Approach and considerations for surgery in subaxial cervical spine injury: A narrative review

Subaxial cervical spine injuries are common and encompass a spectrum of injuries ranging from a minor ligamentous sprain to fracture dislocation with spinal cord injury. These injuries are often missed in the initial evaluation, and a high index of suspicion is needed to evaluate and diagnose these injuries, which otherwise could lead to spinal cord injury. Computed tomography scans are the gold standard in the evaluation of fractures as plain radiographs have limited sensitivity. Magnetic resonance imaging (MRI) is necessary to identify injury to the disco-ligamentous complex and to assess cord injury. The principles of the treatment of cervical spine injuries include early immobilization to prevent secondary neurological injury, achieving alignment by reduction and stabilization of the unstable injured segment and decompression of the cord in the presence of cord injury. Owing to a broad spectrum of injuries, there is no unified approach, and the management plan depends on the morphology of injury, the extent of structures damaged, and the presence of neurological impairment. Various classifications grade and help assess the severity of the injury. Minor injuries are conservatively managed with cervical orthoses, and unstable injuries require stabilization either anterior, posterior, or combined approaches, depending on the injury morphology. Controversy exists over the safety of closed reduction in facetal subluxations, need for pre-reduction MRI, and the ideal approach for each injury. This review presents the current evidence and guidelines on the management of subaxial cervical spine injuries.