What is C2 Fractures?
Studies show that the occurrence of C2 fractures, which are fractures of the second cervical bone in the spine, is about 6 in every 100,000 people. In Sweden, among 6,370 patients with this type of fracture, over half were men, and the average age was 72. Those who were younger, male, and had a spinal cord injury were more likely to need surgery. In children, injuries to the first and second cervical bones made up 7.7% of all spinal fractures. These were usually the result of multiple forceful impacts.
What Causes C2 Fractures?
Blunt trauma, which means injury caused by a blunt force or impact, is the most common cause of injuries. This often happens due to falls, car accidents, physical assaults, and other types of incidents. It’s crucial to understand that in older people, even low-energy injuries to the neck can cause severe and unstable neck fractures.
Risk Factors and Frequency for C2 Fractures
The number of C2 fractures, a type of neck injury, in the Medicare population went up by 135% between 2000 and 2011. These injuries can be quite serious, leading to a 20% increased risk of death within 3 months and a 40% increased risk within 2 years. The most common type of C2 fractures is known as type-II dens fractures. It’s important to note that more than half of these fractures won’t properly heal on their own, a condition known as pseudoarthrosis.
- The occurrence of C2 fractures increased by 135% from 2000 to 2011 among Medicare beneficiaries.
- C2 fractures can increase the risk of death by 20% within 3 months and 40% within 2 years.
- The most common type of C2 fracture is the type-II dens fracture.
- Over half of these type-II dens fractures may not fully heal, a condition known as pseudoarthrosis.
Signs and Symptoms of C2 Fractures
Recognizing that even a mild, non-penetrating injury can cause serious unstable conditions is crucial, particularly among older adults. It’s also key to consider factors that could increase chances of fractures, like weak bones from osteoporosis, cancerous lesions spread to the bones, or lack of vitamin D. When a person has been injured, doctors will look for certain signs and symptoms during their examination. These include pain when the back of the neck is touched, nerve pain (radiculopathy), spinal cord dysfunction (myelopathy), and potential signs related to vertebral artery injury. It’s absolutely necessary to perform a detailed neurological examination, which includes checking the cranial nerves, sensory and motor function, and muscle tone in the rectum.
- Pain when the back of the neck is touched
- Nerve pain (radiculopathy)
- Spinal cord dysfunction (myelopathy)
- Potential signs related to vertebral artery injury
- Checking the cranial nerves during neurological examination
- Checking sensory and motor function during neurological examination
- Checking muscle tone in the rectum during neurological examination
Testing for C2 Fractures
Before a surgical procedure, certain laboratory tests may be required to understand a patient’s overall health. These tests might include measuring levels of hemoglobin, hematocrit, and platelets, as well as reviewing a person’s coagulation profile. These results help doctors prepare for the operation.
X-rays can provide some useful information, particularly for cervical spine injuries. The imaging should carefully capture areas from the base of the skull to the first thoracic disc space. Essential views for obtaining a comprehensive picture are lateral, front-to-back, and open mouth odontoid. Together, these views reveal about 93% of all cervical spine injuries. X-rays are also important for watching the alignment during and after surgery, and for long-term monitoring.
A Computerized Tomogram (CT) scan is the go-to choice when determining the nature of a fracture or when a C2 fracture – a break in a specific neck vertebra – is suspected. So even if an X-ray doesn’t show any injury but the doctor presumes a problem, a CT scan may still be conducted. CT scans are particularly well-suited for examining bony anatomy for fractures. They do not give a detailed view of soft tissues or the spinal cord, however.
Magnetic Resonance imaging (MRI) scans are crucial when you need a detailed look at ligaments, disc space, spinal cord, nerve roots, and other soft tissue injuries. MRIs can be instrumental in understanding whether a fracture is new, which is determined without using any contrast substance.
Finally, vascular imaging, which focuses on the blood supply, might be necessary. This is especially true if there’s fear of injury to the vertebral artery – a key artery that runs through specific vertebrae. If left untreated, an injured vertebral artery can lead to a stroke in 24% of cases. A CT angiography can check for any potential damage, taking into account the patient’s kidney function. Techniques like multi-slice multi-detector CT angiography are recommended for patients with certain types of fractures. At this stage, MR angiography alone is not considered sufficient to evaluate vertebral artery injuries.
Treatment Options for C2 Fractures
Treatment options for certain fractures include at-home care, wearing a neck brace, an external rigging device, and surgery.
A stiff neck brace can be used as the immediate first step in treatment for particular fractures. Most of the time, this method is good enough for types I and III odontoid fractures and 90% of hangman’s fractures. For some forms of type-II odontoid fractures or if the hangman’s fracture has been displaced, an external brace device can be used to stabilize and align the bone structures, although it may not be well-received by older people.
Surgery is another treatment method. This can be achieved through either front-facing or a variety of back-facing surgical methods.
The front-facing procedure involves placing a screw in type-II odontoid fractures when it’s well aligned and the surrounding ligament is unharmed. However, there’s a concern about this method in older people and situations of delayed bone healing.
Several methods can be used for a back-facing surgical approach:
– Screws from the first to the second cervical vertebra
– Screws in the lateral mass of the first cervical vertebra and the central portion of the second cervical vertebra
– Screws in the lateral mass of the first cervical vertebra and a specific part of the second cervical vertebra
– Wiring from the first to the second cervical vertebra (also a supplementary technique)
Choosing the back-facing surgical method requires significant examination and should be determined by a neurosurgeon or orthopedic spine surgeon. They will take into account several things, including their experience, where the fracture is, where the arteries are in the vertebrae, anatomical variations, and the suitability of the procedure for the bone mechanics. It’s very important that the arteries in the second and third segments of the affected vertebrae are imaged. Additionally, the patient’s overall health, medical readiness, and bone health must be evaluated when deciding which surgery is best. This is also taken into consideration for specific types of odontoid fractures.
What else can C2 Fractures be?
- Os odontoideum (a certain condition of the spine)
- Mach effect (an x-ray phenomenon)
- Persistent ossiculum terminale (an unusual growth at the top of the spine)
- Pseudosubluxation (commonly affecting the second and third spine segments)
What to expect with C2 Fractures
Treatments for C2 fractures, a type of neck injury, are generally quite successful. A study comparing two types of surgical interventions – posterior cervical fusion with either C2 pedicle screws or C2 translaminar screws – found that the former was quite often not ideally placed. This study also found that while the durability of translaminar screws was weaker than pedicle screws for subaxial fusions (lower neck area), they were just as effective for axial fusions (upper neck area).
It’s important to note that treating neck injuries as soon as possible is recommended to ensure better recovery outcomes.
Possible Complications When Diagnosed with C2 Fractures
Complications may arise from the treatment of a C2 fracture. These issues are more common in patients receiving non-surgical treatment. The complications include nonunion (when the fractured bone doesn’t heal), malunion (when the fractured bone heals in the wrong position), and pseudoarthrosis (formation of a false joint). If the fracture doesn’t heal after initial non-surgical treatment, surgery may be necessary.
The same risks that come with any surgery also apply here, such as the risk of infection. In particular, there might be a risk of developing a bone infection called osteomyelitis. The surgical insertion of hardware could fail or cause injury to the nerves and blood vessels.
Additionally, patients who undergo a frontal surgery run a risk of complications with the airway. This could lead to a need for breathing tube placement for a prolonged period.
Common Complications of C2 Fracture Treatment:
- Nonunion (bone doesn’t heal)
- Malunion (bone heals in wrong position)
- Pseudoarthrosis (formation of a false joint)
- Infections, including bone infection (osteomyelitis)
- Hardware failure
- Injury to nerves and blood vessels
- Airway complications requiring long-term breathing tube placement in front-facing surgeries
Preventing C2 Fractures
It’s crucial for patients to understand and follow their treatment plans, particularly for non-surgical or ‘conservative’ treatments. They should also be aware of the importance of regular check-ups and medical imaging (like X-rays or scans), to ensure everything is going as expected and to prevent any negative consequences.
