Article
C2-fractures – need for a new classification
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Authors
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P. Bartels
- Klinik für Neurochirurgie, Vivantes Klinikum im Friedrichshain, Berlin
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J. Leibling
- Klinik für Neurochirurgie, Vivantes Klinikum im Friedrichshain, Berlin
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H. Hosch
- Klinik für Neurochirurgie, Vivantes Klinikum im Friedrichshain, Berlin
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D. Moskopp
- Klinik für Neurochirurgie, Vivantes Klinikum im Friedrichshain, Berlin
| Published: | May 20, 2009 |
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Outline
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Objective: Fractures of the second cervical vertebra (C2) are common injuries (one third of all cervical spine fractures). Half of them are fractures of the odontoid process. Motor vehicle crashes and falls are responsible for most injuries of C2.
The current classification of odontoid fractures was published by Anderson and d'Alonzo (AA) in 1974 and is based upon plain film x-ray. It is described that on a lateral radiograph, a type III fracture can be clearly distinguished from a type II fracture by evaluating for disruption of the “ring shadow” of the axis.
Methods: From April 2007 to October 2008, 14 patients with complex injuries of C2 were prospectively investigated. As initial radiographic evaluation a 3D CT (64-slices) scan was performed. Follow-up was one week and eight weeks after trauma.
Results: It was not possible in any of the cases to assign the fracture exclusively to type II or type III based on the existing classification. In all cases both, the odontoid process and the body of the vertebra were involved in the fracture. Due to the lack of classification we decided in favor of a conservative treatment with a halothoracic vest or a Philadelphia collar in all cases. One patient died due to other trauma sequelae. In 4 cases we saw a non-union of the odontoid fracture (one alcoholic patient, three patients >70y), but without clinical symptoms except for slight back pain after removal of the orthesis.
Conclusions: Today CT scanning is a standard procedure in the initial imaging assessment in trauma patients. It permits a more detailed description of the fracture with a coronal, sagittal, and 3D reconstruction of the vertebra. It is obvious that today’s high-definition diagnostics can visualize fracture lines which were not visible in 1974. Cases which are formally classified as Type II fractures by X-ray can now be identified as more complex fractures. We were able in none of the cases to distinguish clearly between Type II and Type III fractures. The still used AA classification is outdated. Our data indicates the need for a new classification of C2 fractures, which has to be evaluated prospectively. To decide whether or not to operate, a new classification should respect fragment displacement of more than 4mm and the size of the comminuted area in the base of the vertebra to assess whether the screws can fix the fragments. Furthermore, it should regard additional cervical spine injuries, age, and co-morbidity.
