Type II fractures at risk for nonunion should be considered for odontoid screw placement or posterior C1 to C2 fusion. All fractures of the C1 to C2 complex are considered unstable and should be treated initially with a hard cervical collar, and then evaluated by a spine surgeon. Risk factors for nonunion include 5mm or more of displacement, greater than 10 degrees of angulation, or age older than 50. Type II fractures without risk of nonunion can be considered for hard cervical collar or halo. Type I and III fractures should be treated in a rigid cervical collar or halo. Type I is avulsion of the tip of the dens, type II is a fracture through the base of the dens, and type III is a fracture extending into the C2 vertebral body. Associated disruption of the C2 to C3 disc with a Hangman fracture requires surgical fixation. Fracture through the C2 dens can be classified as type I, II, or III.

If the fracture is displaced greater than 3mm or with greater than 11 degrees of angulation, reduction with halo placement or surgical fixation should be considered. Hangman fracture with less than 3mm of displacement and no significant angulation may be treated in a hard cervical collar. If the fracture extends bilaterally through the pars interarticularis, a Hangman fracture is described. Ĭ2 fractures can result in a fracture through the body, dens, or pars. If the TAL is disrupted C1 to C2 posterior fusion should be considered. C1 fractures may be managed in a rigid cervical collar or halo if the transverse alar ligament (TAL) remains intact on MRI. Neurological injury rarely results from an isolated C1 fracture due to abundant space surrounding the spinal cord. Fractures of C1 occur through the lateral mass or arch in single or multiple places (multiple arch fractures, Jefferson fracture). Injuries to C1 and C2 compose approximately 30% of cervical spine fractures. A SLICS score of 1 to 3 is nonsurgical, a score of 4 is not specified, and a score of 5 or greater is a surgical indication. Scoring systems in dealing with cervical spinal cord injury that includes ligamentous, bony and neurologic injury exist, a common one is called SLICS (Subaxial Cervical Spine Injury Classification System), and this can be used to help with evaluation and guidance of surgical or nonsurgical management. Further evaluation of ligamentous structures of the spinal cord with MRI is important for determining spinal stability and in planning surgical treatment. Computed tomography is the preferred imaging in acute spine trauma as it is more sensitive for detection of bony cervical spine injury when compared to plain radiographs (sensitivity of 98% versus 52%). Indications for cervical spine imaging include localized neck pain, deformity, edema, altered mental status, head injury, or neurological deficit.

Compressed spine treatment