What is the treatment for a C2 (cervical spine) compression fracture?

Treatment of C2 Compression Fractures

For C2 compression fractures, treatment depends critically on the presence of neurological deficits and spinal instability: patients with neurological compromise or instability require urgent surgical intervention, while neurologically intact patients with stable fractures can be managed conservatively with external immobilization.

Initial Assessment and Risk Stratification

The first priority is determining whether the fracture is stable and whether neurological deficits are present 1, 2:

• Immediate surgical consultation is mandatory for patients presenting with neurological deficits, as delays in decompression lead to worse outcomes 1
• Assess for spinal instability on imaging, which requires immediate surgical referral 2
• Evaluate fracture type using CT imaging—odontoid (dens) fractures represent 50% of all C2 fractures 3

Surgical Management

Surgery is the standard of care for C2 fractures complicated by spinal instability and/or neurological deficits 1:

Indications for Surgery

• Neurological deficits requiring urgent decompression 1
• Spinal cord compression from epidural hemorrhage or retropulsed bone fragments 1
• Unstable fracture patterns 2
• Failed conservative management after 3 months 2

Surgical Approaches

• Type II odontoid fractures: Direct anterior screw fixation of the dens is the procedure of choice 4
• C1-C2 dislocations or certain odontoid fractures: Anterior transarticular screw fixation for C1/C2 fusion 4
• Complex injuries with cord compression: Combined anterior and posterior approach for complete decompression and stabilization 1
• Anterior plate fixation with iliac crest or fibular strut graft for lower C2 body fractures 4, 5

Timing

• Initiate corticosteroid therapy immediately upon presentation with neurological deficits 1
• Perform surgery as soon as possible to prevent further neurological deterioration 1

Expected Outcomes

• Surgical decompression and stabilization improve neurological status and provide pain relief 1
• Most patients with surgically treated fractures return to normal or independent daily living 6

Conservative Management

For neurologically intact patients with stable, non-displaced fractures, external immobilization is appropriate and achieves bony consolidation in over 70% of cases 7:

Immobilization Options

• Philadelphia collar for most stable fractures (used in 80% of conservatively managed cases) 7
• Halo-vest immobilization for 3 months, particularly effective for Type II odontoid fractures in children and adolescents 6, 7
• Halo-thoracic vest reserved for more unstable patterns requiring rigid immobilization 7

Success Rates by Fracture Type

• Type I fractures: Highest consolidation rates with conservative management 7
• Type II odontoid fractures: 71.4% achieve successful ossification with external immobilization 7
• Type III fractures: High consolidation rates with conservative management 7

Duration and Monitoring

• Continue immobilization for 3 months 6, 7
• Perform follow-up CT imaging at 9 months to confirm healing 3
• Reassess at 4-6 weeks to evaluate response to initial treatment 2

Age-Specific Considerations

Pediatric and Adolescent Patients

• Children under 13 years: Higher incidence of atlantoaxial dislocation without fracture, usually requiring fusion procedures 6
• Adolescents over 13 years: Higher incidence of dens fractures, most achieve bony union with halo-vest immobilization 6
• Avoid prolonged immobilization which worsens bone loss and muscle weakness 8

Elderly Patients

• Conservative management with semi-rigid collar is a valuable option for non-displaced Type II fractures without neurological deficits 7
• Consider increased perioperative risk from comorbidities when weighing surgical versus conservative approaches 7

Common Pitfalls and Caveats

• Undetected injuries lead to chronic myelopathy: Proper diagnosis at initial presentation is mandatory to prevent delayed neurological deterioration 6
• Failure to rule out pathologic fractures: Complete spine MRI without and with contrast is indicated if malignancy is suspected 2
• Inadequate immobilization: 23.7% of conservatively managed fractures fail to achieve stability and require subsequent surgery 7
• Delayed surgical referral: Patients with neurological deficits require immediate referral to prevent permanent damage 2
• Atlantoaxial dislocation without fracture: These injuries typically require fusion procedures rather than immobilization alone 6

Adjunctive Management

• Pain control: Calcitonin for the first 4 weeks shows clinically important pain reduction in acute compression fractures 2, 8
• Physical therapy: Focus on maintaining mobility, strengthening core and back muscles, and improving posture once fracture stability is confirmed 8
• Osteoporosis treatment: Address underlying bone health to prevent future fractures 2