The surgical approach to subaxial cervical spine injuries: an evidence-based algorithm based on the SLIC classification system

Abstract

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?"