cervical trauma classification, CLICS, Vocaro,AO spine trauma, tear drop fracture

1. Trauma -Classification
• Functions ->
• 1) Improves communication between health care providers.
• 2) Can guide medical decision making.
• 3) Can determine injury prognosis.
• 4) Allows for valid and reliable research using a standard, universal language.
• An ideal classification system  both descriptive and prognostic information.
• (1)The descriptive component relays information about the traumatic
condition, organized by injury severity, based upon consistent radiographic and
clinical parameters, in an easily understood, reproducible language.
• (2)The prognostic component  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.

2. Calenoff classification
• Patients with severe trauma may simultaneously sustain more than one level of
spinal injury. Often, the second or third levels of Injury are not recognized early
enough to prevent clinically signIficant extension of the neurologic deficit, pain
pattern, spinal instabilfty, and/or deformity. Of the secondary lesions, 40%
occurred above and 60% below the primary lesion.
Three major patterns of
multiple level injury.
Pattern A, Primary lesion
at C5-C7 with secondary
lesion at T12 or lumbar
spine.
Pattern B, Primary lesion at
T2-T4 with secondary
lesion in cervical spine.
Pattern C, Primary lesion
in thoracolumbar junction
with secondary lesion at
L4-L5. O

3. • Six main classification systems for acute subaxial cervical trauma->
• (1)Holdsworth's classification-> classified the injuries into 5 distinct groups:
– Pure flexion injuries
– Flexion-rotation injuries
– Extension injuries
– Compression injuries
– Shearing injuries
• (2)Allen's classification-> opt for a mechanistic classification and within
each group they classify each injury into a subgroup (stage) based on radiographic
pathology.
– Compressive flexion (5 stages)
– Vertical compression (3 stages)
– Distractive flexion (4 stages)
– Compressive extension (5 stages)
– Distractive extension (2 stages)
– Lateral flexion (2 stages)

7. compressive flexion (CF) phylogeny
Stage 1 (A) is associated with blunting of the antero-superior end plate of the vertebral body.
Stage 2 (B) there is a “beak-shape” deformity of the vertebral body without translation.
Stage 3 (C) there is a “broken beak” of the vertebral body without translation.
Stage 4 (D) indicates a broken beak with up to 3 mm translation
Stage 5 (E) we have a broken vertebral body with more than 3 mm translation.
Stages 4 and 5 are very much reminiscent of “teardrop” fracture

8. vertical compression (VC) fracture.
stage 2 (A) there is cupping of superior and inferior end plates of C6 vertebral body
stage 3 (B) there is significant compression fracture of the vertebral body with
protrusion of bone fragments into the spinal canal.
Stage 3 is an example of a burst fracture

9. Distractive flexion (DF)
stage 2 (A), there is unilateral
locked facets.
stage 3 (B) facets are
bilaterally locked with partial
translation of the rostral
vertebral body
stage 4 (C) there is significant
translation of the rostral
vertebral body in conjunction
with bilateral locked facets

10. (CE) stage 1 (A), a typical floating lateral mass of C5
vertebral body compatible with compressive extension
(CE) stage 4 (B) reformatted sagittal computed
tomography views of cervical spine indicating fracture
of the superior articulating processes of C7 bilaterally
The findings on imaging studies
and the history were compatible
with a compressive extension
injury phylogeny Stage 5 of Allen
Classification

11. Sagittal reformatted views of cervical spine indicating distractive extension
stage 2 of Allen Classification.

12. • (3)Harris Classification-> Major vector forces were flexion, extension, rotation,
vertical compression, and lateral bending. A combination of vector forces such as
flexion-rotation, extension-rotation, and lateral bending may produce added
varieties of injuries.
• White and Panjabi Clinical Checklist ->in 1990, White and Punjabi
described a formula for evaluating fracture stability. The amount of displacement
at this time was 3.5 mm of translation and 11 degrees of greater angulation
than adjacent levels
• Stability and neurologic status are the most important factors when treating
patients with cervical spine trauma .

13. • (4)Cervical Spine Injury Severity Score->
• CSISS is based on independent analysis of four columns (anterior, posterior, right
column, and left lateral column) .
• The anterior column includes the body, disc including the annulus, anterior and
posterior longitudinal ligaments.
• Each lateral column is scored separately and includes the facet projections, lateral
mass, pedicles, and facet joint capsules.
• The posterior column includes the lamina, spinous process, ligamentum flavum,
and nuchal ligaments.
• Each column is scored using a 0-5 analog scale.
•
• Each column is scored independently and summed, giving the CSISS ranging 0-20.

14. A nondisplaced fracture is valued at “1,” while increasing scores
are given proportionally to the amount of displacement.
A “5” is given for the worst injury to a given column that is
possible.

15. • (5)Subaxial Cervical Spine Injury Classification->2007 by Vaccaro and the
STSG
• SLIC evaluates fracture morphology, the discoligamentous complex, and neurologic
function, creating a comprehensive system to aid treatment decision
making,
• Disruption of the DLC may be represented 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 extension radiographs, translation or rotation
of the vertebral bodies, 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.

16. • (6)AO Subaxial cervical spine classification-> Based on four criteria:
• (A) morphology of the injury,
• (B) facet injury,
• (C) neurologic status, and
• (D) any case-specific modifiers.
• (A) Morphology:-> Three basic categories (Types) were used in a similar manner
to the AO thoracolumbar fracture
• ‘‘Type A’’ injuries are fractures that result in compression of the vertebra with
intact tension band.
• ‘‘Type B’’ injuries include failure of the posterior or anterior tension band through
distraction with physical separation of the subaxial spinal elements while
maintaining continuity of the alignment of the spinal axis without translation or
dislocation.
• ‘‘Type C’’ includes those injuries with displacement or translation of one vertebral
body relative to another in any direction; anterior, posterior, lateral translation, or
vertical distraction

23. • (B) Facet injury:->
• If there are multiple injuries to the same facet (for example, a small fracture
and dislocation), only the highest level of injury is classified (dislocation).
• If both facets on the same vertebrae are injured, the right-sided facet injury is
listed before the left sided injury if the injuries are of different subcategories.
• The ‘‘Bilateral’’ (BL) modifier is used if both facets have the same type of injury.

27. • (C) Neurology:
• It is graded according to a six-part system similar to the system described with
the TL classification:
• N0—neurologically intact
• N1—transient neurologic deficit that has completely resolved by the time of
clinical examination (usually within 24 h from the time of injury)
• N2—radiculopathy
• N3—incomplete spinal cord injury
• N4—complete spinal cord injury
• NX—neurology undetermined—used to designate patients who cannot be
examined due to head injury or another condition which limits their ability to
complete a neurological examination such as intoxication, multiple trauma, or
intubation/sedation

28. • (D) Case-specific modifiers: additional modifiers created to describe unique
conditions relevant to clinical decision makingare as follows:
• M1—posterior capsulo-ligamentous complex injury without complete disruption:
This modifier designates injuries, which may appear stable from a bony stand
point , but there is some evidence of injury to the posterior ligamentous
structures without complete disruption. This is often identified on MRI imaging
and associated with very localized posterior tenderness on clinical examination.
• M2—Critical disk herniation defined by tissue signal intensity that is consistent
with nucleus pulposus protruding posteriorly to a vertical line drawn along the
posterior border of the inferior vertebral body at the injured level .
• M3—Stiffening/metabolic bone disease [i.e., Diffuse Idiopathic Skeletal
Hyperostosis (DISH), Ankylosing Spondylitis (AS), Ossification of the Posterior
Longitudinal Ligament (OPLL) or Ossification of the LigamentumFlavum (OLF)].
This modifier describes conditions that may argue either for or against surgery for
those patients.
• M4—Signs of vertebral artery injury

29. Flowchart of cervical classification.

30. • Anterior Column Injuries->
• easily recognizable on plain radiographs or CT.
• usually hyperflexion mechanism and a search for a concomitant injury to the
posterior ligamentous complex should ensue. The notable exception is the disc-
distraction injury resulting from opposite forces ( extension and posterior shear).
• (1) Anterior Compression Fractures->
• Mechanism of Injury-> Due to hyperflexion and/or axial loading forces, it leads
to , failure of the endplate(sup.) and creating wedging of the vertebral body.
During hyperflexion the posterior ligaments ->disruption. This injury pattern has
been termed “hidden flexion injury” and often fails nonoperative treatment.
• Radiographic Characteristics-> wedging of the anterior body and fractures of the
superior endplate is seen. The posterior wall is intact. Widening of the space
between spinous processes or perching of the facets is pathognomonic of PLC
injury. In some cases associated fractures of the lamina or spinous processes are
present.
• Assessment-> Isolated compression fractures without posterior or lateral mass
involvement almost always score low.

31. • (2)Burst Fractures
• Mechanism of Injury-> Rapid increase in intradiscal pressure resulting in
failure of the superior endplate, which is driven along with the disc into the
vertebral body,eventual failure of the body with radial displacement of bone
fragments. In addition, the pedicles are pushed outward, fragment from the
body displaces posteriorly into the spinal canal.
• Often flexion is present, causing posterior ligamentous complex disruption
and/or facet subluxation, fracture, or dislocation.
• Radiographic Assessment -> most commonly at C6 and C7 .
• Both anterior and posterior vertebral body heights are shortened and a small
fragment from the posterior superior body is rotated into the spinal canal.
Interspinous widening or facet perching or subluxation, when present, indicate
posterior ligamentous injury.
• Clinical Assessment -> isolated to the anterior column have low score, but if
associated with posterior ligamentous complex disruption have significantly
higher score.

32. • (3)Flexion Axial Loading Injury (tear drop fractures)
• Mechanism of Injury ->devastating injuries due to the propensity for neurologic
injury and often are the result of diving or other sports-related activities.
• The injury occurs from a compression force oblique applied in a downward and
posterior direction. Forces are concentrated in the anterior inferior corner of the
vertebral body, which is sheared off, giving the injury its name The remaining
part of the vertebral body shears through the disc space and rotates posteriorly
into the spinal canal, crushing the spinal cord . Varying amounts of flexion strain
occur in the posterior ligamentous complex, which accounts for a wide
presentation of stability with this injury.

33. • Radiographic Assessment-> confused with burst fractures.
• In this the vertebral body is displaced posteriorly and not a fracture fragment as
in the latter. Displacement of the main fragment in the flexion/axial loading
injury occurs by shearing through the posterior half of the disc space. Further, a
small triangular fragment (teardrop) is located in its normal position at the
anterior inferior vertebral body margin.
• Assessment-> without posterior ligamentous disruption, CSISS scores range from
3 to 5 because of anterior displacement with minimal injury to lateral masses or
posterior ligamentous complex. The SLIC score is 3 for a distraction injury with
increasing scores being based on neurologic involvement. When associated with
posterior ligamentous complex injury or facet fractures/subluxation, high scores
on both CSISS and SLIC are present.
• (4)Transverse Process Fractures-> quite common. not involved with spinal
stability and therefore are not significant in treatment decision making for the
spine. fractures at C6 and above may warn of possible vertebral artery injury

34. • (5)Disc-Distraction Injury
• Mechanism of Injury -> Impacting the head or face in a fall or forward striking a
windshield creates hyperextension, compression, and posterior shear. ALL and
disc annulus can fail from tension, may avulse a small fragment, which can be
confused with the teardrop fragment. Excessive compressive loading of the
lateral masses and impaction of the spinous process .In transiently narrow the
spinal canal, causing spinal cord injury, typical of the central cord type.
• Radiographic Analysis-> MRI -> Classic findings are increased signal in anterior
soft tissues both rostral and caudal to the injured disc. Increased signal intensity
across the disc space transversing the anterior annulus and anterior longitudinal
ligament is pathognomonic . Posterior increased signal in the facet joints and
ligamentum flavum are indicative of more extensive injury and greater instability.
• Assessment
• Disc-distraction injuries are difficult to diagnose and MRI is essential if these
lesions are suspected. Isolated disc distraction injuries of the anterior column
usually have small amounts of subluxation or hyperlordosis, thus scoring low.
• more severe injury ranging from 3 to 6 with higher scores when spinal cord injury
has occurred .

35. • Treatment of Anterior Column Injuries ->
• Anterior column injuries with low SLIC or CSISS scores can be treated non-
operatively . Less significant injuries can be treated with a cervical collar, while
burst fractures and flexion/axial loading injuries can be treated with a cervical
thoracic orthosis (CTO) or halo vest.
• Surgical indications for anterior column injuries are those with evidence of
disruption of the posterior ligamentous complex as demonstrated by high CSISS
and SLIC scores,
• In the case of compression fractures-> recommends posterior fusion because a
single-level anterior fusion may fail in the face of a vertebral fracture at the
location of caudal screw fixation. Burst fractures and flexion/axial loading injuries
can be reduced or significantly improved with tong traction. Although both
anterior and posterior approaches may be used, the authors recommend
addressing pathology at its major location(ant).

36. • Surgical indications for disc distraction injuries are cases with any significant
displacement, ongoing neurologic symptoms, or chronic pain. Anterior
discectomy and fusion are indicated in neurologically intact patients and those
with radiculopathy.

37. • Posterior Column Injuries->
• Isolated injuries to the posterior column are less common. Isolated injuries
include spinous process and lamina fractures and disruption of the posterior
ligamentous complex without facet subluxation .
• Spinous Process and Lamina Fractures->
• Mechanism of Injury->forced hyperextension or hyperflexion.Paraspinal muscle
contractions can also result in spinous process fractures termed clay shoveler’s
fracture. Lamina fractures also occur from similar mechanisms, although these
herald a more significant injury and should prompt a search for other injuries.
• Radiographic Analysis
• Spinous process fractures are easily visualized except at C6 and C7, which may
require CT. They are usually displaced due to muscle tension, and kyphosis may
be present. Multilevel injuries are not uncommon. Lamina fractures occur
bilaterally except when combined with a lateral mass fracture, where they may
be unilateral. In some cases the lamina may be displaced, compressing the dorsal
side of the spinal cord.
• Assessment
• Isolated spinous process and lamina fractures score low (0 to 2) on both CSISS
and SLIC.

38. • Posterior Ligamentous Injury without Subluxation ->
• Mechanism of Injury ->from hyperflexion and are worsened with any rotation.
• Radiographic Analysis -> suspected when interspinous process spreading is
present but without vertebral or facet subluxation. MRI with T2 fat-suppression
techniques is useful in confirming ligamentous injury.
• Assessment -> Posterior ligamentous injuries without subluxation score slightly
higher,.
• Treatment of Posterior Column Injuries-> Isolated posterior ligamentous injuries
without subluxation have a worse prognosis , Initial management of these
injuries unless there is MRI evidence of complete disruption is nonoperative in a
collar or CTO. If upright radiographs demonstrate increasing deformity or
excessive motion after 8 to 10 weeks of immobilization, surgery is
recommended.

39. • Lateral Column Injuries->
• Anatomically the lateral column consists of the lateral masses with their superior
and inferior articular process projections.
• Lateral column injuries include a wide variety of fracture types including isolated
facet fractures without subluxation, lateral mass fractures, and unilateral and
bilateral dislocation with and without fractures.
• 1)Isolated Facet Fractures->
• Mechanism of Injury ->Isolated facet fractures occur from forced impaction
against the neighboring facet, usually with a component of anterior shear.
• Radiographic Characteristics-> CT is sensitive for these injuries, and they are
best evaluated on sagittal reconstructions through the plane of the lateral mass.
• Assessment-> Isolated facet fractures without subluxation have low CSISS (0-3)
and SLIC (1) scores and are deemed stable.
• (2)Lateral Mass Fractures->
• Mechanism of Injury-> result from lateral compression or hyperextension where
facets impact each other. Transiently this may narrow the neuroforamina with
resultant root injury.

40. • Radiographic Characteristics->Kotani->
• Type I-> is a fracture separation, creating a free floating lateral mass , can rotate
forward, which allows for anterior subluxation at both cranial and caudal
articulations, rendering two motion segments unstable.
• Type II-> lateral mass fractures are highly comminuted also with a similar
potential as type I for instability.
• Type III-> is a vertical fracture in the coronal plane with invagination of the
superior facet into the cranial lateral mass.
• Type IV=> fractures are traumatic spondylolisthesis, which usually occurs at C7 or
T1. This is caused by bilateral fractures of the pedicles or pars interarticularis and
vertebral subluxation., spinal cord injury may be absent or minimal as the spinal
canal opens due to separation of the anterior and posterior components.

41. • Assessment->Type I and type II lateral mass fractures have moderate CSISS
scores, depending on the amount of translation ,The type III split fractures are
more stable. The type IV traumatic spondylolisthesis fractures are highly
unstable, having more score.
• (3)Unilateral Facet Dislocations->
• Mechanism of Injury-> Head rotation or rotation associated with flexion cause
forward and upward translation of the opposite facet.
• Radiographic Analysis-> On lateral views, unilateral facet dislocations result in
10% to 25% vertebral body rotation. CT will show better way. Facet fractures are
common. Interspinous widening or increased posterior signal heralds disruption
of the posterior ligamentous complex. Disc disruption is seen in the majority of
cases and frank herniation in a small percent.
• Assessment-> Unilateral facet dislocations are graded according to amount of
displacement. However, stability ultimately depends on the severity of injury to
the posterior ligamentous complex. The CSISS ranges from 5 to 13 and SLIC
ranges from 4 to 20.

42. • (4)Bilateral Facet Dislocation->devastating injuries resulting in quadriplegia.
• Mechanism of Injury-> from hyperflexion with or without rotation. There will
always be associated disruption of the posterior ligamentous complex. Another
potential mechanism has been shown to be cranial impaction with the head
slightly flexed, which transmits flexion loads causing facet dislocation.
• Radiographic Analysis->
• Bilateral facet dislocations result in a minimum of 50% vertebral body translation.
Fractures of the facets, lamina, and spinous processes are common. Posterior
interspinous widening is usually present. The disc may be inappropriately
narrowed, suggesting posterior herniation. The spinal canal is significantly
narrowed, accounting for the high incidence of quadriplegia. Disc disruption is
almost always present, and nuclear herniation may be present in up to 65% of
cases.3
• Assessment ->
• Bilateral facet dislocations should be considered unstable and have the highest
CSISS (15 to 20) and SLIC (6 to 10) scores.

43. • Treatment of Lateral Column Injuries->