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

Management of Cervical Vertebral Collapse

For cervical vertebral collapse, immediately stabilize the spine with a rigid cervical collar and manual in-line stabilization, obtain CT imaging, maintain systolic blood pressure >110 mmHg, and proceed urgently to surgical decompression combined with high-dose dexamethasone if spinal cord compression is present. 1

Immediate Stabilization

Apply a rigid cervical collar with head-neck-chest stabilization immediately upon suspicion, combined with manual in-line stabilization (MILS) to prevent neurological deterioration. 1, 2

Hemodynamic Management

• Maintain systolic blood pressure >110 mmHg continuously before and during assessment, as this reduces mortality risk. 1, 2
• Target mean arterial pressure ≥70 mmHg during the first week post-injury to limit neurological deterioration. 1, 2
• Place an arterial line for continuous accurate blood pressure monitoring. 1, 2

Critical Pitfall

• Allowing systolic blood pressure to drop below 110 mmHg significantly increases mortality risk. 1, 2

Diagnostic Imaging Protocol

Obtain CT cervical spine without IV contrast as the initial imaging study for all patients with suspected cervical vertebral collapse. 3, 1, 2

• If ligamentous injury is suspected without fracture on CT, proceed to MRI cervical spine without IV contrast. 3, 1, 2
• Perform CT angiography if vascular injury is suspected based on clinical or imaging findings (sensitivity 90-100%, specificity 98.6-100%). 1, 2
• For distinguishing malignant from benign vertebral collapse when diagnosis remains uncertain, consider PET-CT or diffusion/perfusion MRI, as increased FDG uptake and hyperintensity on diffusion-weighted images indicate malignant etiology. 4

Medical Management

Immediately initiate high-dose dexamethasone therapy for patients with spinal cord compression from cervical vertebral collapse. 1

• Dexamethasone is effective for neurologic symptoms and pain based on randomized trials. 1
• Initiate local radiotherapy for patients with neurologic impairment (deficits and/or symptoms). 1
• Administer high-dose methylprednisolone within 8 hours of injury if traumatic etiology (though this was used in only 12/295 patients in one series). 5

Surgical Management

If spinal cord compression is due to bone fragments from vertebral collapse, perform surgery immediately. 1

Timing

• Early surgery within 24 hours is associated with improved neurological recovery (RR of recovery = 8.9,95% CI [1.12-70.64], P = 0.01) and reduced pulmonary complications. 1, 2
• Ultra-early surgery (<8 hours) may further reduce complications and increase neurological recovery in stable patients at well-organized trauma centers. 1, 2

Surgical Approach Selection

• For burst fractures or compression fractures with disc herniation, anterior decompression achieves 88% improvement rate. 5
• For developmental spinal canal stenosis with trauma, lamina fractures, ligament injuries, or hematoma, posterior approach surgery achieves 87.1% improvement rate. 5
• Combined anterior and posterior approach may be necessary for complex injuries. 5
• Surgical decompression such as posterior laminectomy is effective in patients with neurologic symptoms, with clinical improvement noted in 82% of patients refractory to previous radiotherapy. 1

Critical Pitfall

• Delaying surgical decompression beyond 24 hours when indicated worsens neurological outcomes. 1, 2

Airway Management (If Required)

Use videolaryngoscopy in preference to direct laryngoscopy to reduce cervical spine movement and improve first-pass success rates (RR of intubation failure 0.53,95% CI 0.35-0.80). 1, 2, 6

• Remove the anterior portion of the cervical collar during intubation attempts while maintaining MILS to improve mouth opening and glottic exposure. 1, 2, 6
• Use jaw thrust rather than head tilt-chin lift for airway opening. 6
• Do not use Sellick maneuver as it increases cervical spine movement. 2
• Use rapid sequence induction in emergency conditions. 2

Critical Pitfall

• Never leave the cervical collar fully in place during intubation, as this significantly worsens glottic visualization and increases failure rates. 1, 2

Respiratory Management

For upper cervical injuries (C2-C5), perform early tracheostomy (<7 days) to reduce ventilator weaning failure. 3, 1, 2

• For lower cervical injuries (C6-C7), perform tracheostomy only after one or more tracheal extubation failures. 3
• Implement a comprehensive respiratory bundle combining abdominal contention belt during spontaneous breathing periods, active physiotherapy with mechanically-assisted insufflation/exsufflator device, and aerosol therapy combining beta-2 mimetics and anticholinergics. 3, 1, 2

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, cover the patient, and increase ambient temperature. 1

Pain Management

• Introduce multimodal analgesia combining non-opioid analgesics, ketamine, and opioids during surgical management to prevent prolonged pain. 1, 2
• Initiate oral gabapentinoid treatment for >6 months to control neuropathic pain. 1, 2

Early Rehabilitation

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

• Perform stretching for at least 20 minutes per zone. 1, 2
• Apply simple posture orthoses (elbow extension, metacarpophalangeal joint flexion-torsion, thumb-index commissure opening). 1, 2
• Use proper bed and chair positioning to correct and prevent predictable deformities. 2

Collar Management

Avoid prolonged rigid collar immobilization beyond 48-72 hours without definitive treatment, as complications rapidly escalate including pressure sores requiring skin grafting, increased intracranial pressure, airway problems, difficult central venous access, poor oral care leading to sepsis, failed enteral nutrition, gastrostasis with aspiration pneumonia, restricted physiotherapy, and thrombo-embolism. 3, 2

• Pressure sores are common and increase with prolonged collar use, particularly after 48-72 hours, costing approximately $30,000 per ulcer. 3
• Among elderly patients with cervical spine injuries, 26.8% died during treatment, principally from respiratory complications related to prolonged immobilization. 3

Patient Education and Screening

Patients should be aggressively screened and educated about spinal cord compression, as early recognition and treatment is critical for optimal outcomes, with recovery of neurologic functions after treatment mainly dependent on pretreatment levels. 1