Guideline sources The following summarized guidelines for the evaluation and management of C1-C2 fractures are prepared by our editorial team based on guidelines from the American Association of Neurological Surgeons (AANS/CNS 2013). 1 2 3 3 4 4 Definition C1-C2 fractures are acute cervical spine injuries of the atlas and axis associated with a high rate of other spinal injuries, neurological morbidity, and biomechanical instability. 3 Epidemiology The most common causes of C1-C2 fractures are mechanical falls and motor vehicle accidents. 3 Disease course Forced hyperextension, forced flexion, and compression to the upper cervical spine due to trauma can result in C1-C2 fractures, which causes complete or partial loss of all movements and/or sensations due to cervical spinal cord injury, neurologic deficit, respiratory failure, and death. 4 Prognosis and risk of recurrence 30-day mortality associated with spinal cord injury is 20.2% in C1-C2 fracture. 4 https://web.pathway.md/diseases/recLPX8AkpYuOYxt4 1/3 6/29/23, 3:23 AM C1-C2 fractures Pathway Guidelines 1. Diagnostic investigations Evaluation for vertebral artery injury: obtain imaging to assess for vertebral artery injury in patients with comminuted fractures of the axis body. B 2. Therapeutic procedures Cervical immobilization (C1 fractures): Manage isolated fractures of C1 (fractures of the atlas) based on the specific fracture type and the integrity of the transverse atlantal ligament. B Perform external cervical immobilization alone for isolated fractures of C1 with an intact transverse atlantal ligament. B Cervical immobilization (C2 fractures): perform external cervical immobilization alone in patients with isolated fractures of the body of C2, if adequate fracture alignment can be achieved, and in the absence of severe ligamentous disruption. B Show 2 more 3. Surgical interventions Surgical stabilization, C1 fractures: perform either external cervical immobilization alone or surgical fixation and fusion in patients with isolated fractures of C1 with disruption of the transverse atlantal ligament. B Surgical stabilization, C2 fractures (odontoid fractures): Perform surgical stabilization and fusion in patients with type II and type III odontoid fractures meeting 1 of following criteria: dens displacement 5 mm comminution of the odontoid fracture inability to achieve or maintain fracture alignment with external immobilization. B Show 2 more Surgical stabilization, C2 fractures (Hangman's fractures): Perform surgical stabilization and fusion in patients with traumatic spondylolisthesis of C2 (Hangman's fractures) meeting 1 of the following criteria: severe angulation of C2 on C3 disruption of the C2-C3 disk space inability to achieve or maintain fracture alignment with external immobilization. B https://web.pathway.md/diseases/recLPX8AkpYuOYxt4 2/3 6/29/23, 3:23 AM C1-C2 fractures Pathway Surgical stabilization, C2 fractures (body fracture): consider performing surgical stabilization and fusion in patients with isolated fractures of the body of C2 in whom there is severe ligamentous disruption and/or inability to achieve or maintain fracture alignment with external immobilization. C Clinical findings Symptoms Past medical history Dysarthria Traumatic injury Fecal incontinence Musculoskeletal exam Loss of sensation Swelling Muscle atrophy Urinary incontinence Neurological exam Paralysis Quadraplegia Quadriparesis References 1. Ryken TC, Hadley MN, Aarabi B et al. Management of isolated fractures of the axis in adults. Neurosurgery. 2013 Mar;72 Suppl 2 132 50. Open 2. Ryken TC, Aarabi B, Dhall SS et al. Management of isolated fractures of the atlas in adults. Neurosurgery. 2013 Mar;72 Suppl 2 127 31. Open 3. Joseph DiDomenico, Kingsley Abode-Iyamah, Ryan Khanna et al. Management of acute combined fractures of the atlas and axis: A retrospective study of two trauma centers. J Craniovertebr Junction Spine. Oct-Dec 2017;8 4 311 315.Oct-Dec 2017;8 4 311 315. Open 4. Jiang Shao, Wei Zhu, Xiongsheng Chen et al. Factors associated with early mortality after cervical spinal cord injury. J Spinal Cord Med. 2011 Nov; 34 6 555 562. Open 5. Yadollahi M, Paydar S, Ghaem H et al. Epidemiology of Cervical Spine Fractures. Trauma Mon. 2016 Mar 16;21 3):e33608. eCollection 2016 Jul. Open 6. Joseph DiDomenico, Kingsley Abode-Iyamah, Ryan Khanna et al. Management of acute combined fractures of the atlas and axis: A retrospective study of two trauma centers. J Craniovertebr Junction Spine. 2017 Oct-Dec; 8 4 311 315. Open 7. Jiang Shao, Wei Zhu, Xiongsheng Chen et al. Factors associated with early mortality after cervical spinal cord injury. J Spinal Cord Med. 2011 Nov; 34 6 555 562. Open https://web.pathway.md/diseases/recLPX8AkpYuOYxt4 3/3