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Subaxial (C3–C7) Cervical Spine Fractures

Subaxial fractures are evaluated primarily based on injury morphology and

neurologic status, both of which are included in the SLIC classification system.
Stability in this region is largely determined by the integrity of the posterior
ligamentous complex.


• How much energy was involved in the trauma?

• Was there head strike?
• Do you have other sites of pain along your spine?
• Do you have any weakness, numbness, or tingling?

Physical Exam

• Absence of posterior c-spine midline ttp in cooperative patient strongly suggests

lack of substantial c-spine injury
• Malrotation of head suggesting facet dislocations
• Inspect for signs of head trauma
• Trauma evaluation (Appendix A)
• Complete neurologic exam (Appendix A)

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• C-spine XRs—AP, lateral, flexion/extension views

° Evaluate instability in cooperative patients

° Must have normal mental status and a normal neurologic exam
° Must visualize cervicothoracic junction to T1 *IMPORTANT*
• C-spine CT—required to evaluate fracture pattern and facet alignment
• C-spine MRI—necessary to evaluate for acute disc herniation or disrupted disco-
ligamentous complex


Sub-axial Cervical Spine Injury Classification System (SLIC)

Morphology type
Normal (0)
Compression (1)
Burst (2)
Distraction (3)
Translational/rotational (4)
Neurologic Involvement
Intact (0)
Nerve root (1)
Complete cord (2)
Incomplete cord (3)
Continuous cord compression with deficit (+1)
Discoligamentous Complex
Intact (0)
Injury suspected/indeterminate (1)
Injury (2)

Treatment Plan

Non-operative Conditions

• SLIC score of 0–3 points

• Unilateral lateral pillar fracture
• Posterior column fracture
Subaxial (C3–C7) Cervical Spine Fractures 59

Non-operative vs. Operative Management

• SLIC score of 4 points

• Bilateral lateral pillar fractures

Operative Management

• SLIC score of 5–10 points

• Locked dislocated facets (unilateral or bilateral)
• Instability, demonstrated by spondylolisthesis
• Neurologic compromise due to vertebral body retropulsion


• For patients with SCI, consider IV methylprednisone based on the NASCIS II/III
studies (see chapter “Incomplete Spinal Cord Injury”)
• C-collar, halo vest, cervico-thoracic orthosis
• High morbidity/mortality of halo vests, especially in patients >70 years old (2x
mortality than c-collar)

° Aspiration, cardiac arrest, pin-site infection, pin loosening

• Closed reduction with axial traction and serial neurologic exams and imaging

° Unilateral or bilateral facet dislocations

° In alert patient
° MRI to detect disc herniations prior to reduction in non-communicative patient


• Anterior decompression, corpectomy, and fusion with instrumentation

° Unstable burst, tear drop, or quadrangular fractures with cord compression

° Primary anterior column pathology
• Posterior decompression and fusion with instrumentation

° Indicated with posterior ligamentous complex disruption

° Primary posterior column pathology
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Vaccaro AR, Hulbert RJ, Patel AA, Fisher C, Dvorak M, Lehman RA, et al. The subaxial cervical
spine injury classification system: a novel approach to recognize the importance of morphol-
ogy, neurology, and integrity of the disco-ligamentous complex. Spine. 2007;32(21):2365–74.