Journal of Pediatric Orthopaedics - 2026-08-26 - Journal Article
Subaxial Cervical Spine Injuries in Children: Do Adult Classification Systems Help With Surgical Decision-Making?
Paulson AE, La Poche A, Montgomery A, Metcalf T, Vittetoe K, Benvenuti T, Benvenuti M, Ross K, Martus JE, Mencio GA, Schoenecker JG, Moore-Lotridge SN, Louer CR
Topics
Key Takeaway
The SLIC system achieved an AUC of 0.968 and F1 of 0.78 in pediatric subaxial cervical spine injuries, but over-recommended surgery in children under 10, with 4 of 11 SLIC>4 patients successfully managed nonoperatively—all under age 10.
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Summary
This study evaluated whether adult SLIC thresholds accurately predict operative versus nonoperative treatment in pediatric subaxial cervical spine injuries at a single Level I pediatric trauma center from 2006–2020. Of 47 patients (7 operative, 40 nonoperative), SLIC correctly identified all nonoperative cases with SLIC<4, but over-recommended surgery in 4/11 patients with SLIC>4, all of whom were under age 10. Overall AUC was 0.968 with an F1 score of 0.78, with performance degrading specifically in the under-10 subgroup.
Key Limitation
The operative cohort of only 7 patients severely limits statistical power for subgroup analysis and threshold validation, making age-specific cutoff recommendations unreliable.
Original Abstract
BACKGROUND
There is no validated system for classifying and treating traumatic subaxial cervical spine injuries in children. The subaxial cervical spine injury classification (SLIC) system is widely used in adults, but its applicability in children is uncertain. This study evaluated the validity of the SLIC system in predicting operative versus non-operative treatment in pediatric patients with traumatic subaxial cervical spine injuries.
METHODS
Patients younger than 18 years with acute, traumatic, subaxial cervical spine injuries (without concomitant occipitocervical injury) were identified at a single pediatric level I trauma center from 2006 to 2020. Classification scores were determined from initial imaging and neurological examinations. Patients were grouped according to adult SLIC thresholds (<4 nonoperative, =4 indeterminate, >4 operative), and recommended treatment was compared with the treatment received. Validity was assessed using sensitivity, specificity, positive and negative predictive values, receiver-operating-characteristic area under the curve, and F1 score. Subgroup analyses were performed for children younger than 10 years and those 10 years or older.
RESULTS
Forty-seven patients met the inclusion criteria (7 operative, 40 nonoperative). No patient with SLIC<4 (recommended nonoperative treatment) required surgery. All patients with SLIC=4 (indeterminate) were successfully treated without surgery, as were 4/11 patients with SLIC>4 (recommended surgery). Overall area under the curve and F1 scores were 0.968 and 0.78, respectively. Performance decreased in children younger than 10 years, but was excellent in older children.
CONCLUSIONS
The subaxial cervical spine injury classification system can be helpful in pediatric patients, though this study identifies key differences from its performance in adults. SLIC remains highly sensitive at identifying severe injury; however, it recommended surgery for multiple patients who were ultimately treated non-operatively in this cohort. All patients with SLIC >4 (recommended operative treatment) who were treated without surgery were younger than 10 years. While SLIC demonstrates modest validity in children, our findings suggest that younger patients may be recommended for unnecessary surgery. These results support the selective use of SLIC in pediatric patients, though larger studies are imperative for further age-specific validation.
LEVEL OF EVIDENCE
Level III-retrospective cohort study.