Monday, November 9th 2020

SUBAXIAL CERVICAL FRACTURES:

Clinical Evaluation, Diagnosis and Treatment Methods
Team: Spine
VI/MX

Mod: SV

Supervisor:
dr. Jainal Arifin, M.Kes, Sp.OT(K)Spine
CASE

 A 71-year-old woman presented after an automotive accident with an

incomplete spinal cord injury (American Spine Injury Association
Impairment Scale [AIS] grade B).

 (A, B) A distractive injury is identified at C6–7 in the sagittal CT scan

reconstruction (white arrow).

 The Subaxial Injury Classification score was 3 points (distractive injury) + 2

points (discoligamentous complex injury) + 3 points (incomplete neurologic
deficits) = 8 points — surgical treatment was performed.

 Postoperative sagittal(C) and 3-D reconstruction (D) CT scans showing

reestablishment of cervical alignment and facet joint congruence, with
lateral mass screws at C5 and C6 and pedicle screws at C7 and T1. After 6
months of followup, she had some neurologic improvement (AIS grade C).
INTRODUCTION
 Cervical spine trauma is one of the most common sites of spinal cord
injury (SCI). Anatomically, subaxial cervical spine trauma consists of
injuries from C3 to C7 with more than 50% of the cervical spine injuries
located between C5 and C7.
 Fracture patterns vary by mechanism and include:
 compression fracture
 burst fracture 
 flexion teardrop fracture
 extension teardrop avulsion fracture
Classification

 Descriptive classification (subaxial cervical spine
injuries) includes
 compression fracture
 burst fraction
 flexion-distraction injury
 facet dislocation (unilateral or bilateral)
 facet fracture
 Allen and Ferguson classification 
DIAGNOSIS

 Cervical Spine Injury Severity Score (CSISS)

 Subaxial Cervical Spine Injury Classification (SLIC)
Cervical Spine Injury Severity
Score (CSISS)
 The cervical spine is conceptualized in terms of four
columns (anterior, posterior, and right and left lateral
columns). Each column is scored from 0 to 5 using an
analog scale based on degree of osseous displacement
and ligamentous injury.
 The resulting injury severity score ranges from 0 (no
injury) to 20 (most severe injury). Scores of 7 or more
generally require surgery and scores less than 5 are
generally treated nonoperatively.
Subaxial Cervical Spine Injury
Classification (SLIC)
Total score
≤3 : nonoperative treatment is recommended
4 : either surgery or nonoperative treatment is indicated,
≥5 : surgery is recommended
Cervical Facet Dislocations & Fractures

 Represent spectrum of osteoligamentous pathology that

includes
 unilateral facet dislocation
 bilateral facet dislocation
 facet fractures
 Pathophysiology
 Mechanism  flexion and distraction forces +/- an
element of rotation
Clinical presentation

 Monoradiculopathy
 spinal cord injury symptoms
 seen with bilateral dislocations
 symptoms worsen with increasing subluxation
Treatment

 Nonoperative
 cervical orthosis or external immobilization (6-12 weeks)
indications
 facet fractures without significant subluxation, dislocation, or
kyphosis
 Operative
 immediate closed reduction, then MRI, then surgical stabilization 
indications 
 bilateral facet dislocation with deficits in awake and cooperative patient 
 unilateral facet dislocation with deficits in awake and cooperative patient 
 immediate MRI then open reduction surgical stabilization
Indication
 facet dislocations (unilateral or bilateral) in patient with mental status changes
 patients who fail closed reduction
Cervical Lateral Mass Fracture Separation

 mechanism of injury
 traffic accident, falls, heavy object landing on head
 hyperextension, lateral compression and rotation of the cervical spine
Clinical presentation

 Symptoms
 Neurologic symptoms common (up to 66%)
 radicular pain, radiculopathy or spinal cord injury/myelopathy
 can be classified by Frankel grade or ASIA impairment scale
 Physical exam
 Inspection
 torticollis, paravertebral muscle spasm
 Neurovascular
 radicular pain and numbness
 myelopathy
Treatment

 Nonoperative
 NSAIDS, rest, immobilization
 Operative
 Posterior decompression and two-level instrumented fusion
 Anterior plating and interbody fusion
 Single posterior pedicle screw
 Anterior and posterior decompression and fusion
Subaxial Cervical Vertebral Body Fractures
 Mechanism:
1. Compression fracture

Characterized by
 Compressive failure of anterior vertebral body without disruption of posterior body
cortex and without retropulsion into canal
 Cften associated with posterior ligamentous injury
2. Burst fracture   

Characterized by
 fracture extension through posterior cortex with retropulsion into the spinal canal
 often associated with posterior ligamentous injury

Prognosis
 often associated with complete and incompete spinal cord injury

Treatment
 unstable and usually requires surgery
3. Flexion teardrop fracture 

Characterized by
 anterior column failure in flexion/compression 
 posterior portion of vertebra retropulsed posteriorly
 posterior column failure in tension 
 larger anterior lip fragments may be called 'quadrangular fractures’ 

Prognosis
 associated with SCI

Treatment
 unstable and usually requires surgery
4. Extension teardrop avulsion fracture  

Characterized by
 small fleck of bone is avulsed of anterior endplate
 usually occur at C2
 must differentiate from a true teardrop fracture

Mechanism
 extension

Prognosis
 stable injury pattern and not associated with SCI

Treatment
 cervical collar
TREATMENT METHODS
Nonoperative
 Collar immobilization for 6 to 12 weeks
 Indications
 Stable mild compression fractures (intact posterior ligaments
& no significant kyphosis)
 Anterior teardrop avulsion fracture
 External halo immobilization
 Indications
 Only if stable fracture pattern (intact posterior ligaments &
no significant kyphosis)
TREATMENT METHODS
Operative
 Anterior decompression, corpectomy, strut graft, & fusion with
instrumentation
 Indications
 Compression fracture with 11 degrees of angulation or 25% loss of
vertebral body height
 Unstable burst fracture with cord compression
 Unstable tear-drop fracture with cord compression
 Minimal injury to posterior elements
 Posterior decompression, & fusion with instrumentation
 Indications
 Significant injury to posterior elements
 Anterior decompression not required
QUESTIONS AND ANSWERS
1. A 40-year-old male sustains subaxial cervical spine fracture and after a
motor vehicle accident. Physical exam is significant for an incomplete
upper cervical spinal cord injury. Which of the following CT scans is
associated with the worst ultimate clinical outcome?
1 Figure A
2 Figure B
3 Figure C
4 Figure D
5 Figure E
A B C

D E
1. A 40-year-old male sustains subaxial cervical spine fracture and after a
motor vehicle accident. Physical exam is significant for an incomplete
upper cervical spinal cord injury. Which of the following CT scans is
associated with the worst ultimate clinical outcome?
1 Figure A
2 Figure B
3 Figure C
4 Figure D
5 Figure E
Figure B is an axial CT scan demonstrating bilateral facet dislocations, which
is associated with more severe initial neurologic injury and inferior outcomes
compared to patients with cervical spine injuries without facet dislocations.
2. A 40-year-old male patient fell asleep at the wheel and was involved in a
motor vehicle accident. At the emergency room, he presented with an ASIA C
spinal cord injury. An AP radiograph is shown in Figure A. An axial CT scan at
the C5 level is shown in Figure B. Management of this injury should include:

1. Anterior cervical discectomy and fusion of C5-6

2. Corpectomy of C5 and instrumented fusion C5-6
3. Corpectomy of C5 and instrumented fusion C4-5
4. Posterior instrumented fusion of C4-6
5. Posterior instrumented fusion of C5-6
 B

A
2. A 40-year-old male patient fell asleep at the wheel and was involved in a
motor vehicle accident. At the emergency room, he presented with an ASIA C
spinal cord injury. An AP radiograph is shown in Figure A. An axial CT scan at
the C5 level is shown in Figure B. Management of this injury should include:

1. Anterior cervical discectomy and fusion of C5-6

2. Corpectomy of C5 and instrumented fusion C5-6
3. Corpectomy of C5 and instrumented fusion C4-5
4. Posterior instrumented fusion of C4-6
5. Posterior instrumented fusion of C5-6
This patient has fracture separation of the lateral mass. This is best treated
with posterior two-level fusion involving both the level above and the level
below. 
3. A 24-year-old male sustains the injury shown in Figure A. What was the
most likely mechanism of injury?
1. Hyperextension
2. Flexion-distraction
3. Flexion-compression
4. Rotational
5. Pure axial load
3. A 24-year-old male sustains the injury shown in Figure A. What was the
most likely mechanism of injury?
1. Hyperextension
2. Flexion-distraction
3. Flexion-compression
4. Rotational
5. Pure axial load
Figure A shows a quadrangular fracture pattern of C5. These injuries are
observed with flexion-compression loads.
THANK YOU