What is the appropriate treatment for a patient with a minimally distracted fracture through the lateral mass of the C1 (cervical 1) vertebral body, posterior and anterior C1 arch fractures, a sagittally oriented nondisplaced fracture through the C6 vertebral body, an anterior superior teardrop fracture at the C6 vertebral body, a nondisplaced fracture through the superior articular process of the C6 vertebral body, a perched facet at the left C5-C6 level, and degenerative changes, with possible small prevertebral blood product at the level of C1?

Management of Complex Multi-Level Cervical Spine Fractures

This patient requires urgent neurosurgical consultation for staged surgical intervention given the combination of unstable C1 fractures, multiple C6 fractures with a perched facet at C5-C6, which represents a highly unstable injury pattern with significant risk of neurological deterioration. 1, 2

Immediate Management

Initial Stabilization and Imaging

• Apply rigid cervical collar immediately and maintain strict spinal precautions until definitive treatment is established 1
• Obtain MRI of the entire cervical spine urgently to assess for ligamentous injury, disc herniation, spinal cord compression, and epidural hematoma, as CT alone misses purely ligamentous injuries and cord contusions that are critical for treatment planning 2, 3
• Complete cervical spine imaging is mandatory because 8-31% of patients have non-contiguous injuries at multiple levels, which this patient clearly demonstrates 1, 2
• MRI is essential before any reduction maneuvers in perched facet injuries, as traumatic disc herniation occurs frequently and closed reduction can cause devastating iatrogenic spinal cord injury 3

Neurological Assessment

• Document complete neurological examination using ASIA classification to establish baseline function and guide surgical urgency 2
• Any neurological deficit attributable to these fractures mandates immediate surgical intervention regardless of fracture pattern 1
• Even neurologically intact patients with perched facets require urgent surgery due to the imminent risk of delayed neurological injury 3

Surgical Treatment Algorithm

Classification and Surgical Indication

• Calculate the Subaxial Injury Classification (SLIC) score for the C5-C6 perched facet and C6 fractures; a score ≥5 indicates significant instability requiring surgical intervention 1, 2
• The perched facet at C5-C6 represents an unstable ligamentous injury with facet compromise, which typically generates a SLIC score ≥5 4, 2
• The C1 fractures (lateral mass, posterior arch, and anterior arch) combined with C6 multi-level fractures and perched facet constitute a complex multi-level trauma requiring comprehensive surgical stabilization 5, 6

Staged Surgical Approach

Stage 1: Anterior Cervical Procedure (C5-C6)

• Perform anterior cervical discectomy and fusion (ACDF) at C5-C6 to address the perched facet, decompress neural elements, and stabilize the disco-ligamentous injury 5, 7
• Anterior surgery is particularly effective for C5-C6 dislocations and perched facets, with 88% achieving at least one Frankel grade improvement in similar injuries 6
• Anterior approach allows direct visualization and removal of any traumatic disc herniation that commonly accompanies perched facets and could cause spinal cord compression during reduction 3, 8
• Use intervertebral biomechanical devices (cage or structural graft) with anterior plate fixation for immediate stability 5, 8

Stage 2: Posterior Cervical Procedure (C1 and C6)

• Perform posterior instrumentation and fusion for the C1 fractures if they demonstrate instability on MRI (posterior ligamentous complex disruption) 1, 5
• Address the C6 posterior element fractures (superior articular process) with posterior segmental instrumentation if anterior stabilization alone is insufficient 5, 6
• The sagittal fracture through C6 body and teardrop fracture may require combined anterior-posterior stabilization for three-column injury 6, 8

Approach Selection Rationale

• Combined anterior-posterior surgery is indicated for bilateral or complex dislocations with severe instability, which this patient demonstrates with the perched facet and multiple fracture components 7, 6
• Anterior-alone approaches have higher revision surgery rates (14.3%) compared to combined approaches (36.4% neurologic recovery) in complex injuries 7
• Posterior approaches are necessary when posterior column injuries (C1 arch fractures, C6 articular process fracture) require direct stabilization 6, 8

Critical Management Considerations

Pre-Reduction Protocol

• Do NOT attempt closed reduction of the perched facet without MRI confirmation that no disc herniation is present in the spinal canal 3
• If MRI reveals disc herniation, proceed directly to anterior surgical decompression and reduction under direct visualization 3, 8
• Consider temporary external Halo fixator application without reduction maneuvers to prevent iatrogenic spinal cord injury until definitive surgery 3

Timing of Surgery

• Surgery should be performed as soon as possible once the injury pattern is fully characterized by MRI, as early intervention (within 8 hours) may improve neurological outcomes 6
• High-dose methylprednisolone within 8 hours of injury should be considered if neurological deficits are present, though this remains controversial 6

Common Pitfalls to Avoid

• Never rely on CT alone for treatment planning in perched facets or complex cervical injuries, as purely ligamentous injuries and disc herniations are invisible on CT but critically affect surgical approach 2, 3
• Do not assume C1 fractures are stable without MRI assessment of the transverse ligament and posterior ligamentous complex 1, 2
• Avoid single-level fixation for the C5-C6 perched facet without addressing the C6 fractures, as this creates a stress riser and increases failure risk 5, 6
• Plain radiographs miss up to 77% of cervical spine abnormalities and should not guide treatment decisions 2

Post-Operative Management

Follow-Up Imaging Protocol

• Obtain baseline CT within the first week to establish reference alignment and hardware position 1
• Serial CT at 4-6 weeks to assess healing progression, as some initially stable injuries demonstrate delayed instability 1
• CT at 8-12 weeks to confirm solid bony union before discontinuing external immobilization 1

Rehabilitation

• Early mobilization is possible with rigid internal fixation, decreasing nursing complications and allowing neurological recovery 6, 8
• Patients with Frankel grade C or better have the highest likelihood of functional ambulation recovery (82%) 6