Initial Evaluation and Medical Management

The initial management of cervical burst fractures occurs outside of the hospital at the scene of injury. These fractures often occur in the setting of polytrauma where other life-threatening injuries can distract from possible neurologic deterioration. Full cervical spine precautions with immobilization and transfer to an appropriate trauma center should be performed efficiently and safely. Once at the trauma center, the Advanced Trauma Life Support protocol is instituted. In the setting of retropulsed segments and compressive spine injury, particular attention is paid to oxygenation and maintenance of adequate perfusion. Strict blood pressure control is important with a target mean arterial pressure (MAP) above 80. Hypotension can initially be managed with fluid boluses; however, initiation of vasopressors should be considered if adequate perfusion is not achieved with fluid boluses alone. The role of steroids remains ambiguous and is well reviewed elsewhere. Once the patient is stabilized, a thorough history can reveal the mechanism of injury and timing of neurologic deterioration. Cervical flexion compression injuries are particularly concerning for burst fractures.

Following the primary survey, a thorough physical exam is required. Initial inspection and palpation can identify obvious deformities, external soft tissue injuries, and local areas of tenderness or asymmetry. When a history is not available, patterns of injuries can sometimes suggest the mechanism of injury. Next, a dedicated neurologic exam should focus on limb strength, sensation and reflexes, truncal sensation, and perspiration as well as bowel and bladder sphincter function. The American Spinal Injury Association classification system (ASIA) is a common clinical classification system that allows for an organized approach to the neurologic exam and categorizes degree of injury into four groups. ⁹ ASIA A injuries are complete SCIs where no sensory or motor function is preserved. ASIA E injuries have no motor or sensory deficit. ASIA B to D injuries are incomplete SCIs where sensory function is preserved but with varying degrees of loss in motor function. Importantly, ongoing progression of neurologic deficits can suggest ongoing or progressive compression whether by unstable or retropulsed fracture fragments or an expanding hematoma. These are important to identify early as timely decompression can have significant impact on overall outcome.

Early optimization of medical management has been shown to benefit long-term prognosis; however, the timing of surgical intervention remains somewhat more controversial. There exists a large body of literature investigating the role of early surgical intervention. The best evidence to date was put forward by Fehlings et al in the Surgical Timing in Acute Spinal Cord Injury Study (STASCIS trial). ¹⁰ This international multicenter prospective cohort study looked at 313 patients with acute cervical SCI. Of these, 182 underwent early surgery (within 24 hours) and 131 underwent late surgery (after 24 hours). Primary outcome was change in ASIA Impairment Scale (AIS) grade at 6 months. Secondary outcomes were rates of complication and mortality. Twenty percent of patients undergoing early surgery showed a ≥ 2 grade improvement compared to 8.8% in the late decompression group. Mortality and rates of complication were not statistically significant between the two groups. This study would suggest that decompression within 24 hours is beneficial.

Closed reduction, if attempted, is a relatively well-tolerated procedure with an overall reduction rate of approximately 80%, 30% recurrent displacement or malalignment, 2 to 4% chance of transient deficit, and 1% chance of permanent deficit. Overall rates of failure in compression fractures of the subaxial C-spine were found to be around 5%. Similarly, Koivikko et al found a rate of reoperation in patients treated with orthosis to be 4% (compared to 3% in surgically managed patients). ¹¹ While nonsurgical management is certainly the appropriate decision in a large percentage of patients, there is some evidence that neurologic improvement, kyphotic deformity, and canal stenosis were all improved in patients treated surgically. ¹¹ Most studies, however, were retrospective reviews and outcomes were generalized to a spectrum of fracture patterns. Furthermore, the differences in recovery between surgical and nonsurgical management is far outweighed by the status at presentation than choice of treatment. Patients who are treated with a halo vest or hard cervicothoracic orthosis for 2 to 3 months should be followed up with flexion-extension X-rays to help determine success of fusion.