Proposal of Treatment Strategy for Pedicle Fractures of the C2: An Analysis of 49 Cases

Spine surgeons often confuse C2 pedicle fractures (PFs) with pars interarticularis fractures. In addition, little information is available about the characteristics and treatment strategies for C2 PFs. We sought to investigate the characteristics of C2 PFs and to propose an appropriate treatment strategy. A total of forty-nine patients with C2 PFs were included in this study. We divided these patients into unilateral and bilateral C2 PF groups. The incidence rates and characteristics of other associated C2 and C2-3 injuries, and other cervical injuries, were evaluated. In addition, treatment methods and outcomes were analyzed. Twenty-two patients had unilateral C2 PFs and twenty-seven patients had bilateral C2 PFs. Among the cases of unilateral C2 PFs, all patients had one or more other C2 fractures, and twenty patients (90.9%) had one or two C2 body fractures. Meanwhile, among the cases of bilateral C2 PF, all patients had two or more other C2 fractures and one or two C2 body fractures. In unilateral C2 PFs, three patients with C2-3 anterior slip or adjacent cervical spine (C1-3) injury underwent surgery and nineteen patients (86.4%) were treated with conservative methods. In bilateral C2 PFs, three patients with C2-3 anterior slip or SCI at C2-3 underwent surgery and twenty-four patients (88.9%) were treated with conservative methods. Our results showed that C2 PFs do not occur alone and are always accompanied by other associated C2 injuries. C2 PFs should, generally, be thought of as a more complex fracture type than hangman's fracture or dens fracture. Despite the complex fracture characteristics, most C2 PFs can be managed with conservative treatment. However, surgical treatments should be considered if the C2 PFs are accompanied by the C2-3 anterior slip and adjacent cervical spine injury.