What is the management approach for a patient with a history of trauma or osteoporosis who presents with either a cervical lamina fracture or a facet fracture?

Management of Cervical Lamina Fractures versus Facet Fractures

For cervical lamina fractures, immobilization with a rigid cervical collar for 4-8 weeks is sufficient for achieving solid bony union in isolated stable fractures, whereas facet fractures require more aggressive management with surgical intervention often necessary for unstable patterns, particularly bilateral facet dislocations which carry 84% risk of complete neurological injury. 1, 2

Initial Assessment and Stabilization

Immediate Imaging Protocol

• Obtain CT imaging immediately with 1.5-2 mm collimation of the entire cervical spine, as plain films miss approximately 15% of cervical injuries 1
• CT is mandatory for distinguishing lamina fractures from facet involvement and assessing fracture displacement 3
• MRI should be obtained acutely if neurological symptoms are present or if ligamentous injury is suspected, as this significantly impacts stability assessment and treatment decisions 4, 5
• Look specifically for non-contiguous injuries, as 8-31% of patients have additional cervical fractures at different levels 1, 3

Neurological Assessment

• Document complete neurological examination, as the presence of any deficit attributable to the fracture mandates immediate surgical intervention regardless of fracture pattern 1
• Spinal shock is a poor prognostic indicator for neurological recovery and occurs in approximately 19% of facet injury patients 2
• Bilateral facet injuries carry 84% risk of complete neurological injury compared to unilateral patterns 2

Treatment Algorithm by Fracture Type

Cervical Lamina Fractures (Isolated and Stable)

• Immobilize with rigid cervical collar for 4-8 weeks, which achieves solid bony union in isolated spinous process and lamina fractures 1
• Prohibit all neck extension and rotational movements, as extension combined with rotation significantly narrows the spinal canal 1
• Monitor for skin breakdown and muscle atrophy during prolonged collar use 1, 4
• Patient compliance with immobilization is critical, as irregular collar use leads to instability development requiring surgical intervention 5

Facet Fractures - Unilateral Pattern

• Attempt closed reduction with skull traction first in patients without contraindications, successful in 58% of cases 2
• If closed reduction fails or fracture is irreducible due to posterior facet fractures or ligamentous injury, proceed to surgical intervention 6
• For irreducible unilateral facet dislocations, the combination of posterior reduction and anterior fixation with fusion is the preferred approach, offering clinical safety and less iatrogenic damage 6
• Alternative anterior-only approach using kyphotic paramedian distraction with Caspar pins plus anterior facetectomy can achieve 100% reduction success without posterior supplementation 7

Facet Fractures - Bilateral Pattern

• Bilateral facet injuries require surgical intervention due to high instability and 84% complete injury rate 2
• Closed reduction should be attempted first but has lower success rates in bilateral patterns 2
• Timing of decompression-realignment is more important than the means of reduction for neurological recovery, with rapid reduction (within hours) associated with 78% improvement rate 2
• Open reduction-internal fixation achieves 83% success rate with 4% morbidity when closed reduction fails 2

Surgical Indications (Both Fracture Types)

• SLIC score ≥5 indicating significant instability 1
• Any neurological deficit attributable to the fracture 1, 4
• Failed closed reduction attempts 2, 6
• Multiple associated unstable cervical injuries that cannot be managed with external immobilization 1
• Development of delayed instability during conservative management 5

Follow-Up Protocol

Imaging Surveillance

• Obtain baseline CT within the first week to establish reference point for fracture alignment 1, 4
• Serial CT at 4-6 weeks to assess healing progression, as some initially stable injuries demonstrate delayed instability 1, 3
• CT at 8-12 weeks to confirm solid bony union before discontinuing collar 1
• Avoid routine dynamic fluoroscopy in the acute phase (first 6-8 weeks), as neck pain and muscle spasm limit diagnostic utility 1, 4

Vascular Monitoring

• If foramen transversarium is involved, obtain vascular imaging and begin aspirin therapy with consideration for systemic anticoagulation 4, 3
• Monitor for vertebrobasilar insufficiency symptoms including vertigo, visual disturbances, syncope, or ataxia 4

Critical Pitfalls to Avoid

• Never 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 permit chiropractic manipulation, as high-velocity rotational techniques risk worsening nerve compression and fracture displacement 1
• Do not assume all facet fractures are stable based on initial imaging, as diagnosis is often missed and late instability develops 5, 8
• Seven patients (11%) deteriorated during closed reduction attempts, emphasizing the need for careful neurological monitoring during reduction maneuvers 2
• Do not delay surgical intervention in bilateral facet dislocations, as only 10 of 68 patients (15%) make significant neurological recoveries overall, with timing being critical 2

Special Considerations for Osteoporotic Patients

• Adequate calcium intake (1000-1200 mg/day) together with vitamin D 800 IU/day is essential during fracture healing 9
• Vitamin D supplementation reduces non-vertebral fractures by 15-20% and falls by 20% 9
• Consider pharmacological treatment with bisphosphonates (alendronate, risedronate, zoledronic acid) or denosumab to prevent subsequent fractures 9
• Implement multidimensional fall prevention and balance training during rehabilitation 9