Spine iSAWE 17

Question

A 55 year old driver is in a head on collision and strikes the windscreen with his forehead.

Spine iSAWE 17, sagittal and axial CT of the upper cervical spine
Sagittal and axial CT of the upper cervical spine. Image by Michael Utz, Shadab Khan, Daniel O’Connor & Stephen Meyers, Wikimedia Commons, CC BY 4.0.
  1. Describe the CT.
  2. Classify the injury.
  3. How would you treat each type?

Answer

CT

  • Bilateral fractures through the pars interarticularis of C2
  • Traumatic spondylolisthesis of the axis (hangman fracture)
  • Hyperextension and axial load mechanism
  • Canal widens, so neurological injury is uncommon
  • Check vertebral arteries with CTA, foramen transversarium involvement

Levine and Edwards classification

TypeFeatures
IUnder 3 mm translation, no angulation
IIOver 3 mm translation and angulation, C2 to C3 disc injury
IIAAngulation without much translation, flexion distraction
IIIType I with bilateral C2 to C3 facet dislocation

Treatment

  • Type I, rigid collar 6 to 12 weeks
  • Type II, traction reduction then halo, or surgery
  • Type IIA, avoid traction (it worsens angulation), reduce in extension with compression then halo
  • Type III, open reduction of the facets and posterior C2 to C3 fusion
  • Anterior C2 to C3 discectomy and fusion for disc disruption
  • Pars screws can repair the fracture directly

Related pages

Author Contributions

Orthofracs team

Reviewed by Professor Phong Tran, Head of Orthopaedic Surgery, Western Health. Last updated 10 October 2026.