What is the appropriate management for a patient with a spinous process fracture, considering potential underlying spinal instability or associated injuries?

Management of Spinous Process Fractures

Most isolated spinous process fractures are mechanically stable injuries that do not require spine service consultation or surgical intervention and can be managed conservatively with pain control and activity modification. 1

Initial Assessment

Imaging Evaluation

• Obtain CT imaging immediately to characterize the fracture pattern, assess for displacement, and exclude associated spinal injuries 2, 3
• CT is the reference standard for bony evaluation with 98.5% sensitivity for fracture detection 4
• Do not rely solely on plain radiographs, as CT provides superior fracture characterization 2

Critical Exclusions

• Actively search for associated spinal injuries, as spinous process fractures may be a warning sign of more severe injuries including vertebral body fractures, facet dislocations, or ligamentous disruption 5, 1
• Evaluate for neurologic deficits through complete neurological examination 1
• Screen for abdominal injuries, which occur frequently in patients with transverse process fractures (approximately 30% of cases) 1

Treatment Algorithm

Isolated Spinous Process Fractures (No Associated Injuries)

• Conservative management without spine service consultation is appropriate 1
• Cervical collar immobilization for cervical spinous process fractures 5
• Analgesics and local heat application for pain control 6
• Activity modification during acute healing phase 6
• Expected return to normal activities within 3 weeks 6

Spinous Process Fractures with Associated Spinal Injuries

When other spinal injuries are present (vertebral body fractures, ligamentous disruption, facet injuries):

• Obtain MRI if ligamentous injury is suspected, as disruption of the discoligamentous complex significantly impacts stability 3
• MRI identifies abnormalities in 23.6% of patients with negative CT, including ligamentous injury (16.6%), soft-tissue swelling (4.3%), and vertebral disc injury (1.4%) 4
• Apply the Subaxial Injury Classification (SLIC) System for cervical injuries to determine stability 3
• Surgical consultation is indicated when SLIC score ≥5 or neurological deficit is present 3

Special Considerations

Neurologic Deficits

• If neurologic deficits are present, CT alone is inadequate 7
• MRI is mandatory to identify soft-tissue pathology including spinal cord contusion, epidural hematoma, and nerve root injuries 7, 4
• CT should not be considered adequate for excluding significant soft-tissue pathology in patients with signs or symptoms of spinal cord or nerve root injury 7, 4

Persistent Pain Despite Conservative Treatment

• Consider pseudoarthrosis if localized pain persists beyond expected healing timeframe (typically >3 months) 8
• Exhaust conservative treatment and rule out other causes of back pain before considering surgical excision 8
• Surgical excision of symptomatic pseudoarthrosis can resolve pain and allow return to competitive sports 8

Common Pitfalls

• Do not assume all spinous process fractures are isolated injuries - diligently search for associated vertebral body fractures, facet injuries, or ligamentous disruption 5, 1
• Do not miss abdominal injuries, which occur in approximately 30% of patients with thoracolumbar process fractures 1
• Avoid routine spine service consultation for truly isolated spinous process fractures, as these are neurologically and structurally stable injuries 1
• Do not perform dynamic fluoroscopy in the acute phase (first 6-8 weeks), as neck pain and muscle spasm limit diagnostic utility 2

Follow-Up Protocol

• Monitor for resolution of pain over 3-week period 6
• No routine imaging follow-up is required for isolated spinous process fractures without associated injuries 1
• If pain persists beyond 3 months despite appropriate conservative treatment, consider imaging to evaluate for pseudoarthrosis 8