An Emergency Medicine Disposition Challenge: A Scoping Review of Isolated Transverse Process Fractures of the...

Isolated cervical transverse process fractures (TPFs) are increasingly identified in trauma. Although generally considered stable and nonoperative, current guidelines provide inconsistent recommendations on when to pursue spine consultation or computed tomography angiography (CTA) to assess for blunt cerebrovascular injury (BCVI). This scoping review aimed to determine which clinical or radiographic features of isolated cervical TPFs have been used or reported in association with spine consultation and/or BCVI screening.

A comprehensive search of 5 databases and gray literature was conducted. Eligible studies included outcomes related to spine stability or BCVI. Data extraction focused on spine consultation, imaging, fracture characteristics, management, and BCVI related outcomes. Risk of bias was assessed using the ROBINS-E tool, and certainty of evidence was evaluated using the Grading of Recommendations Assessment, Development and Evaluation methodology. A narrative synthesis was performed due to heterogeneity.

Nine studies met inclusion criteria, comprising approximately 129 cases of isolated cervical TPFs. All fractures were managed nonoperatively, with variable collar usage. No studies explicitly reported rates of spinal instability or spine consultation. CTA use was variable, reflecting differences in imaging protocols. BCVI rates ranged from 0% to 23%, with multiple TPFs and fractures involving the transverse foramen (TF) being more frequent in cases positive for BCVI. Certainty of evidence for both outcomes was rated as very low due to methodological limitations and inconsistent reporting.

Although there is insufficient evidence to make definitive recommendations on spine consultation or CTA for isolated cervical TPFs, available studies report exclusively nonoperative management without documented instability; however, the certainty of this evidence is very low. Multiple TPFs and fractures involving the TF were more frequently reported among BCVI cases, though findings were inconsistent. These findings suggest that emergency physicians should consider CTA in cases of multiple TPFs or TF involvement, while routine spine consultation for lesser injuries may be unnecessary; however, given the very low certainty of available evidence and medicolegal considerations surrounding spinal fractures, future prospective research is needed to support evidence-based guidelines and impact clinical practice.