What is the management and treatment for a cervical spinous process fracture?

Management of Cervical Spinous Process Fractures

Isolated cervical spinous process fractures are stable injuries that can be managed conservatively with rigid cervical collar immobilization for 4-8 weeks, followed by clinical and radiographic reassessment to confirm healing. 1, 2

Initial Assessment and Immobilization

• Maintain continuous cervical spine stabilization using manual in-line stabilization combined with removal of only the anterior portion of the cervical collar during airway procedures. 1

• Use jaw thrust maneuver exclusively for airway management—never head-tilt/chin-lift, as this produces three times more cervical movement and risks catastrophic cord injury. 1

• Apply a rigid cervical collar immediately in combination with supportive blocks on a backboard with straps, as this combination is most effective in limiting cervical spine motion. 3

• Require a minimum of four skilled staff for log-rolling and seven for patient transfer to maintain spinal alignment during any repositioning. 1

Diagnostic Imaging Protocol

• Obtain CT imaging immediately with 1.5-2 mm collimation of the entire cervical spine, as plain films alone miss approximately 15% of cervical injuries and unsuspected injuries may be revealed in 8-14% of patients in the mid-cervical spine. 1

• Look specifically for associated injuries, as up to 31% of patients have non-contiguous cervical fractures, including Jefferson fractures, teardrop fractures, or other spinous process fractures at different levels. 1, 2

• Consider MRI if neurological symptoms develop or if ligamentous injury is suspected, though routine MRI is not indicated for isolated stable spinous process fractures. 4

Treatment Algorithm

Conservative Management (First-Line for Isolated Spinous Process Fractures)

• Immobilize with a rigid cervical collar (Philadelphia collar) for 4-8 weeks, as this has been shown sufficient for achieving solid bony union in isolated spinous process fractures and even associated cervical fractures. 2

• Prohibit all neck extension and rotational movements, as extension combined with rotation significantly narrows the spinal canal and can worsen any unrecognized instability. 1

• Monitor for complications of prolonged collar use including skin breakdown and muscle atrophy during the immobilization period. 4

Surgical Intervention Criteria

• Operate if SLIC score ≥5, indicating significant instability requiring surgical stabilization. 1

• Operate immediately if any neurological deficit is attributable to the fracture, regardless of fracture pattern. 1

• Consider surgery if multiple associated unstable cervical injuries are present that cannot be adequately managed with external immobilization alone. 5

Follow-Up Protocol

• Obtain baseline CT imaging within the first week after initiating treatment to establish a reference point for fracture alignment. 1, 4

• Perform serial CT imaging at 4-6 weeks to assess fracture healing progression, as some injuries initially deemed stable may demonstrate delayed instability. 4, 6

• Use CT imaging at 8-12 weeks to confirm solid bony union before discontinuing collar immobilization. 4

• Avoid routine dynamic fluoroscopy in the acute phase (first 6-8 weeks), as neck pain and muscle spasm limit its diagnostic utility. 1, 4

Critical Pitfalls to Avoid

• Do not rely on clinical examination alone to clear the cervical spine, as this has only 85% sensitivity and misses 10-15% of injuries. 1

• Do not use sandbags and tape alone for immobilization, as this long-standing practice is not recommended due to inadequate motion restriction. 3

• Do not permit chiropractic manipulation, as high-velocity rotational techniques risk worsening nerve compression and fracture displacement. 1

• Do not rely solely on MRI abnormalities to guide prolonged immobilization, as MRI has high sensitivity but poor specificity, potentially leading to unnecessary collar use in 25% of patients. 1, 4

• Do not overlook stress fractures in athletes, particularly beginning golfers with severe dorsal neck pain, as these can be missed on plain radiographs and require CT for diagnosis. 7

Special Considerations

• Elderly male patients warrant heightened vigilance for associated cervical fractures, as this demographic demonstrates higher rates of multiple concurrent injuries including Jefferson fractures and other spinous process fractures. 2

• Expect symptom resolution within 4-6 months with appropriate conservative management, as demonstrated in case series of isolated spinous process fractures. 7, 2

• Recognize that halo immobilization is rarely necessary for isolated spinous process fractures, as these are stable injuries that respond well to rigid collar immobilization alone. 8