuries, compared with a sensitivity of just 70% with plain
critical concepts in the diagnosis, classification, and treat- radiographies.7,8 CT imaging with reconstructions provide
ment of subaxial cervical spine trauma. high sensitivity for injury detection and, as such, may allow

received © 2014 Georg Thieme Verlag KG DOI http://dx.doi.org/

December 30, 2012 Stuttgart · New York 10.1055/s-0033-1356764.
accepted after revision ISSN 2192-5682.
August 6, 2013
published online
September 13, 2013
64 Subaxial Cervical Spine Trauma Joaquim, Patel

for early removal of cervical precautions, avoiding complica- Table 1 The subaxial injury classification system
tions associated with prolonged immobilization.5 Anecdotal
cases of occult ligamentous injury have been reported, how- Points
ever.9,10 As such, despite the advances of CT imaging, a Injury morphology
thorough clinical assessment of the patient remains critical. No abnormality 0
Magnetic resonance (MR) imaging is a promising technol-
Compression 1
ogy in subaxial cervical spine trauma. MR is often used in
patients with cervical SCI as well as in patients with cervical Burst þ1
translational or distractive injuries. MR can also be utilized to Distraction 2
identify ventral and dorsal compressive lesions (disk hernia- Translation 3
tion, hematoma, bone) that may be critical for determining
Integrity of the discoligamentous complex
surgical approach. In injuries with questionable stability, MR
has been used to assess the status of the discoligamentous Intact 0
complex (DLC): a descriptive amalgamation of the anterior Indeterminate 1
longitudinal ligament, posterior longitudinal ligament, disk, Disrupted 2
facet capsules, and posterior supporting ligaments.11,12 MR
Neurologic status
may additionally be useful in the evaluation of soft tissue
injuries, disk herniation, and hematomas, especially in neu- Intact 0
rologically injured patients with normal CT scan findings.13 Nerve root injury 1
Although MR has been shown to have a high sensitivity, a low Complete 2
specificity for ligamentous injury has been reported to date.11
Incomplete 3
This may increase the risk of unnecessary treatments, includ-
Persistent cord compression þ1
ing surgery, in an otherwise stable injury and dictates caution
in using MR findings as a definitive surgical indication.11

among others.12 Two illustrative cases of subaxial cervical

Classification
spine trauma treated based on the SLIC are presented
Accurate and reproducible injury classification is an impor- in ►Figs. 1 and 2.
tant step in the decision-making process for all spine injuries.
Moreover, effective injury classification is critical in clinical
Applying the SLIC—Special Considerations
care, education, and comparative research.
Many systems have been historically proposed to classify Morphology
subaxial cervical spine trauma.14–16 One of the most com- Compression injuries encompass compression fractures,
monly used was the Magerl et al classification system, initially burst fractures, teardrop injuries, and sagittal or coronal split
proposed for the thoracolumbar spine, which has been fractures.12 Minimally displaced facet fractures can be pres-
extrapolated to cervical spine injuries, classifying them as ent, as well as small posterior elements injuries, without
type A (axial force injuries), type B (distraction), and type C evidence of distraction or rotation deformity. Distraction
(rotational).16 However, this system is based on plain radio- injuries are represented by vertical dissociation of the spinal
graphs and does not consider the neurologic status of the elements and perched facet joints. Translational/rotational
patient, a critical determinant of surgical treatment. injuries are defined by axial listhesis of the vertebral bodies
Based on these potential weaknesses, the Spinal Trauma with either unilateral or bilateral facet joint dislocations. The
Study Group has proposed a new classification system, the floating lateral mass is considered a translational/rotational
Subaxial Injury Classification System (SLIC), and injury sever- injury given its risk for displacement. Spinous process frac-
ity score.12 This system is based on three major characteristics tures and nondisplaced small facet fractures, although often
that should be taken in account in the decision-making associated with other injury patterns, are not accounted for
process: (1) injury morphology; (2) integrity of the DLC; within the described injury morphologies.
and (3) the neurologic status of the patient. Each one of these
three factors is classified in isolation, with a final score Integrity of Discoligamentous Complex
resulting from the summation of these three variables The status of the DLC is defined as disrupted in patients with
(►Table 1). The system recommends treatment based on distraction and translation/rotational morphologies, receiv-
the final severity score. A score of less than 4 points supports ing 2 points for DLC injury. Other patients with compression
conservative treatment and 5 or more points supports surgi- injuries or those with radiographically stable injuries are
cal treatment. Patients with 4 points may be treated conser- inferred to have an intact DLC. The indeterminate state of
vatively or surgically, depending on surgeon’s experience, the DLC is the most controversial aspect of the SLIC system.
patient’s preference, and additional comorbid conditions. The The lack of specificity of MR can overestimate injuries to the
authors of the SLIC suggested that specific confounding DLC, leading to a higher severity score and unnecessary
factors may further influence the treatment chosen, including surgeries.8 Based on this, it should be used cautiously in
obesity, poor bone quality, and severe systemic trauma, the medical decision-making process.11,12 In patients with

Global Spine Journal Vol. 4 No. 1/2014

 Subaxial Cervical Spine Trauma Joaquim, Patel 65

Fig. 1 This 25-year-old man presented with neck pain after a diving injury. His neurologic exam was without deficits. (A) An axial computed
tomography (CT) scan demonstrates a linear sagittal fracture crossing the vertebral body. (B) Height loss of the vertebral body is noted in the
sagittal CT scan reconstruction, without canal compression. (C, D) A CT scan reconstruction shows facet joint integrity without evident posterior
elements injury. The Subaxial Injury Classification score was 2 points (burst) þ 0 points for discoligamentous complex status þ 0 points for
neurologic status ¼ 2 points—conservative treatment was performed with a rigid cervical collar and closed radiologic follow-up. (E) Lateral
cervical X-ray 8 months after treatment with good spinal alignment and fracture healing. The patient was asymptomatic.

more stable injuries, MR should not be used in isolation to differentiated from traumatic injuries by the presence of facet
access the status of the DLC. joint arthritis or osteophytes, without signs of acute fracture
Another important clinical confounding factor is the pres- or translational injury, and should be scored as 0 for
ence of concomitant cervical degenerative disease in the morphology.2
setting of a cervical spine trauma. For instance, in patients
with cervical spinal stenosis, incomplete neurologic deficits, Neurologic Status
and no evidence of fracture or dislocations, the SLIC final The neurologic status is among the most important determi-
assessment results in 4 points (0 for morphology þ 3 for nants of surgical treatment and is also the most important
incomplete deficit þ 1 for persistent cord compression þ 0 prognostic factor in SCI patients. Patients with American
for DLC status).17 This clinical scenario is typical for a central Spine Injury Association (ASIA) Impairment Scale (AIS) grade
cord syndrome. Though surgical treatment may be advisable A (complete injury) receive 2 points.18 Patients with AIS grade
in this situation, other reports have continued to recommend B, C, and D (incomplete deficits) receive 3 points. Neurologic
nonoperative management.17 Last, patients may also present impairment is most often defined by motor and sensory
with degenerative spondylolisthesis. This finding can be examination. However, some patients may have other

Fig. 2 A 71-year-old woman presented after an automotive accident with an incomplete spinal cord injury (American Spine Injury Association
Impairment Scale [AIS] grade B). (A, B) A distractive injury is identified at C6–7 in the sagittal CT scan reconstruction (white arrow). The Subaxial
Injury Classification score was 3 points (distractive injury) þ 2 points (discoligamentous complex injury) þ 3 points (incomplete neurologic
deficits) ¼ 8 points—surgical treatment was performed. Postoperative sagittal (C) and 3-D reconstruction (D) CT scans showing reestablishment
of cervical alignment and facet joint congruence, with lateral mass screws at C5 and C6 and pedicle screws at C7 and T1. After 6 months of follow-
up, she had some neurologic improvement (AIS grade C).

Global Spine Journal Vol. 4 No. 1/2014

66 Subaxial Cervical Spine Trauma Joaquim, Patel

symptoms of cord dysfunction, such as paresthesias, loss of undergoing cervical traction until performing definitive
motor dexterity, or balance impairment.2 These are currently surgical stabilization. Weight can be increased rapidly as
not accounted for by the SLIC system but, depending on the allowed by a reliable, new neurologic examination and new
intensity of these symptoms, may need to be considered in cervical radiographs. An earlier reduction may potentially
the neurologic classification of patients. improve ultimate neurologic function and should always be
After understanding the system nuances, the clinical ap- attempted.
plication can be easily incorporated in daily practice. Studies The main objective of traction is to obtain and maintain
of reproducibility of the SLIC among surgeons suggest that the closed reduction on lateral cervical radiographs. During
system is easily applied and comprehensive.19,20 We applied reduction, surgeons should be aware of the risk of over
the SLIC in a retrospective series of patients treated for distraction as well as the potential for neurologic worsen-
subaxial cervical spine trauma, determining that the system ing. Regarding Gardner-Wells tong application, the patient
matched with the proposed treatment in up to 90% of patients is placed in a neutral supine position. After local asepsis,
treated with conservative or surgical approaches.2 High- local and periosteal infiltration with anesthetic is per-
quality, prospective evidence validating the SLIC system, formed. The pins are placed below the greatest diameter
however, is lacking. of the skull. The surgeon must avoid entering the temporal
muscle and artery, as such the common site is generally
1 cm above the pinna and 1 cm posterior to the external
Treatment
auditory meatus. The pins can be placed asymmetrically
Methylprednisolone for Spinal Cord Injuries (slightly anterior or posterior) to influence flexion or
The potential benefits in neurologic recovery with early extension according to injury morphology/dislocation. As
administration of high doses methylprednisolone in patients an example, cervical flexion (tongs placed slightly posteri-
with acute closed SCI have been reported by the National or) can help achieve reduction of locked facet joints. In
Acute Spinal Cord Injuries Studies (NASCIS II, III).21 However, unilateral locked facet joint, some flexion and rotation
many other authors have pointed out flaws in the studies, away from the luxation side can help achieve reduction.
questioning the widespread use of steroids in acute SCI.22,23 In addition to pin placement, in the setting of a reliable
These concerns include limited clinical benefits, a post hoc examination, the surgeon can also obtain a reduction by
analysis, statistical artifacts, and the significance of the flexing and/or rotating the cervical spine to further “un-
potential complications of high doses of corticosteroids lock” dislocated facet joints by recreating the traumatic
use.22,23 Considering these points, methylprednisolone ad- deformity. Once a facet reduction is obtained, cervical
ministration in the setting of an acute SCI should be consid- extension and lower-weight in-line traction (15 to 20
ered when the potential risks are balanced with the pounds) can be utilized to maintain the reduction.
potentially limited benefits of its use. Patients in whom a reliable neurologic exam cannot be
obtained should not undergo closed reduction. This in-
Management in the Emergency Room cludes obtunded patients, inebriated patients, sedated or
During clinical stabilization, following standard trauma pro- intubated patients, and patients who cannot comply with a
tocols, patients should be maintained in supine position with neurologic examination. Traction is also contraindicated in
a rigid cervical collar and lateral immobilization.1 Radiologic patients with rostral injuries, especially distractive ones,
screening should be based on CT scan with multiplanar such as atlantoaxial or occipitocervical dislocations.25,26
reconstructions.24 After a thorough examination, patients An MR prior to closed reduction is recommended to iden-
without pain, neurologic deficit, and radiologic abnormalities tify a traumatic cervical disk herniation. However, routine
can have their cervical collars removed. MR can be performed pre-reduction MR can delay spinal decompression and
as a complementary radiologic study, by surgeon discretion, increase hospital costs.26,27 As such, it commonly obtained
but it may have its greatest impact in patients with cervical prior to reduction only in select patients, most notably
burst fractures, with neurologic deficits, or with uncertain surgical patients who are unable to undergo a safe, closed
injuries on CT scan. reduction.
In patients with a cervical dislocation, early closed
reduction with traction is an important part of treatment. 3 Nonsurgical Treatment
Reduction can simplify surgical treatment as well as pro- Injuries with SLIC score of less than 3, and sometimes 4,
vide prompt decompression of the neural tissues in neuro- points are treated nonsurgically. As they are generally stable
logically impaired patients. Cervical traction for close lesions, the use of a cervical orthosis is not mandatory.
reduction can be safely performed in the emergency de- However, a cervical collar may help in healing of soft tissue
partment or after patient admission to a definitive hospital injuries and in the management of acute pain. Though no
bed or intensive care unit. Up to 70% of the cervical evidence-based guidelines are available, we have generally
fractures can be realigned with traction.3,25 Usually the prescribed a rigid cervical collar for 6 to 12 weeks when stable
weight necessary is 5 pounds (2.5 kg) per level of injury fractures are present, performing clinical and radiologic
and can be performed in neutral, flexion, or extension follow-up. Soft collars may be used in mild cervical trauma
position, according to injury characteristic.3 Close clinical without evident bone fractures. Another potential advantage
and radiologic observations are mandatory in patients of prescribing an orthosis is to emphasize, to the patient and

Global Spine Journal Vol. 4 No. 1/2014

 Subaxial Cervical Spine Trauma Joaquim, Patel 67

those around them, the importance of activity restrictions Brodke et al evaluated the results of 52 patients with
and risk-behavior modifications. reduced unstable cervical spine injuries who were random-
ized for anterior versus posterior stabilization and fusion.31
Patients who required reduction and decompression were
Surgical Treatment
not included in the study. They reported no significant differ-
Timing for Surgery in Patients with Neurologic Deficits ences in neurologic recovery, fusion rates, or long-term
Once surgical treatment is chosen, the benefits of early complaints with regards to the approach chosen. Similarly,
decompression have been well demonstrated. The Surgical Kwon et al performed a prospective randomized study com-
Timing in Acute Spinal Cord Injury Study (STASCIS) was a paring anterior versus posterior stabilization for unilateral
multicenter international prospective cohort study with pa- facet injuries in 42 patients.32 The authors concluded that
tients aged from 16 to 80 with a cervical SCI.28 The primary even though anterior approaches had a lower rate of wound
outcome was neurologic status at 6-month follow-up. Early infections, less postoperative pain, and a higher fusion rate,
surgery (<24 hours after injury) was performed in 182 they also had a higher risk of postoperative swallowing
patients (mean of 14.2  5.2 hours), and 131 patients under- difficulty. There were no reported differences in patient
went late surgery (48.3  29.3 hours). Follow-up was avail- outcome measures. The authors conclude that either anterior
able in 222 patients at 6 months after injury. In 19.8% of the or posterior fixation approaches are valid and safe techniques
patients in the early group, there was a  2 grade improve- to treat unilateral facet injuries.
ment in ASIA Impairment Scale compared with a 8.8% rate of
improvement in the late decompression group (odds ratio Surgical Considerations in Specific Injuries
¼ 2.57, 95% confidence interval: 1.11 to5.97). There were no By considering common clinical scenarios, we can discuss
differences regarding complications when comparing the two general principals of the evaluation and treatment of subaxial
groups, attesting that early decompression poses no addi- cervical spine injuries. However, it should be emphasized that
tional risks. The authors concluded that early decompression treatment should ultimately be individualized according to
was safe and associated with improvement in neurologic injury characteristics and based on surgeon experience and
outcome in cervical spine injuries.28 preference.
Given these recent clinical data and the breadth of pre-
clinical animal data, we emphasize that neurologic decom- Vertebral Burst Fractures
pression should be performed as soon as possible considering Severe anterior vertebral body fractures have been assigned
the availability of sufficient human and structural resources different nomenclature in the literature, such as quadrangu-
as well as the patient’s clinical conditions. lar fractures, teardrop injuries, and burst fractures and dis-
locations.33,34 Most of the time, these more severe injury
Anterior versus Posterior Approaches patterns have an associated DLC injury and neurologic defi-
In addition to the timing of surgical treatment, the best cits, reaching an SLIC score that recommends surgical treat-
approach (anterior, posterior, combined) is another critical ment. Anterior cervical corpectomy with graft and plating is
decision point. As a general rule, the approach is chosen generally recommended, restoring anterior column support
based on the needs of cervical decompression, reconstruc- and providing access for direct neurologic decompression.17
tion, and stabilization. Anterior approaches have the ad- When necessary, especially in cases with disruption of the
vantages of supine position, minor surgical trauma, and posterior elements, a combined approach (anterior-posteri-
direct anterior decompression of the neural elements, or) can provide both direct anterior decompression and
removing ventral compressive structures such as disk and circumferential stabilization.17
bone.3 Anterior stabilization can be also used successfully
in select posterior injuries.29 Posterior approaches, based Central Cord Syndrome
on rigid fixation techniques with lateral mass or pedicle Most of these patients have an SLIC score of 4 points: 0 for
screws, are a good alternative for distraction and transla- morphology þ 0 for DLC status þ 4 for neurologic status
tion/rotational injuries, as reduction forces can be directly (3 for incomplete injury with an extra 1 point for persistent
applied to realign the spine. cord compression). Some of these patients may also have an
Surgeons should pay attention to the presence of a signifi- associated injury to the DLC including disk protrusions
cant anterior disk herniation associated with facet disloca- (þ1 point) and extruded traumatic disk herniation
tions. Reduction in this setting, without a reliable neurologic (þ2 points).2,17 Retrospective data suggest a benefit to surgi-
examination, can lead to neurologic deterioration due to cal treatment in patients with central cord syndrome. Stevens
worsening of the anterior cord compression.30 Closed reduc- et al reported the results of a series of 126 patients treated
tion in an awake patient prior to doing posterior stabilization with central cord syndrome.35 Sixty-seven patients were
is safer than intraoperative direct posterior reduction in the surgically treated whereas 59 were managed nonoperatively.
presence of anterior compression, avoiding posterior migra- The study divided surgically treated patients in three sub-
tion of the disk against the spinal cord. An MR is recom- groups: early surgery (<24 hours after injury), late surgery
mended to access the presence of an important disk (>24 hours but in the same hospital admission), and delayed
herniation prior to open surgical reduction to avoid clinical surgery (after primary hospital discharge). From the 67
worsening. patients surgically treated, 16 received early surgery, 34

Global Spine Journal Vol. 4 No. 1/2014

68 Subaxial Cervical Spine Trauma Joaquim, Patel

received late surgery during the hospital admission (mean of Severe Fracture Dislocation/Subluxation
6.4 days), and 17 had late surgery after first hospital admis- Although surgical decision making can be straightforward,
sion (mean of 137 days after injury). With a mean follow-up of these injuries are among the most challenging to treat.
32 months, an improvement in Frankel grade was seen in the Combined approaches are generally required for spinal canal
overall surgical group compared with the nonsurgically decompression, anterior column height restoration, and re-
treated group. However, there were no differences regarding construction of the posterior tension band. Alternatively,
the three surgery subgroups. Their findings suggest that severe distraction injuries can be seen in patients with
surgical intervention should be recommended in central ankylosing spondylitis, diffuse idiopathic skeletal hyperosto-
cord syndrome, even though prospective comparative studies sis (DISH), or severe osteoarthritis. These represent unstable
are still needed. injury patterns with a highly reported rate of neurologic
As central cord syndrome generally occurs in patients with injury and/or progressive decline. In this context, extended
previous cervical spondylosis, treatment should be based on posterior fixation is advised as the disease processes create
the number of involved levels and the source of compression. significant spinal stiffness and long lever arms on the fusion
Patients with kyphotic alignment should be preferentially construct.40
treated by an anterior approach or an anterior followed by a
posterior approach, whereas patients with lordotic sagittal
alignment and multilevel compression can be treated by Conclusions
laminoplasty or laminectomy and fusion.17 The current state of subaxial cervical spine trauma is one of
great progress. Rapid emergency evaluation and treatment
Unilateral/Bilateral Facet Injuries of the injured patient allows for early identification of
These injuries can be surgically treated using an anterior or a cervical injuries. The SLIC system represents an improve-
posterior stabilization with similar outcomes.17,32 A high rate of ment in the classification of injured patients, and early
minor and asymptomatic herniated disks can be found in up to surgical decompression has been shown to improve neuro-
half of the patients with facet subluxation, but after reduction, logic outcome in patients with spinal cord injuries. How-
stabilization can be performed by an anterior or a posterior ever, many questions remain unanswered. The role of MR in
approach, despite the presence of a disk herniation.36,37 With the assessment of acute trauma remains uncertain. Current
regards to unilateral facet joint injuries, as mentioned previously, classification systems require prospective validation and
there is good evidence suggesting similar outcomes comparing may require further revisions. Last, although we have
anterior and posterior approaches.32 moved toward standardized care of the traumatized pa-
Anterior reduction of facet dislocation is feasible in many tient, we need to continue to account for the individual
cases. After complete disk and posterior ligament resection, patient, surgeon, and hospital circumstances that effect
pins can be inserted from 10 to 20 degrees of convergence. decision making and care.
Distractor placement results in local kyphosis, unlocking the
posterior facet joints with additional posterior force applied
in the rostral body.38 In unilateral dislocation, the pins are Disclosures
placed in a similar fashion but with additional coronal None
separation of 10 to 20 degrees to allow for rotation. Distractor
placement results in kyphosis (similarly to bilateral disloca-
tion) as well as derotation; a manual posterior force is applied
in the rostral body, resulting in reestablishment of facet joint References
congruence.38 Continuous intraoperative traction and the use 1 Torretti JA, Sengupta DK. Cervical spine trauma. Indian J Orthop
2007;41(4):255–267
of a Cobb elevator in the disk can be further utilized to
2 Joaquim AF, Lawrence B, Daubs M, Brodke D, Patel AA. Evaluation
disengage dislocated facets and facilitate obtaining a reduc-
of the subaxial injury classification system. J Craniovertebr Junc-
tion. These maneuvers also provide distraction, allowing for
tion Spine 2011;2(2):67–72
the removal of an anterior disk herniation. Most of the times,
3 Aebi M. Surgical treatment of upper, middle and lower cervical
anterior cervical diskectomy and interbody fusion is sufficient injuries and non-unions by anterior procedures. Eur Spine J
to remove the disk fragment present into the canal. If not, the 2010;19(1, Suppl 1):S33–S39
disk cannot be removed; for example, in large retrovertebral 4 Joaquim AF, Patel AP. Occipito-cervical trauma: evaluation, classi-
herniations, the procedure can be converted to an anterior fication and treatment. Contemporary Spine Surgery 2010;11(4):
corpectomy. 1–5
In cases of an anterior approach and incomplete reduction, 5 Joaquim AF, Patel AP. Occipito-cervical trauma: evaluation, classi-

a combined approach should be performed, with open pos- fication and treatment. Contemporary Neurosurgery 2010;
32(12):1–6
terior reduction. Locked facet joints not reducible by traction
6 Joaquim AF, Patel AP. C1 and C2 spine trauma: evaluation, classifi-
or anterior open approaches should be treated with a poste-
cation and treatment. Contemporary Spine Surgery 2010;11(3):
rior direct approach. Patients with severe disk collapse 1–7
treated by a posterior approach can develop segmental 7 Sanchez B, Waxman K, Jones T, Conner S, Chung R, Becerra S.
collapse and important kyphosis, even though its relationship Cervical spine clearance in blunt trauma: evaluation of a computed
with clinical outcome remains uncertain.18,39 tomography-based protocol. J Trauma 2005;59(1):179–183

Global Spine Journal Vol. 4 No. 1/2014

 Subaxial Cervical Spine Trauma Joaquim, Patel 69

8 Antevil JL, Sise MJ, Sack DI, Kidder B, Hopper A, Brown CV. Spiral 24 Mower WR, Hoffman JR, Pollack CV Jr, Zucker MI, Browne BJ,
computed tomography for the initial evaluation of spine trauma: a Wolfson AB; NEXUS Group. Use of plain radiography to screen for
new standard of care? J Trauma 2006;61(2):382–387 cervical spine injuries. Ann Emerg Med 2001;38(1):1–7
9 Schenarts PJ, Diaz J, Kaiser C, Carrillo Y, Eddy V, Morris JA Jr. 25 Hadley MN. Guidelines for management of acute cervical injuries.
Prospective comparison of admission computed tomographic scan Neurosurgery 2002;50(3, Suppl):S1
and plain films of the upper cervical spine in trauma patients with 26 Farmer J, Vaccaro A, Albert TJ, Malone S, Balderston RA, Cotler JM.
altered mental status. J Trauma 2001;51(4):663–668, discussion Neurologic deterioration after cervical spinal cord injury. J Spinal
668–669 Disord 1998;11(3):192–196
10 Menaker J, Philp A, Boswell S, Scalea TM. Computed tomography
27 Rosenfeld JF, Vaccaro AR, Albert TJ, Klein GR, Cotler JM. The benefits
alone for cervical spine clearance in the unreliable patient—are we
of early decompression in cervical spinal cord injury. Am J Orthop
there yet? J Trauma 2008;64(4):898–903, discussion 903–904
1998;27(1):23–28
11 Rihn JA, Fisher C, Harrop J, Morrison W, Yang N, Vaccaro AR.
28 Fehlings MG, Vaccaro A, Wilson JR, et al. Early versus delayed
Assessment of the posterior ligamentous complex following acute
decompression for traumatic cervical spinal cord injury: results of
cervical spine trauma. J Bone Joint Surg Am 2010;92(3):583–589
the Surgical Timing in Acute Spinal Cord Injury Study (STASCIS).
12 Vaccaro AR, Hulbert RJ, Patel AA, et al; Spine Trauma Study Group.
PLoS ONE 2012;7(2):e32037
The subaxial cervical spine injury classification system: a novel
29 Woodworth RS, Molinari WJ, Brandenstein D, Gruhn W, Molinari
approach to recognize the importance of morphology, neurology,
RW. Anterior cervical discectomy and fusion with structural
and integrity of the disco-ligamentous complex. Spine 2007;
allograft and plates for the treatment of unstable posterior cervical
32(21):2365–2374
spine injuries. J Neurosurg Spine 2009;10(2):93–101
13 Kaiser ML, Whealon MD, Barrios C, Kong AP, Lekawa ME, Dolich
MO. The current role of magnetic resonance imaging for diagnos- 30 Eismont FJ, Arena MJ, Green BA. Extrusion of an intervertebral disc
ing cervical spine injury in blunt trauma patients with negative associated with traumatic subluxation or dislocation of cervical
computed tomography scan. Am Surg 2012;78(10):1156–1160 facets. Case report. J Bone Joint Surg Am 1991;73(10):1555–1560
14 Holdsworth F. Fractures, dislocations, and fracture-dislocations of 31 Brodke DS, Anderson PA, Newell DW, Grady MS, Chapman JR.
the spine. J Bone Joint Surg Am 1970;52(8):1534–1551 Comparison of anterior and posterior approaches in cervical spinal
15 Allen BL Jr, Ferguson RL, Lehmann TR, O’Brien RP. A mechanistic cord injuries. J Spinal Disord Tech 2003;16(3):229–235
classification of closed, indirect fractures and dislocations of the 32 Kwon BK, Fisher CG, Boyd MC, et al. A prospective randomized
lower cervical spine. Spine 1982;7(1):1–27 controlled trial of anterior compared with posterior stabilization
16 Magerl F, Aebi M, Gertzbein SD, Harms J, Nazarian S. A compre- for unilateral facet injuries of the cervical spine. J Neurosurg Spine
hensive classification of thoracic and lumbar injuries. Eur Spine J 2007;7(1):1–12
1994;3(4):184–201 33 Ianuzzi A, Zambrano I, Tataria J, et al. Biomechanical evaluation of
17 Dvorak MF, Fisher CG, Fehlings MG, et al. The surgical approach to surgical constructs for stabilization of cervical teardrop fractures.
subaxial cervical spine injuries: an evidence-based algorithm Spine J 2006;6(5):514–523
based on the SLIC classification system. Spine 2007;32(23): 34 Fisher CG, Dvorak MF, Leith J, Wing PC. Comparison of outcomes
2620–2629 for unstable lower cervical flexion teardrop fractures managed
18 Marino RJ, Barros T, Biering-Sorensen F, et al. International stand- with halo thoracic vest versus anterior corpectomy and plating.
ards for neurological classification of spinal cord injury. J Spinal Spine 2002;27(2):160–166
Cord Med 2003;26(Suppl 1):50–56
35 Stevens EA, Marsh R, Wilson JA, Sweasey TA, Branch CL Jr, Powers
19 Lee WJ, Yoon SH, Kim YJ, Kim JY, Park HC, Park CO. Interobserver
AK. A review of surgical intervention in the setting of traumatic
and intraobserver reliability of sub-axial injury classification and
central cord syndrome. Spine J 2010;10(10):874–880
severity scale between radiologist, resident and spine surgeon. J
36 Eismont FJ, Arena MJ, Green BA. Extrusion of an intervertebral disc
Korean Neurosurg Soc 2012;52(3):200–203
associated with traumatic subluxation or dislocation of cervical
20 Whang PG, Patel AA, Vaccaro AR. The development and evaluation
facets. Case report. J Bone Joint Surg Am 1991;73(10):1555–1560
of the subaxial injury classification scoring system for cervical
37 Grant GA, Mirza SK, Chapman JR, et al. Risk of early closed
spine trauma. Clin Orthop Relat Res 2011;469(3):723–731
reduction in cervical spine subluxation injuries. J Neurosurg
21 Bracken MB, Shepard MJ, Collins WF, et al. A randomized, con-
1999;90(1, Suppl):13–18
trolled trial of methylprednisolone or naloxone in the treatment of
acute spinal-cord injury. Results of the Second National Acute 38 Kim S, Sebastian CT, Nathan DJ, Park J, Kim D. In: Kim D, Ludwig SC,
Spinal Cord Injury Study. N Engl J Med 1990;322(20):1405–1411 Vaccaro AV, Chang J, eds. Atlas of Spine Trauma: Adult and
22 Nesathurai S. Steroids and spinal cord injury: revisiting the NASCIS Pediatric. Philadelphia, PA: Saunders; 2008:135–150
2 and NASCIS 3 trials. J Trauma 1998;45(6):1088–1093 39 Lifeso RM, Colucci MA. Anterior fusion for rotationally unstable
23 Botelho RV, Daniel JW, Boulosa JL, et al. [Effectiveness of methyl- cervical spine fractures. Spine 2000;25(16):2028–2034
prednisolone in the acute phase of spinal cord injuries—a system- 40 Einsiedel T, Schmelz A, Arand M, et al. Injuries of the cervical spine
atic review of randomized controlled trials]. Rev Assoc Med Bras in patients with ankylosing spondylitis: experience at two trauma
2009;55(6):729–737 centers. J Neurosurg Spine 2006;5(1):33–45

Global Spine Journal Vol. 4 No. 1/2014