What is the management of a cervical spine (c-spine) spinous process fracture?

From the Guidelines

Management of cervical spinous process fractures should prioritize conservative treatment, focusing on pain management and stabilization, rather than immediate surgical intervention, as these fractures are generally stable and heal well without surgery, as indicated by the principles of trauma care 1.

Key Considerations

• Conservative treatment typically involves pain management with NSAIDs, such as ibuprofen (400-600mg every 6-8 hours) or naproxen (500mg twice daily), and muscle relaxants like cyclobenzaprine (5-10mg three times daily) for associated muscle spasm.
• Initial rest for 1-2 weeks followed by gradual return to activities as pain allows is recommended, with physical therapy starting after the acute pain phase, focusing on gentle range of motion exercises and strengthening of neck muscles.
• The use of cervical collars is suggested against by first aid providers due to the potential for complications and the difficulty in distinguishing between high- and low-risk criteria for spinal injuries 1.

Diagnostic Approach

• Imaging, particularly CT scans, plays a crucial role in assessing the extent of the injury and guiding treatment decisions, with the entire spine being imaged in obtunded blunt trauma patients using modern MDCT 1.
• MRI may be considered if there is a positive neurological examination referable to the spinal cord (myelopathy), but the decision to use MRI after a normal CT should be made cautiously, considering the implications of both approaches 1.

Treatment and Prognosis

• Surgery is rarely needed unless there is significant displacement causing neurological symptoms, instability of the cervical spine, or if the fracture is part of a more complex injury pattern.
• The prognosis for these fractures is generally good due to their location away from the spinal canal and nerve roots, with the spinous process serving primarily as an attachment point for muscles rather than having a critical role in spinal stability.

Monitoring and Follow-Up

• Patients should be monitored with follow-up X-rays at 2-4 weeks and again at 6-8 weeks to ensure proper healing, and clinicians should be vigilant for developing neurological signs despite a spine having been ‘cleared’ 1.

From the Research

Cervical Spinous Process Fracture Management

• The management of cervical spinous process fractures involves initial assessment and stabilization to prevent further injury, as outlined in studies 2, 3.
• The Advanced Trauma Life Support (ATLS) protocol is recommended for initial assessment and management, including triple immobilization to protect the cervical spine 2, 3.
• Clinical decision rules, such as the Canadian C-Spine Rule, can be used to risk-stratify patients and determine the need for radiography 2.
• Imaging, including CT scans, is crucial for diagnosing and classifying cervical spine fractures, with the goal of guiding definitive management 2, 3.

Immobilization Protocols

• Immobilization protocols for cervical spine fractures are widely accepted, but consensus on their effectiveness is lacking 4.
• A scoping review of cervical immobilization protocols found that most studies were retrospective cohort studies of poor to moderate quality, with significant risk of bias 4.
• The effectiveness of these protocols remains unclear, and adverse events such as mortality, musculoskeletal complications, and delayed surgery are common 4.
• Conservative treatment with a cervical collar may be used for isolated spinous process fractures, but these fractures may be a warning sign of more severe spinal injuries 5.

Biomechanics and Mechanisms of Injury

• The cervical spine's unique anatomy and flexibility predispose it to injury, and knowledge of the normal biomechanical anatomy is essential for understanding injury patterns 6.
• Reproducible injury patterns are based on the direction and magnitude of force applied to the cervical spine, and understanding these forces can guide treatment options 6.
• The mechanism of injury and injured cervical structures should be understood based on radiographic findings, as patients may present with non-cervical spine-related injuries 6.