TY - JOUR
T1 - Variations in management of A3 and A4 cervical spine fractures as designated by the AO Spine Subaxial Injury Classification System
AU - the AO Spine Subaxial Injury Classification System Validation Group
AU - Kweh, Barry Ting Sheen
AU - Tee, Jin Wee
AU - Muijs, Sander
AU - Oner, F. Cumhur
AU - Schnake, Klaus John
AU - Benneker, Lorin Michael
AU - Vialle, Emiliano Neves
AU - Kanziora, Frank
AU - Rajasekaran, Shanmuganathan
AU - Schroeder, Gregory
AU - Vaccaro, Alexander R.
AU - Grin, Andrey
AU - Abdelgawaad, Ahmed Shawky
AU - Zubairi, Akbar Jaleel
AU - Castillo, Alejandro
AU - Lezica, Alejo Vernengo
AU - Ramieri, Alessandro
AU - Guiroy, Alfredo
AU - Grundshtein, Alon
AU - Godinho, Amauri
AU - Henine, Amin
AU - Pershin, Andrei A.
AU - Athanasiou, Alkinoos
AU - Zarate-Kalfopulos, Baron
AU - Benzarti, Sofien
AU - Bernucci, Claudio
AU - Rebholz, Brandon J.
AU - Direito-Santos, Bruno
AU - Costa, Bruno Lourenço
AU - Saciloto, Bruno
AU - Majer, Catalin
AU - Tannoury, Chadi
AU - Cheng, Christina
AU - Cheung, Jason Pui Yin
AU - Konrads, Christian
AU - Jetjumnong, Chumpon
AU - Chung, Chun Kee
AU - Popescu, Eugen Cezar
AU - Kilinçer, Cumhur
AU - Harrism, Colin B.
AU - Steiner, Craig D.
AU - Igualada, Cristina
AU - Perovic, Darko
AU - Picazo, David Ruiz
AU - Falcone, Luis David Orosco
AU - Gopalakrishnan, Dilip
AU - Ankit, Desai
AU - Tokala, Devi Prakash
AU - Karmacharya, Balgopal
AU - Wagner, Scott C.
N1 - Publisher Copyright:
© 2022 The authors.
PY - 2022/1
Y1 - 2022/1
N2 - OBJECTIVE Optimal management of A3 and A4 cervical spine fractures, as defined by the AO Spine Subaxial Injury Classification System, remains controversial. The objectives of this study were to determine whether significant management variations exist with respect to 1) fracture location across the upper, middle, and lower subaxial cervical spine and 2) geographic region, experience, or specialty. METHODS A survey was internationally distributed to 272 AO Spine members across six geographic regions (North America, South America, Europe, Africa, Asia, and the Middle East). Participants’ management of A3 and A4 subaxial cervical fractures across cervical regions was assessed in four clinical scenarios. Key characteristics considered in the vignettes included degree of neurological deficit, pain severity, cervical spine stability, presence of comorbidities, and fitness for surgery. Respondents were also directly asked about their preferences for operative management and misalignment acceptance across the subaxial cervical spine. RESULTS In total, 155 (57.0%) participants completed the survey. Pooled analysis demonstrated that surgeons were more likely to offer operative intervention for both A3 (p < 0.001) and A4 (p < 0.001) fractures located at the cervicothoracic junction compared with fractures at the upper or middle subaxial cervical regions. There were no significant variations in management for junctional incomplete (p = 0.116) or complete (p = 0.342) burst fractures between geographic regions. Surgeons with more than 10 years of experience were more likely to operatively manage A3 (p < 0.001) and A4 (p < 0.001) fractures than their younger counterparts. Neurosurgeons were more likely to offer surgical stabilization of A3 (p < 0.001) and A4 (p < 0.001) fractures than their orthopedic colleagues. Clinicians from both specialties agreed regarding their preference for fixation of lower junctional A3 (p = 0.866) and A4 (p = 0.368) fractures. Overall, surgical fixation was recommended more often for A4 than A3 fractures in all four scenarios (p < 0.001). CONCLUSIONS The subaxial cervical spine should not be considered a single unified entity. Both A3 and A4 fracture subtypes were more likely to be surgically managed at the cervicothoracic junction than the upper or middle subaxial cervical regions. The authors also determined that treatment strategies for A3 and A4 subaxial cervical spine fractures varied significantly, with the latter demonstrating a greater likelihood of operative management. These findings should be reflected in future subaxial cervical spine trauma algorithms.
AB - OBJECTIVE Optimal management of A3 and A4 cervical spine fractures, as defined by the AO Spine Subaxial Injury Classification System, remains controversial. The objectives of this study were to determine whether significant management variations exist with respect to 1) fracture location across the upper, middle, and lower subaxial cervical spine and 2) geographic region, experience, or specialty. METHODS A survey was internationally distributed to 272 AO Spine members across six geographic regions (North America, South America, Europe, Africa, Asia, and the Middle East). Participants’ management of A3 and A4 subaxial cervical fractures across cervical regions was assessed in four clinical scenarios. Key characteristics considered in the vignettes included degree of neurological deficit, pain severity, cervical spine stability, presence of comorbidities, and fitness for surgery. Respondents were also directly asked about their preferences for operative management and misalignment acceptance across the subaxial cervical spine. RESULTS In total, 155 (57.0%) participants completed the survey. Pooled analysis demonstrated that surgeons were more likely to offer operative intervention for both A3 (p < 0.001) and A4 (p < 0.001) fractures located at the cervicothoracic junction compared with fractures at the upper or middle subaxial cervical regions. There were no significant variations in management for junctional incomplete (p = 0.116) or complete (p = 0.342) burst fractures between geographic regions. Surgeons with more than 10 years of experience were more likely to operatively manage A3 (p < 0.001) and A4 (p < 0.001) fractures than their younger counterparts. Neurosurgeons were more likely to offer surgical stabilization of A3 (p < 0.001) and A4 (p < 0.001) fractures than their orthopedic colleagues. Clinicians from both specialties agreed regarding their preference for fixation of lower junctional A3 (p = 0.866) and A4 (p = 0.368) fractures. Overall, surgical fixation was recommended more often for A4 than A3 fractures in all four scenarios (p < 0.001). CONCLUSIONS The subaxial cervical spine should not be considered a single unified entity. Both A3 and A4 fracture subtypes were more likely to be surgically managed at the cervicothoracic junction than the upper or middle subaxial cervical regions. The authors also determined that treatment strategies for A3 and A4 subaxial cervical spine fractures varied significantly, with the latter demonstrating a greater likelihood of operative management. These findings should be reflected in future subaxial cervical spine trauma algorithms.
KW - Burst
KW - Fracture
KW - Junctional
KW - Subaxial cervical spine
KW - Trauma
KW - Variation
UR - http://www.scopus.com/inward/record.url?scp=85124916122&partnerID=8YFLogxK
U2 - 10.3171/2021.3.SPINE201997
DO - 10.3171/2021.3.SPINE201997
M3 - Article
C2 - 34507294
AN - SCOPUS:85124916122
SN - 1547-5654
VL - 36
SP - 99
EP - 112
JO - Journal of Neurosurgery: Spine
JF - Journal of Neurosurgery: Spine
IS - 1
ER -