Abstract

Background: How long do nonoperative cervical fractures have to be followed and with how many imaging studies?

Methods: We reviewed 69 adult patients with 122 (31 occiptocervical and 91 sub-axial) cervical fractures; at least one of the cervical fractures was managed nonoperatively. Outcomes were assessed along with the optimal follow-up duration and frequency of various diagnostic studies.

Results: An average of four follow-up visits occurred on average 28-, 66-, 94-, and 158-day post hospital discharge. The average time between discharge and orthotic clearance was 70 days (±32.4 days). Radiographic studies were obtained at follow-up visits, respectively, in, 82.6%, 83.6%, 94.7%, and 100% of patients.

Conclusion: The trend for managing nonoperative cervical fractures was an unduly prolonged follow-up duration that included obtaining too many imaging studies.

Keywords: Cervical fracture, Cervical spine, Conservative management, Non-operative, Orthotic

INTRODUCTION

Recent studies have reported that 0.6% of the cumulative risk of cancer to 75 years of age can be attributable to diagnostic X-rays and estimate that 0.4% of cancers in the United States are caused by CT scans.[ 2 , 3 ] Here, in an interest of limiting the number of postoperative X-rays, we analyzed how frequently patients with nonoperative cervical spine fractures underwent postoperative X-ray studies, along with their overall follow-up duration and time to orthosis removal.

MATERIALS AND METHODS

Clinical data

There were 69 patients included in this study (122 fractures) who averaged 58 years of age. The most common mechanism of injury was motor vehicle accidents (n = 27, 39%), followed by falls <1 m (n = 21, 30%). Other variables studied included: patient demographics, average hospital length of stay, and the types of nonoperative cervical fractures treated [ Table 1 , Figures 1 and 2 ]. The Miami J was by far the most common orthotic used (n = 48, 71%), followed by Miami J and CTO (n = 11, 16%) [ Figure 3 ]. Patients were cleared by an IRB committee and were selected utilizing multiple inclusion and exclusion criteria were used [ Supplemental Table 1 ].

Table 1:

Patient data.

Figure 1:

Fracture type totals by cervical level.

Figure 2:

Number of fracture types.

Figure 3:

Orthotics used.

RESULTS

The study revealed that all patients had, on average, four follow-up visits occurred on average 28-, 66-, 94-, and 158-day post hospital discharge [Supplemental Table 2 ]. The average time between hospital discharge and clearance from an orthotic was 70 days [ Table 2 ]. At 28 days, X-rays performed in 57 patients impacted clinical decision-making in four; two with vertebral body fractures, one with a facet fracture, and one with a compression fracture [ Table 2 ]. However, at the second postoperative visit at 66 days, the third visit at 94 days, and the fourth visit at 158 days, repeat X-ray studies did not alter the clinical management of any patient [ Table 2 ]. Of note, the average time between hospital discharge and removal of an orthotic device averaged 70 days [ Table 2 ].

Table 2:

Follow-up information.

Table 3:

Pertinent literature findings.

DISCUSSION

This analysis of the nonoperative management of 69 adults confirmed that only their initial postoperative X-rays obtained at an average of 28-day post discharge impacted their clinical management. All subsequent X-rays obtained at an average of 66-, 94-, and 158-day post discharge did not. Therefore, repeating postoperative X-rays and exposing patients to additional radiation with prolongation of the follow-up period were all unnecessary.

Success of conservative management of C1-C2 fractures

Kontautas et al. and Hadley et al. found that isolated C1 fractures heal well with a cervical collar alone(95% fusion rate).[ 4 , 5 ] Type 1 fractures have been reported to achieve 100% union rates; however, Type 2 fractures are the most common and unfortunately present with high rates of pseudoarthrosis.[ 4 , 6 ] For stable Type 3 fractures, conservative treatment is the standard of care due to high union rates [ Table 3 ].[ 1 ]

In our cohort, none the patients with isolated C1 fractures were followed beyond the second follow-up visit at 66-days, and further imaging never altered the clinical management. For isolated C2 fractures, our cohort consisted of 15 patients; managed with various orthoses with orthotic clearance on average 83-day post discharge [ Figure 2 ]. In our cohort, only two patients had a change in intervention from imaging performed during the first follow-up, and only three were followed beyond the second appointment [ Supplemental Table 2 ]. For the 12 patients with stable Type 3 fractures in our series, X-rays did not change management for any patient during follow-up period, with an average orthotic clearance of 89-day post discharge.

Conservative management of sub-axial fractures

Vedantam et al. reviewed 35 patients with sub-axial facet fractures managed non-operatively (cervical bracing alone) and 82.9% of patients fused successfully.[ 7 ] Of our 56 patients with variable sub-axial fractures managed with various orthotics Eighteen patients (32%) with sub-axial facet fractures were cleared from the orthotic on average 60-day post discharge, or at the second follow-up.

Optimal follow-up for nonsurgical cervical fractures

At present, there are few recommendations regarding the optimal the number/types of imaging studies needed to follow patients with nonoperative cervical fractures and the optimal follow-up duration. Here, in 69 patients, we found that most will undergo a change in therapy/intervention based on X-ray studies obtained at the first follow-up visit, 28-day post discharge. Interestingly, no patients required additional alterations in management based on X-rays obtained on average 66-, 94-, and 158-day post discharge. Nonetheless, as patients typically had cervical orthoses removed an average of 70-day post discharge; the second follow-up visit was likely necessary.

CONCLUSION

When we studied 69 patients treated conservatively for nonoperative cervical spine fractures, we found that X-ray studies obtained on average 28-, 66-, 94-, and 158-day post discharge did not significantly alter patients’ clinical management, but unnecessarily prolonged the follow-up duration.

Declaration of patient consent

Institutional Review Board (IRB) permission obtained for the study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

SUPPLEMENTAL TABLES

Supplemental Table 1:

Inclusion and exclusion criteria.

Supplemental Table 2:

Patient demographics, fracture, bracing, and follow-up data.

References

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2. Brenner DJ, Hall EJ. Computed tomography--an increasing source of radiation exposure. N Engl J Med. 2007. 357: 2277-84

3. de Gonzalez AB, Darby S. Risk of cancer from diagnostic X-rays: Estimates for the UK and 14 other countries. Lancet. 2004. 363: 345-51

4. Hadley MN, Dickman CA, Browner CM, Sonntag VK. Acute traumatic atlas fractures: Management and long term outcome. Neurosurgery. 1988. 23: 31-5

5. Kontautas E, Ambrozaitis KV, Kalesinskas RJ, Spakauskas B. Management of acute traumatic atlas fractures. J Spinal Disord Tech. 2005. 18: 402-5

6. Oh J, Hee HT, Butler .editors. Outcomes of cervical spine injuries following non-operative management. Cervical Spine Injuries: Epidemiology, Long-Term Outcomes and Complications. Hauppauge, New York: Nova Publishers; 2015. p. 19-38

7. Vedantam A, Fridley JS, Navarro JC, Gopinath SP. Management of acute unilateral nondisplaced subaxial cervical facet fractures. Oper Neurosurg (Hagerstown). 2018. 14: 104-11