Hangman's fracture: Management strategy and healing rate in a prospective multi-centre observational study of 34 patients

Awake reduction of hangman's fracture: An era of dexmedetomidine

Hangman's fracture is a kind of unstable cervical spine injury which should be treated promptly to avoid life threatening consequences. Advanced neurological monitoring is essential during surgical intrervention. Resource limited setting, where advanced monitors like SSEP and MEP are not available makes it challenging to assess proper reduction of cervical spine without neurological compromise. Dexmedetomidine proved to be very useful drug to assess the neurological status intra operatively by awake sedation.

Comparison of Transoral Anterior Jefferson-Fracture Reduction Plate and Posterior Screw-Rod Fixation in C1-Ring Osteosynthesis for Unstable Atlas Fractures

OBJECTIVE

To compare the clinical outcomes of transoral anterior Jefferson-fracture reduction plate (JeRP) and posterior screw rod (PSR) surgery for unstable atlas fractures via C1-ring osteosynthesis.

METHODS

From June 2009 to June 2022, 49 consecutive patients with unstable atlas fractures were treated by transoral anterior JeRP fixation (JeRP group) or PSR fixation (PSR group) and followed up at General Hospital of Southern Theatre Command of PLA; 30 males and 19 females were included. The visual analogue scale (VAS) score, Neck Disability Index (NDI), distance to anterior arch fracture (DAAF), distance to posterior arch fracture (DPAF), lateral mass displacement (LMD), Redlund-Johnell value, postoperative complications, and fracture healing rate were retrospectively collected and statistically analyzed.

RESULTS

Compared with that in the PSR group, the bleeding volume in the JeRP group was lower, and the length of hospital stay was longer. The VAS scores and NDIs of both groups were significantly improved after surgery. The postoperative DAAF and DPAF were significantly smaller after surgery in both groups. Compared with the significantly shorter DPAF in the PSR group, the JeRP group had a smaller DAAF, shorter LMDs and larger Redlund-Johnell value postoperatively and at the final follow-up. The fracture healing rate at 3 months after surgery was significantly greater in the JeRP group (p < 0.05).

CONCLUSION

Both C1-ring osteosynthesis procedures for treating unstable atlas fractures yield satisfactory clinical outcomes. Transoral anterior JeRP fixation is more effective than PSR fixation for holistic fracture reduction and short-term fracture healing, but the hospital stay is longer.

Biomedical analysis of four fixation systems in treatment of type II traumatic spondylolisthesis of the axis: a finite element analysis

This study aimed to compare the properties and safety of self-designed plates in type II traumatic spondylolisthesis of the axis with those of traditional devices via finite element (FE) analysis. We constructed a hangman's fracture FE model from the occipital bone (C0) level to the C3 level. Then, FE models were constructed for the following four fixation systems: an anterior cervical L-shaped plate with four vertebral screws (4-ACLP), or six screws (6-ACLP), an anterior cervical orion plate (ACOP), and a posterior fixation system. A preloaded compressive force of 50 N and a moment of 1.5 N·m were applied to each model under six working conditions. The mobility of the C2/3 segment decreased significantly in four fixation models. In the Mises stress cloud diagram, 4-ACLP showed a better stress distribution in both the bone graft and fixation system than 6-ACLP and ACOP. The resultant force of 4-ACLP was lower but higher than ACOP in axial force. Additionally, the cage in the 4-ACLP configuration experienced the highest stress in the six working conditions. Hence, this novel self-designed plate has the potential to mitigate the operational difficulties, provide sufficient stability, reduce the risk of plate or screw fractures, and improve bone fusion.

Anterior atlantoaxial motion preservation fixation technique for axis complex fractures (odontoid process with Hangman's fractures) and technique notes

This study aims to investigate the feasibility and efficacy of anterior atlantoaxial motion preservation fixation (AMPF) in treating axis complex fractures involving the odontoid process fracture and Hangman's fractures with C2/3 instability. A retrospective study was conducted on eight patients who underwent AMPF for axis complex fractures at the General Hospital of Central Theater Command from February 2004 to October 2021. The types of axis injuries, reasons for injuries, surgery time, intraoperative blood loss, spinal cord injury classification (American Spinal Injury Association, ASIA), as well as complications and technical notes, were documented. This study included eight cases of type II Hangman's fracture, five cases of type II and three cases of type III odontoid process fracture. Five patients experienced traffic accidents, while three patients experienced falling injuries. All patients underwent AMPF surgery with an average intraoperative blood loss of 288.75 mL and a duration of 174.5 min. Two patients experienced dysphagia 1 month after surgery. The patients were followed up for an average of 15.63 months. One case improved from C to E in terms of neurological condition, three cases improved from D to E, and four cases remained at E. Bony fusion and Atlantoaxial Motion Preservation were successfully achieved for all eight patients. AMPF is a feasible and effective way for simultaneous odontoid process fracture and Hangman's fractures with C2/3 instability, while preserving atlantoaxial movement.

Current Concepts in the Treatment of Traumatic C2 Vertebral Fracture : A Literature Review

The integrity of the high cervical spine, the transition zone from the brainstem to the spinal cord, is crucial for survival and daily life. The region protects the enclosed neurovascular structure and allows a substantial portion of the head motion. Injuries of the high cervical spine are frequent, and the fractures of the C2 vertebra account for approximately 17-25% of acute cervical fractures. We review the two major types of C2 vertebral fractures, odontoid fracture and Hangman's fracture. For both types of fractures, favorable outcomes could be obtained if the delicately selected conservative treatment is performed. In odontoid fractures, as the most common fracture on the C2 vertebrae, anterior screw fixation is considered first for type II fractures, and C1-2 fusion is suggested when nonunion is a concern or occurs. Hangman's fractures are the second most common fracture. Many stable extension type I and II fractures can be treated with external immobilization, whereas the predominant flexion type IIA and III fractures require surgical stabilization. No result proves that either anterior or posterior surgery is superior, and the surgeon should decide on the surgical method after careful consideration according to each clinical situation. This review will briefly describe the basic principles and current treatment concepts of C2 fractures.

Comparison of complication rates between anterior versus posterior approaches for treating unstable Hangman's fracture. A systematic review and meta-analysis

Study design

Systematic Review and Meta-analysis.

Objective

To compare the complication rates associated with anterior and posterior approaches for the surgical treatment of unstable hangman's fractures.

Methods

A systematic review and meta-analysis were performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines in PubMed, Web of Science, and Scopus databases to identify comparative studies reporting complications of anterior versus posterior approaches for the treatment of unstable hangman's fractures.

Results

The search yielded 1163 papers from which 5 studies were fully included. One hundred fifteen (115) patients were operated on using an anterior approach versus 65 through a posterior approach. The average complication rates for the anterior and posterior approaches were 26.1 % and 13.8 %, respectively. No complications following the anterior approach required pharmacological or surgical intervention (Clavien-Dindo, Grade 1), while 88.9 % of complications following the posterior approach did (Clavien-Dindo, Grade 2).

Conclusion

No significant differences in the complication rates were found when comparing anterior versus posterior surgery for treating a C2 traumatic spondylolisthesis. However, most of the complications presented in the posterior surgery group were more severe.

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.

Revision Procedure After Surgery for Atypical Hangman's Fracture Primarily Performed Only from the Posterior Approach - An Attempt to Maintain Head Rotation: Case Report

Introduction

Hangman's fracture, also known as traumatic spondylolisthesis of the axis, is defined as a bilateral fracture of the C2 pars interarticularis. In 1965, Schneider used this term to describe a pattern of similarities seen in fractures associated with judicial hangings. However, this fracture pattern is only observed in approximately 10% of injuries associated with hangings.

Case Report

We present a case of an atypical hangman's fracture caused by a headlong dive into a swimming pool and striking the pool's bottom. The patient had undergone surgery at another centre, where posterior C2-C3 stabilisation was performed. Due to the presence of screws in the C1-C2 joint spaces, the patient could not perform rotational movements of the head. Anterior stabilization to prevent C2 dislocation against C3 was also not performed, and appropriate spinal stability was not ensured. Our decision to reoperate was motivated, among other factors, by our intention to restore rotational head movements. The revision surgery was performed from both an anterior and posterior approach. After the surgery, the patient was able to rotate his head while maintaining cervical spine stability. The case presented here represents not only a unique example of an atypical C2 fracture but also highlights a fixation technique that provided the necessary stability for successful fusion. The utilized method restored functional rotational movement of the head, thus preserving the patient's quality of life, which is of paramount importance considering the patient's age.

Conclusion

The decision-making process regarding the technique for treating hangman's fractures, especially atypical fractures, should account for the patients' quality of life after the operation. The preservation of as much of the physiological range of motion as possible with maintained spinal stability should be the goal of therapy in every case.

Minimally invasive percutaneous new designed transpedicular lag-screw fixation for the management of Hangman fracture using O-arm-based navigation: a clinical study

BACKGROUND

To investigate the outcomes and safety of using minimally invasive percutaneous new transpedicular lag-screw fixation with intraoperative, full rotation, three-dimensional image (O-arm)-based navigation for the management of Hangman fracture.

METHODS

Twenty-two patients with Hangman fracture were treated with minimally invasive percutaneous new transpedicular lag-screws using intraoperative, full rotation, and three-dimensional image (O-arm)-based navigation. The preoperative and postoperative conditions of the patients were evaluated according to the ASIA (American Spinal Injury Association) scale. The patient's VAS (visual analog scale) scores before and after surgery, operation time, cervical vertebral activity, intervertebral angle and bone healing were recorded and collected, and repeated measures analysis of variance was used for statistical analysis.

RESULTS

All patients were satisfactorily repositioned after surgery, and the VAS scores for neck pain were significantly lower than those before surgery on the first day and at 1 month, 3 months and the last follow-up (P < 0.001). According to the ASIA scale, four patients recovered from preoperative grade D to postoperative grade E. Bony fusion was achieved for all cases, and the range of neck rotation was restored to normal at the last follow-up. The post-surgery angular displacement (AD) demonstrated the stability of C2-3 after our new screw fixation for the treatment of Hangman fracture.

CONCLUSIONS

Minimally invasive percutaneous new transpedicular lag-screw fixation using intraoperative, full rotation, three-dimensional image (O-arm)-based navigation achieved satisfactory clinical results with the advantages of immediate stability, safety and effectivity. We suggest that it is a reliable and advanced technique for the management of Hangman fracture.

New Trend in Craniovertebral Junction Surgical Strategy: Technical Note for the Treatment of Hangman's Fractures Through a Minimally Invasive Approach

INTRODUCTION

The reduction, stabilization, and maintenance of alignment are the main goals in the surgical treatment of unstable hangman's fractures. The choice of the surgical strategy remains poorly standardized; anterior and/or posterior fusion could be performed; and none of the available clinical studies in the literature have shown significant differences in outcomes or complication rates. Vertebral anatomy, age, comorbidities, patient factors, and surgical experience may guide the treatment choice.

METHODS

We present a case of a polytraumatized young woman with an unstable hangman's fracture type II, according to Levine-Edwards classification. We treated the fracture by using a plate with four holes to fix C2-C3 without discectomy and body fusion.

RESULTS

We performed a small incision, such as those used for the fixation of odontoid screws, where the working angle allowed us to easily and quickly position the plate by using a minimally invasive approach.

CONCLUSION

The stabilization alone, without discectomy and body fusion with the cage, in the same way favored the natural healing of the bone fracture. In our opinion, in some select cases, fixation of C2-C3 alone through a minimally invasive approach allows for bone healing with fewer risks and an easier surgery.

Traumatic spondylolisthesis of axis: clinical and imaging experience at a level one trauma center

PURPOSE

Traumatic spondylolisthesis of the axis (TSA) with bilateral pars interarticularis fracture (a pattern also known as Hangman's fractures) accounts for 4-5% of all cervical fractures. Various classification systems have been described to assist therapeutic decision-making. The goal is to reassess the utility of these classifications for treatment strategy and evaluate additional imaging associations.

METHODS

This is an IRB approved, retrospective analysis of patients with imaging diagnosis of TSA from 2016 to 2019. Consensus reads were performed classifying TSA into various Levine and Edwards subtypes and typical vs. atypical fractures. Other imaging findings such as additional cervical fractures, traumatic brain injury, spinal cord injury, and vertebral artery injury were recorded. Treatment strategy and outcome were reviewed from clinical charts. Fisher exact test was used for statistical analysis.

RESULTS

A total of 58 patients were included, with a mean age of 62.7 ± 25 years, and male to female ratio of 1:1.2. Motor vehicle collision was the most common cause of TSA. Type I and III injuries were the most and the least common injuries, respectively. Patients with type I injuries were found to have good healing rates with conservative management (p < 0.001) while type IIa and III injuries were managed with surgical stabilization (p = 0.04 and p = 0.01, respectively). No statistical difference was observed in the treatment strategy for type II fractures (p = 0.12) and its prediction of the associated injuries. Atypical fractures were not found to have a higher incidence of SCI (p = 0.31). A further analysis revealed significantly higher-grade vertebral artery injuries (grades III and IV according to Biffl grading) in patients with type IIa and III injuries (p = 0.001) and an 11-fold increased risk of TBI compared to type I and type II fractures (p = 0.013).

CONCLUSION

TSA fracture types were not associated with any clinical outcome. Levine and Edwards type II classification itself is not enough to guide the treatment plan and does not account for associated injuries. Additional imaging markers may be needed.

C2-C3 Anterior Cervical Diskectomy and Fusion for Hangman's Fractures with C2 Posterior Dislocation: Technical Notes

BACKGROUND

The overwhelming majority of hangman's fractures cause anterior dislocation of C2. Hangman's fracture with C2 posterior dislocation is extremely rare; only 1 pediatric case was reported in 2018 to date. This kind of injury cannot be cataloged using current classification schemes, and no established treatment recommendations exist. The purpose of this article is to report a rare case of a hangman's fracture with C2 posterior dislocation, which does not fit into existing classification systems and discuss management technical notes to avoid pitfalls.

METHODS

We describe this case, review relevant literature, and share our experience.

RESULTS

A 31-year-old male sustained a hangman's fracture with C2 posterior dislocation after he fell into a 50-cm deep roadside ditch when riding a motorcycle. Radiograph and computed tomography on admission showed fractures through both pars of C2 and C2 posterior dislocation. Magnetic resonance imaging on admission showed high T2-weighted signal intensity of cervical spinal cord and compression of the cervical spinal cord by posterior dislocation of the C2 vertebral body. A C2-3 anterior cervical diskectomy and fusion was performed. At 6 months after operation, bony fusion was achieved and magnetic resonance imaging showed the T2-weighted signal hyperintensity of cervical spinal cord before surgery disappeared.

CONCLUSIONS

C2-C3 anterior cervical diskectomy and fusion is recommended for hangman's fractures with C2 posterior dislocation. Traction before surgery is not recommended.

Upper Cervical Trauma

Craniocervical injuries (CCJs) account for 10% to 30% of all cervical spine trauma. An increasing number of patients are surviving these injuries due to advancements in automobile technology, resuscitation techniques, and diagnostic modalities. The leading injury mechanisms are motor vehicle crashes, falls from height, and sports-related events. Current treatment with urgent rigid posterior fixation of the occiput to the cervical spine has resulted in a substantial reduction in management delays expedites treatment of CCJ injuries. Within CCJ injuries, there is a spectrum of instability, ranging from isolated nondisplaced occipital condyle fractures treated nonoperatively to highly unstable injuries with severely distracted craniocervical dissociation. Despite the evolution of understanding and improvement in the management of cases regarding catastrophic failure to diagnose, subsequent neurologic deterioration still occurs even in experienced trauma centers. The purpose of this article is to review the injuries that occur at the CCJ with the accompanying anatomy, presentation, imaging, classification, management, and outcomes.

Experience of Using Transpedicular Osteosynthesis in Traumatic Spondylolisthesis of the Axis

The aim of the study was to assess the efficacy and safety of direct posterior transpedicular osteosynthesis in traumatic spondylolisthesis of C₂ vertebra.

Materials and Methods

The present study is an observational retrospective analysis of the results of surgical treatment of 19 patients operated on in 2014-2020 using the posterior transpedicular osteosynthesis technique with Herbert's compression screws for a Hangman's fracture type II according to Levine-Edwards classification. After the operation, the follow-up period lasted for 22 [10; 36] months.

Results

The study group of patients (n=19) made 2.48% of all patients operated on for traumatic injury of the cervical spine (n=766) in the period from 2014 to 2020. In all cases, the surgical treatment was successful; there were no intraoperative complications in the form of damage to the vascular and nerve structures. The average duration of surgery was 70.8±24.5 min, and intraoperative blood loss was 92.9±41.8 ml. The length of hospitalization stay was 7 [5; 17] days. On the postoperative CT scans, no significant screw malposition (>2 mm) was found.

Conclusion

Transpedicular osteosynthesis with compression screws in C₂ traumatic spondylolisthesis is a safe and sparing operation with a short duration and insignificant blood loss. Thorough preoperative planning and knowledge of the anatomic landmarks make it possible to perform this operation effectively under the C-arm X-ray system control without any navigation system.

Hangman's Fracture

STUDY DESIGN

Review article.

OBJECTIVE

A review and update of the treatment of Hangman's fractures including the indications for both nonoperative and operative treatment of typical and atypical fractures.

SUMMARY OF BACKGROUND DATA

Hangman's fractures are the second most common fracture pattern of the C2 vertebrae following odontoid fractures. Many of the stable extension type I and II fractures can be treated with external immobilization, whereas the predominant flexion type IIa and III fractures require surgical stabilization.

METHODS

A review of the literature.

RESULTS

The clinical and radiographic outcomes of the treatment of Hangman's fractures lend a good overall prognosis when the correct diagnosis is made. The nonoperative treatment of stable type I and II fractures with external immobilization leads to excellent long-term outcomes as does the operative treatment of the unstable type IIa and III fractures.

CONCLUSIONS

Hangman's fractures can be classified as stable (type I and most II) or unstable (type IIa and III) and the optimal treatment depends upon this distinction. Stable injuries do well with rigid immobilization and rarely require operative intervention. In contrast, unstable injuries do poorly if treated nonoperatively but do well with surgical intervention. When treating atypical Hangman's variants, great vigilance and close clinical observation is paramount if nonoperative treatment is indicated given the potential for neurological compression in this fracture pattern. Properly identifying and treating these injuries represents an opportunity for the spine surgeon to optimize patient outcomes.