The classifications of subaxial cervical spine traumatic injuries. Part 6. Ben L. Allen biomechanical classification
DOI:
https://doi.org/10.25305/unj.234876Keywords:
traumatic injury, Allen-Ferguson classification, cervical spine, subaxial level, morphology, biomechanicsAbstract
Traumatic injuries of subaxial cervical spine are characterized by a wide range of possible pathomorphological changes that depend not only on the direction and intensity of the traumatic force impact, but also on the initial position of cervical spine at the moment of exposure.
One of the most detailed classifications of cervical spine traumatic injuries, in which the integrated approach to assessing the type of injury considering the mechanism of injury is used, is the system developed by Ben L. Allen and published with co-authors in 1982. It is also known as the Allen-Ferguson classification and despite long history of existence, still has not lost its relevance.
In the classification when characterizing the type of traumatic injury, not only visually detected signs, but also inevitably accompanying changes are given.
In total, 6 types of damage were classified: compression-flexion, vertical compression, distraction-flexion, compression-extension, distraction-extension and lateral-flexion, which were divided into stages depending on the severity of pathomorphological changes. The authors of the classification note a pronounced correlation between the nature of damage to anatomical structures and neurological disorders in all patterns of damage.
When writing this review, a detailed analysis of the original publication was carried out, highlighting the basic biomechanical aspects that underlie the classification and still have not lost their relevance . It is noted that the schematic images of damages found in modern literature often do not correspond to the description proposed by Ben L. Allen et al., Therefore, when preparing the illustrative material, we relied solely on the data of the original article.
Along with the description of morphology, for each type and stage of injury, modern data on possible methods of treatment, both conservative and surgical are given.
The complex analysis suggests that the classification developed by Ben L. Allen is a convenient tool for assessing pathomorphological changes and allows choosing the optimal method of treating the patients in each specific clinical situation.
References
1. 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;7(1):1-27. [CrossRef] [PubMed]
2. Zaveri G, Das G. Management of Sub-axial Cervical Spine Injuries. Indian J Orthop. 2017;51(6):633-652. [CrossRef] [PubMed]
3. Kim KS, Chen HH, Russell EJ, Rogers LF. Flexion teardrop fracture of the cervical spine: radiographic characteristics. AJR American journal of roentgenology. 1989;152(2):319-326. [CrossRef] [PubMed]
4. Harris JH, Jr., Edeiken-Monroe B, Kopaniky DR. A practical classification of acute cervical spine injuries. Orthop Clin North Am. 1986;17(1):15-30. [PubMed]
5. Torg JS, Pavlov H, O’Neill MJ, Nichols CE, Jr., Sennett B. The axial load teardrop fracture. A biomechanical, clinical and roentgenographic analysis. The American journal of sports medicine. 1991;19(4):355-364. [CrossRef] [PubMed]
6. Lee C, Kim KS, Rogers LF. Triangular cervical vertebral body fractures: diagnostic significance. AJR American journal of roentgenology. 1982;138(6):1123-1132. [CrossRef] [PubMed]
7. Scher AT. ‘Tear-drop’ fractures of the cervical spine - radiological features. South African medical journal = Suid-Afrikaanse tydskrif vir geneeskunde. 1982;61(10):355-356. [PubMed]
8. Favero KJ, Van Peteghem PK. The quadrangular fragment fracture. Roentgenographic features and treatment protocol. Clin Orthop Relat Res. 1989(239):40-46. [PubMed]
9. Kahn EA, Schneider RC. Chronic neurological sequelae of acute trauma to the spine and spinal cord. I. The significance of the acute-flexion or tear-drop fracture-dislocation of the cervical spine. J Bone Joint Surg Am. 1956;38-A(5):985-997. [PubMed]
10. Berry CA, Rao RD. Compressive Flexion and Vertical Compression Injuries of the Subaxial Cervical Spine. Seminars in Spine Surgery. 2013;25(1):36-44. [CrossRef]
11. White AA, 3rd, Panjabi MM. Update on the evaluation of instability of the lower cervical spine. Instr Course Lect. 1987;36:513-520. [PubMed]
12. Toh E, Nomura T, Watanabe M, Mochida J. Surgical treatment for injuries of the middle and lower cervical spine. Int Orthop. 2006;30(1):54-58. [CrossRef] [PubMed]
13. Garvey TA, Eismont FJ, Roberti LJ. Anterior decompression, structural bone grafting, and Caspar plate stabilization for unstable cervical spine fractures and/or dislocations. Spine (Phila Pa 1976). 1992;17(10 Suppl):S431-435. [CrossRef] [PubMed]
14. Cybulski GR, Douglas RA, Meyer PR, Jr., Rovin RA. Complications in three-column cervical spine injuries requiring anterior-posterior stabilization. Spine (Phila Pa 1976). 1992;17(3):253-256. [CrossRef] [PubMed]
15. Hansson T, Roos B, Nachemson A. The bone mineral content and ultimate compressive strength of lumbar vertebrae. Spine (Phila Pa 1976). 1980;5(1):46-55. [CrossRef] [PubMed]
16. Dvorak MF, Fisher CG, Fehlings MG, Rampersaud YR, Oner FC, Aarabi B, Vaccaro AR. The surgical approach to subaxial cervical spine injuries: an evidence-based algorithm based on the SLIC classification system. Spine (Phila Pa 1976). 2007 Nov 1;32(23):2620-9. [CrossRef] [PubMed]
17. Carter JW, Mirza SK, Tencer AF, Ching RP. Canal geometry changes associated with axial compressive cervical spine fracture. Spine (Phila Pa 1976). 2000;25(1):46-54. [CrossRef] [PubMed]
18. Bucholz RD, Cheung KC. Halo vest versus spinal fusion for cervical injury: evidence from an outcome study. J Neurosurg. 1989;70(6):884-892. [CrossRef] [PubMed]
19. Koivikko MP, Myllynen P, Karjalainen M, Vornanen M, Santavirta S. Conservative and operative treatment in cervical burst fractures. Arch Orthop Trauma Surg. 2000;120(7-8):448-451. [CrossRef] [PubMed]
20. Rushton SA, Vaccaro AR, Levine MJ, Smith M, Balderston RA, Cotler JM. Bivector traction for unstable cervical spine fractures: a description of its application and preliminary results. J Spinal Disord. 1997;10(5):436-440. [PubMed]
21. Harrington RM, Budorick T, Hoyt J, Anderson PA, Tencer AF. Biomechanics of indirect reduction of bone retropulsed into the spinal canal in vertebral fracture. Spine (Phila Pa 1976). 1993;18(6):692-699. [CrossRef] [PubMed]
22. Allred CD, Sledge JB. Irreducible dislocations of the cervical spine with a prolapsed disc: preliminary results from a treatment technique. Spine (Phila Pa 1976). 2001;26(17):1927-1930; discussion 1931. [CrossRef] [PubMed]
23. Nakashima H, Yukawa Y, Ito K, Machino M, Kato F. Mechanical patterns of cervical injury influence postoperative neurological outcome: a verification of the allen system. Spine (Phila Pa 1976). 2011;36(6):E441-446. [CrossRef] [PubMed]
24. 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 (Phila Pa 1976). 2007;32(26):3007-3013. [CrossRef] [PubMed]
25. Whang PG, Patel AA, Vaccaro AR. The development and evaluation of the subaxial injury classification scoring system for cervical spine trauma. Clin Orthop Relat Res. 2011;469(3):723-731. [CrossRef] [PubMed]
26. Sim E, Vaccaro AR, Berzlanovich A, Schwarz N, Sim B. In vitro genesis of subaxial cervical unilateral facet dislocations through sequential soft tissue ablation. Spine (Phila Pa 1976). 2001;26(12):1317-1323. [CrossRef] [PubMed]
27. Joaquim AF, Patel AA. Subaxial cervical spine trauma: evaluation and surgical decision-making. Global Spine J. 2014;4(1):63-70. [CrossRef] [PubMed]
28. Hart RA. Cervical facet dislocation: when is magnetic resonance imaging indicated? Spine (Phila Pa 1976). 2002;27(1):116-117. [CrossRef] [PubMed]
29. Newton D, England M, Doll H, Gardner BP. The case for early treatment of dislocations of the cervical spine with cord involvement sustained playing rugby. J Bone Joint Surg Br. 2011;93(12):1646-1652. [CrossRef] [PubMed] 30. Cotler JM, Herbison GJ, Nasuti JF, Ditunno JF, Jr., An H, Wolff BE. Closed reduction of traumatic cervical spine dislocation using traction weights up to 140 pounds. Spine (Phila Pa 1976). 1993;18(3):386-390. [CrossRef] [PubMed]
31. Ahmed WA, Naidoo A, Belci M. Rapid incremental closed traction reduction of cervical facet fracture dislocation: the Stoke Mandeville experience. Spinal cord series and cases. 2018;4:86. [CrossRef] [PubMed]
32. Sabiston CP, Wing PC, Schweigel JF, Van Peteghem PK, Yu W. Closed reduction of dislocations of the lower cervical spine. J Trauma. 1988;28(6):832-835. [CrossRef] [PubMed]
33. Grant GA, Mirza SK, Chapman JR, Winn HR, Newell DW, Jones DT, Grady MS. Risk of early closed reduction in cervical spine subluxation injuries. J Neurosurg. 1999 Jan;90(1 Suppl):13-8. [CrossRef] [PubMed]
34. Star AM, Jones AA, Cotler JM, Balderston RA, Sinha R. Immediate closed reduction of cervical spine dislocations using traction. Spine (Phila Pa 1976). 1990;15(10):1068-1072. [CrossRef] [PubMed]
35. Burke DC, Berryman D. The place of closed manipulation in the management of flexion-rotation dislocations of the cervical spine. J Bone Joint Surg Br. 1971;53(2):165-182. [PubMed]
36. Selivanov VP, Nikitin MN. Diagnostika i lechenie vyvikhov sheynykh pozvonkov. Moscow: Meditsina; 1971. 327 p. Russian.
37. Lu K, Lee TC, Chen HJ. Closed reduction of bilateral locked facets of the cervical spine under general anaesthesia. Acta Neurochir (Wien). 1998;140(10):1055-1061. [CrossRef] [PubMed]
38. Nekhlopochyn SN, Usatov SA, Dyshlovoy VN, Derkach VN, Nagiev A. Travma sheynogo otdela pozvonochnika i spinnogo mozga. In: Polishchuk NE, Korzh NA, Fishchenko VYa, editors. Povrezhdeniya pozvonochnika i spinnogo mozga (mekhanizmy, klinika, diagnostika, lechenie). Kiev: Kniga plyus; 2001. p. 72-119.
39. Dvorak M, Vaccaro AR, Hermsmeyer J, Norvell DC. Unilateral facet dislocations: Is surgery really the preferred option? Evid Based Spine Care J. 2010;1(1):57-65. [CrossRef] [PubMed]
40. Kwon BK, Fisher CG, Boyd MC, Cobb J, Jebson H, Noonan V, Wing P, Dvorak MF. A prospective randomized controlled trial of anterior compared with posterior stabilization for unilateral facet injuries of the cervical spine. J Neurosurg Spine. 2007 Jul;7(1):1-12. [CrossRef] [PubMed]
41. Song KJ, Lee KB. Anterior versus combined anterior and posterior fixation/fusion in the treatment of distraction-flexion injury in the lower cervical spine. J Clin Neurosci. 2008;15(1):36-42. [CrossRef] [PubMed]
42. Mubark I, Abouelela A, Hassan M, Genena A, Ashwood N. Sub-Axial Cervical Facet Dislocation: A Review of Current Concepts. Cureus. 2021;13(1):e12581. [CrossRef] [PubMed]
43. Nekhlopochyn OS, Slynko II, Verbov VV. The classifications of subaxial cervical spine traumatic injuries. Part 5. Facet joint and lateral mass lesions. Ukrainian Neurosurgical Journal. 2021;27(2):3-15. [CrossRef]
44. Suk KS, Kim KT, Lee JH, Lee SH, Kim JS, Eoh JH. Stage 4 compressive-extension injury of the cervical spine: a theoretical stage? Spine (Phila Pa 1976). 2010;35(15):E733-738. [CrossRef] [PubMed]
45. Rebich E, Tavolaro C, Yao J, Zhou H, Agel J, Bransford R, Bellabarba C. Advanced compressive extension injuries of the subaxial cervical spine: do we really understand the nuances of this injury? Spine J. 2021 Jul;21(7):1159-1167. [CrossRef] [PubMed]
46. Kinoshita H, Hirakawa H. Pathological studies and pathological principles on the management of extension injuries of the cervical spine. Paraplegia. 1989;27(3):172-181. [CrossRef] [PubMed]
47. Lind B, Sihlbom H, Nordwall A. Halo-vest treatment of unstable traumatic cervical spine injuries. Spine (Phila Pa 1976). 1988;13(4):425-432. [CrossRef] [PubMed]
48. Whitehill R, Richman JA, Glaser JA. Failure of immobilization of the cervical spine by the halo vest. A report of five cases. J Bone Joint Surg Am. 1986;68(3):326-332. [PubMed]
49. Kotani Y, Abumi K, Ito M, Minami A. Cervical spine injuries associated with lateral mass and facet joint fractures: new classification and surgical treatment with pedicle screw fixation. Eur Spine J. 2005;14(1):69-77. [CrossRef] [PubMed]
50. Taylor AR. The mechanism of injury to the spinal cord in the neck without damage to vertebral column. J Bone Joint Surg Br. 1951;33-b(4):543-547. [CrossRef] [PubMed]
51. Newey ML, Sen PK, Fraser RD. The long-term outcome after central cord syndrome: a study of the natural history. J Bone Joint Surg Br. 2000;82(6):851-855. [CrossRef] [PubMed]
52. Schneider RC, Thompson JM, Bebin J. The syndrome of acute central cervical spinal cord injury. Journal of neurology, neurosurgery, and psychiatry. 1958;21(3):216-227. [CrossRef] [PubMed]
53. Wilson JR, Witiw CD, Badhiwala J, Kwon BK, Fehlings MG, Harrop JS. Early Surgery for Traumatic Spinal Cord Injury: Where Are We Now? Global Spine J. 2020;10(1 Suppl):84s-91s. [CrossRef] [PubMed]
54. Zheng C, Yu Q, Shan X, Zhu Y, Lyu F, Ma X, Zhou S, Jiang J. Early Surgical Decompression Ameliorates Dysfunction of Spinal Motor Neuron in Patients With Acute Traumatic Central Cord Syndrome: An Ambispective Cohort Analysis. Spine (Phila Pa 1976). 2020 Jul 15;45(14):E829-E838. [CrossRef] [PubMed]
55. Vaccaro AR, Cook CM, McCullen G, Garfin SR. Cervical trauma: rationale for selecting the appropriate fusion technique. Orthop Clin North Am. 1998;29(4):745-754. [CrossRef] [PubMed]
56. Slucky AV, Eismont FJ. Treatment of acute injury of the cervical spine. Instr Course Lect. 1995;44:67-80. [PubMed]
57. Burkus JK, Denis F. Hyperextension injuries of the thoracic spine in diffuse idiopathic skeletal hyperostosis. Report of four cases. J Bone Joint Surg Am. 1994;76(2):237-243. [CrossRef] [PubMed]
58. Graham JJ. Complications of cervical spine surgery. A five-year report on a survey of the membership of the Cervical Spine Research Society by the Morbidity and Mortality Committee. Spine (Phila Pa 1976). 1989;14(10):1046-1050. [PubMed]
59. Vaccaro AR, Klein GR, Thaller JB, Rushton SA, Cotler JM, Albert TJ. Distraction extension injuries of the cervical spine. J Spinal Disord. 2001;14(3):193-200. [CrossRef] [PubMed]
60. Parent AD, Harkey HL, Touchstone DA, Smith EE, Smith RR. Lateral cervical spine dislocation and vertebral artery injury. Neurosurgery. 1992;31(3):501-509. [CrossRef] [PubMed]
61. Shiina I, Hioki S, Kamada H, Amano K, Noguchi H. Treatment for lateral flexion fracture dislocation of the cervical spine: report of two cases. Journal of rural medicine : JRM. 2010;5(2):194-197. [CrossRef] [PubMed]
62. Sharif S, Ali MYJ, Sih IMY, Parthiban J, Alves OL. Subaxial Cervical Spine Injuries: WFNS Spine Committee Recommendations. Neurospine. 2020;17(4):737-758. [CrossRef] [PubMed]
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