Global Spine Journal - 2026-04-01 - Journal Article
AO Spine Clinical Practice Recommendations for the Management of Subaxial Spine Fractures.
Camino-Willhuber G, Dandurand C, Scherer J, El Naga A, Joaquim AF, Chhabra HS, El-Sharkawi M, Bransford R, Schnake KJ, Schroeder GD, Fisher CG, Bigdon SF, AO Spine Knowledge Forum Trauma & Infection
Topics
Key Takeaway
AO Spine recommends CT/MRI as gold standard for subaxial cervical fracture workup, conditional surgical treatment for floating lateral mass or large fragment unilateral facet fractures, posterior augmentation for stand-alone ACDF when PLL is injured or bilateral facet dislocation is present, and anterior fixation for unilateral facet injuries without cord injury.
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Summary
The AO Spine Knowledge Forum Trauma and Infection group selected four studies addressing diagnosis, surgical versus conservative management, and approach selection for subaxial cervical fractures. Key findings synthesized: CT/MRI outperforms plain radiography and LODOX-Statscan for injury identification; floating lateral mass and larger fragment size predict conservative treatment failure for unilateral facet fractures; PLL injury, bilateral facet dislocation, and age >60 predict stand-alone ACDF failure; and anterior fixation is favored over posterior for unilateral facet injuries without cord injury. Recommendations are graded strong for imaging and conditional for the three surgical decision points.
Key Limitation
All four surgical recommendations are conditional rather than strong, reflecting the low-to-moderate quality of the underlying evidence base, which limits their authority as definitive practice standards.
Original Abstract
Study designLiterature Review with clinical recommendations.ObjectiveTo highlight impactful studies on subaxial cervical fractures, identified by the AO Spine Knowledge Forum Trauma and Infection group, with recommendations for their integration into clinical practice.MethodsFour studies on subaxial cervical fractures that have the potential to shape current practice in subaxial cervical fractures were selected and reviewed. Each study was chosen for its contribution to a critical phase in subaxial fractures management: diagnosis and imaging, surgical vs conservative treatment, and selection of approach.ResultsFour studies were highlighted. Article 1: Rutsch et al evaluated the sensitivity and specificity of CT, MRI, plain radiography, and LODOX-Statscan in identifying cervical spine injuries. We strongly recommend the use of CT/MRI as gold standard for radiological workup in cervical spine injuries. Article 2: Cirillo et al performed a systematic review of predictor of failure to conservative treatment for isolated unilateral facet fractures. We conditionally recommend surgical treatment in floating lateral mass and greater fragment size. Article 3: Singh et al evaluated the predictors of failure after stand-alone ACDF in subaxial fractures. We conditionally recommend adding posterior fusion in PLL injury, bilateral facet joint dislocation and age above 60 years. Article 4: Kwon et al prospectively randomized and compared anterior vs posterior approach in unilateral facet joint injury. We conditionally recommend anterior surgical fixation in unilateral facet injuries without spinal cord injury.ConclusionThis article provides spine surgeons with evidence-based recommendations to enhance standardization and effectiveness of the management of subaxial spine fractures.