• HPI: The patient is a 43-year-old female who was involved in a high speed motor vehicle accident with alcohol intoxication. She was initially intubated, and then extubated complaining of neck pain but with no other neurological complaints. 

    PMH: Otherwise health female 

    Family History: Unremarkable. 

    Exam: Alert, oriented x 3. Cranial nerves II-XII non-focal. 5/5 muscle strength in all extremities. Sensations are intact. Normal cerebellum examination, DTR 2/4. Limited range of motion of the neck, midline spine tenderness opposite the upper cervical spine.

    Figure 1. Axial CT scan of the cervical spine demonstrating oblique fracture of the C2, involving the pedicle on the right side and lamina on the left side with intact left pedicle.

    Figure 2. Sagittal CT scan demonstrating fracture of the posterior body of C2 with some displacement and minimal angulation.

    Figure 3. Sagittal MRI STIR images showing acute nature of the fracture and involvement of the end plate with no disc disruption of compression and intact anterior longitudinal ligament.

    1. How would you classify/describe this fracture?

    2. What would be the plan for managing this patient?

    3. If surgical stabilization is the choice, what would be the approach?

    4. If you choose to perform C1-2 fusion, how would you proceed about it?

    5. Which of the following describes you?

    6. I practice in one of the following locations.

    7. Please add any suggestions or comments regarding this case:

    • would obtain lateral cervical flexion/extension views before designing definitive treatment
    • i'm a second year medical student. don't listen to anything i say.
    • had multiple treatment option
    • I would perform a C2-C3 ACDF with anterior instrumentation and place the patient in a halo. This in my experience has resulted in excellent alignment and stability and has maintained excellent ROM of the cervical spine. An occiput to C2, or a C1-C2 fusion should be avoided as it results in a significant disability.
    • I'd try 6-8 weeks in a collar, and if that failed, consider fusing c2 to itself via bilat pedicle screws.
    • I would actually consider this patient for a SOMI brace !
    • C1-3 fusion also would like flex/ext xrays
    • thanks ,ilike to learn neurosurgery because im somuch like it ineed yoyr help to give me chance to attach it
    • Assuming the radiographs belong to the patient in question, and are not some variant of my grostequesly deformed, presumably infected (how about gonorrhea?)vs. a destructive metastatic process or idiopathic iatrogenic tektite or kryptonite allergy, resulting in right vertebral arteritis and substantial pedicular destruction leading to a 50% or greater chance of my head falling off, which would be a blessing, but I digress. It appears that this is one very large woman with what appears to be a destructive process causing elevation of the ALL w/a prevertebral mass, a large soft tissue mass, a tortuous esophagus/trachea, lytic lesions in the mandible?, a metallic device in the esophagus, and abnormal signal intensity in the upper cervical spine with poorly defined tissue planes. Where would "midline spine tenderness opposite the upper cervical spine" be located? (I am not availing myself of an anatomy treatise and am probably wrong), irregardlessly, all of these findings seem to suggest a chronic process, with what seems to be a pathologic fracture, destruction of the odontoid, and my inability to objectively evaluate the case study. It appears that the process has caused attentuation and sclerosis of the odontoid, with extensive soft tissue invovement. After 17 years of palliative scare and isolation from the medical community, apart from FIFTY psychiatric hospitalizations, my opinion is essentially useless. For some inexplicable reason, I cannot get anyone to tell me what is wrong with my destroyed C spine, apart from the fact that I deserved it.
    • Hybrid transarticular screw and Harms
    • I am in the opinion of non-operative management with cervical rigid collar and analgesic.
    • Stricly speaking, this is not a Hangman's fracture, because a Hangman's fracture involves BILATERAL fracture thru the pars interarticularis of C2. This case involves only a right unilateral fracture thru the C2 pars. I'm not sure if there is such a thing as an "atypical Hangman's fracture" in our literature. Perhaps this could be classified as a "Miscellaneous C2 Fracture", but this option isn't given. So could be "other" as well.
    • As we have a slight anterior displacement of c2 over c3 to fuse the two is the only choice.
    • I think it does not necesary to operate, only halo is the choice.
    • An alternastive could be to place the patient in a halo since the left pedicle is intact and she has no neuro sx/deficits.
    • Very good case and not common fracture.
    • Patient without neurological signs and an almost stable fracture should be treated with simple and safe procedures.
    • i Will do C1-C3 Fixation using Halifax clamps
    • i have had 3 such patients age ranging from 17 yrs to 71 yrs.except for one i have treated coservatively.even the i operated retrospectly i think could have been left alone without surgery
    • Good prognosis
    • Surgery should NOT be the primary treatment for this fracture. This will very likely heal in a cervical collar or at most a Halo. If after 3 months there is not evidence of bony healing, then aurgery may need to be considered.
    • With the fractures through the arch of C2 a fusion from C1-C2 probably would not offer stabilization. Therefore, if surgery were the choice from behind, in my opinion it would have to include C1-C3 and would introduce more rigidity than seems necessary. Therefore, my choice would be surgery with an anterior fusion of C2-C3 and for extra safety I would place the patient in a 4 poster brace. Ernest Fokes

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