Emergency diagnosis and management of C2 vertebrae fractures with artery rupture

Aravindthatchan. K¹, Ashok Nandagopal ², Vidya Saketharaman ³

¹Emergency Medicine Resident, Department of Emergency Medicine, Kauvery Hospital, Alwarpet

²Clinical Lead & Consultant, Department of Emergency Medicine, Kauvery Hospital, Alwarpet

³Consultant in Emergency Medicine, Department of Emergency Medicine, Kauvery Hospital, Alwarpet

Abstract

A 33-year-old male presented to the emergency department after a fall from approximately 12 feet, partially broken by a clothesline. He complained of neck pain, chest discomfort, and swelling in the floor of the mouth. Initial assessment revealed tenderness over the cervical spine with restricted neck movements. Imaging studies showed a C2 vertebra fracture with anterior subluxation over C3, significant paravertebral hematoma, and contrast leak suggestive of vertebral artery injury.

During airway management, the patient experienced bradycardia and desaturation requiring cardiopulmonary resuscitation. An emergency tracheostomy was performed, followed by hemodynamic stabilization in the ICU. Subsequent neurological assessment was intact, and surgical fixation of the cervical spine was planned.

This case highlights the complexity of C2 fractures complicated by vascular injury and airway compromise, underscoring the need for prompt imaging, airway security, and multidisciplinary management for a favourable outcome.

Keywords: C2 vertebra fracture, vertebral artery injury, cervical spine trauma, airway compromise, emergency tracheostomy, spinal stabilization, high-velocity trauma, paravertebral hematoma, multidisciplinary management.

Introduction

C2 vertebra fractures, particularly those complicated by vertebral artery injury, represent a critical emergency scenario due to their anatomical proximity to the brainstem and vital neurovascular structures. These injuries are typically encountered in high-energy trauma among young adults or due to low-energy mechanisms in elderly individuals. Fractures of the axis (C2) may involve multiple elements such as the dens odontoid, lamina, pars interarticularis, and can be associated with vascular insult, airway compromise, and cervical spinal instability.

Recent advancements in imaging and early multidisciplinary intervention have significantly improved outcomes. However, vertebral artery rupture following cervical trauma remains rare and is associated with a high risk of mortality if not promptly addressed. The complexity increases when combined with soft tissue hematomas, which may cause airway obstruction, as seen in this case.

The case presented involves a 33-year-old male with a traumatic C2 vertebra fracture and associated vertebral artery injury following a fall. The fall was partly mitigated by a clothesline, yet the patient sustained significant cervical trauma. Prompt airway intervention, hemodynamic stabilization, and planned surgical fixation contributed to the patient’s favorable recovery. This case is analyzed in light of existing literature which underscores the necessity for timely imaging, suspicion for vascular injury, and a tailored management strategy based on the stability of the fracture and associated neurovascular compromise.

Studies such as those by Alexander et al. have highlighted the diverse and often overlapping mechanisms of injury in C2–C3 subluxations, frequently involving ligamentous and vascular elements that challenge standardized treatment algorithms. Similarly, Kalantar et al. provide a detailed anatomical and biomechanical context of C2 injuries⁽¹⁾, reinforcing the critical need for early recognition and stabilization in cases with risk to vertebral arteries. Additionally, Pearson et al. demonstrated that surgical intervention in C2 fractures is associated with improved survival even among elderly patients, emphasizing its value in unstable fractures with vascular compromise⁽²⁾.

Case Presentation

C2 vertebra fractures, especially when accompanied by arterial injuries, are critical emergencies with potentially fatal outcomes. This case highlights the multidisciplinary approach and rapid intervention required for a young male presenting with a C2 fracture complicated by vascular injury following trauma.

Presenting Complaints

A 33-year-old male was referred from hospital to the emergency department with a cervical collar in place after a fall from a height of approximately 12 feet while painting. The fall was partly broken by a wire before hitting the ground.

Complaints

Pain over the right side of the neck
Pain during neck movement
Left-side chest pain
Pain in the floor of the mouth

No History of;

Loss of consciousness
Vomiting
ENT bleeding (initially)
Giddiness
Abdominal discomfort
Bladder or bowel disturbance
Previous medical illnesses
Drug allergies (NKDA)

Primary Survey

Airway: Patent, no signs of obstruction
Breathing: Normal
Circulation: Stable vitals, pulse palpable
Disability: GCS 15/15, moving all four limbs
Exposure: Neck swelling, tenderness, and visible hematoma

Local Examination

Neck: Mid-neck swelling on the right, tenderness, restricted and painful ROM
Chest: Tenderness and redness over the 3^rd and 4^th left ribs
Oral cavity: Hematoma and swelling in the floor of mouth, no active bleeding

Diagnostic Assessment

1. X-ray: Preliminary cervical imaging

2. MRI Cervical Spine

Mild anterior subluxation of C2 over C3
Disc herniation with hyperintensities and anterior epidural hematoma
Suspicious bilaminar fracture of C2
Paravertebral hematoma predominantly on the right
Disruption of the posterior longitudinal ligament.

Fig (1): X-ray and MRI of Cervical spine, Floor of Mouth

3. MRI Floor of Mouth

Large hematoma in the right submandibular region
Involvement of right parapharyngeal space, lateral tongue
Hemorrhagic signs in masseter and pterygoid muscles

3. CT Carotid & Cerebral Angiogram

contrast leak from left vertebral artery at fracture site
Focal contrast blush from right submandibular artery (facial artery branch)

Fig (2): CT – carotid artery , right submandibular artery

Fig (3): Vertebral artery – Cerebral Angiogram

Management

The patient was diagnosed with an unstable C2 fracture involving the vertebral artery, confirmed by imaging. Due to active bleeding and risk of vascular compromise, he underwent embolization of the left vertebral and right lingual arteries. Multidisciplinary management was initiated, involving spine surgery, ENT, and critical care teams. After initial stabilization, the patient underwent left C1 to C3 unilateral posterior spinal stabilization under general anaesthesia.

Airway Management

As facial swelling and stridor progressed, an awake fibrotic intubation was attempted but failed due to poor visibility. During the attempt, the patient developed bradycardia and cardiac arrest. CPR was initiated, and ROSC was achieved. An emergency tracheostomy was performed to secure the airway, followed by ICU admission for close monitoring and supportive care.

Treatment Outcome

Post-procedure, the patient’s neurological status improved steadily. By Day 3, patient was hemodynamically stable with improving GCS. He tolerated the tracheostomy well and was decannulated without complications. After continued supportive care, including transfusions and cardiac management for LAHB, he was discharged in a stable condition with advice for follow-up.

Discussion

C2 vertebra fractures are complex injuries due to the anatomical and functional significance of the axis, particularly its proximity to critical neurovascular structures like the vertebral arteries. The present case—a 33-year-old male with a C2 fracture complicated by vertebral artery rupture—demonstrates the severe consequences of high-velocity trauma and underscores the importance of early recognition, imaging, and multidisciplinary management.

The findings in this case, including paravertebral hematoma, airway compromise, and vertebral artery contrast extravasation, reflect the high-risk profile of such injuries. While the patient did not exhibit focal neurological deficits—a point of divergence from some reported cases—the presence of a C2-C3 disc injury, hematoma in the floor of mouth, and vascular leak signaled impending airway and vascular compromise.

The literature supports prompt imaging with CT angiography (CTA) for suspected vertebral artery injury in cases of high-energy cervical spine trauma. Matsuzaki et al. (2023) emphasized the efficacy of CTA in diagnosing Denver Grade IV vertebral artery injuries, with coil embolization proving both safe and effective in their case series⁽³⁾. In our case, although embolization wasn’t done, immediate airway intervention and planned surgical stabilization played key roles in patient survival and recovery.

Additionally, data from the Pearson et al. (2016) Medicare cohort indicate that surgical stabilization, though associated with higher short-term complications, confers a significantly reduced 30-day and 1-year mortality compared to non-operative treatment⁽²⁾. This supports the decision to pursue surgical intervention in our young patient with an unstable fracture.

Unlike many cases of C2 fractures described in the literature such as Bakhsh et al ⁽⁴⁾, where neurological involvement is rare and conservative management is often sufficient, this case involved vascular rupture—a rare but severe complication highlighted in the study by Lee et al. (2024), which discusses the importance of understanding vertebral artery anatomy when planning intervention⁽⁵⁾.

Our patient’s outcome also reflects findings from Lee et al., where early intervention tracheostomy, followed by surgical stabilization led to functional recovery even in the setting of vascular injury⁽⁵⁾. It also highlights the importance of being prepared for airway emergencies during attempted intubation, as emphasized by the bradycardia and need for CPR during the fiberoptic attempt.

Conclusion

This case reinforces the critical importance of high clinical suspicion, early CTA imaging, and multidisciplinary intervention in managing C2 fractures with associated vascular injury. Though neurologically intact at presentation, the presence of a vertebral artery leak and oropharyngeal hematoma mandated urgent airway and hemodynamic management followed by spinal stabilization.

The successful outcome supports current literature advocating for aggressive early intervention in selected cases of unstable C2 fractures, particularly when vascular structures are involved. Continued vigilance, individualized care, and timely surgical input remain key to improving survival and functional outcomes in such high-stakes trauma cases.

Acknowledgements: I would like to sincerely thank Dr. Ashok Nandagopal and Dr.Vidya Saketharaman for their invaluable guidance, expertise, and constant support throughout the management and reporting of this case. I am also deeply grateful to Kauvery Hospital, Alwarpet, Chennai, for providing the facilities and resources necessary for the successful diagnosis, management, and documentation of this complex case.

Reference

Babak Kalantar S. Fractures of the C1 and C2 Vertebrae. Semin Spine Surg. 2013 Mar;25(1):23–35.
Pearson AM, Martin BI, Lindsey M, Mirza SK. C2 vertebral fractures in the medicare population incidence, outcomes, and costs. Journal of Bone and Joint Surgery – American Volume. 2016 Mar 16;98(6):449–56.
Matsuzaki R, Nakada C, Kondo K, Mikai M, Sakaeyama Y, Fuchinoue Y, et al. Diagnosis and treatment of vertebral artery injuries due to blunt trauma: A case series. Trauma Case Rep. 2023;44.
Bakhsh A, Alzahrani A, Aljuzair AH, Ahmed U, Eldawoody H. Fractures of C2 (Axis) vertebra: Clinical presentation and management. Int J Spine Surg. 2020 Dec 1;14(6):908–15.
Lee S, Hur JW, Oh Y, An S, Yun GY, Ahn JM. Current Concepts in the Treatment of Traumatic C2 Vertebral Fracture: A Literature Review. Vol. 67, Journal of Korean Neurosurgical Society. 2024.

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Emergency diagnosis and management of C2 vertebrae fractures with artery rupture