The classifications of subaxial cervical spine traumatic injuries. Part 4. AOSpine Subaxial Classification System
Keywords:traumatic injury, classification, cervical spine, subaxial level, AOSpine Subaxial Classification System
Cervical spine injuries are a fairly common consequence of mechanical impact on the human body. The subaxial level of the cervical spine accounts for approximately half to 2/3 of these injuries. Despite the numerous classification systems that exist for describing these injuries, the recommendations for treatment strategy are very limited, and currently none of them is universal and generally accepted. Consequently, treatment decisions are based on the individual experience of the specialist, but not on evidence or algorithms. While the classification system based on the mechanism of trauma originally proposed by B.L. Allen et al. and subsequently modified by J.H. Harris Jr et al., was comprehensive, but lacked evidence, which to some extent limited its clinical applicability. Similarly, the Subaxial Injury Classification System proposed by the Spine Trauma Group, had no distinct and clinically significant patterns of morphological damage. This fact hindered the standardization and unification of tactical approaches.
As an attempt to solve this problem, in 2016 Alexander Vaccaro, together with AO Spine, proposed the AO Spine subaxial cervical spine injury classification system, using the principle of already existing AOSpine classification of thoracolumbar injuries. The aim of the project was to develop an effective system that provides clear, clinically relevant morphological descriptions of trauma patterns, which should contribute to the determination of treatment strategy. The proposed classification of cervical spine injuries at the subaxial level follows the same hierarchical approach as previous AO classifications, namely, it characterizes injuries based on 4 parameters: (1) injury morphology, (2) facet damage, (3) neurological status, and (4) specific modifiers. The morphology of injuries is divided into 3 subgroups of injuries: A (compression), B (flexion-distraction), and C (dislocations and displacements). Damage types A and B are divided into 5 (A0-A4) and 3 (B1-B3) subtypes, respectively. When describing damage of the facet joints, 4 subtypes are distinguished: F1 (fracture without displacement), F2 (unstable fracture), F3 (floating lateral mass) and F4 (dislocation). The system also integrates the assessment of neurological status, which is divided into 6 subtype). In addition, the classification includes 4 specific modifiers designed to better detail a number of pathological conditions. The performance evaluation of AOSpine SCICS showed a moderate to significant range of consistency and reproducibility.
Currently, a quantitative scale for assessing the severity of classification classes has been proposed, which also, to a certain extent, contributes to decision-making regarding treatment strategy.
1. Müller ME, Nazarian S, Koch P. Classification AO des fractures: les os longs. Springer-Verlag; 1987.
2. Marsh JL, Slongo TF, Agel J, Broderick JS, Creevey W, DeCoster TA, Prokuski L, Sirkin MS, Ziran B, Henley B, Audigé L. Fracture and dislocation classification compendium - 2007: Orthopaedic Trauma Association classification, database and outcomes committee. J Orthop Trauma. 2007 Nov-Dec;21(10 Suppl):S1-133. [CrossRef] [PubMed]
4. 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;25(7):2173-84. [CrossRef] [PubMed]
6. Vaccaro AR, Oner C, Kepler CK, Dvorak M, Schnake K, Bellabarba C, Reinhold M, Aarabi B, Kandziora F, Chapman J, Shanmuganathan R, Fehlings M, Vialle L. AOSpine thoracolumbar spine injury classification system: Fracture description, neurological status, and key modifiers Spine (Phila. Pa. 1976). 2013 Nov 1;38(23):2028–37. [CrossRef] [PubMed]
7. Divi SN, Schroeder GD, Oner FC, Kandziora F, Schnake KJ, Dvorak MF, Benneker LM, Chapman JR, Vaccaro AR. AOSpine-Spine Trauma Classification System: The Value of Modifiers: A Narrative Review With Commentary on Evolving Descriptive Principles. Global Spine J. 2019 May;9(1 Suppl):77S-88S. [CrossRef] [PubMed] [PubMed Central]
8. Aarabi B, Oner C, Vaccaro AR, Schroeder GD, Akhtar-Danesh N. Application of AOSpine Subaxial Cervical Spine Injury Classification in Simple and Complex Cases J. Orthop. Trauma. 2017 Sep;31:S24–32. [CrossRef] [PubMed]
9. Reinhold M, Knop C, Lange U, Rosenberger R, Schmid R, Blauth M. Reposition von verrenkungen und verrenkungsbrüchen der unteren halswirbelsäule Unfallchirurg. 2006 Dec;109(12):1064–72. [CrossRef] [PubMed]
10. Slynko II, Nekhlopochin AS, Verbov VV. [The classifications of subaxial cervical spine traumatic injuries. Part 1. General principles]. Ukrainian Neurosurgical Journal. 2019 Sep 28;25(3):12–26. Russian. [CrossRef]
12. Vaněk P. New AOSpine subaxial cervical spine injury classification and its clinical usage. Rozhl Chir. 2018 Spring;97(6):273-278. English. [PubMed]
13. da Silva OT, Rodrigues SA, Ghizoni E, Tedeschi H, Joaquim AF. Can Injury Type/Subtype of the New Aospine Subaxial Cervical Trauma Classification Dictate Patient’s Treatment? International Journal of Orthopaedics. 2020 Dec 28;7(6):1397-401. [CrossRef]
14. Mushlin H, Kole MJ, Chryssikos T, Cannarsa G, Schwartzbauer G, Aarabi B. AOSpine Subaxial Cervical Spine Injury Classification System: The Relationship Between Injury Morphology, Admission Injury Severity, and Long-Term Neurologic Outcome. World Neurosurg. 2019 Oct 1;130:e368–74. [CrossRef] [PubMed]
15. Du JP, Fan Y, Zhang JN, Liu JJ, Meng Y Bin, 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 Aug 1;28(8):1855–63. [CrossRef] [PubMed]
16. Canseco JA, Schroeder GD, Paziuk TM, Karamian BA, Kandziora F, Vialle EN, Oner FC, Schnake KJ, Dvorak MF, Chapman JR, Benneker LM, Rajasekaran S, Kepler CK, Vaccaro AR. The Subaxial Cervical AO Spine Injury Score. Global Spine J. 2020 Dec 11:2192568220974339. [CrossRef] [PubMed]
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