CHAPTER
Alpesh A. Patel
128
Classification of Cervical
Spine Injury
INTRODUCTION
Cervical spine injuries are a common clinical condition observed
across a wide spectrum of the population. Traumatic injury to
the cervical spine, especially when associated with spinal cord
injury, has a profound impact on the individual patient as well
as society. Despite the frequency and implications of cervical
spine trauma, there remains little consensus as to the classifica-
tion and treatment of cervical fractures and dislocations.
Classification systems are widely utilized across medical and
surgical specialties, from trauma to oncology to blood pressure
management. Although injury and disease occur on a contin-
uum, the use of classification systems is critical. Classification
systems serve many functions in defining traumatic injury. First,
classification improves communication between health care
providers. Second, classification can guide medical decision
making. Third, a well-structured classification system can deter-
mine injury prognosis. Lastly, classification allows for valid and
reliable research using a standard, universal language.
Classification systems are generalizations or estimates of a
highly variable morphologic and biomechanical structure.
These generalizations sacrifice data that can result in decreased
precision, from attempting to place into categories of injury,
which in reality are continuous variables across a spectrum.
Attempting to increase the precision by utilizing more catego-
ries decreases reliability and makes the system more confusing
and not usable.
An ideal classification system, therefore, provides both
descriptive and prognostic information. The descriptive com-
ponent relays information about the traumatic condition, orga-
nized by injury severity, based upon consistent radiographic
and clinical parameters, in an easily understood, reproducible
language. The prognostic component of an ideal system affects
clinical decision making by accounting for natural history and
known injury outcomes to guide treatment. Lastly, this system
must be reproducible, incorporate commonly used clinical
parameters and be readily implemented into regular clinical
practice.
To aid physicians in caring for patients, classification systems
must be valid and reliable. Reliability is the reproducibility by the
observer (intraobserver) and between observers (interobserv-
ers). Many classic classification systems including Gardens hip
fracture, Neers proximal humerus fracture, Catteralls Perthes
LWBK836_Ch128_p1381-1389.indd 1381
Alexander R. Vaccaro
Paul A. Anderson
disease, and the Arbeitsgemeinschaft fr Osteosynthesefragen
(AO) Pilon fracture that, when tested, have proven unreliable
and unsatisfactory for decision making.4,5,15,16
Six attributes of a quality classification system have been
described by Mirza et al.11 The system should aid in the identi-
fication of injury and provide a description. It should reflect
the injury mechanism and pathogenesis, and therefore guide
treatment. The classifications should be based on easily deter-
mined clinical and radiographic characteristics, which should
also allow differentiation from other injury types. The system
should account for, and quantify, neurologic injury. The skele-
tal injury should be graded for both bony and ligamentous
integrity. Finally, a classification should provide an estimate of
the prognosis for healing and adverse events such as chronic
pain and/or deformity.
The vast majority of current classification systems fall short
of these expectations (Table 128.1). They are often convoluted
systems based upon inferred, mechanistic descriptors of bony
injury. They do not account for potential intervertebral disc or
ligamentous injury. They all ignore the clinical status of the
patient, specifically the presence of neurological injury. Because
of these factors, none of the current classification systems has
stood out as a gold standard.
The purpose of this chapter is to review current cervical
spine trauma classification systems, to review the critical con-
cepts in cervical spine trauma, and to describe two new quanti-
tative classification systems.
CLASSIFICATION SYSTEMS
A number of classification schemes have been described in an
attempt to better define spine trauma and spinal instability.
Many of these systems have added to the collective understand-
ing and vocabulary of spinal trauma, but none has distinguished
itself as the best.
The concept of spinal stability and instability is one that has
proven difficult to define. Nicoll defined functional spinal sta-
bility based upon return to work after thoracolumbar spinal
fracture in a group of 152 Welsh miners.13 Contrary to the prior
teachings of Bohler and Watson-Jones, Nicoll demonstrated
that functional outcomes did not correlate with radiographic
appearance, most notably in individuals without neurological
1381
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 1382 Section XII Trauma

TABLE 128.1 Classification Systems for Subaxial Cervical Injuries

Classification System Strengths Weaknesses

Nicoll Functional outcomes Retrospective
Lacks details
No neurological assessment
Holdsworth Posterior ligament complex Limited descriptors
Ignores anterior soft tissues (disc, ALL, PLL)
No neurological assessment
Louis Conceptually simple Anatomic description only
Ignores soft tissues (anterior and posterior)
No neurological assessment
White and Panjabi Neurological assessment Intricate radiographic criteria
Point based Stretch test
Limited assessment of soft tissues (anterior and posterior)
Allen et al Comprehensive Mechanisticinferred description and assessment of stability
Harris et al Organized by severity Large number of subgroups
No neurological assessment
Poor to fair reliability
AO Comprehensive Large, complex number of subgroups
Organized by severity No neurological assessment
Universal language Poor to moderate reliability
Cervical Spine Injury Quantifies instability No neurological or morphologic assessment
Severity Score Proven reliable and valid
Subaxial Injury Directs treatment Unproven reliability
Classification (SLIC) Comprehensive by including Indeterminate group difficult to define
and Severity Scale neurologic function

ALL, anterior longitudinal ligament; AO, Arbeitsgemeinschaft fr Osteosynthesefragen; PLL, posterior longitudinal ligament

injury.3,19 While this supports nonoperative treatment, the defi-
nition of stability is broad, overlooking many of the details
involved with the management of acute cervical trauma and
acute neurological injury. In addition, it is a purely retrospec-
tive description, based upon functional outcomes and, there-
fore, provides no prognostic information.
Holdsworth, through a review of more than 1000 patients,
divided fractures into two large groups (stable and unstable)
based primarily upon disruption of the posterior ligament
complex.7 Stable patterns included wedge fractures, burst frac-
tures, and extension injuries; unstable patterns included dislo-
cation, rotational-fracture dislocation, and shear injuries.
Although based solely on radiographs, Holdsworth astutely
identified the critical importance of the posterior cervical liga-
ments in spinal stability. His description fell short, however, due
to a lack of anatomic fracture detail and by not accounting for
the neurologic status of the patient.
Louis defined cervical spinal stability upon three anatomic
pillars (columns)one anterior (vertebral body, intervertebral
disc) and two posterior (each lateral mass).9 Although concep-
tually easy to understand, this remains primarily a descriptor of
bony injury location, without accounting for spinal alignment
or ligamentous injury and without any implication as to injury
severity.
White and Panjabi through a review of clinical cases and in
vitro biomechanical testing have suggested a point-based clas-
sification system for cervical trauma.20 Radiographic criteria,
physical examination (including neurological status), and a
stretch test are required and have an assigned point system.
The stretch test, involving sequential traction, aims to quantify
disc or ligamentous disruption through radiographic changes.
The White and Panjabi system is the first to designate neuro-
logic status as a component of cervical stability and the first to
provide radiographic measurements as criteria for instability. The
system is limited in its usefulness, however, by the stretch test,
which is now rarely required due to current imaging technologies
and an improved understanding of soft tissue disruptions. It is
further limited by the number of radiographic criteria present,
the disproportionate weight given to radiographic criteria over
ligamentous and neurological status, and unproven reliability.
Whereas others had classified injuries based on concepts of
stability, Allen et al developed a mechanistic classification sys-
tem.1 Based upon a review of 165 patients with subaxial cervical
trauma, the authors divided injuries into groups based upon a
common mechanism of injury with emphasis on a progression
of severity within each mechanism. Six main categories were
derived based upon inferred force vectorscompressive flex-
ion, vertical compression, distractive flexion, compressive
extension, distractive extension, and lateral flexion. This was
later modified by Harris et al to include rotational vectors in
both flexion and extension.6
The system is comprehensive, detailing an array of potential
cervical injuries. The system is also appropriately organized by
severity and can, therefore, aid in injury stratification. The sys-
tem is, however, also handcuffed by the multitude of options.
Furthermore, the system is fundamentally limited because it is
based upon mechanisms that are inferred from the recoil posi-
tion of the spine on radiographic imaging. This leaves the clas-
sification open to interpretation and has been reflected in the
poor to fair reliability of this system.17
The AO classification of spinal trauma defines injuries into
one of three large categories (A, B, C) with nine subgroups.10

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Type A injuries are compression injuries of the anterior col-
umn; type B injuries involve distraction injuries, with or without
angulation; type C injuries additionally involve a translational
or rotational component. Subgroups are further defined
according to the standard AO 3 3 system.
The AO system provides a well-defined, well-organized
means of describing a broad array of injury patterns.
Classification is based upon severity of injury and can thereby
guide treatment. The system also allows for a universal lan-
guage that can improve communication between treating phy-
sicians. The complexity of the AO system, specifically the array
of subgroups, limits its usefulness in routine clinical care. The
large AO categories (A, B, C) have additionally demonstrated
only poor to moderate reliability, with results worsening when
AO subcategories are tested.14,21
MODERN CLASSIFICATION SYSTEMS
THE CERVICAL SPINE INJURY SEVERITY SCORE
The Cervical Spine Injury Severity Score (CSISS) was devel-
oped to quantify the degree of traumatic instability.2,12 The sys-
tem is based on a four-column model of the cervical spine and
an analog scale to assess injury of each column (Figs. 128.1A
and B). The four columns are anterior, each lateral pillar, and
the posterior osseous ligamentous complex (Fig. 128.1A). The
anterior column consists of the body, disc and annulus, and the
anterior and posterior longitudinal ligaments. Each lateral pil-
lars includes the pedicles, lateral masses with facet articulations,
and facet capsules. The posterior column includes the lamina,
spinous processes, ligamentum flavum, and all the nuchal liga-
ments.
Each column is scored independent of the others using an
analog scale from 0 to 5 (Fig. 128.1B). A zero is no injury and
five is the worst injury that could occur to that column. Scores
in-between are based on degree of displacement. For example,
a nondisplaced fracture is graded as a 1, while a subluxation
of 3 mm would be graded as a 3. Fractional values can be
used. The score for each column is summed giving a potential
score from 0 to 20.
A
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Chapter 128 Classification of Cervical Spine Injury 1383
The reliability of the system was tested on 35 cervical spine
injured patients.2 The radiographs and computed tomography
(CT) scans were reviewed by 15 investigators of varying experi-
ence and the CSISS measured. The reliability was assessed by
determining the mean intraobserver and interobserver differ-
ences using intraclass correlation coefficients (ICCs). For this
metric, any score greater than 0.75 indicates excellent reliabil-
ity. The intraobserver ICC was 0.98, and the interobserver ICC
was 0.88, both indicating excellent reliability. No difference was
noted based on experience of the examiner. The worst cases
with the greatest variance in scores where in patients with anky-
losed spines or those with subtle ligamentous injury.
Validity indicates that the test or instrument is correctly
gauging reality. In most cases, this requires that the results be
compared with a gold standard. Validity was tested by compar-
ing the CSISS to the presence of neurologic injury and whether
surgery was performed (Figs. 128.2A to D). All 14 patients with
scores of 7 or greater had surgery whereas only 3 out of 20
with scores below 7 had surgery (Figs. 128.3A to D). All three
of these patients had a neurologic deficit. Furthermore, 65% of
patients with scores greater than 7 had neurologic deficits
compared with only 15% with lower than 7 scores.
In summary, the CSISS causes the surgeon to critically exam-
ine all components of the injury and can reliably measure the
degree of instability. It is easy to use and can be based on com-
puted tomography (CT) and magnetic resonance imaging
(MRI).
SUBAXIAL CERVICAL INJURY CLASSIFICATION
The Subaxial Cervical Injury Classification (SLIC) system and
severity score have been described by Vaccaro et al as a novel
system to define subaxial cervical trauma (C3-C7).17 It is an
adaptation of a thoracolumbar injury classification system
described by Vaccaro et al in an attempt to standardize
approaches to and descriptors of spine trauma across anatomic
regions.18
The SLIC system describes the injury by spinal level, injury
morphology, bony description, discoligamentous status, and
neurological examination. The SLIC system identifies three
Figure 128.1. The Cervical Spine Injury Severity
Score. (A) Four columns of the cervical spine. Each col-
umn will be scored independently using analog scale.
(B) Analog scoring ranging from 0 to 5. Zero is no
injury and a 5 is the worst injury possible of that col-
umn. A 1 is a nondisplaced fracture and the remain-
ing scores are based on increasing displacement of bony
fractures or from ligamentous disruption. Fractional val-
ues can be used.
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 1384 Section XII Trauma

A B

C D

Figure 128.2. (A) A 27-year-old man with facet fracture of C6 and C7 body and right facet. The sagittal
computed tomography (CT) demonstrates the body fractures and opening between spinous processes
(arrows). His anterior column is scored 2.0 for slightly fractures without vertebral subluxation. The posterior
column is disrupted and scored 4.0. (B) Axial CT. Arrow indicates body fracture of C7. (C) Left pillar was
scored 2.0 for facet subluxation (arrow). (D) Right pillar was scored 3.0 for having both subluxation and supe-
rior facet fracture. The overall Cervical Spine Injury Severity Score was 11.0, and the patient was treated by
posterior fusion.

critical components in subaxial cervical spine trauma: injury
morphology, discoligamentous injury, neurological status.
Injury Morphology
The injury morphology defines the structural relationship of
the vertebral bodies to each other in terms of anterior ana-
tomical support, soft tissue structures, facet relationships, and
overall alignment as determined by plain radiographic and
advanced imaging characteristic. Injury morphology is classi-
fied as compression, distraction, or rotation/translation.
Compression injuries are defined by a visible loss of height
of the vertebral body or disruption through the vertebral end
plate. This includes traditional compression and burst frac-
tures, sagittal or coronal plane fractures of the vertebrae, and
teardrop, or flexioncompression fractures.
The distraction injury pattern is readily identified by
anatomical dissociation in the vertical axis. A representative

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A B
C D
example would be a hyperextension injury causing disruption
of the anterior longitudinal ligament (ALL) with subsequent
widening of the anterior disc space. Posterior element fractures
(facet, lamina, spinous process) may also be present. Bilateral
perched facets or other kyphotic deformities of the spine,
through a tensile failure of the ligamentous restraints, repre-
sent another clinical example of the distraction morphology.
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Chapter 128 Classification of Cervical Spine Injury 1385
Figure 128.3. (A) A 35-year-old womans
sagittal computed tomography (CT) demon-
strating a flexion distraction injury. The ante-
rior column is significantly translated into
canal and scored a 3.5 interspinous widening
is noted (arrow). (B) The axial CT shows dis-
placement of bilateral laminar fractures. The
posterior column is disrupted and scored 5.
(C) Left pillar is minimally involved with only
questionable diastasis of C4-5 facet and scored
0.5. (D) Right lateral mass of C3 is fractured,
and there is dislocation of the C3-4 facet artic-
ulation. The right pillar is scored 5.0. Overall
the Cervical Spine Injury Severity Score is
14 and the patient was treated by anterior
posterior fusion.
The rotation/translation injury is defined by horizontal dis-
placement of one vertebral body of the subaxial cervical spine
with respect to another other. Biomechanical work suggests that
adequate thresholds for stability are less than 3.5 mm of displace-
ment or relative angulation of less than 11.20 It is typified by
unilateral and bilateral facet dislocations or fracture-dislocations,
fracture separation of the lateral mass (floating lateral mass)
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 1386 Section XII Trauma

with vertebral subluxation, and bilateral pedicle fractures with
vertebral subluxation (traumatic spondylolisthesis).
Discoligamentous Complex
The discoligamentous complex (DLC) component is based
upon integrity of the intervertebral disc, anterior and posterior
longitudinal ligaments, interspinous ligaments, facet capsules,
and ligamentum flavum. This is a descriptor unique to the
SLIC system and is divided into three categories: intact, inde-
terminate, and disrupted. Disruption of the DLC may be repre-
sented by abnormal facet alignment (articular apposition
50% or diastasis 2 mm through the facet joint), abnormal
widening of the anterior disc space either on neutral or exten-
sion radiographs, translation or rotation of the vertebral bod-
ies, or kyphotic alignment of the cervical spine. Indeterminate
injury may exist when radiographic disruption of the DLC is
not otherwise obvious on radiographic or CT imaging but a
hyperintense signal is found through the posterior ligamentous
regions on T2-weighted MRI images, suggesting edema and
injury. Intact DLC is defined by a lack of radiographic evidence
of abnormal spinal alignment in addition to normal disc space
and ligamentous appearance.
Neurological Status
The neurologic status of the patient is often the most influen-
tial component of medical decision making. In addition, it can
be inferred that neurologic injury is a critical indicator of the
degree of spinal column injury. The neurologic status, another
unique component of the SLIC system, is defined as one of
the following: root injury, complete cord injury, or incomplete
cord injury. An additional modifier, continuous cord compres-
sion, is described in the setting of either complete or incom-
plete spinal cord injury with ongoing spinal cord compression
due to disc, bone, ligamentum flavum, hematoma, or other
structures.
Injury Severity Score
A numeric value has been assigned to each descriptor within
these three critical components. Injury patterns that are known
to result in worse outcomes or require urgent surgical interven-
tion (spinal instability, neurological injury) are weighted to
receive greater point values. These three numbers are summed
to provide an overall SLIC score. The resultant score can then
be used to guide treatment of that particular injury. Surgical
versus nonsurgical treatment is determined by a threshold
value of the SLIC severity score. If the total score is less than
four (1 to 3), nonoperative treatment is suggested. If the total
is greater than or equal to five (5), operative treatment is rec-
ommended. This may consist of realignment, neurological
decompression (if indicated), and stabilization. A total score of
four (4) may be treated operatively or nonoperatively (Figs.
128.4A to D).
In instances of multiple levels of cervical trauma, each level
is treated as a separate injury and SLIC scores are calculated
independently for each level. If a single level has multiple injury
patterns, only the most severe injury is considered for scoring.
For example, if the injured level showed signs of both compres-
sion and rotation, morphology would be scored as rotation/
translation. The descriptive identifiers and the point scores for
each SLIC category are summarized in Table 128.2.
CLINICAL USE OF MODERN
CLASSIFICATION SYSTEMS
These two classification systems are designed to aid treatment
decisions as presented in Figure 128.5. Greater scores generally
indicate that surgery is indicated as attested by the primary
authors of the system. However, the reader should consider
these systems as tools and that each patient should be evaluated
on its own merits. Both systems require further validation to
establish their role in evaluating spinal injured patients.

TABLE 128.2 Subaxial Injury Classification (SLIC) and Severity Scale

Points
Morphology No Abnormality 0
Compression 1
Burst 1 2
Distraction (e.g., facet perch, hyperextension) 3
Rotation/translation (e.g., facet dislocation, unstable teardrop, or advanced 4
staged flexion compression injury)
Discoligamentous Complex (DLC) Intact 0
Indeterminate (e.g., isolated interspinous widening, MRI signal change 1
only)
Disrupted (e.g., widening of anterior disc space, facet perch or dislocation, 2
kyphotic deformity)
Neurological Status Intact 0
Root injury 1
Complete cord injury 2
Incomplete cord injury 3
Continuous cord compression (in setting of a neurologic deficit) 1

MRI, magnetic resonance imaging.

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 Chapter 128 Classification of Cervical Spine Injury 1387

A B

C D

Figure 128.4. Subaxial Cervical Injury Classification (SLIC): Translational C4-C5 bilateral facet disloca-
tion with disruption of the discoligamentous complex, complete spinal cord injury. (A) Sagittal computed
tomography (CT) shows greater than 50% vertebral translation and wide interspinous distraction. (B) Axial
CT demonstrating bilateral facet dislocation. (C, D) Ventral cord compression and disruption of interverte-
bral disc and posterior ligamentous structures are seen on (C) T2 and (D) short TI inversion recovery
(STIR) magnetic resonance imaging (MRI). SLIC Severity Scale:
Morphology
Rotation/Translation 4 pts
DLC
Disrupted 2 pts
Neurological Status
Complete Spinal Cord Injury 2 pts
SLIC Score 4 2 2 8 (operative)

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 1388 Section XII Trauma
History
Physical examination
Neurologic examination
Plain radiographs
CT scan (with reconstructions)
Injury type
Cervical spine injury severity score Subaxial cervical injury classification
Four columns
0-5 Rating
Discoligamentous complex
<5 5-7 0-3
Nonoperative Either 7 Nonoperative
treatment Operative
MORPHOLOGIC DESCRIPTIONS
Despite limitations of morphologic classification systems, they
are of value as they are descriptive of most injury patterns.
Unfortunately, morphologic descriptions often use mechanistic
terms without actual basis, and therefore at times can be con-
fusing. Arbitrarily, we have grouped injuries into categories
based on which is commonly thought of as the most injured
segment. In reality, most injuries occur globally across all seg-
ments. In each column, injuries may be isolated to that column
and are usually stable, or may be part of a multicolumn injury
and are potentially unstable.
ANTERIOR COLUMN
Anterior column injuries include any vertebral body fracture or
major injury to the intervertebral disc and annulus, without sig-
nificant facet subluxation. Vertebral body injuries include com-
pression fractures where the anterior body is fractured but the
posterior body wall remains intact. Burst fractures are where
the entire body is fractured and radially dispersed. The hall-
mark of a burst fracture is the retropulsion of a fragment of the
posterior wall into the spinal canal. Both a compression and
burst fracture can be associated with varying amounts of poste-
rior ligamentous injury.
The flexion-axial loading injury or the so-called teardrop
fracture is sometimes confused with a burst fracture. In this
injury, the body is sheared in a coronal plane leaving an ante-
rior inferior small triangular fragment attached to the caudal
disc (teardrop), and the remaining body is rotated posteriorly
into the spinal canal. In addition, there is often a significant
injury to posterior osseousligamentous complex.
LWBK836_Ch128_p1381-1389.indd 1388
MRI
Unexplained neurologic deficits
Possible ligamentous injury
Neurologic deterioration
Preoperative evaluation
Injury morphology
Neurological status
=4
Either 5
treatment Operative Figure 128.5. Flowchart of cervical
classification.
Discoligamentous injuries can be more subtle and are
underrecognized. These occur most commonly from hyperex-
tension injuries and result in tensile failure of the ALL,
disc annulus, and the posterior longitudinal ligament.
Morphologically the disc is distracted anteriorly and there may
be small amounts of retrolisthesis of the vertebral body.
Occasionally, there will be a small avulsion fracture of the ante-
rior vertebral body that can be confused with the teardrop in a
flexion-distraction injury. MRI will demonstrate increased sig-
nal in the disc and failure of the ALL. These injuries occur
more commonly in the spondylotic spines where the disc is
most likely narrowed before injury but after is open and not
appreciated as injured. Also, this is a common injury in patients
with ankylosed spines either from inflammatory disease, spon-
dylosis, diffuse idiopathic spinal hyperostosis (DISH), or sur-
gery. Rarely a patient may have an isolated traumatic disc her-
niation without other skeletal involvement.
LATERAL PILLARS
Injuries that involve primarily the lateral pillars have a wide
variety of mechanisms, morphologic patterns, and stability. We
divide them into fractures of the lateral mass, facet articula-
tions, and subluxations and dislocations.
Lateral mass fractures are common injuries resulting from
lateral compression or extension. Kotani divided them into
four types.8 Type 1 is a fracture separation of the lateral mass.
This is caused by ipsilateral fractures of the pedicle and lamina
creating a free-floating lateral mass. Rotation of the loose lat-
eral mass can allow facet subluxation at one or both facet artic-
ulations. Type 2 injuries are severely comminuted fractures of
the lateral mass and facet articulations. Type 3 is a split type
8/26/11 2:36:36 PM

where there is an invagination of the superior facet into a coro-
nal split fracture in the inferior facet. Type 4 is traumatic spon-
dylolysis where bilateral pedicle fractures separate the posterior
element from the body, which may be associated with vertebral
subluxation.
Facet fractures occur to the superior, inferior, or both facets
and may involve varying amounts of the articular surface. Often
they are associated with facet subluxation or dislocation.
However, even nondisplaced fractures should be viewed suspi-
ciously as progressive instability can occur with these injuries.
The degree of facet involvement may have a role in prediction
of late displacement.
Unilateral facet dislocations occur in isolation; or with frac-
ture of the facet articulation; or from fracture separation of the
lateral mass. These will result in a malrotational and forward slip-
page of the vertebral body up to 25%. The presence and degree
of subluxation may be related to the amount of associated injury
to the disc and posterior osseous ligamentous complex.
Bilateral facet dislocations result in 50% or greater vertebral
translation and may be associated with facet fractures. Rarely
these may be associated with distractive lesions as evident by
diastasis of the disc space and facet joints.
POSTERIOR INJURIES
Simple posterior injures include fractures of the spinous pro-
cesses and lamina. These injuries, especially when associated
with a vertebral body or disc injury, may indicate loss of integ-
rity of the posterior ligamentous complex. Posterior ligamen-
tous disruption from tensile failure of the posterior ligamentous
complex results in acute kyphosis, spreading of the spinous
process, and perching of the facets. These may be occult or
seen with other injuries such as vertebral body compression
fractures.
SPECIAL CASES
Several injuries occur to the spinal cord and spinal column that
deserve special mention. Spinal cord injuries can occur without
obvious skeletal injury. In children, this has been termed Spinal
Cord Injury Without Radiographic Abnormality (SCIWORA).8
This is thought to occur from hyperflexion or distraction where
the spinal cord is less elastic than the spinal column. Occasion-
ally, spinal cord injury occurs in a delayed fashion. In some
cases, histopathologic examination has revealed separations
between the cartilaginous end plate and body (Salter Harris 1
lesion). In patients with congenital stenosis or spinal stenosis
from spondylosis, hyperextension can result in neurologic
injury. The most discussed injury is the central cord syndrome.
In any of these cases, there may be an accompanying discoliga-
mentous injury and small amounts of retrolisthesis. Fractures
in ankylosing spondylitic patients can result from hyperexten-
sion, and occur thorough the disc space and facet articulations.
These may appear benign but all should be considered highly
unstable.
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Chapter 128 Classification of Cervical Spine Injury 1389
CONCLUSION
Classification systems of subaxial cervical trauma have a broader
impact on the quality of health care delivered to patients. An
effective system can reproducibly define the injury to improve
communication between health care providers. A strong system
will also address the clinical status of the patient and provide
prognostic information about injury severity and outcomes to
help guide treatment. Overall, a truly effective classification sys-
tem will bring consistency to the evaluation and management
of cervical trauma that is, otherwise, severely lacking.
The CSISS and the SLIC system offer a systematic, reproduc-
ible means of defining cervical spine trauma. Future investiga-
tions will help determine the clinical impact of these systems on
trauma care and treatment outcomes.
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