Table 6.
Subaxial cervical spine management on the basis of morphology
| Mechanism (Allen’s stage) | Morphology and AO type | Management |
|---|---|---|
| Vertebral compression stages 1 & 2 | Superior or inferior endplate fracture AO Spine A1 | Stable, external immobilization for 8–12 weeks |
| Both endplates AO Spine A2 (Fig. 5) | ||
| Vertebral compression stage 3 | Burst vertebral body with variable comminution | SOMI brace/halo 12 weeks with intact neurology |
| AO Spine A3 and A4 (Fig. 5) | Surgery- worsening neurological deficit (anterior cervical corpectomy and instrumented fusion, or posterior lateral mass/pedicle screw stabilization) | |
| Compressive flexion stages 1 & 2 | Wedge (CF1) | Cervical orthosis: 8–12 weeks |
| Wedge with localized kyphosis or breaking (CF2) | ||
| AO Spine A1 (Fig. 6) | ||
| Compressive flexion stages 3 & 4 | Teardrop CF3, retrolisthesis < 3 mm CF4 | Anterior corpectomy with instrumented fusion |
| AO Spine type A (Fig. 6) | ||
| Compression flexion stage 5 | Retrolisthesis > 3 mm | Anterior corpectomy with instrumented fusion/posterior stabilization in severe posterior ligament injury or when multilevel anterior corpectomy |
| AO Spine type C (Fig. 6) | ||
| Distraction flexion stage 1 | Flexion sprain | Rigid external immobilization for 8–12 weeks |
| Distraction flexion stage 2 | Unifacet dislocation | Closed/posterior or anterior open reduction |
| Distraction flexion stages 3–5 | Allen’s 3 (Bifacet dislocation with anterolisthesis < 50%) | Anterior or posterior open reduction (for osteoporosis, posterior reduction) |
| Allen’s 4 (Anterolisthesis > 50%) | ||
| Allen’s 5 Complete spondyloptosis | ||
| AO Spine type F4 (Fig. 7) | ||
| Compressive extension stages 1 & 2 | Unilateral vertebral arch fracture, bilateral vertebral arch fractures | Rigid cervical orthosis for 12 weeks |
| AO Spine A0 (Fig. 8) | ||
| Compressive extension stage 3 | Bilateral vertebral arch fractures with the anterior extension of the fracture, with maintained spinal alignment | External immobilization |
| AO Spine B3 (Fig. 8) | ||
| Compressive extension stages 4 & 5 | Dissociation between anterior and posterior vertebral columns with progressive anterior translation AO Spine type C (Fig. 8) | Surgery with multilevel posterior lateral mass or pedicle screw fixation |
| With significant vertebral body comminution, additional anterior reconstruction may be required to restore the load-bearing mechanics | ||
| Distractive extension stage 1 | Distraction injury of the anterior column but PLL intact | Surgically managed with anterior cervical fusion with plating |
| AO Spine type B3 (Fig. 11) | ||
| Distractive extension stage 2 | Distraction injury involving both columns with PLL torn | Posterior reduction with stabilization+anterior fusion if anterior column involved |
| AO Spine type C (Fig. 11) | If the spine gets realigned with gentle traction, then multilevel posterior instrumentation | |
| If spinal realignment cannot be achieved, then posterior instrumentation+anterior decompression and fusion | ||
| Lateral flexion stage 1 | Ipsilateral posterior elements involved | Managed nonsurgically |
| Lateral flexion stage 2 | Contralateral posterior elements involved | Posterior stabilization for one motion segment |
AO, Arbeitsgemeinschaft für Osteosynthesefragen (German for “Association for the Study of Internal Fixation”); SOMI Brace, sternal occipital mandibular immobilizer.