Fractures of the axis: a review of pediatric, adult, and geriatric injuries

Abstract

Fractures of the second cervical vertebra (C2, axis) are common in adult spine surgery. Those fractures occurring in younger adult patients are often associated with high-energy mechanism trauma, resulting in a "Hangman's Fracture." Management of these fractures is often successful with nonoperative means, though surgery may be needed in those fractures with greater displacement and injury to the C2-C3 disc. Older patients are more likely to sustain fractures of the odontoid process. The evidence supporting surgical management of these fractures is evolving, as there may be a mortality benefit to surgery. Regardless of treatment, longer-term mortality rates are high in this patient population, which should be discussed with the patient and family at the time of injury. Pediatric patients may suffer fractures of the axis, though differentiation of normal and pathologic findings is necessary and more difficult with the skeletally immature spine.

Keywords: Axis; C2; Fracture; Hangman’s; Odontoid; Spondylolisthesis.

Fig. 1

Type II odontoid fracture in a 74-year-old woman after a fall from standing

Fig. 2

Foramen transversarium residing within the pars interarticularis, precluding safe pedicle or pars screw fixation

Fig. 3

Transarticular screws fixing a type II odontoid fracture in a patient with falls due to subaxial spondylotic myelopathy. Surgery consisted of C1-C2 transarticular screws with posterior element wiring (using the C3 lamina) and C4, C5, and C6 laminoplasty

Fig. 4

Effendi-Levine type 2a spondylolisthesis of the axis. Notice the angulation of the odontoid fragment with the relative absence of translation

Fig. 5

“Atypical” Hangman’s fracture with an oblique fracture line leaving a portion of the posterior vertebral body wall (arrow) attached to the dorsal fragment

Fig. 6

Effendi-Levine type 3 spondylolisthesis with dislocation of the right C2-C3 joint (arrow). Notice the large pedicle on the left, without fracture involvement of the foramen transversarium

Fig. 7

Traction applied to the patient in Fig. 4. Notice the worsening of fracture displacement. The patient was reduced and immobilized for surgery using a Mayfield positioner

Fig. 8

Postoperative radiographs of Fig. 6. A C2 lag screw was placed on the left to fix the fracture and the segment, sparing a fusion level