Mark W. McFarland, DO
What happens to the patient from the scene of the accident, during transport to the hospital and after they make it to the hospital trauma unit? In this article, I’ll talk about treatment for this type of cervical fracture and how we start to put the pieces back together for the patient after this catastrophic type of accident.
Emergent stabilization of a cervical dislocation fracture must be the priority of any first responder. As I discussed in Part II of this article series, some level of quadriplegia/tetraplegia is almost guaranteed with this injury, so it is imperative that the patient’s neck be immobilized before any treatment or transport to an ER takes place. As breathing inability or difficulty often accompanies cervical level dislocation fractures, patients often must be sedated and intubated at the scene of the accident and have machine-assisted breathing while being transported to the hospital. In fact, this is so common that this injury is often called “The Hangman’s Fracture” due to the risk of suffocation. However, it is not due to strangulation (like from hanging from a rope), but the fact that the nerves which signal the muscles in the chest to inflate and deflate the lungs with air can’t send and receive messages to and from the brain. Some form of steroid may be administered by IV to retard the inevitable swelling of the spinal cord and nerve roots that will have been injured in the accident.
At the trauma unit/ER, the patient will be assessed quickly by the lead trauma/ER physician and diagnostic tests will be ordered. A CT scan of the entire body, to look for internal injuries, as well as x-rays will be performed immediately, as soon as the patient’s vital signs are stable enough to undergo these tests. If the fractured vertebra is the only issue, then I can proceed with my evaluation and treatment.
As is usually the case, a variety of injuries must be considered – maybe a ruptured spleen, a concussion, an eye injury, all of which are important and need attention, must be prioritized. The most life-threatening/altering injury gets precedence. Sometimes, I must wait for the steroids to reduce inflammation before I can operate, or I will cause more harm than good to the patient. It is a strategic planning process that all the attending physicians will participate in for the benefit of the severely injured patient.
With dislocated cervical fractures, I typically have two treatment options – 1) a halo screwed into the skull, weighted vest, and traction, which will slowly pull the spinal bones into alignment or 2) urgent surgery to reduce the fracture, stabilize the spine and remove boney debris impinging on the spinal cord or nerve roots.
In 2022, surgery is almost always the preferred option, as there is research that suggests that patients tend to recover better and have more and improved neurologic function as a result. It is also important to note that lying in a bed, in traction for weeks or months at a time, is not good for anyone, because of risks of pneumonia, decubitus ulcers, etc. Remember that these patients are compromised in their breathing and coughing so they are already at high risk for respiratory complications. It is better to mechanically stabilize their fracture, and even if they are paralyzed, be able to move them, instead of having them lie in one position for months.
Surgery often will be approached from both the anterior and posterior sides of the body as the trauma to both bones and the soft tissue making up the vertebral column will be extensive and will often require removal of bone fragments and extensive stabilization efforts. Bone grafting, cadaver bone and biologics may be used, as may cages, rods, plates, screws, wires, etc. to fuse the vertebra(e) to one another or in some cases, the skull. Special attention will be given to allow enough room for the spinal cord and nerve roots to go through the inflammatory process of healing without being further compromised.
There can be exceptions to surgery, as is the case with some C1 or C2 dislocated fractures. Sometimes, the best option is to affix the halo immobilization vest to the skull and use traction, especially if the fracture is comminuted (broken into lots of pieces), which are very hard to put back together surgically. This can be done at first to give the spinal cord time to heal, while slowly pulling the fracture into place. This is typically followed by a period of wearing a Philadelphia collar to keep the neck immobilized.