Traumatic spondylolisthesis of the axis: a biomechanical comparison of clinically relevant anterior and posterior fusion techniques

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.

MAZOR-X robotic-navigated percutaneous C2 screw placement for hangman's fracture: a case report

Robotic-navigated screw placement has potential for higher precision and accuracy. Robotic assistance is well-described in the lumbar spine, however only few studies have evaluated its use in the cervical spine. Surgical treatment for hangman's fractures after nonunion typically involves C2-3 anterior fusion or posterior occipito-cervical fusion. However, occipito-cervical fusion involves loss of mobility in the cervical spine with associated morbidity. We have previously described a minimally invasive approach using percutaneous screw fixation with X-ray navigation. Robotic assistance is ideally suited for cervical fusion given smaller bony anatomy and adjacent critical structures. We describe a young healthy patient who presented with a hangman's fracture initially managed conservatively with immobilization. She presented with nonunion and persistent symptoms. Surgical options considered included anterior cervical discectomy and fusion, or posterior cervical fusion with or without extension to the occiput. These options would have involved some loss of flexion/extension and rotational motion with associated morbidity. We performed percutaneous screw fixation of the hangman's fracture using MAZOR-X robotic navigation and achieved good radiographic fracture reduction with accurate screw placement. To our knowledge this is the first case of a robotic-assisted percutaneous screw fixation for a hangman's fracture. Robotic-navigated screw placement can be used safely and accurately for cervical spine fractures.

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.

Hangman's fracture: a clinical review based on surgical treatment of 15 cases

This is a retrospective analysis of cases with hangman's fracture. The subject of 'hangman's fracture' has been elaborately evaluated in the literature. The authors propose an alternative format of surgical treatment that is based on modification of existing classification schemes. During the period 2015 to March 2020, 15 patients having hangman's fracture were identified and were surgically treated. The clinical condition was classified on the basis of American Spinal Injury Association scale (ASIA scale) and VAS parameters. The patients were classified into 4 groups depending on the presence (or absence) of atlantoaxial and/or C2-3 instability. Surgical decisions were guided by the proposed classification. Clinical evaluation and dynamic CT scan were done at follow-up visits. During the average follow-up of 26 months, all patients are essentially asymptomatic. There was marginal restriction of extent of neck movements in all cases. There was solid bone fusion in all cases. The proposed novel classification scheme based on the presence of atlantoaxial and C2-3 instability assisted in directing the treatment strategy of hangman's fracture.

Curious Case of Atypical Hangman’s Fracture: C2–C3 Listhesis without Pars Fracture

Traumatic spondylolisthesis of axis or hangman’s fracture is the second most common C2 vertebra injury. We present a report of a young man presenting with a history of fall from height with C2 to C3 spondylolisthesis without any evidence of injury to pars interarticularis but with associated injury to capsular ligament of facet joint along with posterior spinous ligamentous injury. The patient underwent intraoperative reduction in listhesis with posterior screw fixation. The patient showed uneventful postoperative course with neurological improvement at 6-week follow-up. Hangman’s fracture refers to a diverse group of injury in which the soft tissue injury has an equally important part to play as the bone fracture.

Treatment of Axis Ring Fractures: Recommendations of the Spine Section of the German Society for Orthopaedics and Trauma (DGOU)

STUDY DESIGN

Narrative literature review and expert recommendation.

OBJECTIVE

To establish treatment recommendations for axis ring fractures based on the knowledge of the experts of the Spine Section of the German Society for Orthopaedics and Trauma.

METHODS

This recommendation summarizes the knowledge of the experts of the Spine Section of the German Society for Orthopaedics and Trauma with regard to the treatment of axis ring fractures based on a narrative literature review.

RESULTS

Typical "hangman's fractures" with bilateral separation of the neural arch from C2 and atypical "hangman's fractures" with irregular fracture morphology are described. Computed tomography is the "gold" standard used to detect and analyse these fractures adequately. Furthermore, the detection of vertebral artery integrity is necessary. To classify axis ring fractures, the Levine-Edwards or Josten classification is recommended. In particular, the integrity of the C2/3 disc and the integrity of the anterior longitudinal ligament are used to determine the treatment strategy. While Levine-Edwards type I and type IIA (Josten type 1 and 2) fractures should be treated conservatively, Levine type II and type III (Josten type 3 and 4) fractures should be treated operatively. Levine-Edwards type II fractures will be predominately treated by anterior C2/3 fusion. Levine-Edwards type III fractures have to be primary reduced, if an anterior fusion is planned (anterior cervical discectomy and fusion [ACDF] C2/3). If a closed reduction of a type III fracture is impossible, an open reduction and posterior fixation/fusion is the treatment of choice.

CONCLUSION

Conservative treatment is predominantly reserved for Levine-Edwards I and IIA fractures. Operative treatment should be performed in case of Levine-Edwards II and III fractures.

Management challenges of traumatic spondylolisthesis of the Axis with an unusual C2-C3 posterior subluxation in a paediatric patient: case report and literature review

Introduction

Paediatric cervical spine injuries are uncommon. Traumatic spondylolisthesis of the axis (TSA) is commonly encountered in the trauma setting. The management of TSA may be surgical or non-surgical. Decision making is quite challenging depending on patient presentation and nature of injury, and even more so in the paediatric age group.

Objectives

To present a case report highlighting the challenges in the management of TSA.

Methods

We present an 8 year old male, who sustained a bilateral C2 pars fracture with associated unusual C2-C3 posterior subluxation.

Results

Neuroradiological studies identified the fracture/subluxation of C2-C3 and revealed an intact but posteriorly displaced C2-C3 disc causing cord compression. An Extension Halter traction was initially commenced. This seemed to have worsened the patient's neck pains, and caused motor weakness and autonomic dysfunction. An anterior cervical discectomy and fusion was finally decided on and performed after evaluation and brainstorming by our spinal Unit. Intra-operative findings revealed separation of the C2-C3 disc from the C3 superior end plate which probably explains the unusual nature of the subluxation.

Conclusion

The case shows that surgical intervention as a primary management for TSA even in the paediatric age group is safe and also avoids risks inherent in conservative management.

A New Minimally Invasive Technique for Primary Unstable C2 Spondylolysis in an 8-Year-Old Child: A Case Report and Review of the Literature

BACKGROUND

Posterior arch defect of C2 with an unstable spondylolysis is a rare condition mostly occurring within children. Its management is still controversial.

CASE DESCRIPTION

We report in this article the first minimally invasive surgery (MIS) technique for this condition in an 8-year-old boy. A primary unstable C2 spondylolysis was diagnosed on the exploration of episodic paresthesia of upper limbs associated with headache lasting for several months. The surgical technique consisted in a direct pars repair through an MIS approach: METRx tubular retractor system (Medtronic Sofamor Danek, Memphis, Tennessee, USA), intraoperative C-arm fluoroscopy, surgical microscope, endoscopic spine instrument, and high-speed drill were required. Muscles were split and retracted. One-year postoperative course was excellent.

CONCLUSIONS

After reviewing the past literature of this pathology, we discuss the minimally invasive posterior approach of the upper cervical spine. It is the first case, to our knowledge, describing direct minimally invasive repair for bilateral primary C2 pars defect in a child. Image guidance and surgical microscope help safe and effective screw placement.

Functional outcome in unstable Hangman's fracture managed with anterior approach: A prospective study

Aim:

To study the functional outcome in unstable Hangman s fracture managed with anterior decompression and stabilization with cervical locking plate and tricortical bone graft.

Materials and Methods:

Between 2010 and 2016, 44 patients (range: 19-75 years) with unstable Hangman's fracture underwent anterior decompression and stabilization with cervical locking plate and tricortical bone graft in our institution.

Result:

According to the Levine and Edwards classification, all patients were unstable with Type IA 6 (13.6), Type IIA 35 (79.5%), Type II (0), and Type III (6.8). The mean period of follow-up was 17 months (range: 6-48 months). Neurological recovery was observed in all nine patients. All patients were relieved from axial pain. None of the patients received blood transfusion. All patients showed solid fusion with no complication related to bone graft and plate.

Conclusion:

The anterior C2/C3 discectomy, fusion, and stabilization with cervical locking plate and tricortical bone graft are feasible and safe method in treating HangmanÊs fracture, with the benefit of high primary stability, anatomical reduction, and direct decompression of the spinal cord.

Low energy chronic traumatic spondylolisthesis of the axis

OBJECTIVE

The aim of this study is to present a unique case of a patient who presented to our Emergency Department with evidence of a chronic traumatic spondylolisthesis of the axis with severe displacement treated with anterior cervical discectomy and fusion (ACDF) of C2-C3 as well as and posterior cervical fusion (PCF) of C1-C3.

METHODS

One patient with an untreated traumatic spondylolisthesis of the axis with Levine type II injury pattern and 1.2 cm of anterior subluxation underwent ACDF C2-C3 and PCF C1-C3.

RESULTS

The patient recovered well, radiographs demonstrated reduction of the anterior subluxation, and the patient reported a neck disability index (NDI) score of 20 at 6-month follow-up with full neurologic function intact. The patient was then lost to follow-up.

CONCLUSION

In this report, we present an alcoholic patient with a history of many falls who presented with a Levine type II traumatic spondylolisthesis of the axis with signs of chronicity seen on magnetic resonance imaging (MRI). We were able to partially reduce the anterior displacement with traction, but needed both anterior and posterior cervical approaches to achieve adequate reduction and stabilization of the injury.

Imaging findings of flexion type of hangman's fracture; an attempt for a more objective evaluation with newly introduced scoring system

OBJECTIVE

To identify the flexion type of hangman's fracture on imaging studies.

METHODS

38 cases of hangman's fracture were retrospectively studied and categorized into flexion and non-flexion groups. Plain radiograph, CT and MRI of these patients were evaluated; 13 radiological parameters that might define flexion injuries were measured. The data were statistically analyzed to identify good criteria and to rank them according to their importance in predicting flexion.

RESULTS

Seven radiological criteria that have the highest correlation with flexion injury were identified. These are C2-3 lower end-plate angle, C2-3 posterior body angle, interspinous angle, disc disruption (MRI), widening of interspinous distance, disruption of the posterior ligamentous complex (MRI) and angle at the fracture site. Scoring 1 point for each positive criterion, a total score of 4 predicts flexion injury with 100% sensitivity and 96.9% specificity. Score of 5 has 83.3% sensitivity and 100% specificity.

CONCLUSION

Flexion hangman's injury can be diagnosed by the presence of four out of seven radiological criteria in the newly introduced scoring system. The authors believe that this method may help spinal surgeons in their selection of therapeutic strategy. Advances in knowledge: This study introduces fast, simple and more objective imaging criteria for the diagnosis of flexion hangman's injury and separates it from the non-flexion pattern.

Fractures of the axis: a review of pediatric, adult, and geriatric injuries

Fractures of the second cervical vertebra (C2, axis) are common in adult spine surgery. Those fractures occurring in younger adult patients are often associated with high-energy mechanism trauma, resulting in a "Hangman's Fracture." Management of these fractures is often successful with nonoperative means, though surgery may be needed in those fractures with greater displacement and injury to the C2-C3 disc. Older patients are more likely to sustain fractures of the odontoid process. The evidence supporting surgical management of these fractures is evolving, as there may be a mortality benefit to surgery. Regardless of treatment, longer-term mortality rates are high in this patient population, which should be discussed with the patient and family at the time of injury. Pediatric patients may suffer fractures of the axis, though differentiation of normal and pathologic findings is necessary and more difficult with the skeletally immature spine.

Burst C2 Fractures Combined with Traumatic Spondylolisthesis: Can Atlantoaxial Motion Be Preserved? Including Some Technical Tips for Reduction and Fixation

STUDY DESIGN

Retrospective comparative clinical case series.

OBJECTIVE

Burst C2 fractures are very rare. Treatment options include conservative treatment or fusion (anterior, posterior, or anterior and posterior). Anterior fusion addresses mainly hangman component. The bursting body usually needs posterior or combined anterior-posterior fusion, but both permanently sacrifice atlantoaxial motion. Can anterior-"first" approach preserve C1-C2 motion and restore function?

METHODS

We report nine cases of burst C2 combined with C2-C3 spondylolisthesis and an odontoid fracture. The surgical group included six patients treated initially with an anterior approach, moving to a posterior one when necessary. All were treated with anterior diskectomy fusion using one session and one incision. The halo group included three patients treated conservatively using halo traction followed by rigid collar. Assessments included self-reported, physiologic, and functional measures. Reduction was assessed using Roy-Camille's criteria and improvement of canal compression ratio. Clinical outcome was graded excellent, very good, good, or poor according to pain, range of motion, and work status.

RESULTS

Mean follow-up was 44.5 ± 8.3 (range 36.0 to 62.0) weeks. Results in the surgical group were judged to be excellent in four and good in two. One patient developed atlantoaxial osteoarthritis. Results were good in one patient and poor in two patients in the halo group. Two patients developed atlantoaxial osteoarthritis. All three cases had work limitations.

CONCLUSION

A single anterior approach achieved union and preserved C1-C2 motion and function in some cases. Conservative treatment achieved union but failed to achieve good reduction or good clinical outcome in grossly instable fractures. However, we believe that the ideal management is yet to evolve.

Case Report: A case report of unstable Hangman fracture in a eighty year old male

Herein we discuss a rare variant of hangman's fracture in an eighty year old male with good Karnofsky performance score. We performed X-ray and magnetic resonance imaging (MRI) of the cervical spine to confirm the diagnosis. The patient was placed on a gentle cervical traction which showed good reduction. Despite being on a resource limited setup,  we performed posterior occipitocervical fusion with bone graft fusion followed by early mobilization. A postoperative scan showed good reduction and purchase of the screws. This case highlights the importance of choosing the correct therapeutic attitude for the management of the geriatric population especially in those who do not have any significant co-morbid conditions.

Traumatic Spondylolisthesis of the Axis Vertebra in Adults

Study Design Narrative review. Objective To elucidate the current concepts in diagnosis and treatment of traumatic spondylolisthesis of the axis. Methods Literature review using PubMed, Google Scholar, and Cochrane databases. Results The traumatic spondylolisthesis of the axis accounts to 5% of all cervical spine injuries and is defined by a bilateral separation of the C2 vertebral body from the neural arch. The precise location of the fracture line may vary widely. For understanding the pathobiomechanics, the involvement of the C2-C3 disk is essential. Although its synonym "hangman's fracture" suggests an extension moment as primary injury mechanism, flexion moments are also proven to cause such fracture morphology. The axial force vector (distraction versus compression) is thought to have a significant effect on the neurologic involvement. The most widely accepted classifications, according to Effendi and modified by Levine, regard the displacement of the C2 vertebral body and possible locking of the facet joints. For decisions on conservative versus surgical therapy, a definitive statement about the stability is essential. The stability is determined by involvement of the C2-C3 disk and longitudinal ligaments, which frequently cannot be assessed by X-ray or computed tomography alone. The assessment of this soft tissue injury therefore requires additional imaging either by magnetic resonance imaging to display the disk and longitudinal ligaments or dynamic fluoroscopy to assess functional behavior of the C2-C3 motion segment. If stability is proven, an immobilization of the cervical spine in a semirigid cervical collar is sufficient. Unstable lesions require surgical stabilization. The standard procedure is an anterior C2-C3 diskectomy and fusion, because of the lower morbidity of the anterior approach and the motion preservation between C1 and C2. In rare cases (irreducible locked facet joints, the necessity of decompression of the vertebral artery, contraindication for anterior approach), a posterior approach is sometimes necessary. Isolated direct screw osteosynthesis is of little value, because it only makes sense in cases with an intact C2-C3 disk, which is usually regarded as stable and therefore might be treated conservatively. Conclusions Overall, the clinical evidence regarding traumatic spondylolisthesis of the axis is very low and mainly based on small case series, expert opinion, laboratory findings, and theoretical considerations.

Minimally invasive percutaneous screw fixation of traumatic spondylolisthesis of the axis

OBJECT

Most cases of traumatic spondylolisthesis of the axis (hangman's fracture) can be treated nonoperatively with reduction and subsequent immobilization in a rigid cervical collar or halo. However, in some instances, operative management is necessary and can be accomplished by using either anterior or posterior fusion techniques. Because open posterior procedures can result in significant blood loss, pain, and limited cervical range of motion, other less invasive options for posterior fixation are needed. The authors describe a minimally invasive, navigation-guided technique for surgical treatment of Levine-Edwards (L-E) Type II hangman's fractures.

METHODS

For 5 patients with L-E Type II hangman's fracture requiring operative reduction and internal fixation, percutaneous screw fixation directed through the fracture site was performed. This technique was facilitated by use of intraoperative 3D fluoroscopy and neuronavigation.

RESULTS

Of the 5 patients, 2 were women, 3 were men, and age range was 46–67 years. No intraoperative or postoperative complications occurred. All patients wore a rigid cervical collar, and flexion-extension radiographs were obtained at 6 months. For all patients, dynamic imaging demonstrated a stable construct.

CONCLUSIONS

L-E type II hangman's fractures can be safely repaired by using percutaneous minimally invasive surgical techniques. This technique may be appropriate, depending on circumstances, for all L-E Type I and II hangman's fractures; however, the degree of associated ligament injury and disc disruption must be accounted for. Percutaneous fixation is not appropriate for L-E Type III fractures because of significant displacement and ligament and disc disruption. This report is meant to serve as a feasibility study and is not meant to show superiority of this procedure over other surgical options.

The surgical management of traumatic lower cervical spondylolisthesis with posterior percutaneous pedicle screw fixation

We reported a technical report of traumatic lower cervical spondylolisthesisca used by bilateral pedicle fracture, without neurological compression. The patient was treated with the minimally invasive technique of percutaneous pedicle screw fixation. Fracture healing and normal cervical motion were confirmed by plain films and physical examinations on the 18-monthpostoperatively. The technique of percutaneous pedicle screw fixation might be an alternative strategy for the treatment of traumatic lower cervical spondylolisthesis with pedicle fracture.

C1-C3 Lateral Mass Screw-Rod Fixation and Fusion for C2 Pathologies and Hangman's Fractures

Study Design

Retrospective clinical study.

Purpose

We report our experience of eight patients treated with C1-C3 lateral mass rod-screw stabilization and fusion in the treatment of Hangman's fracture and other axis pathologies.

Overview of Literature

Different surgical approaches, both anterior and posterior, have been described for treating Hangman's fracture and other pathologies where surgery is indicated.

Methods

All patients who underwent surgical treatment for Hangman's fracture and axial pathology where C1-C3 lateral mass screw-rod stabilization and fusion done, following reduction of the fracture or removal of the pathology were included in this series. The recorded patient management data was retrospectively studied.

Results

There were 8 cases in total. All were male, with an average age of 40.75 years. Hangman's fracture occurred in 6 cases (75%), one with metastatic squamous cell carcinoma and the remaining with plasmocytoma. Among the Hangman's fractures 4 (66.66%) had no neuro-deficit. Reduction and bilateral C1-C3 lateral mass screw and rod fixation with posterior fusion by bone graft was performed in all cases. In 2 cases, a C2 body tumor was removed transorally. All patients with neuro-deficit fully recovered, except one who expired in the early post-operative period. Rest of all patients were leading a normal life till last follow up.

Conclusions

Although the number of cases was very small with a relatively short follow up period, C1 and C3 lateral mass screw-rod fixation followed by fusion showed promise as an effective and biomechanically sound way for the treatment of properly selected Hangman's fracture cases, and may also be suitable in other axial pathologies.

Axis ring fractures due to simulated head impacts

BACKGROUND

We investigated mechanisms of axis ring fractures due to simulated head impacts.

METHODS

Our model consisted of a human upper cervical spine specimen (occiput through C3) mounted to a surrogate torso mass on a sled and carrying a surrogate head. We divided 13 specimens into 3 groups based upon head impact location: upper forehead in the midline, upper lateral side of the forehead, and upper lateral side of the head. Post-impact fluoroscopy and anatomical dissection documented the injuries. Average occurrence times of the peak loads and accelerations were statistically compared (P<0.05) using ANOVA and Bonferroni pair-wise post-hoc tests.

FINDINGS

Of the 13 upper cervical spines tested, 5 specimens sustained axis ring fractures with the most common mechanism being impact to the upper left lateral side of the forehead. The first local force peaks at the impact barrier and neck and all peak head accelerations occurred between 18.0 and 22.8 ms, significantly earlier than the absolute force peaks. The average peak neck loads reached 1761.2N and the axis ring fractures occurred within 50 ms.

INTERPRETATION

We observed asymmetrical fractures of the axis ring including fractures of the superior and inferior facets, laminae, posterior wall of the vertebral body, pars interarticularis, and pedicles. The fracture patterns were related to the morphology of the axis as a transitional vertebra of the upper cervical spine. Understanding the mechanisms of axis ring fractures may help in choosing the optimal reduction technique and stabilization method based upon the specific fracture pattern.

Progressively unstable c2 spondylolysis requiring spinal fusion: case report

Cervical spondylolysis is a rare condition defined as a corticated cleft at the pars interarticularis in the cervical spine. This is the case of C2 spondylolysis demonstrating progressive significant instability, which was successfully treated by anterior cervical discectomy and fusion (ACDF) with cervical anterior plate. We describe a 20-year-old female with C2 spondylolysis presenting with progressive worsening of neck pain associated with progressive instability at the C2/3 segment. The progression of instability was well-documented on flexion-extension cervical spine x-rays. She was successfully treated by C2/3 ACDF with anterior cervical plate. Her preoperative significant neck pain resolved immediately after the surgical intervention. She was completely free from neurological symptoms at 1-year postoperative follow-up. We also review the literature and discuss 24 reported cases with C2 spondylolysis. When planning treatment, we should make sure to differentiate this pathology from acute traumatic fracture, which is a hangman's fracture. Assessment of C2/3 instability associated with neurological deficits is extremely important to consider management properly. C2/3 ACDF with cervical plate is biomechanically viable, less invasive, and provides adequate surgical stabilization for unstable C2 spondylolysis.

Primary surgical management by reduction and fixation of unstable hangman's fractures with discoligamentous instability or combined fractures

Object

Several controversial issues arise in the management of unstable hangman's fractures. Some surgeons perform external reduction and immobilize the patient's neck in a halo vest, while others perform surgical reduction and internal fixation. The nonsurgical treatments with rigid collar or halo vest immobilization present problems, including nonunion, pseudarthrosis, skull fracture, and scalp laceration and may also fail to achieve anatomical realignment of the local C2–3 kyphosis. With recent advances in surgical technique and technology, surgical intervention is increasingly performed as the primary treatment in high cervical fractures. The outcomes of such surgeries are often superior to those of conservative treatment. The authors propose that surgical intervention as a primary management for hangman's fracture may avoid risks inherent in conservative management when severe circumferential discoligamentous instability is present and may reduce the risk of catastrophic results at the fracture site.

The purposes of this study were to assess fracture healing following expedient reduction and surgical fixation and to propose a guideline for treatment of unstable hangman's fractures.

Methods

From April 2006 to December 2011, the authors treated 105 patients with high cervical fractures. This study included 23 (21.9%) of these patients (15 men and 8 women; mean age 46.4 years) with Type II, IIa, and III hangman's fractures according to the Levine and Edwards classification. The patient's age, sex, mechanism of injury, associated injuries, neurological status, and complications were ascertained. The authors retrospectively assessed the clinical outcome (Neck Disability Index), radiological findings (disc height, translation, and angulation), and bony healing.

Results

The average follow-up period was 28.9 months (range 12–63.2 months). The overall average Neck Disability Index score at the time of this study was 6.6 ± 2.3. The average duration of hospitalization was 20.3 days, and fusion was achieved in all cases by 14.8 ± 1.6 weeks after surgery, as demonstrated on dynamic radiographs and cervical 3D CT scans.

The mean pretreatment translation was 6.9 ± 3.2 mm, and the mean postoperative translation was 1.6 ± 1.8 mm (mean reduction 5.2 ± 3.1 mm). The initial angulation was 4.7° ± 5.3° and the postoperative angulation was 2.5° ± 1.8° (mean reduction 6.1° ± 5.3°). The preoperative and postoperative values for translation and angulation differed significantly (p < 0.05). The overall C2–3 disc height was 6.7 ± 1.2 mm preoperatively, whereas 3 months after surgery it was 6.4 ± 1.1 mm. These values did not differ significantly (p = 0.0963).

Conclusions

The authors observed effective reduction and bony healing in cases of unstable hangman's fractures after fixation, and all patients experienced favorable clinical outcomes with neck pain improvement. The protocols allowed for physiological reconstruction of the fractured deformities and avoided external fixation. The authors suggest that posterior reduction and screw fixation should be used as a primary treatment to promote stability of hangman's fracture in the presence of discoligamentous instability or combined fractures.

C1-C3 lateral mass fusion for type IIa and type III Hangman's fracture

Hangman's fractures, also known as traumatic spondylolisthesis of axis, can be managed either conservatively with immobilization or by surgery. Surgery is usually indicated in cases with instability or failure of conservative treatment. Different surgical approaches, both anterior and posterior, have been described for treating Hangman's fracture. We report two patients, one with type IIa and another with type III Hangman's fracture treated with C1-C3 lateral mass fusion and discuss the advantages and limitations of this technique when compared to other techniques for fusion in patients with Hangman's fracture.