Variation in global treatment for subaxial cervical spine isolated unilateral facet fractures
Authors: Karamian Brian A. , Schroeder Gregory D. , Holas Martin , Joaquim Andrei F. , Canseco Jose A. , Rajasekaran Shanmuganathan , Benneker Lorin M. , Kandziora Frank , Schnake Klaus J. , Öner F. Cumhur , Kepler Christopher K. , Vaccaro Alexander R. ,   AO Spine Subaxial Injury Classification System Validation Group, Toluse Adetunji , Atan Ahmad Arieff , Dawoud Ahmed , Abdelgawaad Ahmed Shawky , Zubairi Akbar , Castillo Alejandro , Vernengo-Lezica Alejo , Ramieri Alessandro , Guiroy Alfredo , Athanasiou Alkinoos , Grundshtein Alon , Godinho Amauri , Henine Amin , Grin Andrey , Pershin Andrey , Kaen Ariel , Viswanadha Arun Kumar , Shariati Babak , Karmacharya Balgopal , Rathinavelu Barani , Zarate-Kalfopulos Baron , Garg Bhavuk , Rebholz Brandon , Freedman Brett , Direito-Santos Bruno , Costa Bruno Lourenço , Saciloto Bruno , Majer Catalin , Tannoury Chadi , Konrads Christian , Cheng Christina , Jetjumnong Chumpon , Chung Chun Kee , Bernucci Claudio , Harris Colin , Steiner Craig D. , Valdez Cristian , Igualada Cristina , Kilinçer Cumhur , Perovic Darko , Orosco David , Picazo David Ruiz , Cawley Derek T. , Ankit Desai , Tokala Devi Prakash , Gopalakrishnan Dilip , Pemovska Emilija Stojkovska , Popescu Eugen Cezar , Hinojosa Fabian Catarino Lopez , Medina Fabricio , Landriel Federico , Sartor Federico , Mannara Francisco Alberto , Ricciardi Guillermo Alejandro , Espinosa Guillermo , Ponnusamy Gunaseelan , Amadou Hassane Ali , Sámano Hugo Vilchis , Garfinkel Ignacio , Romero Itati , Cheung Jason Pui Yin , Subbiah Jayakumar , Sharma Jeevan Kumar , Milano Jeronimo B. , Francis Jibin Joseph , Harrop Jim , Vahl Joachim , Guasque Joana , Morais João , Chen John , Koerner John , Duerinck Johnny , Rutges Joost , Corredor Jose Alfredo , Arbatin Jose Joefrey , Perozo Jose , Sauri-Barraza Jose-Carlos , Delgado-Fernandez Juan , Muñoz-Montoya Juan Esteban , Lourido Juan , Margetis Konstantinos , Paterakis Konstantinos , Özdener Kubilay Murat , Cari Lady Yemira Lozano , Fu Lingjie , Rodríguez Luis Miguel Duchén , Luna Luis Muñiz , de los Ángeles  García Pallero María , Alkharsawi Mahmoud , Elshamly Mahmoud , Shoaib Mahmoud , Gruenberg Marcelo , Valacco Marcelo , De Oliveira Ferreira Marcus Vinicius , Ganau Mario , Estefan Martin M. , Pluderi Mauro , Diez-Ulloa Maximo-Alberto , Abeid Mbarak , Amin Mohamad Zaki Haji Mohd , Khattab Mohamed , El-Sharkawi Mohammad , Miyakoshi Naohisa , Nicassio Nicola , Dimas Noe , Neves Nuno , Acosta Olga Carolina Morillo , Guerra Oscar González , Pereira Paulo , Bazán Pedro Luis , Phedy Phedy , Bhatt Pragnesh , Pritchard  , Llombart-Blanco Rafael , Kundangar Raghuraj , Lotan Raphael , Yurac Ratko , Vieira Rian , Rodrigues-Pinto Ricardo , Panchal Ripul R. , Rosas Ronald Alberto Rioja , Manilha Rui , Russo Salvatore , Grozman Samuel , Diniz Sara , Wagner Scott , Smith Sean R. , Fuego Segundo , Franz Seibert , Ramakrishnan Selvaraj , Demiröz Serdar , Hackla Shafiq , Benzarti Sofien , Corluka Stipe , Yuh Sung-Joo , Fang Taolin , ElHewala Tarek , Suri Tarun , Benzakour Thami , Mandizvidza Valentine , Fiorenza Vito , Alsammak Wael , Abdul Waheed , Hassan Waqar , Sorimachi Yasunori , Robinson Yohan , Hickman Zachary , Klezl Zdenek 
Published: April 2021

Abstract
Purpose
To determine the variation in the global treatment practices for subaxial unilateral cervical spine facet fractures based on surgeon experience, practice setting, and surgical subspecialty.

Methods
A survey was sent to 272 members of the AO Spine Subaxial Injury Classification System Validation Group worldwide. Questions surveyed surgeon preferences with regard to diagnostic work-up and treatment of fracture types F1–F3, according to the AO Spine Subaxial Cervical Spine Injury Classification System, with various associated neurologic injuries.

Results
A total of 161 responses were received. Academic surgeons use the facet portion of the AO Spine classification system less frequently (61.6%) compared to hospital-employed and private practice surgeons (81.1% and 81.8%, respectively) (p = 0.029). The overall consensus was in favor of operative treatment for any facet fracture with radicular symptoms (N2) and for any fractures categorized as F2N2 and above. For F3N0 fractures, significantly less surgeons from Africa/Asia/Middle East (49%) and Europe (59.2%) chose operative treatment than from North/Latin/South America (74.1%) (p = 0.025). For F3N1 fractures, significantly less surgeons from Africa/Asia/Middle East (52%) and Europe (63.3%) recommended operative treatment than from North/Latin/South America (84.5%) (p = 0.001). More than 95% of surgeons included CT in their work-up of facet fractures, regardless of the type. No statistically significant differences were seen in the need for MRI to decide treatment.

Conclusion
Considerable agreement exists between surgeon preferences with regard to unilateral facet fracture management with few exceptions. F2N2 fracture subtypes and subtypes with radiculopathy (N2) appear to be the threshold for operative treatment.