Fractures of the C1 and C2 Vertebrae

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

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.

Case report: Interdisciplinary treatment of complex C1/C2 fractures in a patient with concomitant three-vessel coronary artery disease requiring bypass surgery

Background

Acute myocardial infarction (MI) frequently leads to consciousness disturbance following hemodynamic collapse. Therefore, MI can occur together with upper cervical spine trauma. Herein, we report the successful treatment of complex C1/C2 fractures in a patient with concomitant three-vessel coronary artery disease (CAD).

Case presentation

A 70-year-old patient presented in our emergency outpatient clinic after a hemodynamic collapse without neurological deficits or heart-related complaints. Computed tomography (CT) scan of the cervical spine revealed a dislocated odontoid fracture Anderson and D'Alonzo type II and an unstable Gehweiler type III injury (Jefferson's fracture). An intradiploic arachnoid cyst in the posterior wall of the posterior fossa was a coincident radiological finding. Furthermore, coronary angiography confirmed three-vessel CAD with high-grade coronary artery stenosis. Indication for upper cervical spine surgery and bypass surgery was given. An interdisciplinary team of neurosurgeons, cardiothoracic surgeons and anesthesiologists evaluated the patient's case to develop the most suitable therapy concept and alternative strategies. Finally, in first step, C1-C2 fusion was performed by Harms technique under general anesthesia with x-ray guidance, spinal neuronavigation, Doppler ultrasound and cardiopulmonary monitoring. Cardiothoracic surgeons were on standby. One month later bypass surgery was performed uneventfully. Follow-up CT scan of cervical spine revealed intraosseous screw positioning and beginning fusion of the fractures. The patient did not develop neurological deficits and recovered completely from both surgeries.

Conclusions

Treating complex C1/C2 fractures with concomitant severe CAD requiring treatment is challenging and carries a high risk of complications. To our knowledge, the literature does not provide any guidelines regarding therapy of this constellation. To receive upper cervical spine stability and to prevent both, spinal cord injury and cardiovascular complications, an individual approach is required. Interdisciplinary cooperation to determine optimal therapeutic algorithms is needed.

Biomechanical comparison of a C1 posterior arch clamp with C1 lateral mass screws in constructs for C1-C2 fusion

The aim of this experimental study was to assess the biomechanical performance of a novel C1 posterior arch (C1PA) clamp compared with C1 lateral mass (C1LM) screws in constructs used to treat atlantoaxial instability. These constructs had either C2 pedicle (C2P) screws or C2 translaminar (C2TL) screws. Eight fresh-frozen human cadaveric ligamentous spine specimens (C0-C3) were tested under six conditions: the intact state, the destabilized state after a simulated odontoid fracture, and when instrumented with four constructs (C1LM-C2P, C1LM-C2TL, C1PA-C2P, C1PA-C2TL). Each specimen was tested in a spinal loading simulator that separately applied axial rotation, flexion-extension and lateral bending. In each test condition, displacement controlled angular motion was applied in both directions at a speed of 2 deg/s until a resulting moment of 1.5 Nm was achieved. The measured ranges of motion (ROM) of the C1-C2 segments were compared for each test condition using nonparametric Friedman tests. The destabilized state had significantly more C1-C2 motion (p < 0.05) than the intact state in all cases, and all constructs greatly reduced this motion. C2 pedicle screw constructs that used the C1PA clamp had significantly less C1-C2 motion (p < 0.05) than those with C1LM screws in flexion-extension as well as axial rotation and no statistically significant difference was detected in lateral bending. C2 translaminar screw constructs that used the C1PA clamp had significantly less C1-C2 motion (p < 0.05) than those with C1LM screws in flexion-extension and no statistically significant difference was detected in axial rotation or in lateral bending. Data from the current study suggested that constructs using the novel C1PA clamp would provide as good, or improved, biomechanical stability to the C1-C2 segment compared with constructs using C1LM screws.

C1 and C2 Fractures Above a Previous Fusion Treated with Internal Fixation without Fusion: A Case Report

CASE

A 71-year-old woman sustained C1 lateral mass and type 2 odontoid fractures 3 years after C2-T2 anterior-posterior fusion. She was treated with C1-C4 instrumentation without fusion for 9 months followed by instrumentation removal to restore atlantoaxial motion. After instrumentation removal, she maintained clinically relevant cervical lateral bending, rotation, and flexion and extension.

CONCLUSION

The loss of upper cervical motion after C1-C2 instrumented fusion may be debilitating for patients in the setting of previous subaxial cervical fusion. Temporary instrumentation without fusion may allow for preservation of upper cervical motion in patients with concomitant C1 and C2 fractures above a previous cervical fusion.

Predictors of 30-Day Outcomes in Octogenarians with Traumatic C2 Fractures Undergoing Surgery

BACKGROUND

Predictors of surgical outcomes following traumatic axis (C2) fractures in octogenarians remain undercharacterized.

METHODS

Patients age ≥80 years undergoing cervical spine surgery following traumatic C2 fractures were extracted from the National Sample Program of the National Trauma Data Bank (2003-2012). Outcomes include overall inpatient complications, individual complications with an incidence >1%, hospital length of stay (HLOS), discharge disposition, and mortality. Demographics, comorbidities, and injury predictors were analyzed using multivariable regression. Odds ratios (OR), mean differences, and 95% confidence intervals (CIs) were calculated. Statistical significance was assessed at P < 0.05.

RESULTS

The cohort of 442 patients was 48.6% male and had a mean age of 84.3 ± 2.7 years. The distribution of admissions was 42.3% to the hospital floor, 40.3% to the intensive care unit (ICU), 7.7% to telemetry, 2.0% to the operating room, and 7.7% to other/unknown. Mortality was 9.7%, mean HLOS was 13.1 ± 9.2 days, the rate of complications was 38.5%, and 81.5% of survivors were discharged to a nonhome facility. Injury severity was predictive of mortality and overall complications. History of bleeding disorder/coagulopathy predicted mortality (OR, 4.02; 95% CI, 1.07-15.05), overall complications (OR, 3.01; 95% CI, 1.09-8.32), cardiac arrest (OR, 8.19; 95% CI, 1.06-63.54), and renal complications (OR, 10.36; 95% CI, 2.13-50.38). History of congestive heart failure predicted mortality (OR, 3.10; 95% CI, 1.10-8.69). ICU admission (vs. floor) predicted overall complications (OR, 2.01; 95% CI, 1.23-3.27) and pneumonia (OR, 4.65; 95% CI, 1.91-11.30). Telemetry admission (vs. floor) predicted unplanned intubation (OR, 7.76; 95% CI, 1.24-48.49).

CONCLUSIONS

In this cohort of octogenarians undergoing surgery for traumatic C2 fracture, injury severity and a history of bleeding disorder/coagulopathy were identified as risk factors for inpatient complications and mortality. Heightened surveillance should be considered for ICU and/or telemetry admissions for the development of complications. These findings warrant consideration by the clinician, patient, and family to inform clinical decisions and goals of care.

Unstable C1 Fracture Managed with Internal Fixation Using Lateral Mass Screws: A Case Report

CASE

A 47-year-old woman presented with an unstable C1 fracture after falling down several stairs. She was found to have a sagittal split fracture of the right C1 lateral mass extending into the posterior arch. The fracture was treated with a direct posterior osteosynthesis of C1 using lateral mass screws.

CONCLUSION

Surgical management of unstable C1 fractures has traditionally involved posterior fusion of C1 to C2 or fusion from the occiput to C2. These fusion procedures can be quite functionally limiting. Recently, direct osteosynthesis of C1 has been shown to be an effective, motion-preserving alternative.

National trends of incidence, treatment, and hospital charges of isolated C-2 fractures in three different age groups

OBJECT

Incidence of C-2 fracture is increasing in elderly patients. Patient age also influences decision making in the management of these fractures. There are very limited data on the national trends of incidence, treatment interventions, and resource utilization in patients in different age groups with isolated C-2 fractures. The aim of this study is to investigate the incidence, treatment, complications, length of stay, and hospital charges of isolated C-2 fracture in patients in 3 different age groups by using the Nationwide Inpatient Sample (NIS) database. methods The data were obtained from NIS from 2002 to 2011. Data on patients with closed fractures of C-2 without spinal cord injury were extracted using ICD-9-CM diagnosis code 805.02. Patients with isolated C-2 fractures were identified by excluding patients with other associated injuries. The cohort was divided into 3 age groups: < 65 years, 65–80 years, and > 80 years. Incidence, treatment characteristics, inpatient/postoperative complications, and hospital charges (mean and total annual charges) were compared between the 3 age groups.

RESULTS

A total of 10,336 patients with isolated C-2 fractures were identified. The majority of the patients were in the very elderly age group (> 80 years; 42.3%) followed by 29.7% in the 65- to 80-year age group and 28% in < 65-year age group. From 2002 to 2011, the incidence of hospitalization significantly increased in the 65- to 80-year and > 80-year age groups (p < 0.001). However, the incidence did not change substantially in the < 65-year age group (p = 0.287). Overall, 21% of the patients were treated surgically, and 12.2% of the patients underwent nonoperative interventions (halo and spinal traction). The rate of nonoperative interventions significantly decreased over time in all age groups (p < 0.001). Regardless of treatment given, patients in older age groups had a greater risk of inpatient/postoperative complications, nonroutine discharges, and longer hospitalization. The mean hospital charges were significantly higher in older age groups (p < 0.001).

CONCLUSIONS

The incidence of hospitalization for isolated C-2 fractures is progressively increasing in older age groups. Simultaneously, there has been a steadily decreasing trend in the preference for nonoperative interventions. Due to more complicated hospital stay, longer hospitalizations, and higher rates of nonroutine discharges, the patients in older age groups seem to have a higher propensity for greater health care resource utilization.