The classifications of subaxial cervical spine traumatic injuries. Part 1. General principles
Keywords:traumatic injury, clinical classification, cervical spine, subaxial levell
Cervical spine and spinal cord injury is a significant medical and socio-economic problem of modern society. Ongoing urbanization, the development of high-speed modes of transport and the intensification of military conflicts lead to a progressive increase in the number of victims with this pathology. At the same time, unlike several other socially significant diseases, the category of the most employable population suffers from spinal injuries. Achievements of modern medicine to a much greater extent contribute to reducing the mortality of patients, rather than regression of neurological disorders. The usage of new diagnostic methods for neuroimaging and expensive surgical instruments, the continuous improvement of rehabilitation treatment of patients with spinal cord injury determine the progressively increasing costs for medical and social life support expenses.
A large number of experimental and clinical studies, improvement of methods for surgical correction and stabilization of the damaged vertebral motor segment undoubtedly dictate certain changes in the tactics of treatment. The classification of traumatic spinal injuries is of key importance in determining the approaches, timing and volume of surgical intervention. Following the care algorithms helps to minimize the negative effects of traumatic damage to both the spine and the spinal cord and contributes to the maximum possible recovery of neurological functions.
The last few decades have been characterized by the gradual replacement of the previously widely used “morphological” classifications of traumatic injuries of the cervical spine to “clinical” ones, based on an analysis of some heterogeneous factors determining treatment tactics.
The first part of the review deals with a detailed description of the main criteria used in developing modern “clinical” classifications of subaxial cervical spine traumatic injuries. Besides, modern views on imaging methods and algorithms for determining the need to perform diagnostic procedures at primary hospitalization in patients with suspected cervical spine traumatic injury are presented.
2. Chen Y, He Y, DeVivo MJ. Changing Demographics and Injury Profile of New Traumatic Spinal Cord Injuries in the United States, 1972–2014. Arch. Phys. Med. Rehabil. 2016 Oct;97(10):1610-9. [CrossRef] [PubMed]
3. Ni P, Mulcahey MJ, Slavin MD, Thielen CC, Vogel LC, Sadowsky C, Davidson LT, Jette AM. Tracking Spinal Cord Injury Functional Outcomes across the Lifespan: Validation of Linking Coefficients. Arch. Phys. Med. Rehabil. 2019 May 30. pii: S0003-9993(19)30382-X. [CrossRef]
4. Parsons KC. The impact of spinal cord injury on long-term survival. J. Insur. Med. 1991;23(4):227. [PubMed]
5. Pfeifer R, Teuben M, Andruszkow H, Barkatali BM, Pape H-C. Mortality Patterns in Patients with Multiple Trauma: A Systematic Review of Autopsy Studies. PLoS One 2016 Feb 12;11(2):e0148844. [CrossRef] [PubMed]
6. Yue JK, Winkler EA, Rick JW, Deng H, Partow CP, Upadhyayula PS, Birk HS, Chan AK, Dhall SS. Update on critical care for acute spinal cord injury in the setting of polytrauma. Neurosurg. Focus 2017 Nov;43(5):E19. [CrossRef]
8. Oliver M, Inaba K, Tang A, Branco BC, Barmparas G, Schnüriger B, Lustenberger T, Demetriades D. The changing epidemiology of spinal trauma: A 13-year review from a Level I trauma centre. Injury 2012 Aug;43(8):1296-300. [CrossRef] [PubMed]
9. Acton PA, Farley T, Freni LW, Ilegbodu VA, Sniezek JE, Wohlleb JC. Traumatic spinal cord injury in Arkansas, 1980 to 1989. Arch. Phys. Med. Rehabil. 1993 Oct;74(10):1035-40. [PubMed]
10. Burney RE, Maio RF, Maynard F, Karunas R. Incidence, characteristics, and outcome of spinal cord injury at trauma centers in North America. Arch. Surg. 1993 May;128(5):596-9. [PubMed]
12. Knútsdóttir S, Thórisdóttir H, Sigvaldason K, Jónsson H, Björnsson A, Ingvarsson P. Epidemiology of traumatic spinal cord injuries in Iceland from 1975 to 2009. Spinal Cord 2012 Feb 27;50(2):123-6. [CrossRef] [PubMed]
14. Hamilton BB, Deutsch A, Russell C, Fiedler RC, Granger C V. Relation of disability costs to function: spinal cord injury. Arch. Phys. Med. Rehabil. 1999 Apr;80(4):385-91. [PubMed]
15. DeVivo MJ. Causes and costs of spinal cord injury in the United States. Spinal Cord 1997 Dec;35(12):809-13. [PubMed]
16. Richard-Denis A, Ehrmann Feldman D, Thompson C, Bourassa-Moreau É, Mac-Thiong J-M. Costs and Length of Stay for the Acute Care of Patients with Motor-Complete Spinal Cord Injury Following Cervical Trauma. Am. J. Phys. Med. Rehabil. 2017 Jul;96(7):449-56. [CrossRef] [PubMed]
18. Berkowitz M. Assessing the socioeconomic impact of improved treatment of head and spinal cord injuries. J. Emerg. Med. 1993;11 Suppl 1:63-7. [PubMed]
22. Vaccaro AR, Koerner JD, Radcliff KE, Oner FC, Reinhold M, Schnake KJ, Kandziora F, Fehlings MG, Dvorak MF, Aarabi B, Rajasekaran S, Schroeder GD, Kepler CK, Vialle LR. AOSpine subaxial cervical spine injury classification system. Eur. Spine J. 2016 Jul 26;25(7):2173-84. [CrossRef] [PubMed]
23. van Middendorp JJ, Audigé L, Hanson B, Chapman JR, Hosman AJF. What should an ideal spinal injury classification system consist of? A methodological review and conceptual proposal for future classifications. Eur. Spine J. 2010 Aug;19(8):1238-49. [CrossRef] [PubMed]
24. Nightingale RW, McElhaney JH, Richardson WJ, Best TM, Myers BS. Experimental impact injury to the cervical spine: relating motion of the head and the mechanism of injury. J. Bone Joint Surg. Am. 1996 Mar;78(3):412-21. [PubMed]
25. Huelke DF, Mackay GM, Morris A. Vertebral column injuries and lap-shoulder belts. J. Trauma 1995 Apr;38(4):547-56. [PubMed]
26. Swartz EE, Floyd RT, Cendoma M. Cervical spine functional anatomy and the biomechanics of injury due to compressive loading. J. Athl. Train. 2005;40(3):155-61. [PubMed]
27. Carter JW, Mirza SK, Tencer AF, Ching RP. Canal geometry changes associated with axial compressive cervical spine fracture. Spine (Phila. Pa. 1976). 2000 Jan;25(1):46-54. [PubMed]
28. Chang DG, Tencer AF, Ching RP, Treece B, Senft D, Anderson PA. Geometric changes in the cervical spinal canal during impact. Spine (Phila. Pa. 1976). 1994 Apr 15;19(8):973-80. [PubMed]
29. Dai Y, Chen B, Teng H, Huang K, Wang J, Zhu M, Li C. [Correlation among prevertebral hyperintensity signal, canal sagittal diameter on MRI and neurologic function of patients with cervical vertebral hyperextension injury]. Zhongguo Gu Shang 2015 Aug;28(8):686-9. [PubMed]
30. Aebli N, Rüegg TB, Wicki AG, Petrou N, Krebs J. Predicting the risk and severity of acute spinal cord injury after a minor trauma to the cervical spine. Spine J. 2013 Jun;13(6):597-604. [CrossRef] [PubMed]
31. Sances A, Myklebust JB, Maiman DJ, Larson SJ, Cusick JF, Jodat RW. The biomechanics of spinal injuries. Crit. Rev. Biomed. Eng. 1984;11(1):1-76. [PubMed]
32. Coelho DG, Brasil A V, Ferreira NP. Risk factors of neurological lesions in low cervical spine fractures and dislocations. Arq. Neuropsiquiatr. 2000 Dec;58(4):1030-4. [PubMed]
33. Enderson BL, Reath DB, Meadors J, Dallas W, DeBoo JM, Maull KI. The tertiary trauma survey: a prospective study of missed injury. J. Trauma 1990 Jun;30(6):666-9; discussion 669-70. [PubMed]
34. MacDonald RL, Schwartz ML, Mirich D, Sharkey PW, Nelson WR. Diagnosis of cervical spine injury in motor vehicle crash victims: how many X-rays are enough? J. Trauma 1990 Apr;30(4):392-7. [PubMed]
35. Shaffer MA, Doris PE. Limitation of the cross table lateral view in detecting cervical spine injuries: a retrospective analysis. Ann. Emerg. Med. 1981 Oct;10(10):508-13. [PubMed]
36. Turetsky DB, Vines FS, Clayman DA, Northup HM. Technique and use of supine oblique views in acute cervical spine trauma. Ann. Emerg. Med. 1993 Apr;22(4):685-9. [PubMed]
37. Davis JW, Phreaner DL, Hoyt DB, Mackersie RC. The etiology of missed cervical spine injuries. J. Trauma 1993 Mar;34(3):342-6. [PubMed]
39. Nkusi AE, Muneza S, Hakizimana D, Nshuti S, Munyemana P. Missed or Delayed Cervical Spine or Spinal Cord Injuries Treated at a Tertiary Referral Hospital in Rwanda. World Neurosurg. 2016 Mar;87:269-76. [CrossRef] [PubMed]
40. Freemyer B, Knopp R, Piche J, Wales L, Williams J. Comparison of five-view and three-view cervical spine series in the evaluation of patients with cervical trauma. Ann. Emerg. Med. 1989 Aug;18(8):818-21. [PubMed]
41. Gale SC, Gracias VH, Reilly PM, Schwab CW. The inefficiency of plain radiography to evaluate the cervical spine after blunt trauma. J. Trauma 2005 Nov;59(5):1121-5. [PubMed]
42. Theologis AA, Dionisio R, Mackersie R, McClellan RT, Pekmezci M. Cervical Spine Clearance Protocols in Level 1 Trauma Centers in the United States. Spine (Phila. Pa. 1976). 2014 Mar 1;39(5):356-61. [CrossRef] [PubMed]
43. McCracken B, Klineberg E, Pickard B, Wisner DH. Flexion and extension radiographic evaluation for the clearance of potential cervical spine injures in trauma patients. Eur. Spine J. 2013 Jul;22(7):1467-73. [CrossRef] [PubMed]
44. Tran B, Saxe JM, Ekeh AP. Are flexion extension films necessary for cervical spine clearance in patients with neck pain after negative cervical CT scan? J. Surg. Res. 2013 Sep;184(1):411-3. [CrossRef]
45. Oh JJ, Asha SE. Utility of flexion-extension radiography for the detection of ligamentous cervical spine injury and its current role in the clearance of the cervical spine. Emerg. Med. Australas. 2016 Apr;28(2):216-23. [CrossRef] [PubMed]
46. Lewis LM, Docherty M, Ruoff BE, Fortney JP, Keltner RA, Britton P. Flexion-extension views in the evaluation of cervical-spine injuries. Ann. Emerg. Med. 1991 Feb;20(2):117-21. [PubMed]
47. Pollack C V., Hendey GW, Martin DR, Hoffman JR, Mower WR, NEXUS Group. Use of flexion-extension radiographs of the cervical spine in blunt trauma. Ann. Emerg. Med. 2001 Jul;38(1):8-11. [CrossRef] [PubMed]
49. Anglen J, Metzler M, Bunn P, Griffiths H. Flexion and extension views are not cost-effective in a cervical spine clearance protocol for obtunded trauma patients. J. Trauma 2002 Jan;52(1):54-9. [PubMed]
50. Cox MW, McCarthy M, Lemmon G, Wenker J. Cervical spine instability: clearance using dynamic fluoroscopy. Curr. Surg. 2001 Jan;58(1):96-100. [PubMed]
51. Davis JW, Kaups KL, Cunningham MA, Parks SN, Nowak TP, Bilello JF, Williams JL. Routine evaluation of the cervical spine in head-injured patients with dynamic fluoroscopy: a reappraisal. J. Trauma 2001 Jun;50(6):1044-7. [PubMed]
52. Pinheiro DF de C, Fontes B, Shimazaki JK, Oliveira Bernini C de, Rasslan S. Diagnostic value of tomography of the cervical spine in victims of blunt trauma. Rev. Col. Bras. Cir.38(5):299-303. [PubMed]
53. Duane TM, Young AJ, Vanguri P, Wolfe LG, Katzen J, Han J, Mayglothling J, Whelan JF, Aboutanos MB, Ivatury RR, Malhotra AK. Defining the cervical spine clearance algorithm. J. Trauma Acute Care Surg. 2016 Sep;81(3):541-7. [CrossRef] [PubMed]
54. Chilvers G, Janjua U, Choudhary S. Blunt cervical spine injury in adult polytrauma: incidence, injury patterns and predictors of significant ligament injury on CT. Clin. Radiol. 2017 Nov;72(11):907-14. [CrossRef] [PubMed]
56. Pekmezci M, Theologis AA, Dionisio R, Mackersie R, McClellan RT. Cervical spine clearance protocols in Level I, II, and III trauma centers in California. Spine J. 2015 Mar 1;15(3):398-404. [CrossRef] [PubMed]
57. Bernstein MP, Young MG, Baxter AB. Imaging of Spine Trauma. Radiol. Clin. North Am. 2019 Jul;57(4):767-85. [CrossRef]
58. Tamangani J. Neuroimaging. Aust. Fam. Physician 2016 Nov;45(11):788-92. [PubMed]
59. Minja FJ, Mehta KY, Mian AY. Current Challenges in the Use of Computed Tomography and MR Imaging in Suspected Cervical Spine Trauma. Neuroimaging Clin. N. Am. 2018 Aug;28(3):483-93. [CrossRef] [PubMed]
60. Saragiotto BT, Maher CG, Lin C-WC, Verhagen AP, Goergen S, Michaleff ZA. Canadian C-spine rule and the National Emergency X-Radiography Utilization Study (NEXUS) for detecting clinically important cervical spine injury following blunt trauma. Cochrane Database Syst. Rev. 2018 Apr 11; [CrossRef]
61. Stiell IG, Wells GA, Vandemheen KL, Clement CM, Lesiuk H, De Maio VJ, Laupacis A, Schull M, McKnight RD, Verbeek R, Brison R, Cass D, Dreyer J, Eisenhauer MA, Greenberg GH, MacPhail I, Morrison L, Reardon M, Worthington J. The Canadian C-spine rule for radiography in alert and stable trauma patients. JAMA 2001 Oct 17;286(15):1841-8. [PubMed]
62. Bono CM, Vaccaro AR, Fehlings M, Fisher C, Dvorak M, Ludwig S, Harrop J. Measurement Techniques for Lower Cervical Spine Injuries. Spine (Phila. Pa. 1976). 2006 Mar 1;31(5):603-9. [CrossRef] [PubMed]
63. Cobb JR. Outline for the Study of Scoliosis. Instr. Course Lect. Am. Acad. Orthop. Surg. 1948;5:261-75.
64. Schleicher P, Kobbe P, Kandziora F, Scholz M, Badke A, Brakopp F, Ekkerlein H, Gercek E, Hartensuer R, Hartung P, Jarvers J-S, Matschke S, Morrison R, Müller CW, Pishnamaz M, Reinhold M, Schmeiser G, Schnake KJ, Stein G, Ullrich B, Weiss T, Zimmermann V. Treatment of Injuries to the Subaxial Cervical Spine: Recommendations of the Spine Section of the German Society for Orthopaedics and Trauma (DGOU). Glob. spine J. 2018 Sep 7;8(2 Suppl):25S-33S. [CrossRef] [PubMed]
65. Harrison DE, Harrison DD, Cailliet R, Troyanovich SJ, Janik TJ, Holland B. Cobb method or Harrison posterior tangent method: which to choose for lateral cervical radiographic analysis. Spine (Phila. Pa. 1976). 2000 Aug 15;25(16):2072-8. [PubMed]
66. Frobin W, Leivseth G, Biggemann M, Brinckmann P. Vertebral height, disc height, posteroanterior displacement and dens-atlas gap in the cervical spine: precision measurement protocol and normal data. Clin. Biomech. (Bristol, Avon) 2002 Jul;17(6):423-31. [PubMed]
67. van Middendorp JJ, Cheung I, Dalzell K, Deverall H, Freeman BJC, Morris SAC, Sandler SJI, Williams R, Yau YH, Goss B. Detecting Facet Joint and Lateral Mass Injuries of the Subaxial Cervical Spine in Major Trauma Patients. Asian Spine J. 2015 Jun;9(3):327. [CrossRef] [PubMed]
68. Wu S-K, Kuo L-C, Lan H-CH, Tsai S-W, Chen C-L, Su F-C. The quantitative measurements of the intervertebral angulation and translation during cervical flexion and extension. Eur. Spine J. 2007 Sep;16(9):1435-44. [CrossRef] [PubMed]
69. Hsu W-E, Su K-C, Chen K-H, Pan C-C, Lu W-H, Lee C-H. The Evaluation of Different Radiological Measurement Parameters of the Degree of Collapse of the Vertebral Body in Vertebral Compression Fractures. Appl. Bionics Biomech. 2019 May 8;2019:1-5. [CrossRef] [PubMed]
70. Sadiqi S, Verlaan J-J, Lehr AM, Chapman JR, Dvorak MF, Kandziora F, Rajasekaran S, Schnake KJ, Vaccaro AR, Oner FC. Measurement of kyphosis and vertebral body height loss in traumatic spine fractures: an international study. Eur. Spine J. 2017 May 6;26(5):1483-91. [CrossRef] [PubMed]
71. Fehlings MG, Rao SC, Tator CH, Skaf G, Arnold P, Benzel E, Dickman C, Cuddy B, Green B, Hitchon P, Northrup B, Sonntag V, Wagner F, Wilberger J. The optimal radiologic method for assessing spinal canal compromise and cord compression in patients with cervical spinal cord injury. Part II: Results of a multicenter study. Spine (Phila. Pa. 1976). 1999 Mar 15;24(6):605-13. [PubMed]
72. Kuhns LR, Strouse PJ. Facet coverage in children on flexion lateral cervical radiographs. Spine (Phila. Pa. 1976). 1999 Feb 15;24(4):339-41. [PubMed]
73. BROWN T, HANSEN RJ, YORRA AJ. Some mechanical tests on the lumbosacral spine with particular reference to the intervertebral discs; a preliminary report. J. Bone Joint Surg. Am. 1957 Oct;39-A(5):1135-64. [PubMed]
74. Holdsworth F. Fractures, dislocations, and fracture-dislocations of the spine. J. Bone Joint Surg. Am. 1970 Dec;52(8):1534-51. [PubMed]
75. Denis F. The three column spine and its significance in the classification of acute thoracolumbar spinal injuries. Spine (Phila. Pa. 1976). 1983;8(8):817-31. [PubMed]
76. Vaccaro AR, Koerner JD, Radcliff KE, Oner FC, Reinhold M, Schnake KJ, Kandziora F, Fehlings MG, Dvorak MF, Aarabi B, Rajasekaran S, Schroeder GD, Kepler CK, Vialle LR. AOSpine subaxial cervical spine injury classification system. Eur. Spine J. 2016 Jul 26;25(7):2173-84. [CrossRef] [PubMed]
77. WHITE AA, SOUTHWICK WO, PANJABI MM. Clinical Instability in the Lower Cervical Spine A Review of Past and Current Concepts. Spine (Phila. Pa. 1976). 1976;1(1)
78. White AA, Panjabi MM. Update on the evaluation of instability of the lower cervical spine. Instr. Course Lect. 1987;36:513-20. [PubMed]
79. White AA, Johnson RM, Panjabi MM, Southwick WO. Biomechanical analysis of clinical stability in the cervical spine. Clin. Orthop. Relat. Res. 1975;(109):85-96. [PubMed]
80. Marx JA, Hockberger RS, Walls RM, Biros MH, Danzl DF, Gausche-Hill M, Jagoda A, Ling L, Newton E, Zink BJ, Rosen P. Rosen’s Emergency Medicine : Concepts and Clinical Practice, 2-Volume Set. 8th ed. Elsevier Health Sciences; 2013.
How to Cite
Copyright (c) 2019 Ievgenii I. Slynko, Alexey S. Nekhlopochin, Vadim V. Verbov
This work is licensed under a Creative Commons Attribution 4.0 International License.
Ukrainian Neurosurgical Journal abides by the CREATIVE COMMONS copyright rights and permissions for open access journals.
Authors, who are published in this Journal, agree to the following conditions:
1. The authors reserve the right to authorship of the work and pass the first publication right of this work to the Journal under the terms of Creative Commons Attribution License, which allows others to freely distribute the published research with the obligatory reference to the authors of the original work and the first publication of the work in this Journal.
2. The authors have the right to conclude separate supplement agreements that relate to non-exclusive work distribution in the form of which it has been published by the Journal (for example, to upload the work to the online storage of the Journal or publish it as part of a monograph), provided that the reference to the first publication of the work in this Journal is included.