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Subaxial Cervical Spine Fractures

Subaxial cervical spine injuries (C3–C7) are common consequences of high- to moderate-energy trauma, though even low-energy mechanisms can cause significant damage in elderly or ankylosed spines. They result from flexion, extension, compression, or burst mechanisms, most frequently between C5 and C7. Diagnosis begins with ATLS evaluation and cervical immobilization, followed by neurologic assessment and imaging. Standard radiographs (AP, lateral, odontoid) are complemented by CT for fracture detail and MRI for disco-ligamentous complex (DLC) and cord evaluation. Classification systems such as AOSpine, SLIC, and Allen–Ferguson guide management. Stable compression fractures without posterior ligamentous involvement may be managed conservatively using a rigid orthosis, whereas unstable or displaced injuries—especially burst and flexion teardrop fractures—require surgical decompression and fixation. Prognosis depends on the initial neurological deficit, fragment displacement, and timing of surgery; patients with ankylosing spondylitis are at higher risk of neurological deterioration and often need long-segment stabilization.

Overview


Injury to bony and ligamentous anatomy of C3 to C7 levels

Wide range of motion makes this region vulnerable to injury

High energy -moderate energy injury mechanism; in elderly low energy trauma

Anklylosis Spondylitis very low energy trauma may cause injury

Compression,burst, flexion teardrop, extention tear drop mechanisms etc.

Cervical spine injury 3% due to blunt trauma ;50% between C5 and C7


Clinical Presentation


Focal neurologic deficit, neck pain, torticollis,

Reporting diving as the mechanism of injury

1st evaluation is ATLS and suspicion of cervical spine injury requires spinal immobilization

Posterior midline tenderness and step off

Patient transport with spine board log roll technique

*Cervical alignment: In children head size is larger so Alignment of the external auditory meatus with the shoulders, even if this involves a relative extension of the neck, will align the cervical spine in neutral and avoid forward flexion in young children

*Standard sensory and motor exam, with reflexes of the upper and lower extremities, should be documented.

*Findings of upper motor neuron signs (muscle weakness, spasticity, hyperreflexia, and clonus)  may indicate cord compression

*Compromised root may indicate injury level; In cervical spine roots exit above corresponding vertebral body (Figure ROOT MUSCLE TABLOSU)



Imaging


*An anteroposterior, lateral, and open-mouth odontoid xray views are standard

*Normal cervical spine should be 15 to 30 degrees of lordosis from C1 through C7

*NEXUS criterias for radiologic evaluation of cervical spine injury

*Multiplanar CT scans

*Suspicion of neurologic injury and age over 60, polytrauma patients, cervical spondylosi, and a patient that cannot undergo evaluation due to a low GCS or other altered mental status needs MRI



Classification


1-AOSpine Subaxial Cervical Spine Injury Classification  (LINK)

fracture type, facet injury, neurological status, and the presence of

specific modifiers

2-Subaxial Injury Classification System (SLIC) (LINK+ FIGURE)

the type of fracture, the competency of the DLC, and the patient’s neurologic status

3-Allen and Ferguson Classification (FIGURE)

*Subaxial cervical spine injuries are the result of compression or distraction forces that cause flexion or extension moments.



Treatment


Conservative treatment:

*Rigid cervical/cervicothoracic orthosis for 6 to 12 weeks and  follow-up  with interval radiographs to evaluate alignment ( compression fractures; no posterior ligamentous or capsular involvement-stable fracture pattern)

*High risk of posttraumatic kyphosis with conservative treatment if the fracture is a C7


Surgery:


*Unstable fracture w/wo neurologic compromise needs decompression and fixation

*Burst fractures mostly unstable w/wo neurologic deficits and usually require surgical decompression and fixation( displacement to the canal, flexion-type teardrop fractures often treated anterior approach (effected number of levels/intact DLC+ posterior fixation support)

* Awake and alert patient; facet dislocations may be reduced with controlled cervical traction (Unilateral dislocations may be locked and inappropriate for closed reduction)

*Unconscious and incoorperate patient evaluate with MRI before reduction attempt

*Ankylosing spondylitis patient check neuro with intervals; may require long instrumentation


Prognosis


*Larger fragments compressing cord and advanced injury classification scores are related with poor prognosis also increased time to surgery from injury may cause poor prognosis

*60% limits neurologic deficit and 30% improves somewhat

*A flexion moment injury and known AS may be associated with late onset neurologic deterioration

*AS pts tend to have higher incidence of neurologic complications.




References

  1. Fehlings MG, Tetreault LA, Riew KD, Middleton JW. Cervical Spine Trauma: Principles of Evaluation and Management. In: Orthopaedic Knowledge Update: Spine 6. AAOS; 2018.

  2. Vaccaro AR, Hulbert RJ, Patel AA, et al. The Subaxial Cervical Spine Injury Classification System and Case Examples. Spine (Phila Pa 1976). 2007;32(21):2365–2374.

  3. Joaquim AF, Patel AA. Subaxial Cervical Spine Trauma: Evaluation and Surgical Decision-Making. Global Spine J. 2014;4(1):63–70.

  4. AOSpine Knowledge Forum Trauma. AOSpine Subaxial Cervical Spine Injury Classification. Eur Spine J. 2015;24(10):2244–2257.

  5. Allen BL, 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.

  6. Mendenhall SK, Mroz TE, Benzel EC. Subaxial Cervical Spine Trauma. Neurosurgery. 2017;80(3S):S139–S145.

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