Multiplanar realignment for unstable Hangman’s fracture with Posterior C2-3 fusion: A prospective series

Hangman's Fracture in Geriatric Population: A Nationwide Multicenter Study in Japan

STUDY DESIGN

Retrospective multicenter study.

OBJECTIVES

To investigate the treatments of the geriatric population with hangman's fractures using a multicenter database under the Japan Association of Spine Surgeons with Ambition (JASA).

METHODS

The multicenter database included data from 1512 patients. We employed the Levine and Edwards classification for categorizing hangman's fractures. The study incorporated epidemiological data, including the prevalence of hangman's fractures, patient age, and follow-up duration. Bony fusion rates and length of hospitalization were recorded for Type I and Type II fractures, and the degree of neurological impairment was assessed.

RESULTS

Hangman's fractures represented 62 cases, accounting for 7.4% of all cervical spine injuries. The patients had an average age of 76.6 ± 6.5 years, and the mean duration of follow-up was 21.5 ± 23.6 months. The study found that the bony fusion rate for hangman's fractures in the geriatric population was 88.9%. Surgical treatment was associated with a shorter hospitalization period for Type II fractures compared to conservative treatment. Thirteen cases of hangman's fractures in the geriatric population, accounting for 21%, were complicated by spinal cord injury.

CONCLUSIONS

This is the largest study to date on hangman's fractures in geriatric population ≥65 years. Type I and Type II fractures, according to the Levine and Edwards classification, had a bony fusion rate of up to 90%. In patients with Type II fractures, surgical treatment led to a shorter initial hospital stay. Geriatric patients are at risk of spinal cord injury due to hangman's fractures.

Comparison of the efficacies of TINAVI robot-assisted surgery and conventional open surgery for Levine-Edward type IIA (postreduction) hangman fractures

The objective was to compare the clinical efficacy of percutaneous pedicle screw internal fixation with the aid of the TINAVI orthopaedic surgery robot with that of traditional open surgery for Levine-Edward type IIA (postreduction) hangman fractures and to evaluate the safety and efficacy of the TINAVI robot-assisted orthopaedic surgery procedure. The clinical data of 60 patients with Levine-Edward type IIA (postreduction) hangman fractures treated surgically from June 2015 to February 2022 were analysed retrospectively. Among these patients, 25 were treated with percutaneous pedicle screw fixation under TINAVI (the robot group), and 35 were treated with pedicle screw implantation assisted by a conventional C-arm X-ray machine (the traditional operation group). The pedicle screw placement grade was evaluated according to the Rampersaud scale. The correct rate of pedicle screw placement was calculated. The invasion of adjacent facet joints, VAS score (Visual Analogue Scale), NDI score (Neck Disability Index), SF-36 score (36-Item Short-Form Health Survey questionnaire), EQ-5D score (EuroQol-5 dimensions questionnaire) and operation-related data were recorded, and patients were followed up. All patients were followed up for an average of 15.0 ± 3.4 months. The accuracy of screw placement in the robot group was higher than that in the traditional operation group, while the rates of intraoperative blood loss and invasion of the facet joint were lower and the incision length and length of hospital stay were shorter. On the 3rd day after the operation, the VAS score in the robot group was significantly higher than that in the traditional operation group, but there was no significant difference in the NDI score. On the 3rd day after the operation, the SF-36 and EQ-5 questionnaire scores of the robot group were better than those of the traditional operation group. No complications occurred in any of the patients. Postoperative cervical X-ray showed that the cervical vertebra was stable, and there was no fracture, angle or displacement. Postoperative CT showed that all fractures healed, and the average healing time was 3.4 months. The treatment of Levine-Edward IIA (postrepositioning) hangman fractures with percutaneous pedicle fixation assisted by the TINAVI orthopaedic surgery robot can significantly improve screw placement accuracy with a low rate of invasion of the adjacent facet joint, a short operation time, a low bleeding rate, and high patient satisfaction. Although there are still many disadvantages, it still has good prospects for application.

Analysis of the clinical characteristics of adult patients with hangman's fractures: A retrospective study based on multicenter clinical data

Background

There are few reports on the clinical characteristics of adult patients with hangman's fractures.

Methods

The clinical data of adult patients were collected from the hangman's fracture database of 7 medical centers. Data on patients who met the inclusion and exclusion criteria were retrospectively analyzed. Data, including gender, age, mechanism of injury, fracture classification, and treatment, were statistically analyzed.

Results

A total of 216 eligible patients (160 males and 56 females, with a mean age of 49.7 years) were selected. There was no statistically significant difference in gender distribution of different age groups. The male-to-female ratio was similar in the young group (18–44 years) and the middle-aged group (45–64 years) (both about 3:1) but decreased in the elderly group (65 years and above) (about 2:1). Overall, high-energy injury was the main mechanism of injury. There was a statistically significant difference in the percentage of patients with high-energy injury in various age groups (the highest in the young group, and the lowest in the elderly group). Overall, unstable fracture was the main fracture type, with a higher proportion in the young and elderly groups than that in the middle-aged group, but there was no statistically significant difference. From the perspective of treatment options, the percentage of patients receiving surgery was higher in the young and elderly groups than that in the middle-aged group.

Conclusion

Hangman's fracture is predominant in males of all age groups, with high-energy injury as the main mechanism of injury. Unstable fracture is common fracture type. The percentage of patients receiving surgery in the young and elderly groups is higher than that in the middle-aged group, which may be correlated with the high incidence of unstable fracture and the life characteristics of the patients in the young and elderly age groups.

A Novel Pedicle Screw Design with Variable Thread Geometry: Biomechanical Cadaveric Study with Finite Element Analysis

BACKGROUND

Pedicle screw fixation provides one of the most stable spinal constructs. Their designs together with osseous characteristics have been known to influence the screw-bone interplay during surgical maneuvers and thereafter the fusion process. Various technical modifications to enhance screw performance have been suggested. This study evaluated the pull-out strength and axial stiffness of a novel pedicle screw design with variable thread geometry and pitch.

METHODS

The newly designed triple threaded pedicle screw is tapered, and has unique out-turned flanges to hold the cancellous bone and a finer pitch at its distal and proximal end to engage the cortical bone. Five lumbar and 4 lower thoracic cadaveric vertebrae were divided into hemivertebrae. A standard cancellous pedicle screw and the newly designed pedicle screw were inserted into each hemivertebra. Axial stiffness and peak pull-out force between the screw types were compared; a finite element analysis was also performed to additionally compare the pull out under toggle forces.

RESULTS

In cadaveric study, the axial stiffness of the new screw was significantly better than that of the standard screw. However, the peak load between the screws was not statistically different. Finite element analyses suggested lesser stress at bone-implant interface for the new screw along with better axial stiffness under both co-axial and toggle forces.

CONCLUSIONS

Our novel pedicle screw design with variable thread geometry demonstrates greater axial stiffness compared with the standard screws, and therefore is likely to withstand a greater surgical manipulation.

Comparison of C2-3 Pedicle Screw Fixation With C2 Spinous Muscle Complex and Iliac Bone Graft for Instable Hangman Fracture

Purpose: To compare the effect between C2 spinous muscle complex graft and iliac bone graft in C2-3 pedicle screw fixation for instable Hangman fracture. Using axial spinous muscle complex instead of iliac bone for instable Hangman fracture can decrease neck pain, bone donor site complication, and operation time.

Method: The outcomes of C2-3 pedicle screw fixation with C2 spinous muscle complex were compared with iliac bone graft in 18 and 21 patients with instable Hangman fracture. The mean age was 49.1 ± 15.8 years in the complex group and 55.3 ± 12.2 years in the Iliac group, and the mean time to surgery of the patients was 3.3 ± 0.6 days in the complex group and 3.6 ± 0.9 days in the iliac group. Outcome measures including operation time, blood loss, visual analog scale (VAS) for pain, Japanese orthopedic association score (JOA), American spine injure association classification (ASIA), and bone fusion time were collected from medical records. In addition, the postoperative complications were also recorded.

Results: There were significant differences in operation time and interoperative blood loss between the two groups (P < 0.01). Also a significant difference was found in VAS score and JOA score between the two groups (P = 0.0012 and P < 0.001, respectively) at 1-month follow-up, whereas, no significant difference was found at other visit time. In the final visit, all patients showed good bone fusion, and two patients shows incision edema and exudation in the iliac group.

Conclusion: C2-3 pedicle screw fixation with C2 spinous muscle complex graft maybe a feasible and safe procedure for instable Hangman fracture.

[Neurosurgical treatment of cervical spine injuries]

BACKGROUND

Injuries of the cervical spine are quite common with an incidence of more than 3% in trauma patients. The incidence is even higher in elderly patients. Cervical spine injuries might induce severe neurological deficits. Therefore, they must be quickly and adequately diagnosed and treated. Depending on the pattern of injury, conservative or surgical treatment is indicated.

OBJECTIVE

The authors describe the different surgical strategies and treatment options based on the pattern of injury. Typical surgical methods are illustrated by case presentations.

CONCLUSION

Cervical spine injuries should be treated in a trauma centre with extensive expertise in spine surgery. The immobilisation and gentle transportation is important already at the scene of the accident. Nowadays, there are excellent surgical options and strategies available as well as excellent intensive care therapy. These possibilities lead to rapid and good stabilisation of cervical spine injuries and the posttraumatic morbidity and mortality can be reduced significantly especially in elderly patients.

Posterior fixation for paediatric and adolescent unstable hangman's fracture: evolution to C1 sparing techniques

PURPOSE

The aim was to study surgical outcomes in hangman's fractures in paediatric and adolescent patients and to demonstrate evolution in posterior surgery from C1-C2-C3 fusion to C1 sparing techniques.

METHODS

Patients (aged ≤ 18 years) operated at a tertiary level centre between September 2011 to February 2018 with more than 1 year of follow-up were included. Neurological status, type of fracture, operating time, blood loss, follow-up, and complications were assessed.

RESULTS

Nine patients were included, with mean age mean of 16.45 years, with a mean follow-up of 42.78 months. Six patients having neurological deficit showed improvement. Two patients, one having undergone C1-C3 lateral mass screw rod fixation (LMSF) and other had C2 pedicle screw with C3 LMSF, developed kyphosis for which fixation was further extended caudally. One patient with an old hangman's fracture with reabsorbed axis pedicle underwent C2 body screw along with C3-C4 pedicle screw rod fixation and C2 pedicle reconstruction. All patients showed evidence of postoperative fusion.

CONCLUSION

Hangman's fractures in young patients can be successfully managed via posterior fixation. In our centre, we have evolved in the direction of motion preservation at C1 C2 joint, along with 3 column stable fixation of the C2 pedicle. C2 pedicle reformation has allowed motion preserving surgery in complex fracture types. Extension of construct till C4 in selected cases is important to prevent postoperative kyphosis.

Anterior C2-3 fusion surgery alone for highly displaced Hangman's fracture with severe angulation of C2-3 of more than 30°

BACKGROUND

Highly displaced Hangman's fracture is a very rare and extremely unstable fracture of the C2 axis. Combined anteroposterior or posterior long-segment fusion surgery is typically performed for the treatment of highly displaced Hangman's fracture. However, these kinds of surgeries increase the risk of complications, loss of motion, and hospital costs.

OBJECTIVE

We sought to investigate the surgical outcomes of anterior C2-3 fusion surgery alone for highly displaced Hangman's fractures with severe angulation of C2-3 by more than 30° and discoligamentous injury.

METHODS

A total of five patients (four men and one woman) were included in this study with a mean age of 40.4 years (range, 26-70 years). The mean follow-up period after surgery was 37.2 months (range, 12-96 months). The fracture characteristics, treatment methods, and outcomes were retrospectively analyzed.

RESULTS

All five patients had type II Hangman's fractures (according to the Levine and Edwards classification scheme). None of the included patients had neurologic deficit or other spine injury but all patients had complete C2-3 discoligamentous injury. Before surgery, all patients successfully achieved closed reduction by skull traction, followed by C2-3 anterior decompression and fusion (ACDF) with plating. For interbody grafting, three patients received a polyetheretherketone (PEEK) cage filled with an autogenous cancellous iliac bone graft and two received autogenous tricortical iliac bone grafts. Severe angulation (39.2° vs. 3.0°, P < 0.001) and severe displacement (76.1% vs. 4.0%, P < 0.001) of C2-3 were both significantly corrected after surgery. All patients had achieved solid fusion at last follow-up. In terms of clinical outcomes, the mean neck pain visual analog scale score was significantly improved (8.6 points vs. 1.8 points, P < 0.001). The mean neck disability index value was also significantly improved (45.4 points vs. 13.0 points, P < 0.01). According to Odom's criteria, all patients achieved satisfactory outcomes. No major complications occurred. One patient complained of dysphagia, but recovered after three months with conservative treatment.

CONCLUSIONS

Preoperative closed reduction and anterior C2-3 fusion surgery alone should be considered as a less-invasive and useful surgical option for highly displaced Hangman's fracture with severe angulation of C2-3, which is an extremely unstable fracture of the C2 axis.

Evolution to Pedicle Reformation Technique in Surgical Management of Hangman's Fracture

BACKGROUND

Opinions vary regarding optimal treatment of unstable hangman's fractures. Recent technological advances have allowed short segment, motion preserving fixation, even in complex cases. The aim of the study was to demonstrate C1-C2 motion-preserving short-segment fusion in hangman's fracture and the evolution of technique from pedicle realignment to pedicle reformation in complex fractures with resorbed/destroyed C2 pedicles.

METHODS

This was a retrospective study. Patients operated by a single surgeon at a tertiary level center from 2012 to 2018 were included. The type of fracture, operating time, and blood loss was recorded. Neurologic deficits were recorded using the American Spinal Injury Association scale with regular clinicoradiologic follow-up.

RESULTS

Nine patients (8 male), with a mean age of 36 ± 16.9 years were included. In the initial 7 patients, C2 pedicle screw, C3-C4 lateral mass screw, and rod fixation was done. The last 2 patients were complex neglected injuries, with 1 having severe angulation and displacement and the other having spondyloptosis with C2 body placed anterior to C4 body. In both these patients, direct C2 body screw were placed and pedicle reconstruction was done. Mean follow up was 41.4 ± 29.8 months. All 5 patients with preoperative neurologic deficits had improvement in power. C1-C2 joint motion was preserved in all. All patients had bony fusion.

CONCLUSIONS

Preservation of motion at the C1-C2 joint should be the goal in all surgically managed hangman's fracture patients. The technique of C2 pedicle reconstruction can be utilized for the same in old neglected hangman's fractures.

Failure of C2-3 anterior arthrodesis for the treatment of atypical Hangman's fractures: A three case series

Background

Hangman's fractures (HF) are defined by bilateral fractures of pars interarticularis of the axis. Most can be treated with a collar. However, the treatment strategies for atypical HF (AHF) involve the pedicles, are unstable, and require fusion. Here, we present three cases of AHF that failed anterior arthrodesis warranting repeat anterior (one case), and posterior fusions (three cases).

Case Description

One female and two males, ranging from 48 to 69 years of age, presented with AHF. All three were originally treated with C2-3 anterior cervical discectomy/fusion, and all three failed (e.g., resulted in pseudarthrosis/ anterolisthesis/instability). The first patient required a secondary C3 corpectomy/C2-4 arthrodesis, with C1-C4 posterior instrumentation. The latter two patients required secondary C1-C3 posterior fusions. For all three patients, 3-12 months follow-up X-rays confirmed the excellent alignment of the instrumentation and bony fusion.

Conclusion

Anterior arthrodesis can be utilized to treat AHF, but often fail when addressing AHF. All AHF warranted secondary posterior fusions (e.g., C1-C3 two cases; and C1-C4 one case) and a subset may additionally require more extensive anterior fusions (e.g., C2-C4 with corpectomy of C3).