This document discusses subaxial cervical spine injuries, including: - Assessment and emergency treatment of cervical spine injuries following trauma. - Classification systems for cervical spine injuries including AO Spine, SLIC, and others which classify injuries based on morphology, neurological status, and stability. - Types of cervical injuries such as flexion-compression, burst fractures, distraction injuries, and recommendations for treatment and surgery based on classification. - Illustrative case examples of different cervical injury types classified using AO Spine and SLIC systems along with their treatments. - Key points about immobilizing the cervical spine, rational use of imaging, importance of stability especially the posterior column, and indications for early surgery.

1. SUBAXIAL CERVICAL SPINE INJURIES-
CLINICAL SPECTRUM AND
EMERGENCY TREATMENT
Dr Sumit Sinha MS, DNB, MCh
Additional Professor
Deptt of Neurosurgery, AIIMS and JPNATC, New Delhi
Faculty, Advanced trauma Life Support
Faculty, AO Spine

2. SUBAXIAL CERVICAL SPINE INJURIES
Assessment of Cervical spine injuries
• AIRWAY+ CERVICAL SPINE IMMOBILIZATION
• BREATHING
• CIRCULATION
• DISABILITY
• EXPOSURE
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3. SUBAXIAL CERVICAL SPINE INJURIES
NEXUS Low risk criteria
Cervical spine imaging recommended for all pts with trauma
EXCEPT
• No midline tenderness
• No intoxication
• Normal alertness
• No FND
• No other injuries
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*Hoffman JR et al. Ann Emerg Med 1998;32:461-469

4. SUBAXIAL CERVICAL SPINE INJURIES
Indications for Surgery
• Unstable injuries
• Injuries with neurological deficits with proven
mechanical compression
• Inability to reduce dislocation by closed means
• To facilitate nursing care
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5. SUBAXIAL CERVICAL SPINE INJURIES
INSTABILITY
White and Punjabi et al
• ‘the loss of the spine’s ability to maintain its patterns
of displacement under physiologic loads so there is no
initial or additional neurologic deficit, no major
deformity, and no incapacitating pain’
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*A.A. White, M.M. Panjabi (Eds.), Clinical biomechanics of the spine, 2nd ed, JB
Lippincott, Philadelphia, PA, 1990.

6. SUBAXIAL CERVICAL SPINE INJURIES
INSTABILITY
Anterior Column Middle Column Posterior Column
Anterior third VB, disc,
ALL
Posterior third VB and
Disc, PLL
Posterior spinal arch and
laminae
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7. SUBAXIAL CERVICAL SPINE INJURIES
Classification systems
• Nicoll et al- functional outcomes
• Holdsworth et al- stable/ unstable- PLC integrity
• White and Punjabi- neurology, radiology, stretch test
• Allen et al- mechanistic
• Harris et al
• AO Spine
• CSISS
• SLIC
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8. SUBAXIAL CERVICAL SPINE INJURIES
Classification systems
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9. SUBAXIAL CERVICAL SPINE INJURIES
Classification systems
AO Spine
• Type A- compression
• Type B- Distraction
• Type C- Rotation
*Magerl F et al. Eur Spine J 1994;3:184-201
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10. SUBAXIAL CERVICAL SPINE INJURIES
Classification systems
A B C
1 Impaction Posterior disruption-
ligamentous
Rotational wedge
2 Split Posterior disruption-
bony
Rotational split
3 Burst Anterior disruption-
disc
Rotational burst
AO Spine
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11. *Vaccaro et al. AO Spine Knowledge forum- TLICS validation study
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12. SUBAXIAL CERVICAL SPINE INJURIES
Classification systems
Neurological Modifiers
• N0-No Neurological deficit
• N1- transient deficit,
resolved
• N2- Radiculopathy
• N3- incomplete SCI / CES
• N4- complete SCI
• NX- cant be assessed
Patient specific modifiers
• M1- Indeterminate tension
band injury
• M2- comorbidity (DISH/ AS)
*Vaccaro et al. AO Spine Knowledge forum- TLICS validation study
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13. Classification systems
Subaxial cervical injury severity score (SLIC)
*Vaccaro AR et al. Spine 2007;32:2365-74
**Vaccaro AR et al. Spine 2005;30(20):2325-33
Morphology Points
No Abn 0
Compression 1
Burst 2
Distraction 3
Rotation/ translation 4
PLC
Intact 0
Indeterminate 1
Disrupted 2
Neurology
Intact 0
Root Injury 1
Complete cord injury 2
Incomplete cord injury 3
Continuous cord compression +1
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14. Classification systems
Subaxial cervical injury severity score (SLIC)
Burst morphology (2)- Type
A3
Compression morphology (1)- Type A1,A1
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15. Classification systems
Subaxial cervical injury severity score (SLIC)
Translation/Rotation morphology (4)- Type
C
Distraction Morphology (3)- Type B1, B2, B3
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16. SUBAXIAL CERVICAL SPINE INJURIES
Flexion-Compression Injuries
(Type A2,A3 ,B1 and C AO Spine
SLIC- Compression/ Burst)
Rizzolo SJ et al. J Am Acad Orthop Surg. 1993:1:57-66
rigid orthosis
Sx- Ventral/ dorsal/
360°
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17. SUBAXIAL CERVICAL SPINE INJURIES
Classification systems
Flexion-Compression Injuries
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18. SUBAXIAL CERVICAL SPINE INJURIES
Classification systems
Vertical Compression (Burst) Injury
(Type A3 AO Spine/ SLIC- Compression/ Burst)
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19. •
Recommendations for SLIC Burst inuries
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20. SUBAXIAL CERVICAL SPINE INJURIES
Classification systems
Compression Extension Injury
(Type B3, C AO Spine, SLIC- Distraction)
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21. SUBAXIAL CERVICAL SPINE INJURIES
Classification systems
Distractive Extension Injuries
(Type B3, C AO Spine- SLIC- Distraction)
ACDF+ Plating
360 ° Fusion
Skeletal traction-
CAUTION
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22. Recommendations for SLIC Hyperextension inuries
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23. SUBAXIAL CERVICAL SPINE INJURIES
Distractive flexion Injuries
(Type B1,B2 and C AO Spine
SLIC- Translation/ Distraction)
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URGENT CLOSED/
OPEN REDUCTION

24. Recommendations for SLIC Rotation/ translation inuries
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25. SUBAXIAL CERVICAL SPINE INJURIES
Illustrative Cases
Distractive flexion Injury Stage 3
Type B2 #
SLIC- 3+2+2=7
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26. SUBAXIAL CERVICAL SPINE INJURIES
Illustrative Cases
Distraction Hyperextension Injury Stage 2
Type B3 #
SLIC- 3+2+1=6
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27. SUBAXIAL CERVICAL SPINE INJURIES
Illustrative Cases
Distractive Flexion Injury Stage 3
Type C#
SLIC- 3+2+2=7
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28. SUBAXIAL CERVICAL SPINE INJURIES
Illustrative Cases
Vertical Compression Injury
Type A3 #
SLIC- 2+0+3+1=6
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29. SUBAXIAL CERVICAL SPINE INJURIES
Illustrative Cases
Distractive Flexion Injury Stage 3
Type B1 #
SLIC- 3+2+3=8
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30. SUBAXIAL CERVICAL SPINE INJURIES
Illustrative Cases
Compression Flexion Injury Stage III
Type B2 #
SLIC- 2+1+3=6
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31. SUBAXIAL CERVICAL SPINE INJURIES
Illustrative Cases
Flexion Compression Injury Stage 3
Type A2 #
SLIC- 1+1+3=5
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32. SUBAXIAL CERVICAL SPINE INJURIES
Illustrative Cases
Distraction Hyperextension Injury Type 1
Type B3 #
SLIC- 3+1+3=7
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33. SUBAXIAL CERVICAL SPINE INJURIES
TAKE HOME MESSAGE
• IMMOBILIZE C-Spine- Priority
• Rationalization of Radiography- 10% contiguous spine #
• Look for instability- Classify- Decompress and Reconstitute the
column which is disrupted
• Posterior column most important for stability- reconstitute
whenever disrupted
• EARLY SURGERY- ?? hours (Level III evidence)
• Urgent reduction of bilateral locked facets in incomplete
tetraplegia- (Level II evidence)- Closed OR open reduction- Role of
Pre-reduction MR ?
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34. THANKYOU FOR YOUR ATTENTION
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