Does a patient with a subtle C6 (cervical 6) central compression fracture without retropulsion and approximately 10% loss of central vertebral body height require immediate assessment by orthopedics (orthopedic surgery) or neurosurgery?

Management of C6 Vertebral Compression Fracture

A stable C6 central compression fracture without retropulsion and with only 10% loss of central vertebral body height does not require immediate assessment by orthopedics or neurosurgery and can be managed conservatively in the ED without transfer. 1

Assessment of Fracture Stability

The key factors in determining management of vertebral compression fractures include:

• Neurological status: Absence of neurological deficits indicates a stable fracture 1
• Degree of compression: 10% loss of vertebral body height is considered mild 1
• Absence of retropulsion: No bone fragments in the spinal canal means lower risk of neurological compromise 1
• Spinal stability: Fractures without significant deformity (defined as <15% kyphosis, <10% scoliosis) are considered stable 1

Management Algorithm

Immediate Management in ED

• Pain control with appropriate analgesics 1
• Consider cervical collar for comfort and mild stabilization 1
• Discharge with outpatient follow-up rather than transfer for immediate specialist consultation 1

Indications for Immediate Surgical Consultation

Surgical intervention is reserved for patients with:

• Neurologic deficits 1
• Significant spinal deformity (e.g., >15% kyphosis) 1
• Spinal instability 1
• Retropulsion of bone fragments into spinal canal 1

Follow-up Care

• Outpatient follow-up with primary care within 1-2 weeks 2
• Consider referral to spine specialist for evaluation within 2-4 weeks 1
• Follow-up imaging to assess healing and stability 3
• Physical therapy for pain management and to prevent deconditioning 2

Evidence-Based Rationale

According to the ACR Appropriateness Criteria for Management of Vertebral Compression Fractures, surgical intervention is reserved specifically for patients with "neurologic deficits, spinal deformity (e.g., junctional kyphosis, retropulsion), or spinal instability" 1. The patient described has none of these complications.

The natural history of most vertebral compression fractures is "gradual improvement in pain over 2 to 12 weeks, with variable return of function" 1. Conservative management is the initial treatment of choice for uncomplicated vertebral compression fractures 1.

Potential Pitfalls and Caveats

• Missed instability: While the fracture appears stable, careful documentation of neurological examination is essential to establish baseline 1
• Pain management challenges: Inadequate pain control can lead to immobility and associated complications 2
• Patient deterioration: Clear return precautions should be provided for any new neurological symptoms or significant worsening of pain 4
• Underlying pathology: Consider whether this is truly an osteoporotic/traumatic fracture versus a pathologic fracture from malignancy, especially in patients with risk factors 3

For this specific case with a stable C6 compression fracture without retropulsion and minimal height loss, the evidence strongly supports conservative management without the need for immediate specialist consultation or transfer 1.