J Med Cases

Journal of Medical Cases, ISSN 1923-4155 print, 1923-4163 online, Open Access

Article copyright, the authors; Journal compilation copyright, J Med Cases and Elmer Press Inc

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Case Report

Volume 16, Number 11, November 2025, pages 461-466

Management of Multilevel Mid-Cervical Fractures in an Adult With Osteopetrosis

Figure 1. Axial (a) and sagittal (b) views of C4 vertebral body showing displaced fracture involving the posterior aspect of the C4 vertebral body and left lateral mass of C4, with involvement of the pedicle, lamina, transverse foramen and the superior and inferior articular facets. A nondisplaced fracture of the left inferior articular facet of C4 (red arrow) and pedicle of C6 (not shown) is also present.

Figure 2. T1- (a), T2- (b) and STIR-weighted (c) magnetic resonance (MR) images showing mild spinal cord edema at the C3-C4 level and the left ventral aspect of the cord with thin posterior epidural hematoma. Posterior longitudinal ligament injury is seen at C4, with suspected ligamentum flavum injury at C3-C4. Interspinous ligamentous injury extends from C3 to C6 with left facet capsular injury from C3-C4 and C4-C5 (red arrows). STIR: short tau inversion recovery.

Figure 3. Radiographic follow-up at 1 year showing flexion (a), neutral (b) and extension (c) positions with no dynamic instability (red arrows).

Figure 4. Final CT at 1-year follow-up demonstrating healed C4 fracture and lateral mass alignment in axial view (a), right (a) and left (c) side (red arrows). CT: computed tomography.

**Table 1.** Summary of Management of All Cervical Fractures in Adults With Osteopetrosis Found in the Systematic Literature Search, Including the Present Case
Reference	Patient age/sex	Fracture	Surgical?	Management/outcome
TAL: transverse atlantal ligament; ADI: atlantodental interval; AAS: atlantoaxial subluxation; MRI: magnetic resonance imaging; CT: computed tomography; ROM: range of motion.
[1]	55/F	Unstable multilevel cervical injuries: C1 anterior arch; bilateral pedicle fractures C3-C6; C5 body fracture; laminar and transverse-foramen involvement.	No	Managed nonoperatively with halo vest → stable by 4 months; asymptomatic at 4-year follow-up with CT showing healed/sclerotic fracture lines and normal alignment.
[2]	21/F	Subacute type II odontoid (C2 dens) fracture with C1-C2 instability	Yes	Posterior C1-C2 fusion (transarticular screws + interspinous wiring + iliac crest graft); Miami-J 3 months; solid/stable fusion at 2-year follow-up, mild ROM limitation.
[3]	63/M	C1 anterior arch fracture detected 1 week post-C1 laminectomy; preoperative ADI 6.68 mm (AAS); TAL intact; peri-fracture hemorrhage on MRI; later calcification of the TAL.	No	Nonoperative: Philadelphia collar; pseudoarthrosis at 1 year (collar stopped); partial gap fill by 3 years, persistent painless nonunion at 5-year follow-up; no surgery needed, asymptomatic and stable.
[4]	27/M	No vertebral fracture described; traumatic central cord syndrome on MRI with congenitally stenotic cervical canal.	Yes	C3-C7 laminoplasty; spine hardware stable at 6 weeks and 3 months; patient then lost to follow-up, reported no issues at departure.
[5]	76/F	C2 traumatic spondylolisthesis (Levine-Edwards type II hangman’s) with severe translation; osteopetrotic bone dense, cancellous bone absent.	Yes	Anterior C2-3 discectomy/reduction and plated interbody fusion using titanium-coated PEEK cage + synthetic graft; drilling with high-speed burr, minor C2 corner fracture during tapping, managed intraoperatively; collar × 6 months total; solid union at 1 year.
Ours	22/M	Displaced fracture of the posterior C4 vertebral body and a complex fracture of the left C4 lateral mass (involving the pedicle, lamina, transverse foramen, and both articular facets). Nondisplaced fractures of the left C6 pedicle and the left C3 inferior facet. MRI confirmed a spinal cord contusion at the C3-4 level, evidenced by a focal T2-hyperintense signal. It also revealed significant ligamentous injury, including damage to the posterior longitudinal ligament at C4, attenuation of the ligamentum flavum at C3-4, traumatic widening of the left C3-4 facet joint, and a small C4-5 epidural hematoma.	No	Immobilized in a rigid cervical orthosis (Miami J^® collar) and monitored with serial imaging. Three months post-injury, he remained asymptomatic with stable cervical alignment. Dynamic flexion-extension CT of the cervical spine at 1 year post-injury showed interval healing, with complete bone fusion of the C3 and C4 body fractures but incomplete fusion of the C4 facet and lamina.

Table 1. Summary of Management of All Cervical Fractures in Adults With Osteopetrosis Found in the Systematic Literature Search, Including the Present Case

Reference

Patient age/sex

Fracture

Surgical?

Management/outcome

TAL: transverse atlantal ligament; ADI: atlantodental interval; AAS: atlantoaxial subluxation; MRI: magnetic resonance imaging; CT: computed tomography; ROM: range of motion.

[1]

55/F

Unstable multilevel cervical injuries: C1 anterior arch; bilateral pedicle fractures C3-C6; C5 body fracture; laminar and transverse-foramen involvement.

Managed nonoperatively with halo vest → stable by 4 months; asymptomatic at 4-year follow-up with CT showing healed/sclerotic fracture lines and normal alignment.

[2]

21/F

Subacute type II odontoid (C2 dens) fracture with C1-C2 instability

Yes

Posterior C1-C2 fusion (transarticular screws + interspinous wiring + iliac crest graft); Miami-J 3 months; solid/stable fusion at 2-year follow-up, mild ROM limitation.

[3]

63/M

C1 anterior arch fracture detected 1 week post-C1 laminectomy; preoperative ADI 6.68 mm (AAS); TAL intact; peri-fracture hemorrhage on MRI; later calcification of the TAL.

Nonoperative: Philadelphia collar; pseudoarthrosis at 1 year (collar stopped); partial gap fill by 3 years, persistent painless nonunion at 5-year follow-up; no surgery needed, asymptomatic and stable.

[4]

27/M

No vertebral fracture described; traumatic central cord syndrome on MRI with congenitally stenotic cervical canal.

Yes

C3-C7 laminoplasty; spine hardware stable at 6 weeks and 3 months; patient then lost to follow-up, reported no issues at departure.

[5]

76/F

C2 traumatic spondylolisthesis (Levine-Edwards type II hangman’s) with severe translation; osteopetrotic bone dense, cancellous bone absent.

Yes

Anterior C2-3 discectomy/reduction and plated interbody fusion using titanium-coated PEEK cage + synthetic graft; drilling with high-speed burr, minor C2 corner fracture during tapping, managed intraoperatively; collar × 6 months total; solid union at 1 year.

Ours

22/M

Displaced fracture of the posterior C4 vertebral body and a complex fracture of the left C4 lateral mass (involving the pedicle, lamina, transverse foramen, and both articular facets). Nondisplaced fractures of the left C6 pedicle and the left C3 inferior facet. MRI confirmed a spinal cord contusion at the C3-4 level, evidenced by a focal T2-hyperintense signal. It also revealed significant ligamentous injury, including damage to the posterior longitudinal ligament at C4, attenuation of the ligamentum flavum at C3-4, traumatic widening of the left C3-4 facet joint, and a small C4-5 epidural hematoma.

Immobilized in a rigid cervical orthosis (Miami J^® collar) and monitored with serial imaging. Three months post-injury, he remained asymptomatic with stable cervical alignment. Dynamic flexion-extension CT of the cervical spine at 1 year post-injury showed interval healing, with complete bone fusion of the C3 and C4 body fractures but incomplete fusion of the C4 facet and lamina.