What is the treatment for a transverse process articular pillar fracture of the cervical spine?

Treatment of Transverse Process Articular Pillar Fractures of the Cervical Spine

Isolated transverse process fractures of the cervical spine require conservative management with pain control and mobilization, without need for surgical intervention or spine service consultation, but when these fractures result in isolation of the articular pillar, they create mechanical instability requiring surgical reduction and internal fixation of three contiguous vertebrae. 1

Critical Distinction: Isolated vs. Articular Pillar Involvement

The treatment pathway depends entirely on whether the transverse process fracture has created an isolated articular pillar:

Isolated Transverse Process Fractures (Without Articular Pillar Isolation)

These fractures are structurally and neurologically stable injuries that do not require spine service intervention. 2

• Conservative management only: No surgery, no bracing, and no spine service consultation needed 2, 3
• Pain control protocol: NSAIDs, muscle relaxants, flexible support corsets, and early mobilization reduce pain from average 8.8/10 to 5.2/10 on visual analog scale 4
• Neurologic outcomes: 100% of patients remain neurologically intact with no long-term deficits 2, 3
• Long-term pain resolution: At 6+ months follow-up, only 1.1% have persistent back pain, with 100% fully ambulatory 3

Transverse Process Fractures with Articular Pillar Isolation

When imaging reveals isolation of the articular pillar, this creates two levels of mechanical instability requiring surgical reduction and internal fixation. 1

• Surgical indication: 18 of 21 patients (86%) with isolated articular pillar required surgical reduction and internal stabilization 1
• Neurologic risk: 62% present with neurologic deficits including spinal cord injury (48%) or radiculopathy (14%) 1
• Fixation requirement: Three contiguous vertebrae must be stabilized due to two levels of mechanical instability 1

Imaging Protocol for Diagnosis

CT imaging with 1.5-2mm collimation is essential to distinguish isolated transverse process fractures from articular pillar isolation. 5, 6

• CT is mandatory: Plain radiographs miss critical details; CT remains the reference standard for bony evaluation 5, 6, 7
• Look for foramen transversarium involvement: 90% of articular pillar isolations have ipsilateral transverse foramen fractures 1
• Assess for contralateral injuries: 67% have contralateral injuries at the same level 1
• Identify mechanism: Hyperflexion-rotation (81%) or hyperflexion-distraction (14%) mechanisms suggest articular pillar isolation 1

Associated Injuries Requiring Evaluation

When transverse process fractures are identified, search diligently for other spinal injuries and abdominal injuries, as these occur frequently. 2

• Vertebral artery injury: If foramen transversarium is involved, obtain vascular imaging and consider anticoagulation 6, 7
• Non-contiguous spinal injuries: 8-14% have unsuspected mid-cervical injuries, with up to 31% having non-contiguous injuries 6
• Abdominal injuries: Occur in approximately 30% of patients with transverse process fractures 2

Follow-Up Protocol

Obtain baseline CT imaging within the first week to establish reference point for fracture alignment. 6, 8

• Serial CT imaging: Critical for isolated fractures managed conservatively to detect delayed instability 8, 7
• Avoid early dynamic fluoroscopy: Not useful in first 6-8 weeks due to pain and muscle spasm limiting diagnostic utility 6, 8, 7
• Monitor for vascular symptoms: Vertebrobasilar insufficiency (vertigo, visual disturbances, syncope, ataxia) requires urgent vascular imaging 8, 7

Common Pitfalls to Avoid

• Do not consult spine service for isolated transverse process fractures: These are stable injuries requiring only conservative management 2, 3
• Do not miss articular pillar isolation: This fundamentally changes management from conservative to surgical 1
• Do not rely on plain radiographs alone: CT is essential for detailed fracture characterization 5, 6, 7
• Do not assume all transverse process fractures are benign: Search for associated spinal and abdominal injuries 2
• Do not overlook foramen transversarium involvement: This requires vascular imaging and potential anticoagulation 6, 7

Evidence Quality Considerations

The evidence base for specific cervical fracture subtypes is limited, with few high-quality comparative studies available. 5 However, the distinction between isolated transverse process fractures (which are universally stable) and articular pillar isolation (which creates mechanical instability) is well-established in the literature and should guide treatment decisions. 2, 1, 3