What is the management of a patient with a cervical (c) spine transverse process fracture, considering immobilization, pain management, and potential surgical intervention?

Management of Cervical Spine Transverse Process Fractures

Cervical spine transverse process fractures should be managed with early immobilization using a rigid cervical collar combined with supportive blocks on a backboard, followed by risk stratification using the Subaxial Injury Classification (SLIC) system to determine if surgical intervention is needed. 1, 2

Initial Immobilization and Stabilization

Early spine immobilization is essential in any trauma patient with suspected cervical spine injury to prevent onset or worsening of neurological deficits. 3, 1

• Use a rigid cervical collar combined with supportive blocks on a backboard with straps as the most effective immobilization method 4
• Avoid sandbags and tape alone, as this method is not recommended 4
• The combination of sandbags, tape, and Philadelphia collar provides superior restriction of cervical movement compared to collars alone 5
• Manual in-line stabilization should be maintained during any airway procedures 3

Assessment and Classification

Apply the Subaxial Injury Classification (SLIC) System to grade instability and determine treatment approach. 1, 2

The SLIC system evaluates three components:

• Fracture morphology - assess the specific pattern of transverse process involvement 2
• Discoligamentous complex (DLC) integrity - disrupted DLC receives 2 points 2
• Neurological status - complete cord injury receives 2 points, incomplete receives 3 points 2

Imaging Protocol

• CT imaging is essential for detailed assessment of fracture pattern and displacement 1
• MRI should be obtained when ligamentous injury is suspected, as DLC disruption significantly impacts stability and treatment decisions 1
• If the transverse process fracture involves the foramen transversarium, obtain vascular imaging to evaluate for vertebral artery injury 6

Treatment Algorithm

Conservative Management (SLIC Score <5)

• Continue rigid cervical collar immobilization 1, 2
• Multimodal pain management with NSAIDs and opioids as needed
• Early mobilization once stability is confirmed
• Serial neurological examinations

Surgical Intervention (SLIC Score ≥5)

Surgery is indicated when the SLIC score is ≥5, which suggests significant instability requiring decompression, realignment, and stabilization. 1, 2

• Surgical approach (anterior, posterior, or combined) depends on fracture pattern and associated injuries 2
• Surgery is also indicated for any neurological deficit attributable to the fracture 1

Special Considerations for Transverse Process Fractures

Vertebral Artery Injury

When the transverse process fracture involves the foramen transversarium:

• Begin aspirin therapy immediately with consideration for systemic anticoagulation 6
• Monitor for vertebrobasilar insufficiency symptoms including vertigo, nausea, visual disturbances, syncope, ataxia, or altered consciousness 6
• Obtain CT angiography or MR angiography to evaluate vertebral artery patency 6

Hemodynamic Management

• Maintain systolic blood pressure >110 mmHg before complete injury assessment to reduce mortality 3
• This is particularly important in the pre-hospital and early hospital phases 3

Critical Pitfalls to Avoid

• Do not rely on clinical examination alone - up to 4.3% of cervical fractures may be missed, with 67% of these patients suffering neurological deterioration 3
• Avoid prolonged immobilization beyond 48-72 hours without definitive diagnosis, as complications escalate rapidly including pressure sores, increased intracranial pressure, airway problems, and aspiration risk 3
• Do not apply cervical traction during airway management, as it causes clinically significant distraction and should be avoided 7
• Rigid collars alone do not adequately restrict unstable cervical injuries and may cause paradoxical movement at the craniocervical and cervicothoracic junctions 3

Airway Management Considerations

If intubation is required:

• Use manual in-line stabilization with removal of the anterior cervical collar to improve glottic exposure while limiting spine movement 3, 1
• Jaw thrust rather than head tilt-chin lift should be used for simple airway maneuvers 1
• Rapid sequence induction with direct laryngoscopy and gum elastic bougie increases first-attempt success 3
• Avoid Sellick maneuver 3

Evidence Quality Note

The evidence base for specific cervical fracture subtypes including transverse process fractures is limited, with few comparative studies providing level II evidence or higher 1. However, the SLIC system provides level I evidence with excellent reliability (ICC 0.49-0.90) for guiding surgical decision-making 2.