A Spine Score for Children: Utility of SLIC in Traumatic Pediatric Cervical Spine Fractures

Background: In adults, the Subaxial Cervical Spine Injury Classification System (SLIC) is widely used to guide management for subaxial cervical spine injuries. SLIC has not yet been validated in children, yet 60-80% of pediatric spine injuries occur within the cervical spine. In this study, we assessed the utility of SLIC scores in children, with a focus on treatment modality and patient outcomes including mortality and need for inpatient rehabilitation.

Methods: Retrospective chart review identified 61 children with traumatic subaxial cervical spine injury treated at a single Level 1 trauma center between 2006 and 2020. Injuries were classified using the SLIC system, which assesses fracture morphology, integrity of the discoligamentous complex, and neurologic status. Patients in this study were sorted into three groups: SLIC ≤3 (n=43), SLIC = 4 (n=3), and SLIC ≥5 (n=15), corresponding with established cutoffs guiding management in adults (≤3=Non-operative management vs. ≥5=Operative management).

Results: Demographics were similar between groups. There was no difference in sex, mechanism of injury, or pediatric trauma score between SLIC ≤ 3 and SLIC ≥ 5 injuries. The median age of children with SLIC ≥ 5 injuries was significantly younger than median age of children with SLIC ≤ 3 injuries. Mortality rate in the SLIC ≥ 5 group was 40% (6/15) versus 9.30% (4/43) in the SLIC ≤ 3 group. Of 51 patients who survived injury, 55.6% of patients with SLIC score ≥ 5 were treated operatively (5/9), versus only 2.56% of patients with SLIC score ≤ 3 (1/39). A significantly greater percentage of patients in the SLIC ≥ 5 group required inpatient rehabilitation compared to the SLIC ≤ 3 group (Table).

In this cohort, the majority of injuries occurred at the C7 level, with most of these injuries affecting the spinous/transverse process or facet. A higher proportion of distraction injuries occurred at C3/C4 compared to lower levels. The highest proportion of compression injuries occurred at C5 and C6 (Figure).

Conclusion: These results suggest that SLIC score has utility in the pediatric population to guide treatment decisions and predict outcomes following traumatic subaxial cervical spine injuries. Although our study is small and retrospective, SLIC score correlated with physician decision to operate as well as mortality and need for inpatient rehabilitation, suggesting that SLIC is useful in stratifying pediatric subaxial cervical spine injuries. Future prospective studies are needed to examine the utility of SLIC in the larger pediatric population.