Acute Respiratory Compromise Associated With Flexed Cervical Traction After C2 Fractures

Acute respiratory compromise is occasionally observed in a subgroup of patients with upper spinal injuries involving the C2 vertebrae. A retrospective review was performed to identify fracture types and risk factors for early respiratory deterioration following injury to the upper cervical spine.To examine the frequency of respiratory complications encountered following traction manipulation of specific upper cervical spinal injuries involving the C2 vertebrae.Major complications related to cervical skeletal traction are uncommon. Respiratory compromise with occasional mortality has been observed. Risk factors for acute respiratory failure are unknown.The medical records of 166 consecutive patients with fractures of the C2 vertebrae admitted between January 1994 and July 1998 to a regional spinal cord injury center were examined. Demographic data, injury subtype, fracture displacement, respiratory status, treatment method, and outcome at discharge were examined. Patients with comorbidities compromising respiratory function were excluded.One hundred fifty-five patients met the inclusion criteria of this study. Sixty-one patients had Type II odontoid fractures of which 53 were displaced (32 posteriorly and 21 anteriorly). In addition, there were 21 patients with Type III odontoid fractures, 33 with axis C2 body fractures, 32 with Hangman's fractures, and eight patients with an os odontoideum. Thirteen of 32 patients with posteriorly displaced odontoid fractures experienced acute respiratory compromise following reduction with cervical skeletal traction and immobilization, while only three of the remaining 123 patients had respiratory difficulties. Respiratory distress as a consequence of cervical spine fractures resulted in three deaths. Two of these patients had posteriorly displaced Type II odontoid fractures whose airway could not be emergently intubated.Frequent respiratory deterioration (40% of patients) during acute management of posteriorly displaced Type II odontoid fractures after reduction was observed. Physicians must be aware that cervical flexion in the treatment of posteriorly displaced odontoid fractures may significantly increase the risk of airway obstruction due to the presence of acute retropharyngeal swelling. This may be avoided with elective nasotracheal intubation in this upper cervical spine fracture subtype.