What are the symptoms and management of C2 (cervical spine) fractures?

C2 Fractures: Symptoms and Management

C2 (axis) fractures require a balanced approach between conservative and surgical management, with most cases (approximately 85%) being successfully treated conservatively, while only a minority require surgical intervention for unstable fractures.

Clinical Presentation

Symptoms

• Pain in the upper cervical spine region
• Neck stiffness and limited range of motion
• Headache, particularly at the base of the skull
• Neurological symptoms (rare, present in only ~4% of cases) 1
  • Weakness or numbness in extremities
  • Difficulty with balance or ambulation
  • Bowel or bladder dysfunction (in severe cases)

Physical Examination Findings

• Tenderness over the upper cervical spine
• Restricted neck movement
• Possible neurological deficits (uncommon)
• Torticollis or abnormal head position in some cases

Diagnostic Evaluation

• CT scan of the cervical spine - Gold standard for diagnosis and classification 1

  • Special attention to the cranio-cervical junction
  • Evaluates fracture pattern, displacement, and stability

• MRI of the cervical spine - Indicated to assess:

  • Ligamentous injuries
  • Spinal cord compression or injury
  • Bone marrow edema 2

• Angiography - Consider when vascular injury is suspected 1

Classification of C2 Fractures

1. Odontoid fractures (50% of C2 fractures) 1

   • Type I: Fracture through the tip of the odontoid
   • Type II: Fracture at the base of the odontoid
   • Type III: Fracture extending into the body of C2

2. Hangman's fractures (Traumatic spondylolisthesis of C2)

   • Bilateral fractures through the pars interarticularis

3. C2 body fractures

   • Including pedicles, laminae, lateral masses, and articular processes 1

4. Tear-drop fractures

   • Often caused by compressive hyperextension injury 3

Management Approach

Initial Management

• Cervical spine immobilization
• Careful airway management
  • Jaw thrust is preferred over head tilt with chin lift to minimize cervical spine movement 4
  • Avoid excessive manipulation of the cervical spine

Conservative Management (85% of cases) 1

• External immobilization options:

  • Rigid cervical collar for stable fractures
  • Halo vest immobilization for more unstable fractures but amenable to non-surgical treatment 5
  • Duration typically 8-12 weeks

• Pain management:

  • Analgesics
  • Activity modification
  • Gradual mobilization as pain allows 2

• Rehabilitation:

  • Early introduction of physical training and muscle strengthening
  • Long-term continuation of balance training 4

Surgical Management (15% of cases) 1

• Indications for surgery:

  • Unstable fractures
  • Significant displacement
  • Neurological deficit
  • Failed conservative management
  • Atlanto-axial instability

• Surgical options:

  • Posterior fusion (C1-C2 or occipito-cervical)
  • Anterior approach with plate fixation for certain fracture types 3
  • Transoral approach for irreducible anterior compression
  • Minimally invasive techniques:
    • Percutaneous screw fixation
    • Cementoplasty with screw fixation for osteolytic lesions 4

Special Considerations for Elderly Patients

• Higher risk of complications with halo immobilization
• Philadelphia collar may be considered in select cases when halo immobilization is contraindicated 5
• Posterior cervical fusion should be strongly considered for initial therapy in fracture types unlikely to heal with external immobilization alone 5
• Calcium (1000-1200 mg/day) and vitamin D (800 IU/day) supplementation for osteoporotic patients 2

Follow-up Care

• Regular clinical and radiological follow-up (every 3 months for 1 year) 1
• CT imaging at 9 months post-injury to confirm healing 1
• Continued rehabilitation to restore function and prevent complications

Prognosis

• Most patients with C2 fractures have good outcomes with appropriate treatment
• Neurological recovery is excellent in most cases
• Surgical intervention leads to early and complete healing in cases requiring operation 1
• Road traffic accidents account for the majority of cases (92%), with young males being most commonly affected 1

Complications

• Pseudarthrosis (non-union)
• Progressive deformity
• Chronic pain
• Neurological deterioration (rare)
• Hardware failure in surgically treated cases

The management of C2 fractures requires careful assessment of fracture stability and patient factors to determine the optimal treatment approach, with the goal of achieving fracture healing while minimizing complications and preserving neurological function.