Fractures of C2 (Axis) Vertebra: Clinical Presentation and Management

Abstract

Background: Injuries of the upper cervical spine are a major cause of morbidity and mortality due to associated spinal cord and head injuries. The injury patterns of the upper cervical spine are numerous, and the neurologic sequelae are diverse. The axis (C2) is the most commonly fractured vertebra in the upper cervical spine; its unique anatomy and architecture pose difficulties in the diagnosis and the management of its fractures.Methods: All cases of acute spinal injuries at Prince Mohammed Bin Abdulaziz Hospital in Riyadh, Saudi Arabia, were screened for fractures of C2 vertebrae. These patients underwent computerized tomography (CT) imaging of the cervical spine with special attention paid to the cranio-cervical junction. Magnetic resonance imaging (MRI) and angiography of the neck were performed to exclude ligamentous tears and vascular injuries. Unstable fractures were fixed surgically. In the remaining cases, a conservative trial was given. All patients were followed up once every 3 months for a period of 1 year. During follow-up, some patients underwent additional CT imaging of the cervical spine to monitor the healing of fractures.Results: Out of 230 spinal trauma patients, 43.5% suffered from cervical spine injury. C2 fractures were recorded in 26% cases, and fractures of the C2 vertebral body, including pedicles, laminae, lateral masses, and articular processes, were found in many cases, followed by odontoid fractures (50%). No case of atlanto-axial or atlanto-occipital dislocation was recorded. Road traffic accidents were found to be responsible for 92% of cases. The majority of patients were young males, and 96% of patients had no neurological deficit. Only 15% of the patients required surgery for their unstable fractures. Half of the patients attended outpatient follow -up appointments, all of whom underwent CT scanning of the cervical spine 9 months after the accident or operation.Conclusions: The axis (C2) is the most commonly affected vertebra in cervical spine trauma, and odontoid fractures make up 50% of all C2 fractures. C2 fractures rarely cause any neurological deficit or vascular injury, and the majority of affected patients can be managed conservatively; only a small proportion requires surgical intervention. Surgical intervention leads to early and complete healing.

Case Report: posterior approach with sub-laminar wiring as management of comminuted fracture of the odontoid process of the axis

“…OF account for approximately one-third of all cervical spine fractures, constituting 18% of cases in the general population and more than 50% in adults over 80 years of age. 5,11 Anderson and D'Alonzo (1974) classified the OFs of C2 into three main types: type I, which are oblique fractures in the apical region of the odontoid process; type II occurring at the junction of the odontoid process with the vertebral body; and type III, which are fractures that pass through the vertebral body. 2,5,14 Type II OFs are the most frequent.…”

“…The anatomy and location of this complex along with the transfer of kinetic energy contribute to a wide variety of fractures. 11,17 The technique of choice was the posterior approach, which involves the loss of lateral rotation of the atlantoaxial joint. The patient was informed of the potential sequelae and agreed to undergo the surgical procedure, judging that the benefits outweigh the surgical risks.…”

“…However, the most efficient treatment strategy is still under debate. 11 The traumatism in the odontoid process of C2 was treated conservatively until 1910, when posterior fixation with wires began to be used as a surgical treatment, a procedure that has evolved since it was first described by Mixter and Osgood. 9,12 The aim of this case report was to describe the surgical experience and favorable evolution in the treatment of a young patient with multiple OF of the axis, in which early age of presentation and causative mechanism in most cases are the cause of death.…”

Analysis of radiological measurement parameters that can predict the type of treatment to be applied in odontoid fractures: Clinical research

“…[ 7 ] Although conservative treatment is preferred for some fracture types (especially Type I and Type III) and surgical intervention is generally recommended, especially for Type II fractures through an anterior or posterior approach, the assessment and treatment of these patients remains a controversial issue. [ 8 9 10 ]…”

Epidemiology of C2 fractures in the United States: A National Electronic Injury Surveillance System database study

“…[ 4 5 ] Younger patients often sustain injuries to the lower cervical vertebra secondary to motor vehicle collisions (MVCs), while elderly patients commonly suffer injuries of the upper cervical vertebrae due to falls. [ 2 4 5 6 7 8 ] Overall, upper cervical fractures comprise approximately 25%–40% of all cervical trauma across all age groups. [ 4 ] Specifically, fractures of the axis (C2 vertebra) are the most common cervical spine fracture, especially in the elderly.…”