Establishing the Injury Severity of Subaxial Cervical Spine Trauma: Validating the Hierarchical Nature of the AO Spine Subaxial Cervical Spine Injury Classification System
AO Spine Cervical Classification Validation Group
(2021) Spine, volume 46, issue 10, pp. 649 - 657
(Article)
Abstract
Study Design. Global cross-sectional survey. Objective. The aim of this study was to validate the AO Spine Subaxial Cervical Spine Injury Classification by examining the perceived injury severity by surgeon across AO geographical regions and practice experience. Summary of Background Data. Previous subaxial cervical spine injury classifications have been limited
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by subpar interobserver reliability and clinical applicability. In an attempt to create a universally validated scheme with prognostic value, AO Spine established a subaxial cervical spine injury classification involving four elements: injury morphology, facet injury involvement, neurologic status, and case-specific modifiers. Methods. A survey was sent to 272 AO Spine members across all geographic regions and with a variety of practice experience. Respondents graded the severity of each variable of the classification system on a scale from zero (low severity) to 100 (high severity). Primary outcome was to assess differences in perceived injury severity for each injury type over geographic regions and level of practice experience. Results. A total of 189 responses were received. Overall, the classification system exhibited a hierarchical progression in subtype injury severity scores. Only three subtypes showed a significant difference in injury severity score among geographic regions: F3 (floating lateral mass fracture, P ¼ 0.04), N3 (incomplete spinal cord injury, P ¼ 0.03), and M2 (critical disk herniation, P ¼ 0.04). When stratified by surgeon experience, pairwise comparison showed only two morphological subtypes, B1 (bony posterior tension band injury, P ¼ 0.02) and F2 (unstable facet fracture, P ¼ 0.03), and one neurologic subtype (N3, P ¼ 0.02) exhibited a significant difference in injury severity score. Conclusion. The AO Spine Subaxial Cervical Spine Injury Classification System has shown to be reliable and suitable for proper patient management. The study shows this classification is substantially generalizable by geographic region and surgeon experience, and provides a consistent method of communication among physicians while covering the majority of subaxial cervical spine traumatic injuries.
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Keywords: AO spine subaxial cervical spine injury, Cervical spine, Classification system, Injury severity score, Trauma, Validation, Orthopedics and Sports Medicine, Clinical Neurology
ISSN: 0362-2436
Publisher: Lippincott Williams & Wilkins
Note: Funding Information: From the aRothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA; bCenter for Spinal Surgery and Neurotraumatology, Ber-ufsgenossenschaftliche Unfallklinik, Frankfurt am Main, Germany; cCajuru Hospital, Catholic University of Parana, Caritiba, Brazil; dUniversity Medical Center, Utrecht, Netherlands; eMalteser Waldkrankenhaus St. Marien, Erlangen, Germany; fVancouver General Hospital, Vancouver, British Columbia, Canada; gHarborview Medical Center, Seattle, WA; hSonnenhofspital Bern, Bern, Switzerland; and iDepartment of Orthopaedic Surgery, Ganga Hospital, Coimbatore, Tamilnadu, India. Acknowledgment date: April 17, 2020. First revision date: September 6, 2020. Acceptance date: October 20, 2020. The manuscript submitted does not contain information about medical device(s)/drug(s). This study was organized and funded by AO Spine through the AO Spine Knowledge Forum Trauma, a focused group of international Trauma experts. Funding Information: This study was organized and funded by AO Spine through the AO Spine Knowledge Forum Trauma, a focused group of international Trauma experts. The AO Spine Injury Classification Systems were developed and funded by AO Spine through the AO Spine Knowledge Forum Trauma, a focused group of international spine trauma experts. AO Spine is a clinical division of the AO Foundation, which is an independent medically-oriented not-for-profit organization. Study support was provided directly through the AO Spine Research Department and AO Innovation Translation Center. Figure 1 provided by © AO Foundation, Switzerland with permission. The authors would like to thank Olesja Hazenbiller (AO Spine) for her editorial and administrative assistance, and Christian Knoll and Cordula Blohm (AO Innovation Translation Center) for their support with statistical analysis. Publisher Copyright: © 2021 The Author(s).
(Peer reviewed)
