What is the appropriate management for a patient with a C2 fracture and cervical spinal stenosis?

Management of C2 Fracture with Cervical Spinal Stenosis

A patient with a C2 fracture and cervical spinal stenosis requires immediate specialist evaluation by a spine surgeon or neurosurgeon, with urgent CT imaging to assess fracture stability and determine whether surgical intervention (SLIC score ≥5) or conservative management is appropriate. 1

Immediate Stabilization and Assessment

• Maintain continuous cervical spine immobilization using manual in-line stabilization combined with removal of only the anterior portion of the cervical collar during any necessary procedures 1, 2

• Use jaw thrust maneuver exclusively for any airway management needs—never use head-tilt/chin-lift, as this produces three times more cervical movement and risks catastrophic cord injury 1, 2

• Require a minimum of four skilled staff for log-rolling and seven for patient transfer to maintain spinal alignment 1, 2

• Assess for neurological deficits immediately, as any neurological deficit attributable to the fracture mandates surgical intervention 1

Imaging Protocol

• Obtain CT imaging immediately with 1.5-2 mm collimation of the entire cervical spine and special attention to the cranio-cervical junction, as plain films alone miss approximately 15% of cervical injuries 1, 2, 3

• Perform MRI if there is concern for ligamentous injury or spinal cord involvement, particularly given the pre-existing stenosis which increases risk of cord compression 4, 3

• Consider CT angiography to evaluate for vertebral artery injury, as C2 fractures (particularly dens fractures and traumatic spondylolisthesis) are specifically associated with vertebral artery injury 5

Treatment Decision Algorithm

Surgical intervention is indicated if: 1

• SLIC (Subaxial Injury Classification) score ≥5
• Any neurological deficit attributable to the fracture
• Evidence of ligamentous disruption causing instability
• Unstable fracture patterns on CT imaging

Conservative management may be appropriate if: 3

• Stable fracture pattern
• No neurological deficit
• No ligamentous disruption
• SLIC score <5

Note that 96% of C2 fracture patients have no neurological deficit, and only 15% require surgery for unstable fractures 3. However, the presence of pre-existing stenosis increases the risk of cord compression and may lower the threshold for surgical intervention.

Critical Movement Restrictions

• Prohibit all neck extension movements, as extension combined with rotation significantly narrows the spinal canal and worsens cord compression in C2 fractures 1, 2

• Avoid any rotational movements of the neck, particularly when combined with extension, as C2 fractures can have rotational instability components 1, 2

• Prevent lateral bending and sudden head turns, as these movements can displace unstable C2 body fractures 2

Specialist Consultation Requirements

Immediate consultation with spine surgery or neurosurgery is mandatory for all C2 fractures with stenosis, as the combination of fracture instability and pre-existing canal narrowing creates high risk for spinal cord injury 6, 7. The specialist will determine:

• Whether anterior, posterior, or combined surgical approach is needed based on fracture pattern and stenosis location 6, 8
• Timing of surgical intervention if indicated
• Duration and type of immobilization if conservative management is chosen

Follow-Up Protocol

• Obtain baseline imaging within the first week after treatment initiation to establish a reference point for fracture alignment 1

• Use CT imaging at 9 months post-injury or post-operation to assess fracture healing and hardware position if surgery was performed 1, 3

• Avoid routine dynamic fluoroscopy in the acute phase (first 6-8 weeks), as neck pain and muscle spasm limit diagnostic utility 1

Critical Pitfalls to Avoid

• Never rely on clinical examination alone to clear the cervical spine, as this has only 85% sensitivity and misses 10-15% of injuries 1, 2

• Do not use high-flow nasal oxygen if basilar skull fracture is suspected due to pneumocephalus risk 1, 2

• Avoid chiropractic manipulation entirely, as high-velocity rotational techniques risk worsening nerve compression and fracture displacement 1, 2

• Do not rely solely on MRI abnormalities to guide prolonged immobilization, as MRI has high sensitivity but poor specificity, potentially leading to unnecessary collar use in 25% of patients 1

• Avoid prolonged immobilization beyond necessary duration, as this causes muscle atrophy, bone density loss, aspiration pneumonia, and thromboembolic complications with mortality rates up to 26.8% in elderly patients 2