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Variations in management of A3 and A4 cervical spine fractures as designated by the AO Spine Subaxial Injury Classification System

Barry Ting Sheen Kweh, Jin Wee Tee, Sander Muijs, F. Cumhur Oner, Klaus John Schnake, Lorin Michael Benneker, Emiliano Neves Vialle, Frank Kanziora, Shanmuganathan Rajasekaran, Gregory Schroeder, Alexander R. Vaccaro, and the AO Spine Subaxial Injury Classification System Validation Group, Andrey Grin MD Ahmed Shawky Abdelgawaad MD Akbar Jaleel Zubairi FCOS Ortho Alejandro Castillo MD Alejo Vernengo Lezica MD Alessandro Ramieri MD, PhD Alfredo Guiroy MD Alon Grundshtein MD Amauri Godinho Jr. MD Amin Henine MD Andrei A. Pershin MD, PhD Alkinoos Athanasiou MD, PhD Baron Zarate-Kalfopulos MD Sofien Benzarti MD Claudio Bernucci MD Brandon J. Rebholz MD, FAAOS, Bruno Direito-Santos MS, MSc, FEBOT, Bruno Lourenço Costa MD, MSc, Bruno Saciloto MD, Catalin Majer MD, PhD, Chadi Tannoury MD, FAOA, FAAOS, Christina Cheng MD, Jason Pui Yin Cheung MD, Christian Konrads MD, Chumpon Jetjumnong MD, Chun Kee Chung MD, PhD, Eugen Cezar Popescu MD, PhD, Cumhur Kilinçer MD, PhD, Colin B. Harrism MD, FAAOS, Craig D. Steiner MD, Cristina Igualada MD, Darko Perovic MD, PhD, David Ruiz Picazo MD, Luis David Orosco Falcone MD, Dilip Gopalakrishnan MS, Desai Ankit MBBS, D.Ortho, DNB (Ortho), Devi Prakash Tokala FRCS (T&O), Balgopal Karmacharya FCPS, Raphael Lotan MD, MHA, Mahmoud Shoaib MSc, Salvatore Russo FRCS (NS), Arun Kumar iswanadha MS, FACS, Bhavuk Garg MS (Ortho), Noe Dimas Uribe CMOT, Fabricio Medina MD, Jayakumar Subbiah DNB (Ortho), Wael Alsammak MD, Valentine Mandizvidza FCS-ECSA (Ortho), Ahmad Arieff Atan MD, Rathinavelu Barani MS (Ortho), MRCS (Ed), Hugo Vilchis Sámano MD, Emilija Stojkovska Pemovska MD, Fabian Catarino Lopez Hinojosa MD, Taolin Fang MD, PhD, Federico Landriel MD, Federico Daniel Sartor PhD, Marcus Vinicius De Oliveira Ferreira MD, Vito Fiorenza MD, Francisco Alberto Mannara MD, Seibert Franz Prof. Dr. Mag., Brett A. Freedman MD, Samuel Arsenio M. Grozman MD, FPOA, FPCS, Guillermo Espinosa MD, Guillermo Alejandro Ricciardi MD, Gunaseelan Ponnusamy MS (Ortho) UKM, Hassane Ali Amadou MD, Itati Romero MD, Joost Rutges MD, PhD, James Harrop MD, MSHQS, Jose-Carlos Sauri-Barraza MD, Jeevan Kumar Sharma MBBS, MS (Ortho), FASSI, Jose Joefrey F. Arbatin Jr. FPOA, Jeronimo B. Milano MD, PhD, Jibin Joseph Francis (SA) FRCS (SN), John Chen Li Tat MB BCh (NUI), BAO, LRCSI, FRCS (Ed), Joachim Vahl MD, Jose Alfredo Corredor MD, João Moreno Morais MD, Joana Guasque MD, John Koerner MD, Duerinck Johnny MD, PhD, Jose Rafael Perozo Ron MD, Juan Delgado-Fernandez MD, Juan Esteban Muñoz Montoya Juan Lourido MD, Ariel Kaen PhD, Kubilay Murat Özdener MD, Konstantinos Margetis MD, PhD, Konstantinos Paterakis MD, Lady Lozano Cari MD, Lingjie Fu MD, PhD, Ahmed Dawoud MD, Luis Muñiz Luna MD, Mahmoud Alkharsawi PhD, Maximo-Alberto Diez-Ulloa MD, Maria A. García-Pallero MD, Mauro Pluderi MD, PhD, Marcelo Gruenberg MD, Marcelo Valacco MD, Mario Ganau MD, PhD, MBA, FEBNS, Martin M. Estefan MD, Luis Miguel Duchén Rodríguez MD, Naohisa Miyakoshi MD, PhD, Mahmoud Elshamly MD, PhD, Mohamed Fawzy Khattab MD, PhD, Sean R. Smith MD, Mbarak Abeid MD, Ignacio Garfinkel MD, Nicola Nicassio MD, Nuno Neves PhD, Olga Carolina Morillo Acosta MD, Pedro Luis Bazán MD, Paulo Pereira MD, PhD, Phedy Lim MD, Patrick R. Pritchard MD, Pragnesh Bhatt MS, MCh, FRCS, FEBNS, Raghuraj Kundangar MS (Ortho), Rian Souza Vieira MD, Ricardo Rodrigues-Pinto MD, PhD, Ripul R. Panchal DO, FACOS, FACS, Rafael Llombart-Blanco MD, PhD, Ronald Alberto Rioja Rosas MD, Rui Manilha MD, Ratko Yurac MD, Sara Diniz MD, Scott C. Wagner MD, Segundo Fuego MD, Selvaraj Ramakrishnan MD, Serdar Demiröz MD, Shafiq Hackla MBBS, MS (Ortho), DNB (Ortho), Babak Shariati FRCS, Mohammad El-Sharkawi MD, PhD, Yasunori Sorimachi MD, DMSc, PhD, Stipe Corluka MD, Sung-Joo Yuh MD, Thami Benzakour MD, Tarek ElHewala MD, PhD, Tarun Suri MS, FNB (Spine surgery), Derek T. Cawley MMSc, MCh, FRCS, Adetunji Toluse MD, FWACS, FMCOrtho, Cristian Valdez MD, Waheed Abdul MD, Waqar Hassan MD, Yohan Robinson MD, PhD, MBA, Zachary L. Hickman MD, FAANS, Mohamad Zaki Haji Mohd Amin MS Ortho, Oscar González Guerra MD, Zdenek Klezl MD, PhD,

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.