Surgical versus Nonsurgical Treatment of Subaxial Cervical Pedicle Fractures

Abstract

Pedicle fractures in the cervical spine are common. They may occur in isolation or in combination with other concomitant fractures. Multiple classification systems have been introduced to provide a clinical framework when approaching these types of fractures; however, these systems do not provide guidelines for optimal treatment. Data regarding decision making are limited. Conservative treatment with orthoses may result in subluxation and instability requiring further treatment. Surgery may not be required in all instances because many of these injuries may heal without surgical intervention. All cases of cervical fractures treated at a single institution over a 5-year period were retrospectively reviewed. Cases with pedicle fractures were further evaluated, and 40 cases managed either with or without surgery were identified. Data on presenting history, neurologic examination, imaging findings, comorbidity, method of treatment, complication rate, and length of hospital stay were collected. Fractures were classified based on computed tomography scans. Data on associated injuries were also collected. Fusion rate and fracture displacement were assessed by plain radiographs and computed tomography scans at follow-up. Follow-up time points included 2, 6, and 12 weeks and 6 months after injury. Primary outcome was fracture healing regardless of modality in the absence of progressive deformity (i.e., listhesis, kyphosis) and need for further surgery. Conservative therapy was administered to 26 patients, and 14 patients underwent surgery. There were no statistically significant differences between the 2 groups in terms of total levels injured (P = 0.9) or injury severity score (P = 0.5). Patients who presented with intact neurologic status were more likely to be treated conservatively (88% vs. 29%; P = 0.0004), whereas patients presenting with spinal cord injuries were more likely to undergo surgical fixation (35% vs. 0%; P = 0.0004). Length of hospital stay trended toward being significantly greater in patients who underwent surgery (10.6 days vs. 5.5 days; P = 0.07). According to our classification system, the most common fracture type was single line horizontal fracture occurring in 68% (27 of 40 cases). Vertical split pedicle fracture occurred in 28% (11 of 40 cases), and double line horizontal fracture occurred in 5% (2 of 40 cases). Posttreatment progressive listhesis was significantly higher in patients who were treated conservatively (31% vs. 0%; P = 0.03), especially when associated with comminuted lateral mass or subluxation or both. This study describes and classifies unique cervical pedicle fractures and associated injuries. Our findings suggest that surgical treatment results in definitive stability for these injuries compared with conservative therapy, particularly for pedicle fractures associated with comminuted lateral mass or initially displaced fractures. However, nondisplaced vertical split pedicle fractures and isolated single line horizontal fractures may be treated nonsurgically without occurrence of further instability. A larger prospective study is required to confirm these findings.