Subaxial Cervical Spine Injuries in Children: Do Adult Classification Systems Help With Surgical Decision-Making?

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.