What is the recommended management for a displaced spinous process fracture?

Management of Displaced Spinous Process Fractures

Immediate Assessment and Risk Stratification

For displaced spinous process fractures, the critical first step is determining whether the fracture represents an isolated stable injury or indicates underlying spinal instability with ligamentous disruption—this distinction fundamentally determines whether conservative management is appropriate or urgent surgical intervention is required. 1, 2

Key Clinical Evaluation Points

• Perform detailed neurological examination immediately to identify any deficits, as even subtle spinous process fractures may indicate serious underlying ligamentous injury and instability 2
• Assess mechanism of injury carefully: High-energy trauma (falls, motor vehicle accidents) carries higher risk of associated instability compared to low-energy mechanisms 2
• Examine for midline tenderness that worsens with flexion rather than extension, which is characteristic of spinous process pathology 3
• Look for delayed or evolving neurological symptoms within 24-48 hours, as these may indicate progressive instability 2

Essential Imaging

• Obtain MRI of the affected spinal region if any neurological symptoms are present or if high-energy trauma occurred, as CT alone may miss critical ligamentous injuries and facet subluxations 2
• MRI is mandatory when there is any concern for instability, as it can reveal posterior ligamentous complex disruption, facet joint subluxation, and anterolisthesis that may not be apparent on CT 2
• Dynamic flexion-extension radiographs may be useful in stable patients to assess for occult instability 3

Treatment Algorithm

Immediate Surgical Consultation Required

Obtain urgent surgical consultation and proceed with decompression and stabilization if any of the following are present:

• Neurological deficits of any kind (weakness, sensory changes, bowel/bladder dysfunction) 4, 1
• Evidence of spinal instability on imaging (facet subluxation, anterolisthesis, ligamentous disruption on MRI) 1, 2
• Progressive neurological deterioration, which requires immediate corticosteroid therapy followed by surgical decompression as soon as possible 4, 1

Conservative Management (Isolated, Stable Fractures Only)

For truly isolated spinous process fractures without neurological deficits or imaging evidence of instability, initial conservative management is appropriate:

• Analgesics and activity modification for 6-12 weeks, as most isolated fractures heal with gradual pain improvement 5, 6
• Physical therapy after acute pain subsides to restore function 6
• Serial clinical examinations to monitor for delayed neurological symptoms 2

When Conservative Management Fails

If localized pain persists beyond 3-6 months despite appropriate conservative treatment:

• Consider pseudoarthrosis of the spinous process as the cause of persistent symptoms 5
• Surgical excision of the symptomatic spinous process can provide complete pain resolution and return to full activity, including competitive sports 5, 3
• For athletes, offer surgical excision after 6 months of failed conservative management to allow definitive treatment and early return to competition (typically 6 weeks post-surgery) 3

Critical Pitfalls to Avoid

• Never assume a spinous process fracture is benign based on CT alone in trauma patients—these fractures may be markers of severe underlying instability requiring MRI evaluation 2
• Do not miss the window for early intervention in patients with evolving neurological deficits, as delayed recognition of ligamentous instability can lead to permanent neurological injury 2
• Avoid overlooking degenerative spondylolisthesis as a risk factor for spinous process fractures, particularly in the context of prior spinal procedures 7
• Do not continue conservative management indefinitely for persistent localized pain—consider pseudoarthrosis and surgical excision after 3-6 months of failed treatment 5, 3

Special Considerations

• In patients with degenerative spondylolisthesis, spinous process fractures are more common and may indicate higher risk of complications 7
• Lumbarized S1 vertebrae with thin spinous processes are more susceptible to fracture from direct trauma 6
• Adolescent athletes with apophyseal avulsion injuries may benefit from earlier surgical intervention (6 months) if conservative management fails 3