Subaxial cervical spine trauma: evaluation and surgical decision-making

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 validation. When the decision for surgical treatment is made, early decompression (less than 24 hours) has been associated with better neurologic recovery. Surgical treatment should be individualized based on the injury characteristics and surgeon's preferences. Conclusions The current state of subaxial cervical spine trauma is one of great progress. However, many questions remain unanswered. We need to continue to account for the individual patient, surgeon, and hospital circumstances that effect decision making and care.

Keywords: classification; diagnosis; subaxial cervical spine trauma; treatment.

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) + 0 points for discoligamentous complex status + 0 points for neurologic status = 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.

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) + 2 points (discoligamentous complex injury) + 3 points (incomplete neurologic deficits) = 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).