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, as early spine immobilization is essential to prevent onset or worsening of neurological deficits. 1, 2

• Manual in-line stabilization should 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
• Perform serial neurological examinations to detect any evolving deficits 1

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 and are inadequate for assessing displaced fractures. 3

• CT is mandatory for assessing fracture displacement and distinguishing the specific fracture pattern 3
• MRI should be obtained when ligamentous injury is suspected, particularly with displaced fractures where discoligamentous complex disruption is likely 1, 3
• Screen for non-contiguous injuries, which occur in 8-31% of patients with cervical spine trauma 3

Stability Assessment Using SLIC Score

Apply the Subaxial Injury Classification (SLIC) System to determine treatment approach, evaluating three components: fracture morphology, discoligamentous complex integrity, and neurological status. 1, 2

SLIC Scoring Components:

• Fracture morphology: Assess the specific pattern of spinous process involvement and any associated vertebral body or posterior element injury 1
• Discoligamentous complex (DLC) integrity: Disrupted DLC receives 2 points; displaced fractures often indicate ligamentous disruption 1
• Neurological status: Complete cord injury receives 2 points, incomplete receives 3 points, nerve root injury receives 1 point 1

Treatment Algorithm Based on SLIC Score

SLIC Score <5 (Conservative Management):

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
• Obtain baseline CT within the first week to establish reference point for fracture alignment 3
• Perform serial CT at 4-6 weeks to assess healing progression, as some initially stable injuries demonstrate delayed instability 3
• Obtain final CT at 8-12 weeks to confirm solid bony union before discontinuing collar 3

SLIC Score ≥5 (Surgical Management):

Proceed with surgical intervention for significant instability requiring decompression, realignment, and stabilization. 1, 2

• Surgery is indicated when SLIC score ≥5, which suggests significant instability 1, 2
• Any neurological deficit attributable to the fracture requires immediate surgical intervention regardless of SLIC score 3
• Posterior stabilization techniques include lateral mass plating or cervical pedicle screws depending on fracture pattern 4
• Anterior intercorporal spondylodesis may be indicated for associated vertebral body injury 5

Critical Pitfalls to Avoid

Do not rely on plain radiographs alone, as they miss approximately 15% of cervical injuries and up to 49% fail to visualize the cervicothoracic junction where 60% of cervical injuries occur. 6

• Do not clear the cervical spine based on lateral plain film alone in obtunded patients, as sensitivity is only 85% in unconscious polytrauma populations 6
• Do not remove cervical immobilization until CT imaging definitively excludes instability 6, 3
• Do not delay MRI if ligamentous injury is suspected, as this significantly impacts stability assessment and treatment decisions 3

Special Considerations for Displaced Fractures

Displaced spinous process fractures warrant heightened suspicion for associated ligamentous injury and potential instability. 1, 5

• Reduction should be performed as soon as possible, as neurologic regeneration and successful reduction are closely time-related 5, 7
• Monitor for respiratory complications, as 40% of cervical spine injury patients present with high fever and difficulty breathing 7
• Maintain systolic blood pressure >110 mmHg before complete injury assessment to reduce mortality 1