Follow ATLS with careful immobilization; CT is first‑line imaging for suspected injury. AO Subaxial classification guides stability and surgical approach; assess disco‑ligamentous injury and neurology. Bilateral facet dislocation: attempt awake traction reduction, then ACDF or posterior fixation depending on disc herniation and stability. Teardrop fractures and burst injuries often need anterior decompression + fixation. Early decompression in incomplete SCI may improve outcomes.
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Overview & Epidemiology
Subaxial cervical spine (C3–C7) trauma encompasses a spectrum of injuries from minor ligamentous sprains to unstable fracture-dislocations with catastrophic spinal cord injury. These injuries are common in road traffic accidents, contact sports, and falls. The neurological consequences can be devastating and permanent, making timely and accurate diagnosis and management critical.
Subaxial cervical injuries are the most common cervical spine fractures — approximately 65% of cervical fractures occur at C3–C7
C5–C6 is the most commonly injured level — greatest mobility, most vulnerable to flexion-compression mechanisms
SCIWORA (Spinal Cord Injury Without Radiological Abnormality): neurological deficit without fracture or dislocation on plain X-ray or CT; more common in children; MRI reveals ligamentous injury or cord contusion
The SLIC system (Vaccaro, 2007) is the most widely used modern classification for subaxial cervical injuries. It scores three independent variables and provides a management algorithm.
Bilateral facet dislocation: >50% anterior subluxation on lateral X-ray is pathognomonic; requires urgent reduction
Central cord syndrome: most common incomplete SCI; hyperextension in elderly with cervical stenosis/spondylosis; disproportionate upper limb weakness > lower limb; bladder dysfunction; best prognosis of incomplete injuries
Investigations
Plain radiographs (lateral, AP, open-mouth odontoid): initial screening; lateral must visualise C1–T1; inadequate lateral = repeat with shoulder traction or swimmer view
CT is the investigation of choice for all significant cervical trauma — superior sensitivity for fractures compared to plain films; reconstructions in all planes; assess canal diameter, facet alignment, vertebral body comminution
MRI: mandatory when neurological deficit present — assesses spinal cord signal (oedema, haemorrhage, transection), disc herniation, epidural haematoma, and DLC integrity; STIR sequences most sensitive for ligamentous injury
MRI before reduction of facet dislocations: controversial — some advocate MRI before reduction to exclude traumatic disc herniation which can worsen with reduction; others favour urgent reduction without MRI in patients with incomplete/complete cord injury and attribute delay to risk
CT angiography: vertebral artery injury occurs in up to 25% of subaxial fractures and dislocations; particularly with transverse foramen involvement or distraction injuries; anticoagulation if vertebral artery injury confirmed without haemorrhagic stroke risk
Management
Non-Operative:
SLIC ≤3: stable injuries managed with cervical collar (soft or rigid) or halo vest immobilisation
Rigid cervical orthosis (Philadelphia collar, Miami-J): for moderate injuries; easier to apply, better compliance
Halo vest: for injuries requiring greater immobilisation; 4 pins (anterior and posterior); significant complications — pin loosening, infection, pin-site sepsis, dysphagia; particularly morbid in elderly
Operative — Reduction and Stabilisation:
Urgent reduction of facet dislocations: awake closed reduction with Gardner-Wells tongs under fluoroscopy for bilateral facet dislocation — progressive traction up to 50–70 lb; neurological monitoring throughout; proceed to open reduction if closed fails
Anterior cervical discectomy and fusion (ACDF): gold standard for most subaxial injuries — decompresses cord anteriorly, restores disc height, and provides anterior column stability; most injuries with anterior cord compression require anterior approach
Posterior cervical fusion: for posterior ligamentous disruption, bilateral facet fracture-dislocation, and posterior instability; lateral mass screws (C3–C6) or pedicle screws (C7); provides excellent rotational stability
Combined anterior-posterior surgery: for severe 3-column injuries, highly comminuted burst fractures, and cases requiring circumferential reconstruction (flexion teardrop, bilateral facet dislocation with disc injury)
Timing: emerging evidence strongly supports early surgery (<24 hours) for incomplete SCI — multiple studies including STASCIS trial show improved neurological outcomes with early decompression; complete SCI: timing less clear but early surgery reduces medical complications
Consultant-Level Considerations
MRI before reduction debate: current evidence (EAST guidelines, AOSpine) suggests that in alert, cooperative patients with incomplete cord injury, urgent closed reduction without MRI is acceptable; for obtunded patients or those with complete injury, MRI before reduction is reasonable to exclude large disc herniation that could worsen with distraction
Vertebral artery injury (VAI) screening: obtain CT angiography for all injuries involving transverse foramen, distraction injuries, and bilateral facet dislocations — VAI present in 20–40% of these; asymptomatic VAI treated with anticoagulation or antiplatelet therapy; untreated symptomatic VAI risks posterior circulation stroke
Elderly patients with central cord syndrome and cervical spondylosis: hyperextension injuries in this group cause central cord syndrome without fracture (SCIWORA equivalent); MRI shows cord contusion at level of maximal spondylosis; initial management is non-operative; surgical decompression for persistent incomplete deficit failing conservative management or cervical instability
Steroid controversy: high-dose methylprednisolone (NASCIS protocols) is no longer recommended as standard of care for acute SCI — meta-analyses show marginal neurological benefit vs significant complications (infection, GI haemorrhage, pulmonary complications); most spine societies recommend against routine use
Ankylosing spondylitis (AS) and DISH: patients with AS or DISH sustain highly unstable hyperextension injuries with minor trauma — the long-lever-arm effect of a fused spine amplifies forces; fractures are highly unstable and often missed; spinal precautions mandatory; typically require long posterior instrumentation spanning the fusion mass
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References
Vaccaro AR et al. A new classification of cervical spine injury: the subaxial injury classification system (SLIC). Spine. 2007;32(21):2365–2374.
Fehlings MG et al. Early versus delayed decompression for traumatic cervical spinal cord injury: results of the STASCIS trial. J Neurotrauma. 2012.
Bracken MB et al. Administration of methylprednisolone for 24 or 48 hours or tirilazad mesylate for 48 hours in the treatment of acute spinal cord injury (NASCIS III). JAMA. 1997.
Harrigan MR et al. Magnitude and timing of vertebral artery injury after blunt cervical trauma. Neurosurgery. 2013.
Allen BL et al. A mechanistic classification of closed, indirect fractures and dislocations of the lower cervical spine. Spine. 1982;7(1):1–27.
Anderson PA et al. Posterior cervical arthrodesis with AO reconstruction plates and bone graft. Spine. 1991.
Campbells Operative Orthopaedics. 14th Edition. Elsevier.
Rockwood and Greens Fractures in Adults. 9th Edition.
AO Spine Subaxial Cervical Classification System. Global Spine J. 2015.
Orthobullets — Subaxial Cervical Spine Trauma, SLIC Classification.
EAST Practice Management Guidelines — Cervical Spine Clearance. 2021.
