Sheen Kweh, Barry TingWee Tee, JinMuijs, SanderOner, CumhurSchnake, Klaus JohnBenneker, Lorin MichaelNeves Vialle, EmilianoKanziora, FrankRajasekaran, ShanmuganathanSchroeder, GregoryVaccaro, Alexander R.AO Spine Subaxial Injury Classification System Validation GroupGrin, AndreyAbdelgawaad, Ahmed ShawkyZubairi, Akbar JaleelCastillo, AlejandroVernengo Lezica, AlejoRamieri, AlessandroGuiroy, AlfredoGrundshtein, AlonGodinho Jr., AmauriHenine, AminPershin, Andrei A.Athanasiou, AlkinoosZarate-Kalfopulos, BaronBenzarti, SofienBernucci, ClaudioRebholz, Brandon J.Direito-Santos, BrunoLourenço Costa, BrunoSaciloto, BrunoMajer, CatalinTannoury, ChadiCheng, CristinaYin Cheung, Jason PuiKonrads, ChristianJetjumnong, ChumponChung, Chun KeePopescu, Eugen CezarKilinçer, CumhurYurac, Ratko2024-01-082024-01-082022Kweh BTS, Tee JW, Muijs S, Oner FC, Schnake KJ, Benneker LM, Vialle EN, Kanziora F, Rajasekaran S, Schroeder G, Vaccaro AR; AO Spine Subaxial Injury Classification System Validation Group, AndreyGrinMD Ahmed ShawkyAbdelgawaadMD Akbar JaleelZubairiFCOS Ortho AlejandroCastilloMD Alejo VernengoLezicaMD AlessandroRamieriMD, PhD AlfredoGuiroyMD AlonGrundshteinMD AmauriGodinhoJr.MD AminHenineMD Andrei A.PershinMD, PhD AlkinoosAthanasiouMD, PhD BaronZarate-KalfopulosMD SofienBenzartiMD ClaudioBernucciMD Brandon J.RebholzMD, FAAOS, BrunoDireito-SantosMS, MSc, FEBOT, Bruno LourençoCostaMD, MSc, BrunoSacilotoMD, CatalinMajerMD, PhD, ChadiTannouryMD, FAOA, FAAOS, ChristinaChengMD, Jason Pui YinCheungMD, ChristianKonradsMD, ChumponJetjumnongMD, Chun KeeChungMD, PhD, Eugen CezarPopescuMD, PhD, CumhurKilinçerMD, PhD, Colin B.HarrismMD, FAAOS, Craig D.SteinerMD, CristinaIgualadaMD, DarkoPerovicMD, PhD, David RuizPicazoMD, Luis DavidOrosco FalconeMD, DilipGopalakrishnanMS, DesaiAnkitMBBS, D.Ortho, DNB (Ortho), Devi PrakashTokalaFRCS (T&O), BalgopalKarmacharyaFCPS, RaphaelLotanMD, MHA, MahmoudShoaibMSc, SalvatoreRussoFRCS (NS), Arun KumariswanadhaMS, FACS, BhavukGargMS (Ortho), Noe DimasUribeCMOT, FabricioMedinaMD, JayakumarSubbiahDNB (Ortho), WaelAlsammakMD, ValentineMandizvidzaFCS-ECSA (Ortho), Ahmad ArieffAtanMD, RathinaveluBaraniMS (Ortho), MRCS (Ed), Hugo VilchisSámanoMD, Emilija StojkovskaPemovskaMD, Fabian CatarinoLopez HinojosaMD, TaolinFangMD, PhD, FedericoLandrielMD, Federico DanielSartorPhD, Marcus ViniciusDe Oliveira FerreiraMD, VitoFiorenzaMD, Francisco AlbertoMannaraMD, SeibertFranzProf. Dr. Mag., Brett A.FreedmanMD, Samuel Arsenio M.GrozmanMD, FPOA, FPCS, GuillermoEspinosaMD, Guillermo AlejandroRicciardiMD, GunaseelanPonnusamyMS (Ortho) UKM, Hassane AliAmadouMD, ItatiRomeroMD, JoostRutgesMD, PhD, JamesHarropMD, MSHQS, Jose-CarlosSauri-BarrazaMD, Jeevan KumarSharmaMBBS, MS (Ortho), FASSI, Jose Joefrey F.ArbatinJr.FPOA, Jeronimo B.MilanoMD, PhD, Jibin JosephFrancis(SA) FRCS (SN), John ChenLi TatMB BCh (NUI), BAO, LRCSI, FRCS (Ed), JoachimVahlMD, Jose AlfredoCorredorMD, João MorenoMoraisMD, JoanaGuasqueMD, JohnKoernerMD, DuerinckJohnnyMD, PhD, Jose RafaelPerozo RonMD, JuanDelgado-FernandezMD, Juan EstebanMuñoz Montoya JuanLouridoMD, ArielKaenPhD, Kubilay MuratÖzdenerMD, KonstantinosMargetisMD, PhD, KonstantinosPaterakisMD, Lady LozanoCariMD, LingjieFuMD, PhD, AhmedDawoudMD, Luis MuñizLunaMD, MahmoudAlkharsawiPhD, Maximo-AlbertoDiez-UlloaMD, Maria A.García-PalleroMD, MauroPluderiMD, PhD, MarceloGruenbergMD, MarceloValaccoMD, MarioGanauMD, PhD, MBA, FEBNS, Martin M.EstefanMD, Luis MiguelDuchén RodríguezMD, NaohisaMiyakoshiMD, PhD, MahmoudElshamlyMD, PhD, Mohamed FawzyKhattabMD, PhD, Sean R.SmithMD, MbarakAbeidMD, IgnacioGarfinkelMD, NicolaNicassioMD, NunoNevesPhD, Olga CarolinaMorillo AcostaMD, Pedro LuisBazánMD, PauloPereiraMD, PhD, PhedyLimMD, Patrick R.PritchardMD, PragneshBhattMS, MCh, FRCS, FEBNS, RaghurajKundangarMS (Ortho), Rian SouzaVieiraMD, RicardoRodrigues-PintoMD, PhD, Ripul R.PanchalDO, FACOS, FACS, RafaelLlombart-BlancoMD, PhD, Ronald AlbertoRioja RosasMD, RuiManilhaMD, RatkoYuracMD, SaraDinizMD, Scott C.WagnerMD, SegundoFuegoMD, SelvarajRamakrishnanMD, SerdarDemirözMD, ShafiqHacklaMBBS, MS (Ortho), DNB (Ortho), BabakShariatiFRCS, MohammadEl-SharkawiMD, PhD, YasunoriSorimachiMD, DMSc, PhD, StipeCorlukaMD, Sung-JooYuhMD, ThamiBenzakourMD, TarekElHewalaMD, PhD, TarunSuriMS, FNB (Spine surgery), Derek T.CawleyMMSc, MCh, FRCS, AdetunjiToluseMD, FWACS, FMCOrtho, CristianValdezMD, WaheedAbdulMD, WaqarHassanMD, YohanRobinsonMD, PhD, MBA, Zachary L.HickmanMD, FAANS, Mohamad Zaki HajiMohd AminMS Ortho, Oscar GonzálezGuerraMD, ZdenekKlezlMD, PhD,.,. (2022). Variations in management of A3 and A4 cervical spine fractures as designated by the AO Spine Subaxial Injury Classification System. Journal of Neurosurgery: Spine, 36(1), 99-112. https://doi.org/10.3171/2021.3.SPINE201997https://repositorio.udd.cl/handle/11447/8302Colin B.HarrismMD, FAAOS, Craig D.SteinerMD, CristinaIgualadaMD, DarkoPerovicMD, PhD, David RuizPicazoMD, Luis DavidOrosco FalconeMD, DilipGopalakrishnanMS, DesaiAnkitMBBS, D.Ortho, DNB (Ortho), Devi PrakashTokalaFRCS (T&O), BalgopalKarmacharyaFCPS, RaphaelLotanMD, MHA, MahmoudShoaibMSc, SalvatoreRussoFRCS (NS), Arun KumariswanadhaMS, FACS, BhavukGargMS (Ortho), Noe DimasUribeCMOT, FabricioMedinaMD, JayakumarSubbiahDNB (Ortho), WaelAlsammakMD, ValentineMandizvidzaFCS-ECSA (Ortho), Ahmad ArieffAtanMD, RathinaveluBaraniMS (Ortho), MRCS (Ed), Hugo VilchisSámanoMD, Emilija StojkovskaPemovskaMD, Fabian CatarinoLopez HinojosaMD, TaolinFangMD, PhD, FedericoLandrielMD, Federico DanielSartorPhD, Marcus ViniciusDe Oliveira FerreiraMD, VitoFiorenzaMD, Francisco AlbertoMannaraMD, SeibertFranzProf. Dr. Mag., Brett A.FreedmanMD, Samuel Arsenio M.GrozmanMD, FPOA, FPCS, GuillermoEspinosaMD, Guillermo AlejandroRicciardiMD, GunaseelanPonnusamyMS (Ortho) UKM, Hassane AliAmadouMD, ItatiRomeroMD, JoostRutgesMD, PhD, JamesHarropMD, MSHQS, Jose-CarlosSauri-BarrazaMD, Jeevan KumarSharmaMBBS, MS (Ortho), FASSI, Jose Joefrey F.ArbatinJr.FPOA, Jeronimo B.MilanoMD, PhD, Jibin JosephFrancis(SA) FRCS (SN), John ChenLi TatMB BCh (NUI), BAO, LRCSI, FRCS (Ed), JoachimVahlMD, Jose AlfredoCorredorMD, João MorenoMoraisMD, JoanaGuasqueMD, JohnKoernerMD, DuerinckJohnnyMD, PhD, Jose RafaelPerozo RonMD, JuanDelgado-FernandezMD, Juan EstebanMuñoz Montoya JuanLouridoMD, ArielKaenPhD, Kubilay MuratÖzdenerMD, KonstantinosMargetisMD, PhD, KonstantinosPaterakisMD, Lady LozanoCariMD, LingjieFuMD, PhD, AhmedDawoudMD, Luis MuñizLunaMD, MahmoudAlkharsawiPhD, Maximo-AlbertoDiez-UlloaMD, Maria A.García-PalleroMD, MauroPluderiMD, PhD, MarceloGruenbergMD, MarceloValaccoMD, MarioGanauMD, PhD, MBA, FEBNS, Martin M.EstefanMD, Luis MiguelDuchén RodríguezMD, NaohisaMiyakoshiMD, PhD, MahmoudElshamlyMD, PhD, Mohamed FawzyKhattabMD, PhD, Sean R.SmithMD, MbarakAbeidMD, IgnacioGarfinkelMD, NicolaNicassioMD, NunoNevesPhD, Olga CarolinaMorillo AcostaMD, Pedro LuisBazánMD, PauloPereiraMD, PhD, PhedyLimMD, Patrick R.PritchardMD, PragneshBhattMS, MCh, FRCS, FEBNS, RaghurajKundangarMS (Ortho), Rian SouzaVieiraMD, RicardoRodrigues-PintoMD, PhD, Ripul R.PanchalDO, FACOS, FACS, RafaelLlombart-BlancoMD, PhD, Ronald AlbertoRioja RosasMD, RuiManilhaMD, RatkoYuracMD, SaraDinizMD, Scott C.WagnerMD, SegundoFuegoMD, SelvarajRamakrishnanMD, SerdarDemirözMD, ShafiqHacklaMBBS, MS (Ortho), DNB (Ortho), BabakShariatiFRCS, MohammadEl-SharkawiMD, PhD, YasunoriSorimachiMD, DMSc, PhD, StipeCorlukaMD, Sung-JooYuhMD, ThamiBenzakourMD, TarekElHewalaMD, PhD, TarunSuriMS, FNB (Spine surgery), Derek T.CawleyMMSc, MCh, FRCS, AdetunjiToluseMD, FWACS, FMCOrtho, CristianValdezMD, WaheedAbdulMD, WaqarHassanMD, YohanRobinsonMD, PhD, MBA, Zachary L.HickmanMD, FAANS, Mohamad Zaki HajiMohd AminMS Ortho, Oscar GonzálezGuerraMD, ZdenekKlezlMD, PhD,OBJECTIVE Optimal management of A3 and A4 cervical spine fractures, as defined by the AO Spine Subaxial Injury Classification System, remains controversial. The objectives of this study were to determine whether significant management variations exist with respect to 1) fracture location across the upper, middle, and lower subaxial cervical spine and 2) geographic region, experience, or specialty. METHODS A survey was internationally distributed to 272 AO Spine members across six geographic regions (North America, South America, Europe, Africa, Asia, and the Middle East). Participants’ management of A3 and A4 subaxial cervical fractures across cervical regions was assessed in four clinical scenarios. Key characteristics considered in the vignettes included degree of neurological deficit, pain severity, cervical spine stability, presence of comorbidities, and fitness for surgery. Respondents were also directly asked about their preferences for operative management and misalignment acceptance across the subaxial cervical spine. RESULTS In total, 155 (57.0%) participants completed the survey. Pooled analysis demonstrated that surgeons were more likely to offer operative intervention for both A3 (p < 0.001) and A4 (p < 0.001) fractures located at the cervicothoracic junction compared with fractures at the upper or middle subaxial cervical regions. There were no significant variations in management for junctional incomplete (p = 0.116) or complete (p = 0.342) burst fractures between geographic regions. Surgeons with more than 10 years of experience were more likely to operatively manage A3 (p < 0.001) and A4 (p < 0.001) fractures than their younger counterparts. Neurosurgeons were more likely to offer surgical stabilization of A3 (p < 0.001) and A4 (p < 0.001) fractures than their orthopedic colleagues. Clinicians from both specialties agreed regarding their preference for fixation of lower junctional A3 (p = 0.866) and A4 (p = 0.368) fractures. Overall, surgical fixation was recommended more often for A4 than A3 fractures in all four scenarios (p < 0.001). CONCLUSIONS The subaxial cervical spine should not be considered a single unified entity. Both A3 and A4 fracture subtypes were more likely to be surgically managed at the cervicothoracic junction than the upper or middle subaxial cervical regions. The authors also determined that treatment strategies for A3 and A4 subaxial cervical spine fractures varied significantly, with the latter demonstrating a greater likelihood of operative management. These findings should be reflected in future subaxial cervical spine trauma algorithms.14 p.enBurstFractureJunctionalSubaxial cervical spineVariationTraumaArticle