What is the initial treatment approach for a patient with a C7 (cervical 7) spinous process displaced fracture following a Motor Vehicle Accident (MVA)?

Management of C7 Spinous Process Displaced Fracture Following MVA

Immediate Stabilization

Maintain rigid cervical collar immobilization immediately and continue until stability is definitively assessed. 1

• Manual in-line stabilization must be maintained during any airway procedures if intubation becomes necessary 1, 2
• Use jaw thrust rather than head tilt-chin lift for simple airway maneuvers to minimize cervical spine movement 1, 2
• Early spine immobilization is essential to prevent onset or worsening of neurological deficits 1, 2

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. 3

• CT is mandatory for assessing fracture displacement and distinguishing the specific fracture pattern 3
• MRI should be obtained when ligamentous injury is suspected, as disrupted discoligamentous complex significantly impacts stability and treatment decisions 1, 3
• Non-contiguous injuries occur in 8-31% of patients, so image the entire cervical spine 3

Classification and Treatment Decision

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

The SLIC system evaluates three components:

• Fracture morphology: Assess the specific pattern of spinous process displacement 1
• Discoligamentous complex (DLC) integrity: Disrupted DLC receives 2 points 1
• Neurological status: Complete cord injury receives 2 points, incomplete receives 3 points 1

Treatment Algorithm Based on SLIC Score

For SLIC score <5 (stable injury):

• Continue rigid cervical collar immobilization for 4-8 weeks to achieve solid bony union 1, 3
• Provide multimodal pain management with NSAIDs and opioids as needed 1
• Implement early mobilization once stability is confirmed 1
• Perform serial neurological examinations 1

For SLIC score ≥5 (unstable injury):

• Surgical intervention is indicated, requiring decompression, realignment, and stabilization 1, 2
• Any neurological deficit attributable to the fracture requires immediate surgical intervention regardless of SLIC score 3

Follow-Up Protocol for Non-Operative Management

Obtain baseline CT within the first week to establish a reference point for fracture alignment. 3

• Serial CT at 4-6 weeks assesses healing progression, as some initially stable injuries demonstrate delayed instability 3
• CT at 8-12 weeks confirms solid bony union before discontinuing collar 3

Special Considerations

If the spinous process fracture involves the foramen transversarium (though uncommon at C7), obtain vascular imaging to evaluate for vertebral artery injury. 1

• Begin aspirin therapy immediately with consideration for systemic anticoagulation if vascular injury is present 1
• Monitor for vertebrobasilar insufficiency symptoms including vertigo, nausea, visual disturbances, syncope, ataxia, or altered consciousness 1

Maintain systolic blood pressure >110 mmHg before complete injury assessment to reduce mortality. 1

Common Pitfalls

• Do not rely on plain radiographs alone, as they miss approximately 15% of cervical injuries and the cervicothoracic junction is inadequately visualized in up to 49% of cases 4, 3
• Do not clear the cervical spine based on clinical examination alone in trauma patients, as clinical criteria carry an unacceptable false negative rate of 10% 4
• Do not assume isolated spinous process fractures are always stable—ligamentous injury can coexist and significantly alter management 1, 3
• Avoid Sellick maneuver during intubation as it may worsen cervical spine injury 1, 2