AANS Recommendations on Classification and Treatment of Subaxial Cervical Spine Injuries

The American Association of Neurological Surgeons (AANS) issued the following level I recommendations regarding classification of subaxial cervical spine injuries^[9]:

The Subaxial Injury Classification (SLIC) and severity scale is recommended as a classification system for spinal cord injury.
The Cervical Spine Injury Severity Score (CSISS) is recommended as a classification system for graded instability and fracture patterns in patients with spinal cord injury.

The Harris and Allen classifications were considered less reliable and were not recommended (level III).

The AANS also published the following level III recommendations with respect to treatment of subaxial cervical spine injuries^[21]:

Closed or open reduction of subaxial cervical fractures or dislocations is recommended, with the goal of decompressing the spinal cord or restoring the spinal canal.
Stable immobilization (via either internal fixation or external immobilization) is recommended to facilitate early patient mobilization and rehabilitation.
If surgical treatment is considered, either anterior or posterior fixation and fusion is acceptable, provided that the setting does not require a particular surgical approach for decompression of the spinal cord.
Use of prolonged bed rest in traction to treat subaxial cervical fractures and dislocations is recommended if more contemporary treatment options are unavailable.
Routine use of CT and MRI is recommended in trauma patients with ankylosing spondylitis, even after minor trauma.
Posterior long-segment instrumentation and fusion or a combined dorsal and anterior procedure is recommended in patients with ankylosing spondylitis who require surgical stabilization.

Uhrenholt L, Charles AV, Hauge E, Gregersen M. Pathoanatomy of the lower cervical spine facet joints in motor vehicle crash fatalities. J Forensic Leg Med. 2009 Jul. 16(5):253-60. [Medline].
Kouyoumdjian P, Guerin P, Schaelderle C, Asencio G, Gille O. Fracture of the lower cervical spine in patients with ankylosing spondylitis: Retrospective study of 19 cases. Orthop Traumatol Surg Res. 2012 Sep. 98(5):543-51. [Medline].
Milligram MA, Rand N. Cervical spine anatomy. Spine State of the Art Reviews. 2000. 14(3):521-32.
Allen BL Jr, Ferguson RL, Lehmann TR, O'Brien RP. A mechanistic classification of closed, indirect fractures and dislocations of the lower cervical spine. Spine (Phila Pa 1976). 1982 Jan-Feb. 7 (1):1-27. [Medline].
Zehnder SW, Lenarz CJ, Place HM. Teachability and reliability of a new classification system for lower cervical spinal injuries. Spine (Phila Pa 1976). 2009 Sep 1. 34(19):2039-43. [Medline].
Hubbard ME, Jewell RP, Dumont TM, Rughani AI. Spinal injury patterns among skiers and snowboarders. Neurosurg Focus. 2011 Nov. 31(5):E8. [Medline].
[Guideline] Hadley MN, Walters BC, Aarabi B, Dhall SS, Gelb DE, Hurlbert RJ, et al. Clinical assessment following acute cervical spinal cord injury. Neurosurgery. 2013 Mar. 72 Suppl 2:40-53. [Medline]. [Full Text].
Vaccaro AR, Hulbert RJ, Patel AA, Fisher C, Dvorak M, Lehman RA Jr, et al. The subaxial cervical spine injury classification system: a novel approach to recognize the importance of morphology, neurology, and integrity of the disco-ligamentous complex. Spine (Phila Pa 1976). 2007 Oct 1. 32 (21):2365-74. [Medline].
[Guideline] Aarabi B, Walters BC, Dhall SS, Gelb DE, Hurlbert RJ, Rozzelle CJ, et al. Subaxial cervical spine injury classification systems. Neurosurgery. 2013 Mar. 72 Suppl 2:170-86. [Medline]. [Full Text].
Vaccaro AR, Koerner JD, Radcliff KE, Oner FC, Reinhold M, Schnake KJ, et al. AOSpine subaxial cervical spine injury classification system. Eur Spine J. 2016 Jul. 25 (7):2173-84. [Medline].
Meinberg EG, Agel J, Roberts CS, Karam MD, Kellam JF. Fracture and Dislocation Classification Compendium-2018. J Orthop Trauma. 2018 Jan. 32 Suppl 1:S1-S170. [Medline]. [Full Text].
Platzer P, Hauswirth N, Jaindl M, Chatwani S, Vecsei V, Gaebler C. Delayed or missed diagnosis of cervical spine injuries. J Trauma. 2006 Jul. 61(1):150-5. [Medline].
Silva CT, Doria AS, Traubici J, Moineddin R, Davila J, Shroff M. Do additional views improve the diagnostic performance of cervical spine radiography in pediatric trauma?. AJR Am J Roentgenol. 2010 Feb. 194(2):500-8. [Medline].
Antevil JL, Sise MJ, Sack DI, Kidder B, Hopper A, Brown CV. Spiral computed tomography for the initial evaluation of spine trauma: A new standard of care?. J Trauma. 2006 Aug. 61(2):382-7. [Medline].
[Guideline] Ryken TC, Hadley MN, Walters BC, Aarabi B, Dhall SS, Gelb DE, et al. Radiographic assessment. Neurosurgery. 2013 Mar. 72 Suppl 2:54-72. [Medline]. [Full Text].
Eismont FJ, Arena MJ, Green BA. Extrusion of an intervertebral disc associated with traumatic subluxation or dislocation of cervical facets. Case report. J Bone Joint Surg Am. 1991 Dec. 73 (10):1555-60. [Medline].
Toh E, Nomura T, Watanabe M, Mochida J. Surgical treatment for injuries of the middle and lower cervical spine. Int Orthop. 2006 Feb. 30 (1):54-8. [Medline].
Marco RA, Meyer BC, Kushwaha VP. Thoracolumbar burst fractures treated with posterior decompression and pedicle screw instrumentation supplemented with balloon-assisted vertebroplasty and calcium phosphate reconstruction. Surgical technique. J Bone Joint Surg Am. 2010 Mar. 92 Suppl 1 Pt 1:67-76. [Medline].
Kim HJ, Lee KY, Kim WC. Treatment outcome of cervical tear drop fracture. Asian Spine J. 2009 Dec. 3(2):73-9. [Medline]. [Full Text].
Dvorak MF, Fisher CG, Aarabi B, Harris MB, Hurbert RJ, Rampersaud YR, et al. Clinical outcomes of 90 isolated unilateral facet fractures, subluxations, and dislocations treated surgically and nonoperatively. Spine. 2007 Dec 15. 32(26):3007-13. [Medline].
[Guideline] Gelb DE, Aarabi B, Dhall SS, Hurlbert RJ, Rozzelle CJ, Ryken TC, et al. Treatment of subaxial cervical spinal injuries. Neurosurgery. 2013 Mar. 72 Suppl 2:187-94. [Medline]. [Full Text].
Tsutsumi S, Ueta T, Shiba K, Yamamoto S, Takagishi K. Effects of the Second National Acute Spinal Cord Injury Study of high-dose methylprednisolone therapy on acute cervical spinal cord injury-results in spinal injuries center. Spine. 2006 Dec 15. 31(26):2992-6; discussion 2997. [Medline].
Bracken MB, Holford TR. Neurological and functional status 1 year after acute spinal cord injury: estimates of functional recovery in National Acute Spinal Cord Injury Study II from results modeled in National Acute Spinal Cord Injury Study III. J Neurosurg. 2002 Apr. 96(3 Suppl):259-66. [Medline].
Young W, Bracken MB. The Second National Acute Spinal Cord Injury Study. J Neurotrauma. 1992 Mar. 9 Suppl 1:S397-405. [Medline].
Bracken MB, Shepard MJ, Hellenbrand KG, Collins WF, Leo LS, Freeman DF, et al. Methylprednisolone and neurological function 1 year after spinal cord injury. Results of the National Acute Spinal Cord Injury Study. J Neurosurg. 1985 Nov. 63(5):704-13. [Medline].
Fehlings MG. Summary statement: the use of methylprednisolone in acute spinal cord injury. Spine. 2001 Dec 15. 26(24 Suppl):S55. [Medline].
Hugenholtz H, Cass DE, Dvorak MF, Fewer DH, Fox RJ, Izukawa DM, et al. High-dose methylprednisolone for acute closed spinal cord injury--only a treatment option. Can J Neurol Sci. 2002 Aug. 29 (3):227-35. [Medline].
[Guideline] Hurlbert RJ, Hadley MN, Walters BC, Aarabi B, Dhall SS, Gelb DE, et al. Pharmacological therapy for acute spinal cord injury. Neurosurgery. 2013 Mar. 72 Suppl 2:93-105. [Medline].
Fehlings MG, Bracken MB. Summary Statement: The Sygen(R) (GM-1 Ganglioside) Clinical Trial in Acute Spinal Cord Injury. Spine. 2001 Dec 15. 26(24 Suppl):S99-S100. [Medline].
Segal JL, Pathak MS, Hernandez JP, Himber PL, Brunnemann SR, Charter RS. Safety and efficacy of 4-aminopyridine in humans with spinal cord injury: a long-term, controlled trial. Pharmacotherapy. 1999 Jun. 19 (6):713-23. [Medline].
Dhillon CS, Jakkan MS, Dwivedi R, Medagam NR, Jindal P, Ega S. Outcomes of Unstable Subaxial Cervical Spine Fractures Managed by Posteroanterior Stabilization and Fusion. Asian Spine J. 2018 Jun. 12 (3):416-422. [Medline]. [Full Text].
Sapkas GS, Papadakis SA. Neurological outcome following early versus delayed lower cervical spine surgery. J Orthop Surg (Hong Kong). 2007 Aug. 15(2):183-6. [Medline].
Furlan JC, Noonan V, Cadotte DW, Fehlings MG. Timing of decompressive surgery of spinal cord after traumatic spinal cord injury: an evidence-based examination of pre-clinical and clinical studies. J Neurotrauma. 2011 Aug. 28(8):1371-99. [Medline]. [Full Text].
Fehlings MG, Vaccaro A, Wilson JR, Singh A, W Cadotte D, Harrop JS, et al. Early versus delayed decompression for traumatic cervical spinal cord injury: results of the Surgical Timing in Acute Spinal Cord Injury Study (STASCIS). PLoS One. 2012. 7 (2):e32037. [Medline]. [Full Text].
Du JP, Fan Y, Zhang JN, Liu JJ, Meng YB, Hao DJ. Early versus delayed decompression for traumatic cervical spinal cord injury: application of the AOSpine subaxial cervical spinal injury classification system to guide surgical timing. Eur Spine J. 2019 Mar 22. [Medline].
Apple DF. Spinal cord injury rehabilitation. Garfin SR, Vaccaro AR, eds. Orthopaedic Knowledge Update: Spine. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2002. Vol 2: 239-44.
Levine AM. Facet fractures and dislocations. Lampert R, ed. Spine Trauma. Philadelphia: WB Saunders; 1998. 331-65.

Media Gallery

Cross-sectional anatomy of the cervical cord.
Normal anatomy of the lower cervical spine.
Lateral film of a C5 burst/teardrop fracture.
Sagittal CT scan of C5 burst fracture.
Axial CT scan of C5 burst fracture.
Reduction of C5 burst fracture after tongs traction.
Postoperative image of C5 burst fracture; note anterior and posterior fixation.
Postoperative image of C5 burst fracture.
Standard lateral cervical spine of an 80-year-old patient after a motor vehicle accident; patient has no neurologic deficits and no neck pain.
Swimmer's view of the same 80-year-old patient as in Image 9; note the C7-T1 fracture/dislocation.
Axial CT scan of C7-T1 fracture/dislocation.
Sagittal CT of C7-T1 fracture/dislocation.
MRI of C7-T1 fracture/dislocation.
Reduction of C7-T1 fracture/dislocation.
Postoperative anteroposterior view of C7-T1 fracture/dislocation.
Postoperative lateral view of C7-T1 fracture/dislocation.

of 16

Author

J Allan Goodrich, MD Staff Physician, Orthopaedic Spine Surgeon, Doctor's Hospital

J Allan Goodrich, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, North American Spine Society, Society of Lateral Access Surgery

Disclosure: Received income in an amount equal to or greater than $250 from: Globus medical<br/>Intellectual property Globus.

Coauthor(s)

Thad Andrew Riddle, MD Orthopedic Surgeon and Partner, Georgia Bone and Joint Surgeons

Thad Andrew Riddle, MD is a member of the following medical societies: AO Foundation, American Academy of Orthopaedic Surgeons, American Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

William O Shaffer, MD Orthopedic Spine Surgeon, Northwest Iowa Bone, Joint, and Sports Surgeons

William O Shaffer, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Association, Kentucky Medical Association, North American Spine Society, Kentucky Orthopaedic Society, International Society for the Study of the Lumbar Spine, Southern Medical Association, Southern Orthopaedic Association

Disclosure: Received royalty from DePuySpine 1997-2007 (not presently) for consulting; Received grant/research funds from DePuySpine 2002-2007 (closed) for sacropelvic instrumentation biomechanical study; Received grant/research funds from DePuyBiologics 2005-2008 (closed) for healos study just closed; Received consulting fee from DePuySpine 2009 for design of offset modification of expedium.

Chief Editor

Jeffrey A Goldstein, MD Clinical Professor of Orthopedic Surgery, New York University School of Medicine; Director of Spine Service, Director of Spine Fellowship, Department of Orthopedic Surgery, NYU Hospital for Joint Diseases, NYU Langone Medical Center

Jeffrey A Goldstein, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American College of Surgeons, American Orthopaedic Association, AOSpine, Cervical Spine Research Society, International Society for the Advancement of Spine Surgery, International Society for the Study of the Lumbar Spine, Lumbar Spine Research Society, North American Spine Society, Scoliosis Research Society, Society of Lateral Access Surgery

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Medtronic, Nuvasive, NLT Spine, RTI, Magellan Health<br/>Received consulting fee from Medtronic for consulting; Received consulting fee from NuVasive for consulting; Received royalty from Nuvasive for consulting; Received consulting fee from K2M for consulting; Received ownership interest from NuVasive for none.

Acknowledgements

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous author Samuel Hu, MD, to the development and writing of this article.

Sections Lower Cervical Spine Fractures and Dislocations
Overview
Presentation
Workup
Treatment
Guidelines
Media Gallery
References

Lower Cervical Spine Fractures and Dislocations Guidelines

AANS Recommendations on Classification and Treatment of Subaxial Cervical Spine Injuries

About

Membership

Apps

WebMD Network

Editions

Lower Cervical Spine Fractures and Dislocations Guidelines

AANS Recommendations on Classification and Treatment of Subaxial Cervical Spine Injuries

References

Tables

Contributor Information and Disclosures

What would you like to print?

Find Us On

About

Membership

Apps

WebMD Network

Editions