Fractures of C2 (Axis) Vertebra: Clinical Presentation and Management

Background Injuries of the upper cervical spine are a major cause of morbidity and mortality due to associated spinal cord and head injuries. The injury patterns of the upper cervical spine are numerous, and the neurologic sequelae are diverse. The axis (C2) is the most commonly fractured vertebra in the upper cervical spine; its unique anatomy and architecture pose difficulties in the diagnosis and the management of its fractures.

Methods All cases of acute spinal injuries at Prince Mohammed Bin Abdulaziz Hospital in Riyadh, Saudi Arabia, were screened for fractures of C2 vertebrae. These patients underwent computerized tomography (CT) imaging of the cervical spine with special attention paid to the cranio-cervical junction. Magnetic resonance imaging (MRI) and angiography of the neck were performed to exclude ligamentous tears and vascular injuries. Unstable fractures were fixed surgically. In the remaining cases, a conservative trial was given. All patients were followed up once every 3 months for a period of 1 year. During follow-up, some patients underwent additional CT imaging of the cervical spine to monitor the healing of fractures.

Results Out of 230 spinal trauma patients, 43.5% suffered from cervical spine injury. C2 fractures were recorded in 26% cases, and fractures of the C2 vertebral body, including pedicles, laminae, lateral masses, and articular processes, were found in many cases, followed by odontoid fractures (50%). No case of atlanto-axial or atlanto-occipital dislocation was recorded. Road traffic accidents were found to be responsible for 92% of cases. The majority of patients were young males, and 96% of patients had no neurological deficit. Only 15% of the patients required surgery for their unstable fractures. Half of the patients attended outpatient follow -up appointments, all of whom underwent CT scanning of the cervical spine 9 months after the accident or operation.

Conclusions The axis (C2) is the most commonly affected vertebra in cervical spine trauma, and odontoid fractures make up 50% of all C2 fractures. C2 fractures rarely cause any neurological deficit or vascular injury, and the majority of affected patients can be managed conservatively; only a small proportion requires surgical intervention. Surgical intervention leads to early and complete healing.