Fracture-Dislocations of the Subaxial Cervical Spine

Fracture-dislocations of the subaxial cervical spine are rare yet potentially devastating injuries often associated with high-energy trauma. These inherently unstable injuries frequently lead to neurologic compromise, necessitating urgent operative intervention. This review provides a comprehensive overview of subaxial cervical spine fracture-dislocations, addressing their epidemiology, anatomy, and classification systems. Classification schemes including Allen and Ferguson, Cervical Spine Injury Severity Score (CSISS), Subaxial Cervical Spine Injury Classification System (SLIC), and AO Spine Subaxial Cervical Spine Injury Classification System are discussed. Prompt recognition and management of these injuries is critical in optimizing long-term functional and neurologic outcomes. Rates of neurologic injury can exceed 50%, with distractive flexion injuries and bilateral facet injuries often presenting with higher ASIA grades and lower neurologic recovery potential. Minimizing time to reduction is the most important factor in optimizing neurologic outcomes in these injury patterns. We discuss both closed and open reduction methods, timing considerations, technical pearls, and potential complications associated with each strategy. We also discuss the diagnosis and management of concurrent acute disc herniations, the role of advanced imaging, and the debated utility of pre-reduction MRI. Many subaxial cervical fracture-dislocations necessitate surgical intervention, which can be approached from an anterior, posterior, or combined approach. Although no standard surgical treatment algorithm exists, we discuss surgical options and situations where a preferred approach may exist. Selection of the approach depends on injury characteristics and surgeon preference, and there are no clearly defined surgical recommendations based on injury pattern.