What is the appropriate treatment and management for a patient with cervical vertebral collapse?

Management of Cervical Vertebral Collapse

Immediate Stabilization and Immobilization

Apply a rigid cervical collar with head-neck-chest stabilization immediately upon suspicion of cervical vertebral collapse, combined with manual in-line stabilization (MILS) to prevent onset or worsening of neurological deficit. 1, 2

• Maintain systolic blood pressure >110 mmHg continuously before and during injury assessment to reduce mortality 1, 2
• Target mean arterial pressure ≥70 mmHg during the first week post-injury to limit neurological deterioration 2
• Place an arterial line for continuous accurate blood pressure monitoring 1, 2
• Transport directly to Level 1 trauma centers within the first hours, as this reduces morbidity, mortality, and improves neurological outcomes through earlier surgical intervention 1

Diagnostic Evaluation

Obtain CT cervical spine without IV contrast as the initial imaging study for all patients with suspected cervical vertebral collapse. 2

• For patients with suspected ligamentous injury without fracture on CT, MRI of the cervical spine without IV contrast is the appropriate next imaging modality 2
• Perform CT angiography if vascular injury is suspected (sensitivity 90-100%, specificity 98.6-100%) 2
• Consider PET-CT and diffusion/perfusion MRI to differentiate malignant from benign vertebral collapse when strong edema is present, as increased FDG uptake, hyperintensity on diffusion-weighted images, and high plasma flow are associated with malignant causes 3

Surgical Management

Timing and Indications

If spinal cord compression is due to bone fragments from vertebral collapse, patients should undergo surgery immediately. 4

• Early surgery (within 24 hours) is associated with improved neurological recovery as measured by ASIA score improvement (RR of recovery = 8.9,95% CI [1.12-70.64], P = 0.01) and reduced pulmonary complications 2
• Ultra-early surgery (<8 hours) may further reduce complications and increase neurological recovery in stable patients at well-organized trauma centers, particularly for reducing respiratory complications 2
• Surgical decompression such as posterior laminectomy can be effective in patients with neurologic symptoms of spinal cord compression, especially if caused by vertebral collapse, with clinical improvement noted in 82% of patients refractory to previous radiotherapy 4

Surgical Technique Considerations

• For metastatic disease causing vertebral collapse, immediate surgical decompression and stabilization followed by involved field irradiation is recommended for pathologic spine fractures with spinal instability or spinal cord compression 5
• Anterior cervical corpectomy with autologous fibula graft and anterior plaque fixation can restore physiological cervical lordosis and achieve excellent fusion in cases of pathologic vertebral collapse 6
• Kyphoplasty (percutaneous cement introduction with balloon-like inflatable bone tamp) can restore 34% of height loss without relevant complications and significantly improve functional status in multiple myeloma patients with vertebral collapse 4

Medical Management

High-Dose Corticosteroids

Patients with spinal cord compression from cervical vertebral collapse should immediately receive high-dose dexamethasone therapy. 4

• Dexamethasone is effective on neurologic symptoms and pain based on randomized trials 4
• This should be initiated before definitive surgical or radiation treatment 4

Radiotherapy

• Patients who have neurologic impairment (deficits and/or symptoms) should receive local radiotherapy 4
• Radiotherapy is less useful if vertebral collapse itself is the cause of spinal cord compression (as opposed to soft tissue mass) 4
• Candidates for surgery should receive radiotherapy post-operatively once healing has occurred 4
• Radiotherapy is effective in controlling back pain 4

Airway Management (If Required)

If intubation is necessary, use videolaryngoscopy in preference to direct laryngoscopy to reduce cervical spine movement and improve first-pass success rates. 4, 2

• Remove the anterior portion of the cervical collar during intubation attempts while maintaining MILS to improve mouth opening and glottic exposure 4, 1, 2
• Use rapid sequence induction with a gum elastic bougie to increase first-attempt success rate 1, 2, 7
• Do not use Sellick maneuver (cricoid pressure) as it increases cervical spine movement 4, 1, 2, 7
• Succinylcholine can be safely used within 48 hours of injury; after 48 hours, switch to rocuronium to avoid hyperkalemia risk from denervation 1, 7

Respiratory Management

For upper cervical injuries (C2-C5), perform early tracheostomy (<7 days) as these patients have >50% reduction in vital capacity and high risk of ventilator weaning failure. 1, 2, 7

• Implement a comprehensive respiratory bundle combining abdominal contention belt during spontaneous breathing periods, active physiotherapy with mechanically-assisted insufflation/exsufflator device (Cough-Assist) for bronchial secretion removal, and aerosol therapy combining beta-2 mimetics and anticholinergics 1, 2, 7
• For lower cervical injuries (C6-C7), perform tracheostomy only after one or more tracheal extubation failures 7

Pain Management

Introduce multimodal analgesia combining non-opioid analgesics, ketamine, and opioids during surgical management to prevent prolonged pain. 1, 2, 7

• Initiate oral gabapentinoid treatment for >6 months to control neuropathic pain 1, 2, 7
• Add tricyclic antidepressants or serotonin reuptake inhibitors when gabapentinoid monotherapy is insufficient 1, 7

Temperature Management

Prevent hypothermia aggressively with target core temperature 36-37°C, as each 1°C drop reduces coagulation factor function by 10%, and temperatures <34°C are associated with >80% mortality. 1, 2

• Remove all wet clothing immediately and cover the patient 1
• Increase ambient temperature in treatment area 1
• Apply forced air warming devices as first-line active warming 1
• Administer only warm intravenous fluids; never use cold IV fluids 1

Early Rehabilitation

Begin joint range-of-motion exercises and positioning immediately upon ICU admission to prevent contractures and deformities. 1, 2, 7

• Perform stretching for at least 20 minutes per zone 1, 2, 7
• Apply simple posture orthoses (elbow extension, metacarpophalangeal joint flexion-torsion, thumb-index commissure opening) 1, 2, 7
• Use proper bed and chair positioning to correct and prevent predictable deformities 1, 2
• For incomplete injuries, implement gravity-assisted ambulation or body weight support with treadmill training 7

Patient Education and Screening

Patients should be aggressively screened and educated about spinal cord compression. 4

• Recovery of neurologic functions after treatment is mainly dependent on pretreatment levels: only 30% of non-ambulatory patients and 2-6% of paraplegic patients regain the ability to walk 4
• Early recognition and treatment is critical for optimal outcomes 4

Critical Pitfalls to Avoid

• Never leave the cervical collar fully in place during intubation, as this significantly worsens glottic visualization and increases failure rates 2
• Do not allow systolic blood pressure to drop below 110 mmHg, as this increases mortality risk 1, 2
• Avoid prolonged rigid collar immobilization beyond 48-72 hours without definitive treatment, as complications rapidly escalate 2
• Do not delay surgical decompression beyond 24 hours when indicated, as this worsens neurological outcomes 2
• Using succinylcholine after 48 hours post-injury risks life-threatening hyperkalemia due to denervation hypersensitivity 1, 7
• Delaying immobilization in suspected cases can lead to worsening neurological outcomes 7