What is the management of a cervical spine fracture?

Management of Cervical Spine Fracture

The management of cervical spine fractures should follow the Subaxial Injury Classification (SLIC) system, with surgical intervention indicated for SLIC scores ≥5, while lower scores may be managed conservatively with appropriate immobilization. 1, 2

Initial Assessment and Immobilization

• Early immobilization of the spine is recommended in any traumatized patient with suspected spinal cord injury to limit the onset or aggravation of neurological deficit 3
• For pre-hospital management, manual in-line stabilization combined with removal of the anterior part of the cervical collar during tracheal intubation is suggested to limit cervical spine mobilization while promoting glottic exposure 3
• CT imaging is essential for detailed assessment of fracture pattern and displacement in acute injuries 1
• MRI is indicated when ligamentous injury is suspected, as disruption of the discoligamentous complex significantly impacts stability and treatment decisions 1

Classification and Treatment Decision-Making

• The SLIC system provides excellent reliability for grading instability and fracture patterns in cervical spine traumatic injuries with intraclass correlation coefficients ranging between 0.49 and 0.90 1, 2
• The SLIC system evaluates three key components:
  1. Morphology of injury (fracture pattern)
  2. Discoligamentous Complex (DLC) integrity (disrupted DLC assigned 2 points)
  3. Neurological status (complete cord injury: 2 points, incomplete cord injury: 3 points) 2

Treatment Algorithm

Conservative Management (SLIC score <5)

• Appropriate for stable fractures without significant displacement or neurological deficit 1, 2
• Options include:
  • Cervical collar immobilization for minor fractures 4
  • Halo vest immobilization for more complex fractures requiring more rigid stabilization 5

Surgical Management (SLIC score ≥5)

• Indicated for unstable fractures, those with neurological deficit attributable to the fracture, or significant displacement 1, 2
• Surgical approach depends on:
  • Location of compression (anterior vs posterior)
  • Pattern of instability
  • Presence of discoligamentous injury 6
• Techniques include:
  • Anterior cervical diskectomy and fusion (ACDF) for anterior compression or instability 6
  • Posterior fixation using lateral mass plating or pedicle screws for posterior element disruption 7
  • Combined approaches for complex three-column injuries 6

Special Considerations for Airway Management

• When airway management is required, minimize cervical spine movement during pre-oxygenation and facemask ventilation 1
• For pre-hospital tracheal intubation, a procedure integrating rapid induction with direct laryngoscopy, use of a gum elastic bougie, and retention of the cervical spine in the axis without Sellick maneuver is recommended to increase first-attempt success 3
• Jaw thrust should be used rather than head tilt plus chin lift when a simple maneuver is required to maintain an airway 1

Common Pitfalls and Caveats

• Reliance on clinical examination alone is sometimes insufficient and may require further imaging 4
• The evidence base for specific cervical fracture subtypes is limited, with few comparative studies providing level II evidence or higher 3, 1
• While the SLIC system guides the need for surgical intervention, specific treatment strategies remain variable based on fracture pattern, associated characteristics, institutional resources, and surgeon preferences 2
• Contraindications to conservative management with halo immobilization include complete cervical spinal cord injury with anesthetic skin, evidence of disc or bone within the spinal canal, and unsatisfactorily reduced subluxations 5

The standardized and systematic approach to cervical spine fractures using evidence-based methodology has merit and potential to identify optimal strategies for assessment, characterization, and clinical management 3. However, it's important to recognize that the application of evidence-based medicine to identify ideal treatment strategies for individual cervical fracture injuries is inherently difficult due to the lack of high-quality comparative studies 3.