Traumatic cervical discoligamentous injuries: correlation of magnetic resonance imaging and operative findings

Utility of Magnetic Resonance Imaging for Ligamentous Injury in Cervical Spine Trauma: A 2-Year Consecutive Case Cohort

BACKGROUND

Magnetic resonance imaging (MRI) is increasingly used as an adjunct to spinal soft tissue evaluation in cervical spine (C-spine) trauma; however, the utility of this information remains controversial. In this consecutive observational study, we reviewed the utility of MRI in patients with C-spine trauma.

METHODS

We identified patients in real time over a 2-year period as they presented to our level 1 trauma center for C-spine computed tomography (CT) scan followed by MRI. MRI was obtained by the trauma team prior to the spine service consultation if (1) they were unable to clear the C-spine according to protocol or (2) if the on-call radiologist reported a concern for ligamentous integrity from the CT findings.

RESULTS

Thirty-three patients, including 19 males (58%) and 14 females, with a mean age of 54 years, were referred to the spine service for concerns of ligamentous instability. The most common mechanisms of injury were motor vehicle accidents (n = 13) and falls (n = 11). MRI demonstrated ligamentous signal change identified by the radiologist as potentially unstable in all patients. Fifteen patients (45%) had multiple C-spine ligaments affected. The interspinous ligament was involved most frequently (28%), followed by the ligamentum flavum (21%) and supraspinous ligament (15%). All patients underwent dynamic upright C-spine X-rays that were interpreted by both the ordering surgeon and radiologist. There was no evidence of instability in any patient; concurrence between X-ray interpretation was 100%. The cervical collar was successfully removed in all cases. No patients required late surgical intervention, and there were no return visits to the emergency department of a spinal nature.

CONCLUSIONS

MRI signal change within the ligaments of the C-spine should be interpreted with caution in the setting of trauma. To physicians less familiar with spinal biomechanics, MRI findings may be perceived in an inadvertently alarming manner. Bony alignment and, when indicated, dynamic upright X-rays remain the gold standard for evaluating the ligamentous integrity of the C-spine.

Role of magnetic resonance imaging features in diagnosing and localization of disc rupture related to cervical spinal cord injury without radiographic abnormalities

STUDY DESIGN

A retrospective study.

OBJECTIVE

Traumatic cervical spinal cord injury (TSCI) is often associated with disc rupture. It was reported that high signal of disc and anterior longitudinal ligament (ALL) rupture on magnetic resonance imaging (MRI) were the typical signs of ruptured disc. However, for TSCI with no fracture or dislocation, there is still difficult to diagnose disc rupture. The purpose of this study was to investigate the diagnostic efficiency and localization method of different MRI features for cervical disc rupture in patient with TSCI but no any signs of fracture or dislocation.

SETTING

Affiliated hospital of University in Nanchang, China.

METHODS

Patients who had TSCI and underwent anterior cervical surgery between June 2016 and December 2021 in our hospital were included. All patients received X-ray, CT scan, and MRI examinations before surgery. MRI findings such as prevertebral hematoma, high-signal SCI, high-signal posterior ligamentous complex (PLC), were recorded. The correlation between preoperative MRI features and intraoperative findings was analyzed. Also, the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of these MRI features in diagnosing the disc rupture were calculated.

RESULTS

A total of 140 consecutive patients, 120 males and 20 females with an average age of 53 years were included in this study. Of these patients, 98 (134 cervical discs) were intraoperatively confirmed with cervical disc rupture, but 59.1% (58 patients) of them had no definite evidence of an injured disc on preoperative MRI (high-signal disc or ALL rupture signal). For these patients, the high-signal PLC on preoperative MRI had the highest diagnostic rate for disc rupture based on intraoperative findings, with a sensitivity of 97%, specificity of 72%, PPV of 84% and NPV of 93%. Combined high-signal SCI with high-signal PLC had higher specificity (97%) and PPV (98%), and a lower FPR (3%) and FNR (9%) for the diagnosis of disc rupture. And combination of three MRI features (prevertebral hematoma, high-signal SCI and PLC) had the highest accuracy in diagnosing traumatic disc rupture. For the localization of the ruptured disc, the level of the high-signal SCI had the highest consistency with the segment of the ruptured disc.

CONCLUSION

MRI features, such as prevertebral hematoma, high-signal SCI and PLC, demonstrated high sensitivities for diagnosing cervical disc rupture. High-signal SCI on preoperative MRI could be used to locate the segment of ruptured disc.

Incidence of discoligamentous injuries in patients with acute central cord syndrome and underlying degenerative cervical spinal stenosis

Introduction

Surgical treatment for CCS in patients with an underlying cervical stenosis without instability remains controversial.

Research question

The aim was to assess the incidence of concomitant discoligamentous injury (DLI) in patients with CCS and underlying degenerative cervical spinal stenosis and to determine the sensitivity of MRI by comparing intraoperative site inspection to preoperative imaging findings.

Material and methods

We performed a retrospective analysis of our clinical prospective database. Fifty-one patients (39 male, 12 female) between January 2010 and June 2019 were included. Age, sex, neurological deficits, preoperative MRI, and surgical treatment were recorded. Sensitivity was determined by the quotient of patients in whom all levels of DLI were correctly identified on MRI and the total number of patients with intraoperatively confirmed DLI.

Results

Mean age at surgery was 64.1 ​± ​11.3 (range 41–86). DLI was suspected in 33 (62.1%) patients based on MRI findings, which could be confirmed intraoperatively in 29 patients (56.9%). In 2 patients, DLI was detected intraoperatively that was not suspected in preoperative MRI; in 5 patients, another level was affected intraoperatively than was indicated by MRI. The overall specificity and sensitivity of preoperative MRI imaging to identify discoligamentous lesions of the cervical spine was 73% and 79%, respectively.

Discussion and conclusion

The incidence of DLI in patients with traumatic CCS based on preexisting spinal stenosis was 60.78%, which is higher than previously reported. The sensitivity of MRI imaging to detect DLI of 79% suggests that these patients are at risk of missing traumatic DLI on imaging.

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Traumatic central cord syndrome (CCS) is the most common form of incomplete spinal cord injury.

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The incidence of DLI in traumatic CCS with preexisting spinal stenosis seems to be higher than previously reported.

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The sensitivity of MRI for detecting DLI is limited in patients with preexisting degenerative cervical spondylosis (79%).

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There is a risk of missing a traumatic disco-ligamentous injury in these patients.

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Limited sensitivity of MRI for DLI in traumatic CCS based on preexisting spinal stenosis should be considered.

Imaging features of spinal fractures in ankylosing spondylitis and the diagnostic value of different imaging methods

Background

Our study aimed to characterize the imaging appearance of spinal fractures in ankylosing spondylitis (AS) and identify situations in which the use of magnetic resonance imaging (MRI) is necessary.

Methods

A total of 70 cases of spinal fractures associated with AS were retrospectively enrolled. Two radiologists independently reviewed the preoperative images. The location, type, ligament injury, neurological injury, and epidural hematoma following spinal fractures were assessed.

Results

Only one patient had a vertebral compression fracture, and 69 patients had 77 transverse fractures involving three columns. The most frequent injuries in AS patients were type B3 (N=32, 43.8%) spine fractures, followed by type C (N= 20, 27.4%) spine fractures. There were significant differences in fracture types of the different spine regions (H=14.1, P<0.0001). Most type C spine fractures were located in the lower cervical spine, while most of the type B2 spine fractures were located in the thoracic spine. Transverse fractures were classified as shear or stress type fractures. In total, there were 62 shear fractures and 15 stress fractures. All of the transverse fractures were detected by computed tomography (CT). The accuracy of CT in the diagnosis of the exact anatomic involvement of transverse fractures was significantly higher than that of MRI (χ²=8.36, P=0.014). The anterior longitudinal ligament (ALL) was the most frequently torn ligament. Tears of ossified ligaments were best visualized by sagittal reformatted CT. Lower cervical fractures were more likely to be associated with neurological injury compared with fractures to other regions of the spine (χ²=7.24, P=0.025). There were six epidural hematoma cases, which were only detected by MRI, were found to have fractures of the lower cervical spine.

Conclusions

We recommend a whole-spine CT examination with three-dimensional reconstruction for detecting a suspected fracture in AS patients. In cases with neurological injury, MRI examinations are always mandatory. AS patients with lower cervical spine fractures require further investigation by MRI. Patients with non-lower cervical spine fractures without any neurological deficits do not need to undergo an immediate MRI.

Occult Disco-Ligamentous Lesions of the Subaxial c-Spine-A Comparison of Preoperative Imaging Findings and Intraoperative Site Inspection

Despite the general acceptance of magnetic resonance imaging (MRI) as the gold standard for diagnostics of traumatic disco-ligamentous injuries in the subaxial cervical spine, clinical experience shows cases where no lesion is detected in MRI exams but obtained during surgery. The aim of this study was to compare intraoperative site inspection to preoperative imaging findings and to identify radiological features of patients having a risk for under- or over-estimating disco-ligamentous lesions. We performed a retrospective analysis of our clinical database, considering all patients who underwent surgical treatment of the cervical spine via an anterior approach after trauma between June 2008 and April 2018. Only patients with availability of immediate preoperative computed tomography (CT), 3-Tesla MRI scans, and information about intraoperative findings were considered. Results of preoperative imaging were set in context to intraoperative findings, and receiver operator characteristics (ROC) were calculated. Out of 144 patients receiving anterior cervical surgery after trauma, 83 patients (mean age: 59.4 ± 20.5 years, age range: 12–94 years, 63.9% males) were included in this study. Included patients underwent surgical treatment via anterior cervical discectomy and fusion (ACDF; 79 patients) or anterior cervical corpectomy and fusion (4 patients) with ventral plating. Comparing preoperative imaging findings to intraoperative site inspection, a discrepancy between imaging and surgical findings was revealed in 14 patients, leading to an overall specificity/sensitivity of preoperative imaging to identify disco-ligamentous lesions of the cervical spine of 100%/77.4%. Yet, adding the existence of prevertebral hematoma and/or vertebral fractures according to preoperative imaging improved the sensitivity to 95.2%. Lack of sensitivity was most likely related to severe cervical spondylosis, rendering correct radiological reporting difficult. Thus, the risk of missing a traumatic disco-ligamentous injury of the cervical spine in imaging seems to be a particular threat in patients with preexisting degenerative cervical spondylosis. In conclusion, incorporating the existence of prevertebral hematoma and/or vertebral fractures can significantly improve diagnostic yield.

Cervical Disc and Ligamentous Injury in Hyperextension Trauma: MRI and Intraoperative Correlation

BACKGROUND AND PURPOSE

To identify and evaluate diagnostic magnetic resonance imaging (MRI) features in patients with suspicion of discoligamentous cervical injury after hyperextension trauma of the cervical spine.

METHODS

MR images with a standard protocol (1.5 T, including sagittal T2‐weighted images and short tau inversion recovery [STIR]) in 21 patients without any sign of fracture or instability on multidetector computed tomography of the cervical spine were assessed. Among other structures we evaluated the following: prevertebral hematoma, anterior longitudinal ligament (ALL), intervertebral disc, and spinal cord. Presence and the anatomic level of injury were identified and recorded. Results were then compared with intraoperative findings as a reference standard. Simple descriptive statistical analysis, agreement coefficients (given by calculating the percent agreement), and the determination of Gwet's AC1 coefficient were used to analyze our results.

RESULTS

The overall percent agreement between STIR and intraoperative findings was 90.9% (AC1 = .881) and for T2 69.7% (AC1 = .498). For the ALL, the overall agreement was 87.9% (AC1 = .808) and for the intervertebral disc 78.8% (AC1 = .673), in which STIR always showed a higher agreement. Prevertebral hematoma was found in 20 of 21 patients with the maximum thickness at the same anatomic level as the intraoperatively proven lesion in 12 of 18 patients (67%). Edema and/or hemorrhage of the spinal cord was shown in 16 of 21 being at the same anatomic level as the intraoperatively confirmed pathology in 16 of 16 patients (100%).

CONCLUSIONS

MRI is a reliable tool for the evaluation of discoligamentous injuries in the cervical spine, with ancillary features proven as helpful information.

Reliability of Allen Ferguson classification versus subaxial injury classification and severity scale for subaxial cervical spine injuries: a psychometrics study

STUDY DESIGN

A psychometrics study.

OBJECTIVES

To determine intra and inter-observer reliability of Allen Ferguson system (AF) and sub-axial injury classification and severity scale (SLIC), two sub axial cervical spine injury (SACI) classification systems.

SETTING

Online multi-national study METHODS: Clinico-radiological data of 34 random patients with traumatic SACI were distributed as power point presentations to 13 spine surgeons of the Spine Trauma Study Group of ISCoS from seven different institutions. They were advised to classify patients using AF and SLIC systems. A reference guide of the two systems had been mailed to them earlier. After 6 weeks, the same cases were re-presented to them in a different order for classification using both systems. Intra and inter-observer reliability scores were calculated and analysed with Fleiss Kappa coefficient (k value) for both the systems and Intraclass correlation coefficient(ICC) for the SLIC.

RESULTS

Allen Ferguson system displayed a uniformly moderate inter and intra-observer reliability. SLIC showed slight to fair inter-observer reliability and fair to substantial intra-observer reliability. AF mechanistic types showed better inter-observer reliability than the SLIC morphological types. Within SLIC, the total SLIC had the least inter-observer agreement and the SLIC neurology had the highest intra-observer agreement.

CONCLUSION

This first external reliability study shows a better reliability for AF as compared to SLIC system. Among the SLIC variables, the DLC status and the total SLIC had least agreement. Low-reliability highlights the need for improving the existing classification systems or coming out with newer ones that consider limitations of the existing ones.

Neuronavigation and 3D fluoroscopy-guided lag screw reduction and osteosynthesis for traumatic spondylolistheses of the axis: a path worth exploring?

OBJECTIVE In traumatic spondylolistheses of the axis, there is a marked heterogeneity of the observed injury patterns, with a wide range of the severity-from stable fractures, which can be treated conservatively with very good success, to highly unstable fractures, which should be treated surgically. A number of classification systems have been devised to assess the instability of the injuries and to derive a corresponding therapy recommendation. In particular, the results and recommendations regarding medium-severity cases are still inconclusive. Minimally invasive percutaneous procedures performed using modern techniques such as 3D fluoroscopy and neuronavigation have the potential for improvements in the therapeutic outcome and procedural morbidity against open surgical procedures and conservative therapy. METHODS A minimally invasive method using 3D fluoroscopy and neuronavigation for percutaneous lag screw osteosynthesis of the pars interarticularis was performed in 12 patients with a Levine-Edwards Type II fracture. Ten patients had an isolated hangman's fracture and 2 patients had an additional odontoid fracture of the axis (Type II according to the Anderson and D'Alonzo classification system). Complications, operating parameters, screw positions, and bony fusion were evaluated for the description and evaluation of the technique. RESULTS In 6 men and 6 women, percutaneous lag screw osteosynthesis was performed successfully. Correct placement could be verified postoperatively for all inserted screws. In the case series, nonunion was not observed. In all patients with a complete follow-up, a bony fusion, an intact vertebral alignment, and no deformity could be detected on CT scans obtained after 3 months. CONCLUSIONS The percutaneous pars interarticularis lag screw osteosynthesis is a minimally invasive and mobility-preserving surgical technique. Its advantages over alternative methods are its minimal invasiveness, a shortened treatment time, and high fusion rates. The benefits are offset by the risk of injury to the vertebral arteries. The lag screw osteosynthesis is only possible with Levine-Edwards Type II fractures, because the intervertebral joints to C-3 are functionally preserved. A further development and evaluation of the operative technique as well as comparison with conservative and alternative surgical treatment options are deemed necessary.

Imaging findings of flexion type of hangman's fracture; an attempt for a more objective evaluation with newly introduced scoring system

OBJECTIVE

To identify the flexion type of hangman's fracture on imaging studies.

METHODS

38 cases of hangman's fracture were retrospectively studied and categorized into flexion and non-flexion groups. Plain radiograph, CT and MRI of these patients were evaluated; 13 radiological parameters that might define flexion injuries were measured. The data were statistically analyzed to identify good criteria and to rank them according to their importance in predicting flexion.

RESULTS

Seven radiological criteria that have the highest correlation with flexion injury were identified. These are C2-3 lower end-plate angle, C2-3 posterior body angle, interspinous angle, disc disruption (MRI), widening of interspinous distance, disruption of the posterior ligamentous complex (MRI) and angle at the fracture site. Scoring 1 point for each positive criterion, a total score of 4 predicts flexion injury with 100% sensitivity and 96.9% specificity. Score of 5 has 83.3% sensitivity and 100% specificity.

CONCLUSION

Flexion hangman's injury can be diagnosed by the presence of four out of seven radiological criteria in the newly introduced scoring system. The authors believe that this method may help spinal surgeons in their selection of therapeutic strategy. Advances in knowledge: This study introduces fast, simple and more objective imaging criteria for the diagnosis of flexion hangman's injury and separates it from the non-flexion pattern.

Post-traumatic lower cervical spine instability: arthrodesis clinical and radiological outcomes at 5 years

BACKGROUND

Anterior cervical fusion is widely used to treat spinal injuries. Radiological evidence of disc abnormalities may develop on either side of the fused segment, raising concern about the potential for inducing adjacent-segment disease. Here, we report the long-term clinical, functional, and radiological outcomes after anterior cervical fusion.

HYPOTHESIS

Anterior cervical fusion influences the development of adjacent-segment disease.

MATERIALS AND METHODS

In a retrospective study, 15 patients aged 17 to 50 years were re-evaluated more than 5 years after anterior spinal fusion to treat post-traumatic cervical-spine instability. We used the Neck Disability Index (NDI) to assess function. Static and dynamic radiographs of the cervical spine were obtained.

RESULTS

NDI values indicated good clinical and functional outcomes, and fusion was achieved consistently. Adjacent-segment disease was a consistent finding at last follow-up but induced no neurological manifestations. Complete fusion of a level adjacent to the treated level was noted in 2 patients. Revision surgery for adjacent-segment disease was not required in any patient.

CONCLUSION

The causative factors of adjacent-segment disease are controversial. Disc degeneration is a normal manifestation of the ageing process. Nevertheless, disc disease is more prevalent at levels adjacent to interbody fusion than in the normal population, suggesting accelerated disc degeneration due to increased loading of the adjacent levels. Furthermore, lesions that are missed during the pre-operative work-up may play a role, as the available investigations do not always have high negative predictive values.

LEVEL OF EVIDENCE

Level IV, retrospective study.

Hidden discoligamentous instability in cervical spine injuries: can quantitative motion analysis improve detection?

PURPOSE

Recent literature shows that occult discoligamentous injuries still remain difficult to diagnose in the first instance. Thresholds as indicators for discoligamentous segmental instability were previously defined. But, since supine radiodiagnostic is prone to spontaneous reduction of a displaced injury, and even some highly unstable injuries reveal only slight radiographic displacement, these criteria might mislead in the traumatized patient. A highly accurate radiographic instrument to assess segmental motion is the computer-assisted quantitative motion analysis (QMA). The aim was to evaluate the applicability of the QMA in the setting of a traumatized patient.

METHODS

Review of 154 patients with unstable cervical injuries C3-7. Seventeen patients (male/female: 1:5, age: 44.6 years) had history of initially hidden discoligamentous injuries without signs of neurologic impairment. Initial radiographs did not fulfill instability criteria by conventional analysis. Instability was identified by late subluxation/dislocation, persisting/increasing neck pain, and/or scheduled follow-up. For 16 patients plain lateral radiographs were subjected to QMA. QMA data derived were compared with normative data of 140 asymptomatic volunteers from an institutional database.

RESULTS

Data analysis of measurements revealed mean spondylolisthesis of -1.0 mm (-3.7 to +3.4 mm), for segmental rotational angle mean angulation of -0.9° (-11.1° to +17.7°). Analysis of these figures indicated positive instability thresholds in 5 patients (31.3 %). Analysis of center of rotation (COR)-shifts was only accomplishable completely in 3/16 patients due to limited motion or inadequacy of radiographs. Two of these patients (12.5 %) showed a suspect shift of the COR.

CONCLUSIONS

Our data show a high rate of false negative results in cases of hidden discoligamentous injuries by using conventional radiographic analysis as well as QMA in plain lateral radiographs in a trauma setting. Despite the technical possibilities in a modern trauma center, our data and recent literature indicate a thorough clinical and radiographic follow-up of patients with cervical symptoms to avoid secondary complications from missed cervical spine injuries.

Soft-tissue damage and segmental instability in adult patients with cervical spinal cord injury without major bone injury

STUDY DESIGN

A retrospective imaging and clinical study.

OBJECTIVE

To evaluate the extraneural soft-tissue damage and its clinical relevance in patients with traumatic cervical spinal cord injury (SCI) without major bone injury.

SUMMARY OF BACKGROUND DATA

To date, various kinds of cervical discoligamentous injuries have been demonstrated on magnetic resonance images in patients with SCI without bony injury. However, it has not been clear whether these magnetic resonance imaging abnormalities are actually related to spinal segmental instability and the patients' neurological status.

METHODS

Eighty-eight adult patients with acute traumatic cervical SCI without major bone injury were examined by flexion-extension lateral radiographs and magnetic resonance images within 2 days after trauma. We excluded patients with flexion recoil injury; therefore, most of the patients included were considered to have sustained a hyperextension injury. Instability of the injured cervical segment was defined when there was more than 3.5-mm posterior translation and/or more than a 11° difference in the intervertebral angle between the site of interest and adjacent segments. The neurological status was evaluated according to the American Spinal Injury Association motor score.

RESULTS

On magnetic resonance images, the damage to the anterior longitudinal ligament and intervertebral disc were apparent in 44 and 37 patients, respectively. Various degrees of prevertebral fluid collection (prevertebral hyperintensity) were demonstrated in 76 patients. These magnetic resonance imaging abnormalities were significantly associated with initial cervical segmental instability as judged by flexion-extension radiographs. Interestingly, the American Spinal Injury Association motor score had a significant association with either magnetic resonance imaging abnormalities or segmental instability but not with the cervical canal diameter.

CONCLUSION

A considerable proportion of the patients with traumatic cervical SCI without major bone injury were shown to have various types of soft-tissue damage associated with cervical segmental instability at the early stages of the injury. The severity of paralysis greatly depended on these discoligamentous injuries.

A biomechanical assessment of soft-tissue damage in the cervical spine following a unilateral facet injury

BACKGROUND

Unilateral cervical spine facet injuries encompass a wide spectrum, including subluxations, dislocations, and fractures, and the instability produced varies greatly. The extent of anatomical disruption secondary to a unilateral facet injury is poorly understood, and few biomechanical studies have quantified the associated kinematics. The purpose of this study was to develop an experimental method that reliably produces an impending unilateral facet dislocation (perched facet) in cadaveric cervical spines and to identify the soft-tissue damage and resulting changes in cervical spine range of motion and neutral zone associated with this injury.

METHODS

Nine fresh-frozen cadaveric human spinal motion segments (C4-C5 or C6-C7) were mounted in a spinal loading simulator to induce a perched unilateral facet injury based on a previously described mechanism of flexion and bending with increasing rotation. Loads were applied to simulate and measure flexion-extension, lateral bending, and axial rotation motions before and after achieving a perched facet. Preinjury and postinjury range of motion and neutral zone were analyzed with use of paired t tests for each movement. Systematic qualitative inspection and gross dissection were then performed to define the soft-tissue injury pattern.

RESULTS

Range of motion and neutral zone increased following the reduction of this injury; the largest increase (294%) occurred in contralateral axial rotation (i.e., right axial rotation after a perched left facet). Postinjury dissections revealed bilateral capsular tears, 50% disc disruption, and 50% tearing of the ligamentum flavum in most specimens. The interspinous and supraspinous ligaments were stretched in less than half of the specimens and were never completely disrupted. The longitudinal ligaments were occasionally torn as extensions of anulus fibrosus disruptions.

CONCLUSIONS

This study indicates that the anulus fibrosus, nucleus pulposus, and ligamentum flavum are important cervical spine stabilizers. Facet capsules were often torn bilaterally, implying a more advanced injury than a unilateral facet injury. These discoligamentous injuries result in increases in range of motion and neutral zone.

CLINICAL RELEVANCE

The results from this work provide further insight into the expected injury and associated instability present in a traumatic unilateral facet injury in the cervical spine.

Evaluation of the subaxial injury classification system

Study design:

Retrospective clinical study of patients treated for subaxial cervical spine trauma (SCST) at a tertiary medical center.

Purpose:

Evaluate the validity of the Subaxial Injury Classification (SLIC) system in surgical versus non-surgical decision making for SCST.

Inclusion criteria:

Age >12 years, presence of SCST with complete clinical and radiological (CT and MRI) data.

Exclusion criteria:

Patients with incomplete radiographic or clinical data, pathological fractures, isolated upper cervical trauma (occiput to C2), isolated transverse process or spinous process fractures, chronic or age indeterminate fractures, isolate MRI findings, and severe systemic trauma with death prior to either surgical or non-surgical treatment.

Results:

Fourteen patients were treated non-surgically (C), whereas 24 were treated surgically (S). In the C group, the SLIC score ranged from 0 to 5 points (standard deviation [SD] = 1.20 points; mean 1.07; median 1). Just 1 patient had an SLIC score greater than 2 (7.1% of the patients). In the S group, the SLIC score ranged from 1 to 10 points (standard deviation [SD] = 2.03 points; mean 5.6; median 6). Just 2 patients had an SLIC score smaller than 4 (both with 1 point each, 8.3% of the total group). All the other 22 (accounting for 91.6%) patients had an SLIC of 4 or more points.

Conclusions:

Our study suggests that the SLIC classification looks to be a promising system to aid spinal surgeons in the decision-making process of subaxial cervical trauma, but a large prospective cohort study is required.

The development and evaluation of the subaxial injury classification scoring system for cervical spine trauma

BACKGROUND

Fractures and dislocations of the subaxial cervical spine may give rise to devastating consequences. Previous algorithms for describing cervical trauma largely depend on retrospective reconstructions of injury mechanism and utilize nonspecific terminology which thus diminish their clinical relevance add to the difficulty of educating doctors and performing prospective research.

QUESTIONS/PURPOSES

We characterized the potential benefits of the Subaxial Injury Classification (SLIC) scale which considers three major variables that influence spinal stability: morphology, integrity of the discoligamentous complex, and neurologic status. Each category was assigned a certain number of points based on the severity of the injury which are added together to generate a total score; this value provides prognostic information and may also be useful for directing subsequent management (ie, nonoperative treatment versus operative intervention).

METHODS

We examined the individual components that comprise the SLIC paradigm and reviewed the manner in which cervical injuries are scored and stratified. We also critically assessed the preliminary data comparing the SLIC scheme to preexisting classification systems.

RESULTS

The results of a preliminary analysis demonstrate that the intraclass coefficients (ICC) for the three primary components range between 0.49 and 0.90, suggesting that the overall reliability of the SLIC system appears to be at least as good as that of other conventional schemes for classifying subaxial cervical spine trauma (ICC between 0.41 and 0.53).

CONCLUSIONS

This scheme will hopefully facilitate the development of evidence-based guidelines that may influence other aspects of the therapeutic decision-making process (eg, which operative approach is most appropriate for a particular injury). We anticipate its accuracy and reproducibility will increase over time as surgeons become more familiar with the protocol.