What is the next step for a patient with a fixed C6 (cervical 6) fracture and C5-6 (cervical 5-6) widening, where neurosurgery has determined that no surgical intervention is required?

From the Guidelines

The next step for a patient with a fixed C6 fracture and C5-6 widening who doesn't require surgery is conservative management with cervical immobilization, as prolonged immobilization has significant attributable morbidity, and rigid collars may not restrict the displacement of unstable cervical injuries 1. Given the potential for secondary neurological injury if cervical spine injuries are missed, it is crucial to manage the patient in the expectation that injury is present, even if the neurosurgeon has determined that surgery is not necessary.

• The patient should wear a rigid cervical collar (such as a Miami J or Philadelphia collar) for 6-12 weeks, depending on fracture stability and healing progress.
• Pain management should include acetaminophen (1000mg every 6 hours) and NSAIDs like ibuprofen (400-600mg every 6-8 hours) if not contraindicated.
• For more severe pain, a short course of muscle relaxants like cyclobenzaprine (5-10mg three times daily) for 1-2 weeks may help.
• Regular follow-up imaging (X-rays at 2,6, and 12 weeks) is essential to monitor healing, as up to 4.3% of all cervical fractures may be missed, with 67% of these patients suffering neurological deterioration as a result 1.
• Physical therapy should begin after adequate healing, typically at 6-8 weeks, focusing on gentle range of motion exercises and gradually progressing to strengthening.
• The patient should avoid high-impact activities, heavy lifting (>10 pounds), and excessive neck movements during recovery, as the potential impact on neurological outcome if these injuries are missed requires careful management 1.

From the Research

Next Steps for a Patient with a Fixed C6 Fracture and C5-6 Widening

The patient's situation involves a fixed C6 fracture with C5-6 widening, and the neurosurgery team has decided that no surgical intervention is necessary. Given this context, the next steps can be considered based on available evidence:

• Conservative Management: A study from 2 discusses the conservative management of a C5-C6 fracture-luxation in an elderly patient, highlighting the complexity of deciding between conservative and surgical treatment. Although the patient in the study passed away due to pulmonary embolism, the discussion around conservative management versus surgery is relevant.
• Use of Orthoses: Research on the Yale cervical orthosis 3 shows its effectiveness in restricting cervical motion, which could be beneficial for a patient with a C6 fracture and C5-6 widening. This orthosis is recommended for postsurgical protection of the middle and lower cervical spine and in select situations of spinal instability.
• Chiropractic Management: A case study 4 describes the chiropractic management of a patient with a unilateral lamina fracture of the sixth cervical vertebra and concomitant subluxation. The patient recovered without late biomechanical or neurological instability, suggesting that conservative chiropractic methods could be considered for similar cases.
• Consideration of Underlying Pathology: A report 5 discusses a traumatic fracture-dislocation of C5 on C6 through a previously solid multilevel anterior cervical discectomy and fusion, highlighting the importance of considering underlying pathology and altered biomechanics in the management of cervical fractures.
• Informed Consent: The process of informed consent 6 is crucial in neurosurgery, ensuring that patients are fully aware of their treatment options, risks, and alternatives. This is particularly important in cases where surgery is not immediately recommended, and conservative management is chosen.