What complications can occur if a patient does not wear a cervical‑spine brace after a cervical spine fracture?

Complications of Not Wearing a Cervical Spine Brace After Fracture

Failure to properly immobilize a cervical spine fracture dramatically increases the risk of secondary neurological injury, with delayed or missed diagnosis producing 10 times higher rates of neurological deterioration (10.5% vs. 1.4%) and potentially permanent neurological deficits in up to 29.4% of cases. 1, 2, 3

Primary Risks of Inadequate Immobilization

Secondary Neurological Injury

• Up to 4.3% of all cervical fractures may be missed initially, and 67% of these patients will suffer neurological deterioration as a direct result of inadequate immobilization. 1, 2, 3
• Before widespread adoption of proper spinal precautions, up to 10% of patients who were initially neurologically intact developed neurological deficits during their emergency care due to inadequate immobilization. 1
• The risk of secondary injury is particularly high in the first 2-35 days after initial trauma, with a mean delay of 15.8 days before neurological complications manifest in inadequately immobilized patients. 4

Fracture Displacement and Instability

• Cervical spine fractures without proper immobilization can progress from stable to unstable injuries, particularly at the craniocervical and cervicothoracic junctions where rigid collars may paradoxically allow movement. 2, 3
• In patients with ankylosing spondylitis, delayed neurological complications occurred in 100% of inadequately immobilized cases, even after seemingly minor trauma, demonstrating the extreme instability of certain fracture patterns. 4

Critical Time-Dependent Factors

Early Phase (0-72 hours)

• The highest risk period for secondary injury occurs when patients are mobilized or inadequately immobilized before definitive diagnosis. 1, 2
• Injudicious movement during this period can convert a neurologically intact patient to one with permanent spinal cord injury. 5, 6

Delayed Complications (>72 hours)

• While prolonged immobilization beyond 48-72 hours carries its own morbidity (pressure sores, aspiration pneumonia, thromboembolic events), premature discontinuation of immobilization before fracture stability is confirmed remains far more dangerous. 2, 7

High-Risk Fracture Patterns

Lower Cervical Spine (C5-C7)

• Fractures at C5-C7 are particularly prone to delayed neurological complications if inadequately immobilized, as all reported cases of delayed neurological injury in one series occurred at these levels. 4
• These injuries may result from minor trauma but require rigid immobilization due to extreme instability. 4

Craniocervical Junction

• This is one of the two most common sites for cervical injuries, and rigid collars may paradoxically cause movement at this location if not properly applied. 2, 3
• Missed or inadequately immobilized craniocervical instability produces devastating neurological outcomes. 3

Specific Complications by Mechanism

Spinal Cord Compression

• Progressive vertebral displacement without proper bracing can lead to cord compression, with 22% of symptomatic and 19% of asymptomatic patients ultimately requiring halo, fusion, or surgical intervention. 8

Vascular Injury

• Inadequate immobilization can cause or worsen vertebral artery injury, particularly at the craniocervical junction. 3

Ligamentous Disruption

• While isolated ligamentous injuries occur in <1% of cases, failure to immobilize these injuries can lead to progressive instability and delayed neurological injury. 1, 2

Critical Clinical Pitfalls

Relying on Absence of Pain

• 21% of patients aged ≥55 years with cervical spine fractures report no neck pain on presentation, making pain an unreliable indicator for determining when immobilization can be discontinued. 8
• Asymptomatic patients without neck pain had higher injury severity scores and were just as likely to require surgical intervention as symptomatic patients. 8

Premature Brace Discontinuation

• Patients with ankylosing spondylitis or other conditions causing spinal rigidity are at extreme risk for delayed neurological complications if immobilization is discontinued prematurely, even after seemingly minor trauma. 4, 9

Inadequate Brace Selection

• Different cervical orthoses vary significantly in their effectiveness at restricting movement at different spinal levels; using an inadequate brace type is equivalent to no immobilization for certain fracture patterns. 5

Management Algorithm

For confirmed cervical spine fractures:

1. Maintain rigid immobilization with appropriate cervical orthosis (semirigid collar minimum, halo vest for unstable fractures) until definitive treatment plan is established. 5, 6
2. Transfer from backboard to padded surface within 2 hours while maintaining cervical precautions to avoid immobilization-related morbidity. 7
3. Obtain definitive imaging (CT with <3mm slices, MRI for ligamentous injury) before any consideration of brace discontinuation. 2, 3
4. For neurologically intact patients with stable burst fractures of the thoracolumbar spine, bracing may be optional, but this does NOT apply to cervical spine fractures. 1

The decision to discontinue cervical immobilization must be based on definitive imaging confirmation of fracture stability and healing, not on symptom resolution alone. 6, 8