Potential knowledge gaps in the classification and management of subaxial cervical spine fractures: A critical review

Traumatic fractures of the subaxial cervical spine are relatively common and may lead to devastating consequences. Despite that, there are still a lot of knowledge gaps regarding the classifications of these fractures and their decision-making. This critical review discusses the shortcomings in current classification approaches and the potential knowledge gap in the clinical decision-making of subaxial cervical fractures. From a diagnostic perspective, the most challenging aspect is the lack of consensus on the criteria for discoligamentous injury, which distinguishes between B-type and A-type injury. Careful analysis of Computed Tomography (CT), Plane Radiography, and Magnetic Resonance Imaging (MRI) may provide the most accurate analysis in subtle cases. Deciding which A3/A4 fractures should be treated surgically vs. non-surgically is still debatable, and it's challenged by the scarcity of available literature. The management of unilateral non-displaced facet injuries, whether they should be treated surgically vs. non-surgically, remains a major challenge. While the F modifier of the AO spine classification is helpful, better distinguishing features of F1 vs. F2 are warranted. The current classification schemes do not help to select the surgical approach (whether anterior, posterior, or combined). The choice of surgical approach is more controversial for B-type injuries due to their heterogeneity and variable involvement of anterior and posterior elements. Characterization of the extent of spinal cord injury may add an important dimension to the current classification, aiding to guide the timing of surgical decompression in patients with spinal cord injury.