Neglected hangman fracture

Is Anterior Cervical Discectomy and Fusion Sufficient for Neglected Unstable Hangman's Fracture? A Retrospective Case Series of Five Patients

Introduction

This study investigates the outcomes of treating neglected unstable Hangman's fractures through a single-stage Anterior Cervical Discectomy and Fusion (ACDF) procedure with tricortical iliac crest bone grafts.

Methods

Five patients with neglected unstable Hangman's fractures, treated at our institution between March 2012 and March 2017, underwent C2-C3 ACDF. Functional outcomes were assessed using the Visual Analog Scale (VAS) score and Neck Disability Index (NDI), and neurological evaluation was done using the American Spinal Injury Association (ASIA) grading system. The radiological assessment included serial plain radiographs and a computed tomography scan at a 12-month follow-up.

Results

Postoperatively, C2-C3 angulation improved significantly, decreasing from 15° to 4.4°, and sagittal translation improved from 4.2 mm to 2 mm. The VAS score improved from 6.4 to 1.4 at 24 months postsurgery. Concurrently, NDI decreased from 70.4% to 14.8%. Fusion occurred in an average of 5.6 months. Neurologically, one patient improved from ASIA grade D to grade E, while the other four retained their grade E status.

Conclusions

A single-stage ACDF with autologous iliac crest bone grafts is an effective surgical option for neglected type II/IIA Hangman's fractures, yielding satisfactory functional and radiological outcomes. This technique significantly corrects anterior translation and angulation, even in neglected cases, with the aid of intraoperative skull traction and plate reduction.

Management of neglected complex hangman's fracture by reforming the C2 pedicle: new innovative technique of motion preservation at the C1-2 joint in 2 cases

Hangman's fracture, also known as traumatic spondylolisthesis of the axis, causes widening of the neural canal and thus a low rate of neurological deficits. This low rate is one of the reasons it is neglected and patients present with late neurological deficits. In an effort to preserve motion at the C1-2 joint, the authors devised a new technique of bilateral C2 pedicle reconstruction. They describe the first two cases in the literature of an old hangman's fracture with resorbed C2 pedicles due to chronic fracture, in which bilateral C2 pedicles were reconstructed. One of the two cases (case 2) is the first reported case of severe C2-3 spondyloptosis with C2 displaced up to the level of C4. Case 1 had a follow up of 21 months, while case 2 had a follow up of 12 months. Both patients experienced neurological improvement with evidence of fusion and artificial pedicle formation at last follow-up. Bilateral C2 pedicle reconstruction is a feasible technique that can be used with a good outcome in select patients.