J Korean Neurosurg Soc.  2024 Jan;67(1):6-13. 10.3340/jkns.2023.0098.

Current Concepts in the Treatment of Traumatic C2 Vertebral Fracture : A Literature Review

• Lee S
• Hur JW
• Oh Y
• An S
• Yun GY
• Ahn JM

• KMID: 2550454
• DOI: http://doi.org/10.3340/jkns.2023.0098

Abstract

The integrity of the high cervical spine, the transition zone from the brainstem to the spinal cord, is crucial for survival and daily life. The region protects the enclosed neurovascular structure and allows a substantial portion of the head motion. Injuries of the high cervical spine are frequent, and the fractures of the C2 vertebra account for approximately 17–25% of acute cervical fractures. We review the two major types of C2 vertebral fractures, odontoid fracture and Hangman’s fracture. For both types of fractures, favorable outcomes could be obtained if the delicately selected conservative treatment is performed. In odontoid fractures, as the most common fracture on the C2 vertebrae, anterior screw fixation is considered first for type II fractures, and C1–2 fusion is suggested when nonunion is a concern or occurs. Hangman's fractures are the second most common fracture. Many stable extension type I and II fractures can be treated with external immobilization, whereas the predominant flexion type IIA and III fractures require surgical stabilization. No result proves that either anterior or posterior surgery is superior, and the surgeon should decide on the surgical method after careful consideration according to each clinical situation. This review will briefly describe the basic principles and current treatment concepts of C2 fractures.

Keyword

Cervical vertebra axis; Hangman’s fracture; Odontoid process; Spinal injuries; Spinal fractures

Figure

• 

  Fig. 1. Grauer’s treatment-oriented classification of odontoid fractures. Type I, above inferior aspect of C1 anterior arch; type IIA, transverse fracture without comminution and displacement <1 mm; type IIB, anterior superior to posterior inferior transverse fracture and/or displacement >1 mm; type IIC, anterior inferior to posterior superior or comminuted fracture; type III, including at least one of the superior articular facets of C2. The illustration was drawn by the authors based on spine images with existing sources. The upper illustration is based on "Cervical Vertebrae C2 Axis White" (https://www.pixelsquid.com/png/cervical-vertebrae-c2-axis-white-2304465720911599106?image=G03), and the lower on "Real Cervical Vertebrae C2 Axis 01 3D model" (https://www.turbosquid.com/3d-models/cervical-vertebrae-c2-axis-3d-model-1520453).

• 

  Fig. 2. Levine-Edwards Hangman's fracture classification. The anterior translation is measured as the distance between a line drawn parallel to the posterior margin of the body of the C3 and the posterior margin of the body of the C2 at the level of the disc space between the C2 and C3. Angulation is calculated as the angle between the inferior endplate of the C2 and the inferior endplate of the C3. The illustration was drawn by the authors based on spine images with existing source (www.MedicalGraphics.de, the license (CC BY-ND 4.0 EN).

• 

  Fig. 3. A : A 71-year-old male patient visited the emergency room after a fall down. He was diagnosed with Hangman's fracture on the initial computed tomography. The dislocated C2 vertebra protrudes anteriorly from the C3 vertebra. According to the literature, anterior-posterior combined surgery is being considered; (B) after successful reduction with an anterior approach, C2–3 interbody fusion and plate fixation was performed; (C) on the fifth postoperative day, re-dislocation with cage migration and screw pull-out occurred; (D) on the sixth day after surgery, posterior C2–3 screw fixation surgery was additionally performed for reduction and stabilization.

Reference

References

1. Agrillo A, Russo N, Marotta N, Delfini R. Treatment of remote type ii axis fractures in the elderly: feasibility of anterior odontoid screw fixation. Neurosurgery. 63:1145–1150. discussion 1150-1151. 2008.

2. Alves OL, Pereira L, Kim SH, Grin A, Shimokawa N, Konovalov N, et al. Upper cervical spine trauma: WFNS spine committee recommendations. Neurospine. 17:723–736. 2020.

3. An S, Hyun SJ. Pediatric spine trauma. J Korean Neurosurg Soc. 65:361–369. 2022.

4. Anderson LD, D'Alonzo RT. Fractures of the odontoid process of the axis. J Bone Joint Surg Am. 56:1663–1674. 1974.

5. Apuzzo ML, Heiden JS, Weiss MH, Ackerson TT, Harvey JP, Kurze T. Acute fractures of the odontoid process. An analysis of 45 cases. J Neurosurg. 48:85–91. 1978.

6. Arand M, Neller S, Kinzl L, Claes L, Wilke HJ. The traumatic spondylolisthesis of the axis. A biomechanical in vitro evaluation of an instability model and clinical relevant constructs for stabilization. Clin Biomech (Bristol, Avon). 17:432–438. 2002.

7. Asemota AO, Ahmed AK, Purvis TE, Passias PG, Goodwin CR, Sciubba DM. Analysis of cervical spine injuries in elderly patients from 2001 to 2010 using a nationwide database: increasing incidence, overall mortality, and inpatient hospital charges. World neurosurg. 120:e114–e130. 2018.

8. Bhimani AD, Chiu RG, Esfahani DR, Patel AS, Denyer S, Hobbs JG, et al. C1-C2 fusion versus occipito-cervical fusion for high cervical fractures: a multi-institutional database analysis and review of the literature. World Neurosurg. 119:e459–e466. 2018.

9. Byeon Y, Lee BJ, Park JH. Freehand placement of the c1 pedicle screw using direct visualization of the pedicle anatomy and serial dilatation. Korean J Neurotrauma. 16:207–215. 2020.

10. Cho DC, Sung JK. Is all anterior oblique fracture orientation really a contraindication to anterior screw fixation of type II and rostral shallow type III odontoid fractures? J Korean Neurosurg Soc. 49:345–350. 2011.

11. Cho DC, Sung JK. Analysis of risk factors associated with fusion failure after anterior odontoid screw fixation. Spine (Phila Pa 1976). 37:30–34. 2012.

12. Duggal N, Chamberlain RH, Perez-Garza LE, Espinoza-Larios A, Sonntag VK, Crawford NR. Hangman's fracture: a biomechanical comparison of stabilization techniques. Spine (Phila Pa 1976). 32:182–187. 2007.

13. Effendi B, Roy D, Cornish B, Dussault RG, Laurin CA. Fractures of the ring of the axis. A classification based on the analysis of 131 cases. J Bone Joint Surg Br. 63-B:319–327. 1981.

14. Fassett DR, Dailey AT, Vaccaro AR. Vertebral artery injuries associated with cervical spine injuries: a review of the literature. J Spinal Disord Tech. 21:252–258. 2008.

15. Fountas KN, Kapsalaki EZ, Karampelas I, Feltes CH, Dimopoulos VG, Machinis TG, et al. Results of long-term follow-up in patients undergoing anterior screw fixation for type II and rostral type III odontoid fractures. Spine (Phila Pa 1976). 30:661–669. 2005.

16. Golob JF Jr, Claridge JA, Yowler CJ, Como JJ, Peerless JR. Isolated cervical spine fractures in the elderly: a deadly injury. J Trauma. 64:311–315. 2008.

17. Grauer JN, Shafi B, Hilibrand AS, Harrop JS, Kwon BK, Beiner JM, et al. Proposal of a modified, treatment-oriented classification of odontoid fractures. Spine J. 5:123–129. 2005.

18. Hadley MN, Dickman CA, Browner CM, Sonntag VK. Acute axis fractures: a review of 229 cases. J Neurosurg. 71(5 Pt 1):642–647. 1989.

19. Huybregts JG, Jacobs WC, Vleggeert-Lankamp CL. The optimal treatment of type II and III odontoid fractures in the elderly: a systematic review. Eur Spine J. 22:1–13. 2013.

20. Jang D, Kim C, Lee SJ, Kim J. Delayed brain infarction due to bilateral vertebral artery occlusion which occurred 5 days after cervical trauma. J Korean Neurosurg Soc. 56:141–145. 2014.

21. Kalantar SB. Fractures of the C1 and C2 vertebrae. Semin Spine Surg. 25:23–35. 2013.

22. Kim BS, Yoo DS, Huh PW, Cho KS, Lee SB. Atlantoaxial transpedicular screw fixation for the management of traumatic upper cervical spine instability. J Korean Neurotraumatol Soc. 6:143–149. 2010.

23. Kim D, Jang Y, Whang K, Kim J, Cho S. Emergent vertebral artery embolization during C12 screw fixation for rheumatoid arthritis. Korean J Neurotrauma. 17:199–203. 2021.

24. Lee BJ, Kim M, Jeong SK, Lee S, Jeon SR, Roh SW, et al. Comparison of the accuracy of C1 pedicle screw fixation using fluoroscopy and freehand techniques in patients with posterior arch thickness of less than 4 mm. Oper Neurosurg (Hagerstown). 19:429–435. 2020.

25. Lee JS, Son DW, Lee SH, Ki SS, Lee SW, Song GS. comparative analysis of surgical outcomes of C1-2 fusion spine surgery between intraoperative computed tomography image based navigation-guided operation and fluoroscopy-guided operation. J Korean Neurosurg Soc. 63:237–247. 2020.

26. Lee S, Hur JW, Lee JB, Park JH, Park D, Park SJ, et al. Radiological evaluation of atlantoaxial fusion using C2 translaminar screws and C2 pedicle screws: does the screw halo sign imply fusion failure? Medicine (Baltimore). 101:e31496. 2022.

27. Lee SH, Park DH, Kim SD, Huh DS, Kim KT. Analysis of 3-dimensional course of the intra-axial vertebral artery for C2 pedicle screw trajectory: a computed tomographic study. Spine (Phila Pa 1976). 39:E1010–E1014. 2014.

28. Lee SH, Sung JK. Anterior odontoid fixation using a 4.5-mm Herbert screw: the first report of 20 consecutive cases with odontoid fracture. Surg Neurol. 66:361–366. discussion 366. 2006.

29. Levine AM, Edwards CC. The management of traumatic spondylolisthesis of the axis. J Bone Joint Surg Am. 67:217–226. 1985.

30. Li G, Wang Q, Liu H, Hong Y. Individual surgical strategy using posterior lag screw-rod technique for unstable atypical Hangman's fracture based on different fracture patterns. World Neurosurg. 119:e848–e854. 2018.

31. Li XF, Dai LY, Lu H, Chen XD. A systematic review of the management of hangman's fractures. Eur Spine J. 15:257–269. 2006.

32. Liu J, Li Y, Wu Y. One-stage posterior C2 and C3 pedicle screw fixation or combined anterior C2-C3 fusion for the treatment of unstable hangman's fracture. Exp Ther Med. 5:667–672. 2013.

33. Longo UG, Denaro L, Campi S, Maffulli N, Denaro V. Upper cervical spine injuries: indications and limits of the conservative management in Halo vest. A systematic review of efficacy and safety. Injury. 41:1127–1135. 2010.

34. Maserati MB, Stephens B, Zohny Z, Lee JY, Kanter AS, Spiro RM, et al. Occipital condyle fractures: clinical decision rule and surgical management. J Neurosurg Spine. 11:388–395. 2009.

35. Menendez JA, Wright NM. Techniques of posterior C1-C2 stabilization. Neurosurgery. 60(1 Suppl 1):S103–S111. 2007.

36. Murphy H, Schroeder GD, Shi WJ, Kepler CK, Kurd MF, Fleischman AN, et al. Management of Hangman's fractures: a systematic review. J Orthop Trauma 31 Suppl. 4:S90–S95. 2017.

37. Park JH, Kang DH, Lee MK, Yoo B, Jung SK, Hwang SH, et al. Advantages of direct insertion of a straight probe without a guide tube during anterior odontoid screw fixation of odontoid fractures. Spine (Phila Pa 1976). 41:E541–547. 2016.

38. Park JW, Kim KT, Sung JK, Park SH, Seong KW, Cho DC. Biomechanical comparison of inter-fragmentary compression pressures: lag screw versus Herbert screw for anterior odontoid screw fixation. J Korean Neurosurg Soc. 60:498–503. 2017.

39. Platzer P, Thalhammer G, Ostermann R, Wieland T, Vécsei V, Gaebler C. Anterior screw fixation of odontoid fractures comparing younger and elderly patients. Spine (Phila Pa 1976). 32:1714–1720. 2007.

40. Pommier B, Ollier E, Pelletier JB, Castel X, Vassal F, Tetard MC. Conservative versus surgical treatment for odontoid fracture: is the surgical treatment harmful? Systematic review and meta-analysis. World Neurosurg. 141:490–499.e2. 2020.

41. Prost S, Barrey C, Blondel B, Fuentes S, Barresi L, Nicot B, et al. Hangman's fracture: management strategy and healing rate in a prospective multi-centre observational study of 34 patients. Orthop Traumatol Surg Res. 105:703–707. 2019.

42. Robinson AL, Olerud C, Robinson Y. Epidemiology of C2 fractures in the 21st century: a national registry cohort study of 6,370 patients from 1997 to 2014. Adv Orthop. 2017:6516893. 2017.

43. Schroeder GD, Kepler CK, Kurd MF, Paul JT, Rubenstein RN, Harrop JS, et al. A systematic review of the treatment of geriatric type II odontoid fractures. Neurosurgery 77 Suppl. 4:S6–S14. 2015.

44. Shim YW, Paeng SH, Lee KS, Kim ST, Lee WH. Trigeminal neuralgia resulting from delayed cervical cord compression after acute traumatic fracture of odontoid process. Korean J Neurotrauma. 15:38–42. 2019.

45. Son JI, An TY, Ko MJ, Park SW, Lee YS. Occlusion of both vertebral arteries with development of collateral circulation from the deep cervical artery after cervical spine trauma. Korean J Neurotrauma. 18:374–379. 2022.

46. Southwick WO. Management of fractures of the dens (odontoid process). J Bone Joint Surg Am. 62:482–486. 1980.

47. Subach BR, Morone MA, Haid RW Jr, McLaughlin MR, Rodts GR, Comey CH. Management of acute odontoid fractures with single-screw anterior fixation. Neurosurgery. 45:812–819. discussion 819-820. 1999.

48. Sung MJ, Kim KT, Hwang JH, Sung JK, Cho DC. Safe margin beyond dens tips to ventral dura in anterior odontoid screw fixation : analysis of three-dimensional computed tomography scan of odontoid process. J Korean Neurosurg Soc. 61:503–508. 2018.

49. Turtle J, Kantor A, Spina NT, France JC, Lawrence BD. Hangman’s fracture. Clin Spine Surg. 33:345–354. 2020.

50. Vaccaro AR, Madigan L, Ehrler DM. Contemporary management of adult cervical odontoid fractures. Orthopedics. 23:1109–1113. quiz 1114-1115. 2000.

51. Wu YS, Lin Y, Zhang XL, Tian NF, Sun LJ, Xu HZ, et al. Management of hangman’s fracture with percutaneous transpedicular screw fixation. Eur Spine J. 22:79–86. 2013.

52. Yi HJ. Epidemiology and management of iatrogenic vertebral artery injury associated with cervical spine surgery. Korean J Neurotrauma. 18:34–44. 2022.