Complications of Halo Placement

Direct Transpedicular C2 Fixation for the Surgical Management of Hangman's Fractures: A "Second Youth" for the Judet Approach

PURPOSE

The optimal management of hangman's fractures is controversial and the standard of care has been neither established nor supported by strong evidence. The Judet approach has been introduced in 1970 as surgical option to treat selected cases of hangman's fractures, harboring the advantage to preserve motion of the craniovertebral junction and to restore the C2 vertebra anatomy by insertion of transpedicular screws through the fracture line. This paper reviews the literature on hangman's fractures surgically managed by Judet approach, and reports two new illustrative cases.

METHODS

The PubMed database was searched for the review process. After initial screening of abstracts and papers, 13 manuscripts were included in the present review.Two cases of hangman's fractures, a Levine-Edwards type I and a type IIA, respectively, treated with direct transpedicular C2 screw fixation are reported. Surgical steps of the Judet approach are also described.

RESULTS

Our literature review revealed that the technique described by Judet is gaining appeal only in recent years and there is no consensus on surgical indications.No surgery-related complications were observed in the two reported cases. Patients experienced a significant reduction of neck pain postoperatively. Motion of craniovertebral junction was preserved in both patients at 3-, 6-, and 12-month follow-ups.

CONCLUSIONS

Direct transpedicular osteosynthesis of C2-pars interarticularis fracture has been already demonstrated as effective in type II and IIA hangman's fractures. The application of such technique in selected patients with atypical type I fractures should also be considered in order to achieve early mobilization and avoid external fixation.

Halter Traction for the Treatment of Atlantoaxial Rotatory Fixation

BACKGROUND

Atlantoaxial rotatory fixation (AARF) comprises a spectrum of abnormal rotational relationships between C1 (atlas) and C2 (axis). We aimed to evaluate the efficacy and long-term clinical outcomes of halter traction in treating patients diagnosed with primary AARF.

METHODS

We included patients <18 years of age who presented with new-onset painful torticollis, neck pain, and sternocleidomastoid muscle spasm, had an AARF diagnosis confirmed by use of 3-dimensional dynamic computed tomography, received in-hospital cervical halter traction under our treatment protocol, and were followed for ≥12 months. Radiographic and long-term clinical outcomes were analyzed.

RESULTS

A total of 43 patients (31 male and 12 female; average age of 7.9 years) satisfied the inclusion criteria. There were 5 acute, 6 subacute, and 32 chronic cases. The mean duration of initial symptoms prior to treatment was 12.1 weeks. Thirty-seven (86.0%) of the patients experienced previous minor trauma, and 6 (14.0%) had a recent history of upper-respiratory infection (Grisel syndrome). The mean duration of in-hospital traction was 17.6 days. The mean follow-up period was 8.5 years. Forty-two (97.7%) of the patients achieved normal cervical alignment after treatment. One patient (2.3%) had recurrence and received a second course of halter traction, with cervical alignment restored without any surgical intervention. No neurological deficits were noted during or after the treatment. No major complications were observed.

CONCLUSIONS

Normal anatomy and restoration of cervical alignment can be achieved by cervical halter traction in most cases of AARF.

LEVELS OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.