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Contemporary
Spine Surgery
VOLUME 10 I NUMBER 2 I FEBRUARY 2009
Subaxial Cervical Trauma: Evaluation,
Classification, and Treatment
LEARNING OBJECTIVES: After reading
this article, the participant should be
able to:
1. Describe critical variables in the evaluation
and treatment of subaxial cervical trauma.
2. Recall and compare subaxial cervical
spine injury classifications.
3. Define appropriate treatment strategies
for subaxial cervical trauma.
S
ubaxial cervical spine trauma
accounts for the majority of cervi-
cal fractures and dislocations.1
Injury may occur after either high-ener-
gy trauma, such as a motor vehicle colli-
sion, or a low-energy injury such as a
ground-level fall. Trauma may be seen
across age, cultural, economic, and geo-
graphic distributions. The additional risk
of associated spinal cord injury makes
the potential impact of subaxial cervical
trauma on the patient profound. Society
also faces a large burden as the immedi-
Dr. Patel is Assistant Professor, Department
of Orthopaedic Surgery, Department of
Neurosurgery, University of Utah School of
Medicine, 590 Wakara Way, Salt Lake City, UT
84108; E-mail: alpesh.patel@hsc.utah.edu.
Dr. Patel has disclosed that he is/was the
recipient of grant/research support from
DePuy, was a consultant/advisor to Ethicon,
and is/was a member of the speakers
bureau for Stryker Spine.
All faculty and staff in a position to control the
content of this CME activity have disclosed
that they have no financial relationships with,
or financial interests in, any commercial com-
panies pertaining to this educational activity.
Lippincott CME Institute, Inc., has identified
and resolved all faculty and staff conflicts of
interest regarding this educational activity.
This continuing education activity is intended for orthopedic and neurologic surgeons and other physicians with an interest in spine surgery.
ate costs associated with injury manage-
ment and the long-term costs associated
with disability can be staggering.
Despite these implications, there
remains little consensus regarding treat-
ment of patients with cervical spine trau-
ma.2,3 Overall, there is a paucity of scien-
tific data concerning treatment and out-
comes of spinal trauma. This article pre-
sents an overview of evaluation and man-
agement of patients with subaxial injuries,
with a focus on injury classification.
CLINICAL EVALUATION
Subaxial cervical injuries most com-
monly present after a high-energy trau-
matic event, most often in younger
patients and in males more commonly
than females. In developed nations, trau-
ma typically involves motor vehicle colli-
sions or falls from height greater than 10
feet. In developing nations, injury occurs
most commonly after a fall from height
greater than 10 feet. Other potential caus-
es of traumatic injury include projectile
trauma, most commonly high- or low-
velocity gunshot wounds, or direct punc-
ture or stab wounds to the spine. Lower-
energy injuries, such as ground-level falls,
may cause spinal trauma in an elderly pop-
ulation with poor bone quality (e.g., osteo-
porosis). Given the aging U.S. population,
a greater number of low-energy fractures
may be expected in the coming decades.
Evaluation of the spine-injured patient
begins similar to that of all trauma patients.
A primary survey of the patient’s airway,
respiratory status, and circulation is per-
formed immediately. Individuals with spinal
cord injury at a high cervical level (above
Alpesh A. Patel MD
C4) may have difficulty with respiratory
effort and require emergent intubation.
Neurogenic shock (hypotension associated
with the loss of sympathetic nervous sys-
tem control over peripheral vascular resis-
tance) may be seen commonly in patients
with cervical or middle to high thoracic
spinal cord injuries. Although it is impor-
tant to diagnose other potential causes,
neurogenic shock should be maintained in
the differential diagnosis of post-traumatic
hypotension. Patients in neurogenic shock
typically present with a low heart rate and
warm, flushed extremities due to the loss of
sympathetic nervous system input. In con-
trast, patients with hemorrhagic shock
have an elevated heart rate and cool, pale
extremities attributable to compensatory
sympathetic activation.
After completion of this primary sur-
vey, a secondary survey should be per-
formed to evaluate other injuries, includ-
ing thoracoabdominal injuries, extremity
fractures, facial and head trauma, and
spinal injuries. Spinal precautions,
including cervical immobilization and
carefully supervised patient movement,
should be strictly maintained in all
patients until complete clinical and radi-
ographic evaluation can be performed.
Physical examination of the spine
includes direct inspection and palpation of
the dorsal spinal elements. Ecchymosis,
tenderness to palpation, and evidence of
spinal malalignment may be hallmark signs
of spinal trauma. Neurologic assessment
should include motor and sensory testing in
the extremities, perineal and perirectal sen-
sation, and an assessment of rectal tone.
The absence of a bulbocavernosus reflex
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Contemporary Spine Surgery VOLUME 10 I NUMBER 2

(contraction of the anal sphincter with of the cervical spine, most commonly
Editor-in-Chief either direct bulbocavernosus pressure to with plain x-rays. Patients presenting
Gunnar B.J. Andersson, MD, PhD* gentle pulling on the Foley catheter) can be with a cervical fracture will have a non-
Chairman, Department of Orthopedic Surgery
Rush-Presbyterian—St. Luke’s Medical Center indicative of spinal shock. Spinal shock contiguous injury in the cervical or thora-
Chicago, IL should be differentiated from neurogenic columbar spine in 20% to 30% of
shock, as these are commonly confused cases.4,5 In this setting, images of the
Associate Editor thoracic and lumbar should be obtained.
Kern Singh, MD
terms. Neurogenic shock refers to hypoten-
Assistant Professor, Department of sion seen in spinal cord-injured patients Otherwise, patient symptoms, such as
Orthopaedic Surgery associated with loss of sympathetic ner- pain or weakness, should guide imaging
Rush University Medical Center
Chicago, IL vous system function and resulting periph- of the thoracolumbar spine. Additionally,
eral vasodilation. a strong suspicion of cervical trauma
Editorial Board Information obtained from the physi- should be maintained until other distract-
Howard S. An, MD ing injuries (extremity fracture, thora-
Chicago, IL
cal examination, most notably the neuro-
logic status of the patient, remains among coabdominal injury, etc.) are stabilized.6
Edward C. Benzel, MD
Cleveland, OH the most crucial in medical decision mak- Plain x-rays may be insufficient.
Scott D. Boden, MD ing. Unfortunately, patients often present Radiographic technique or patient body
Decatur, GA habitus can limit complete assessment of
with multisystem trauma, thereby limit-
Steven R. Garfin, MD the spine, most commonly at the cervi-
San Diego, CA ing a detailed examination. Individuals
with multiple internal thoracoabdominal cothoracic (C7–T1) junction. Additionally,
Clifford Gevirtz, MD, MPH
Harrison, NY injuries or multiple extremity injuries overlap of bony anatomy, most commonly
Kenneth B. Heithoff, MD have been involved in extremely high- a problem with the ribs in the thoracic
St. Louis Park, MN spine, can obscure adequate visualiza-
energy accidents. The likelihood of a con-
Neil Kahanovitz, MD tion. Lastly, in the setting of spinal frac-
Arlington, VA comitant spinal injury is high. Physical
Joel Saal, MD and neurologic examinations may be lim- tures or dislocations, more detailed
SOAR Physiatry Group ited in many of these patients, especially anatomic information is needed than can
Menlo Park, CA
in the setting of head injury. Radiographic be obtained with plain x-rays. For these
Volker K.H. Sonntag, MD reasons, CT scans of spine provide invalu-
Phoenix, AZ imaging and advancements in MRI have
provided valuable information in the iso- able information.
Thomas A. Zdeblick, MD
Madison, WI lated trauma patient but can be even more CT is widely available at nearly all
Dr. Andersson has disclosed that he is/was a indispensable in these difficult cases. medical centers in the United States and
consultant/advisor to Zimmer, Spinal Kinetics, is of critical importance in the rapid eval-
Spinal Therapies, and Biometrix, and that he uation and treatment of trauma patients.
is/was a stock shareholder in Spinal Kinetics, DIAGNOSTIC IMAGING
Spinal Therapies, Biomerix, Crosstrees, and At many high-volume trauma centers,
Radiographic evaluation of the trau- routine CT evaluation of the thorax and
BioAssets; and and Dr. Singh has disclosed
that he is a consultant/advisor to Stryker Spine ma patient, like the initial assessment, abdomen has become standard. Thin-
and Pioneer Spine. should be standardized. All patients slice (1–2 mm) axial CT scans of the cer-
should undergo radiographic assessment vical spine often can be obtained within
a few minutes. Axial and sagittal recon-
Contemporary Spine Surgery (ISSN 1527-4268) is published monthly by Lippincott structed images can then be formatted
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573 trauma patients.7 CT also has been
Publisher: Daniel E. Schwartz • Customer Service Manager: Audrey Dyson
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COPYING: Contents of Contemporary Spine Surgery are protected by copyright. Reproduction, photocopying, and of spinal fractures not visualized on
storage or transmission by magnetic or electronic means are strictly prohibited. Violation of copyright will result
in legal action, including civil and/or criminal penalties. Permission to reproduce in any way must be secured plain x-rays.4 Due to the potential diffi-
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spine has replaced screening x-rays at
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MRI technologies are available at
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Opinions expressed do not necessarily reflect the views of the Publisher, Editor, or Editorial Board. A
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ance only; professional counsel should be sought for specific situations. known spinal trauma or spinal cord

2
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FEBRUARY 2009 Contemporary Spine Surgery

B
A

C D

Fig. 1 A 35-year-old man injured while mountain biking presents with neck pain and a normal neurologic examination. A, Lateral cervical x-ray shows
limited visualization below C6. B, Sagittal, and C, para-sagittal CT scans reveal anterior displacement of C6 on C7. D, MRI confirms disruption of
the posterior ligamentous structures. Subaxial Cervical Spine Injury Classification (SLIC) classification: injury morphology (translation)—4 points; dis-
coligamentous complex (DLC) (disrupted)—2 points; neurologic status (intact)—0 points. Total SLIC score—6 points; operative treatment.

3
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Contemporary Spine Surgery
injury. MRI scans, however, have been shown to be less sen-
sitive than CT and plain x-rays in the diagnosis of fractures
or dislocations and, therefore, MRI should not be used as a
primary screening tool. Additionally, many MRI techniques of
the spine require 30 to 45 minutes per spinal region (cervical,
thoracic, lumbar) to obtain adequate images.8 In the acutely
injured patient, a lengthy study is impractical and potential-
ly unsafe; therefore, plain x-rays and CT scans are preferred.
In summary, initial plain x-rays and CT scans provide
information on the bony anatomy of the spinal column as well
as the alignment of the spinal segments. Once a spinal injury
has been identified, MRI can provide further information
about the intervertebral disc, the ligamentous supporting
structures of the spine, and the spinal cord. In aggregate,
this information can aid in decision making regarding appro-
priate treatment as well as surgical planning.
INJURY CLASSIFICATION
Classification systems have traditionally been based on
mechanisms of injury. The most widely used mechanistic sys-
tem has been described by Allen and Ferguson.9 The authors,
through a retrospective review of 165 patients, defined six dis-
tinct injury patterns: compressive flexion; vertical compres-
sion; distractive flexion; compressive extension; distractive
extension, and lateral flexion. Increasing numeric values were
assigned to each category to account for progressive degrees
of spinal instability. Subsequently, Harris identified six mecha-
nisms of injury: flexion; flexion and rotation; hyperextension
and rotation; vertical compression; extension; and lateral flex-
ion.10 These subjective systems lack any firm injury descrip-
tors and have lead to ambiguity—a single fracture pattern may
be described as a fracture dislocation, a compression flexion
injury, or a facet dislocation. Furthermore, neither of these sys-
tems accounts for the neurologic status of the patient—a crit-
ical determinant of operative treatment.
To address these limitations, two cervical classifications
have recently been validated and reported: (1) Cervical Spine
Injury Severity Score; and (2) Subaxial Cervical Spine Injury
Classification (SLIC). Both systems attempt to define cervi-
cal stability and instability and, in turn, guide surgical deci-
sion making.
Cervical Spine Injury Severity Score
Anderson et. al reported a point-based system basis on
fracture displacement and ligamentous injury to each of four
spinal columns (anterior, posterior, right lateral, left lateral).11
The four-column approach is a modification of the three-column
system described by Louis.12 This system avoids subjective cri-
teria and uses advanced imaging to define injuries on the basis
of measured amounts of fracture or ligamentous displacement.
The system demonstrated good to excellent reliability and a
strong association between cumulative score, clinical status,
and treatment choice. Notably, all patients with a score of at
least 7 were treated surgically. It remains to be seen if this sys-
tem can be effectively applied prospectively in a clinical setting.
4
VOLUME 10 I NUMBER 2
Subaxial Cervical Spine Injury Classification
The SLIC described by Vaccaro et al. defines six critical
clinical criteria: (1) spinal level; (2) injury morphology; (3)
bony injury description; (4) discoligamentous complex (DLC)
injury; (5) neurologic status; and (6) confounders (e.g., dif-
fuse idiopathic skeletal hyperostosis [DISH], cervical steno-
sis, osteoporosis, prior surgery).13,14 The system identifies
three of these—injury morphology, DLC, and neurologic sta-
tus—as the most influential in determining cervical stability
and guiding surgical decision making (Table 1).
Injury morphology defines the relationships of the vertebrae
to each other in anterior anatomic support, soft tissue structures,
facet relationships, and overall alignment on the basis of plain
radiography and advanced imaging techniques. In increasing
order of severity, injury morphology is categorized as compres-
sion, distraction, or rotation/translation. Inferred descriptive
terms of “flexion” and “extension” are not included in this system.
The DLC is defined as the intervertebral disk, the anteri-
or and posterior longitudinal ligaments, interspinous liga-
ments, facet capsules, and ligamentum flavum. This is a
unique descriptor to the SLIC system and is categorized as
disrupted, intact, or indeterminate.
Disruption of the DLC is suggested by abnormal facet align-
ment (articular apposition <50% or diastasis >2 mm through the
facet joint); abnormal widening of the anterior disk space; trans-
lation or rotation of the vertebral bodies; or kyphotic spinal align-
ment. The additional finding of high signal intensity on T2-
weighted, fat-suppressed sagittal MRI involving the nucleus,
annulus, or posterior ligaments may infer disruption of the DLC.
The “disrupted” designation should be used only with convincing
evidence of DLC compromise (Figure 2). Indeterminate injury is
defined when radiographic disruption of the DLC is not otherwise
obvious on x-rays or CT scans, but a hyperintense signal is
Table 1. Subaxial Injury Classification and Severity Scale
Morphology Points
No abnormality 0
Compression 1
Burst +1 = 2
Distraction (e.g., facet perch, hyperextension) 3
Rotation/translation (e.g., facet dislocation, unstable teardrop, 4
advanced staged flexion compression injury)
Discoligamentous complex
Intact 0
Indeterminate (e.g., isolated interspinous widening, 1
MRI signal change only)
Disrupted (e.g., widening of anterior disk space, facet perch 2
or dislocation, kyphotic deformity)
Neurologic status
Intact 0
Root injury 1
Complete cord injury 2
Incomplete cord injury 3
Ongoing cord compression (in setting of a neurologic deficit) +1
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FEBRUARY 2009 Contemporary Spine Surgery

Fig. 2 A 28-year-old man presents with a complete cervical spinal

cord injury after a high-speed motor vehicle collision. A, Sagittal CT
scan, and B, axial CT scan reveal bilateral facet dislocation with 50%
anterior displacement of C5 on C6. C, Sagittal T2-weighted MRI
scan demonstrats disruption of the intervertebral disc and posterior
ligamentous structures. SLIC classification: injury morphology
(translation)—4 points; DLC (disrupted)—2 points; neurologic sta-
tus (complete cord injury)—2 points. Total SLIC score—8 points;
operative treatment.

observed through the posterior ligamentous regions on T2-

weighted MRI scans, suggesting edema and injury. Intact DLC is
defined by normal spinal alignment, normal disk space charac-
teristics, and normal appearance of the ligamentous structures.
The presence of neurologic injury is often a critical fac-
tor in surgical decision making. Neurologic injury is a strong
indicator of spinal instability. Neurologic status is catego-
rized as intact (normal), root injury, complete spinal cord
injury, or incomplete spinal cord injury. An additional modifi-
er, continuous cord compression, is also described in the set-
ting of either complete or incomplete spinal cord injury with
spinal cord compression attributable to disc, bone, ligamen-
tum, hematoma, or other structures. With translation or rota-
tion injuries, assessment of cord compression should be
made after an attempted reduction of the injury.
Weighted scores are assigned to each major injury char-
acteristic (Table 1). The scores are then added to produce an
injury severity score. This score, a quantification of the
5
C
degree of spinal instability, is used to guide surgical decision
making. Patients with scores less than 4 are treated nonop-
eratively; those with scores of 4 or higher undergo surgical
treatment. The SLIC system has demonstrated greater relia-
bility than the Allen-Ferguson or Harris classification sys-
tems and has produced greater than 90% interobserver
agreement on treatment choice.14
Although concise, objective, and promising, the SLIC sys-
tem has yet to be prospectively applied. It is similar in construct
and content, however, to a thoracolumbar injury classification
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Contemporary Spine Surgery
system in widespread use that has demonstrated rapid learning
and easy incorporation into the clinical setting.15,16 Future
investigations may better identify its clinical utility.
TREATMENT
Treatment for subaxial cervical injuries is guided by the
stability of the injury pattern, the neurologic status of the
patient, and the patient’s concurrent injuries and overall med-
ical condition. Both surgical and nonsurgical treatment should
be guided by the same principles—prevention of further injury,
stabilization of the spine, and mobilization of the patient.
Nonsurgical Treatment
Conservative management of subaxial spinal injuries is
the primary treatment option for patients with stable injury
patterns (SLIC <4) those patients who are medically unsta-
ble to undergo general anesthesia and surgical stabilization.
Immobilization is commonly performed with cervical trac-
tion, spinal orthoses, or halo vest immobilization. Immobilization
aims to prevent further spinal deformity and neurologic injury
and provide pain relief. Halo immobilization, although effective
in some upper cervical injuries, has been demonstrated to be
insufficient in patients with some subaxial injury patterns.17,18
Other risks with halo vest immobilization include pin site infec-
tion, loosening and loss of fixation, and dysphagia and malnutri-
tion, most notably in elderly patients.17 Potential risks associat-
ed with spinal orthoses include deformity progression, skin pres-
sure and ulceration, and patient noncompliance.
Surgical Treatment
A variety of surgical procedures and approaches is avail-
able to treat cervical injuries. Although there remains little
consensus as to the best treatment modality, the guiding
principles of treatment remain the same: correction of defor-
mity, decompression of neural elements, and stabilization of
the spinal elements to allow for patient mobilization.
In the setting of spinal cord injury, surgical treatment
aims to prevent further damage to the neural elements by
decompressing the spinal canal. Spinal cord compression
may be caused by deformity of the spine (spinal kyphosis or
dislocation), direct fracture or ligamentous compression, or a
combination of the two.
Closed Reduction
Realignment of the spinal deformity is commonly per-
formed through closed traction reduction. A gradual increase in
weight, at times to greater than 75–100 lbs (330–445 N), with
sequential x-rays and neurologic examination, is a safe strate-
gy to achieve reduction. Both in-line and bi-vector traction
(axial traction with flexion traction) have been described.19
There remains some controversy as to the timing and
risks of closed cervical reduction. Eismont et al. reported the
catastrophic results of closed reduction in six patients, one
resulting in quadriplegia due to an extruded disc fragment.20
All reductions were performed under general anesthesia.
6
VOLUME 10 I NUMBER 2
Other authors have confirmed that traumatic disc herniation
may be present before or after cervical reduction.21,22 Despite
this finding, there has been no documented report of perma-
nent spinal cord injury in an awake, cooperative, neurologi-
cally intact patient under a controlled, closed reduction.
Closed reduction has been shown by several authors to be
effective and safe, even in the setting of disc herniation.19,22,23
Operative Treatment
Surgical planning is often guided by injury pattern and
the location of neurologic compression (ventral vs. dorsal,
single vs. multilevel). Surgeon or institutional preferences for
either the anterior or the posterior approach may also affect
surgical planning. Reports supporting both anterior and pos-
terior approaches have been published.24–29 Additionally, bio-
mechanical studies have demonstrated that both anterior and
posterior constructs provide sufficient stiffness with varying
injury patterns.30,31 Only one study to date has prospectively
compared anterior to posterior treatment.32 Among patients
with unilateral facet fractures, the authors found no differ-
ences in discharge time or in patient satisfaction but did note
both lower pain scores and lower infection rates and a
greater risk of swallowing difficulties with anterior surgery.
An evidence based algorithm based on the SLIC classifi-
cation system has been developed to address these short-
comings.13 Decision algorithms to guide surgical planning
are described on the basis of SLIC injury morphologies: com-
pression; distraction (both hyperextension and hyperflexion);
and translation/rotation. The decision trees also account for
other important variables such as disk herniation, central
canal stenosis, DISH, and ankylosing spondylitis. Use of the
SLIC system and the treatment algorithms requires further
validation but may help guide physicians through evaluation,
classification, and surgical management.
CONCLUSION
After patients are successfully stabilized, they may be active-
ly mobilized. Early ambulation may diminish potential complica-
tions such as deep venous thrombosis, pulmonary atelectasis and
pneumonia, and skin pressure ulcerations. Despite early ambula-
tion and movement, active prevention of these complications
must be performed by the treating physician.
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Contemporary Spine Surgery
20. Eismont FJ, Arena MJ, Green BA. Extrusion of an intervertebral disc
associated with traumatic subluxation or dislocation of cervical facets:
case report. J Bone Joint Surg Am 1991;73:1555-1560.
21. Darsaut TE, Ashforth R, Bhargava R, et al. A pilot study of magnetic
resonance image-guided closed reduction of cervical spine fractures.
Spine 2006;31:2085-2090.
22. Vaccaro AR, Falatyn SP, Flanders AE, Balderston RA, Northrup BE,
Cotler JM. Magnetic resonance evaluation of the intervertebral disc,
spinal ligaments, and spinal cord before and after closed traction
reduction of cervical spine dislocations. Spine 1999;24:1210-1217.
23. Star AM, Jones AA, Cotler JM, Balderston RA, Sinha R. Immediate
closed reduction of cervical spine dislocations using traction. Spine
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Contemporary Spine Surgery VOLUME 10 I NUMBER 2

CME Quiz
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1. Cervical spine injuries are well defined
with strong clinical evidence to support
evaluation and treatment.
A. True
B. False
2. Initial evaluation of the traumatically
injured patient should be focused on
A. cervical stabilization
B. the patient’s airway, ventilation, and
circulation
C. CT evaluation of the entire spine
D. plain radiography of the neck
3. What percentage of patients with a cer-
vical spine fracture may have another
spinal injury?
A. 0–10
B. 20–30
C. 50–60
D. 80–90
4. MRI of the cervical spine is not an effec-
tive screening tool for cervical trauma.
A. True
B. False
5. The Allen and Ferguson classification is
A. based on prospective, clinical data
B. highly reliable and valid
C. based on four primary injury patterns
D. a mechanistic classification system
6. The Subaxial Cervical Spine Injury Classifi- 9. A 27-year-old man presents with a bilat-
cation (SLIC) includes three critical vari- eral C5–C6 cervical dislocation. He is
ables, except awake and cooperative. His examina-
A. injury mechanism tion reveals an incomplete spinal cord
B. injury morphology injury. Which one of the following is not
C. status of the intervertebral disc and an acceptable next step in treatment?
posterior ligaments A. Closed reduction under general anes-
D. neurologic status of the patient thesia
B. High-weight closed reduction
7. A 58-year-old man presents with cervi- C. Cervical MRI scan
cal pain and a normal neurologic exam- D. Combined anterior and posterior sur-
ination after a fall from 25 feet. Imaging gical treatment
reveals a C7 burst fracture with no evi-
dence of disc or ligamentous disruption. 10. Anterior surgical treatment has been
The correct SLIC severity score is proven safer and more effective than
A. 1 posterior surgical treatment for patients
B. 2 with unstable cervical injuries.
C. 4 A. True
D. 6 B. False
8. A 21-year-old woman presents with cervi-
cal pain, right triceps weakness, and right
C7 sensory deficits. Imaging reveals a
C6–C7 facet fracture dislocation with 25%
translation. MRI demonstrates increased
signal within the intervertebral disc and
posterior ligaments. The correct SLIC
severity score is
A. 5
B. 6
C. 7
D. 8