Hangman's Fracture Research Articles

A new transpedicular lag-screw for treatment of Hangman's fracture

Objective To design a novel transpedicular lag-screw for the treatment of Hangman's fracture.Methods Twenty adult dried cervical vertebrae specimens were selected and used vernier caliper to measure the indexes of C2,including the height of pedicle,the width of pedicle,the distance of massa lateralis midpoint (entry point) to anterior vertebral,and the anteroposterior diameter of processus articulares superiores.The X-ray films of six Hangman's fracture patients after reduction were selected,and the indexes of C2 were measured on computer,including the distance of entry point to anterior edge,the distance of entry point to fracture line,and the distance of fracture line to anterior edge.According to the anatomic parameters of C2 pedicle and the characteristics of Herbert-screw,a new type of transpedicular lag-screw was designed,which is more suitable for the treatment of Hangman's fracture.This screw is double-threaded,and the biomechanics of which were compared with ordinary ones.Results Specimen measurements showed the height of pedicle (7.40±1.04) mm,the width of pedicle (7.45±1.54) mm,the distance of massa lateralis midpoint to anterior vertebrae (27.95±1.69) mm,and the anteroposterior diameter of processus articulares superiors (17.29±1.51) mm.X-ray measurements showed the distance of entry point to anterior edge (29.19±3.54) mm,the distance of entry point to fracture line (10.71±2.44) mm,and the distance of fracture line to anterior edge (15.35±1.66) mm.There were no significant differences between the two sides of the pedicle measurements.The new-screw group and the ordinaryscrew group tensile strength was (2266.47±158.82) N and (1715.51±69.99) N,respectively.There were statistically significant differences between the two groups.Conclusion The effect of novel transpedicular lag-screws for the treatment of Hangman's fracture is better than that of the ordinary ones. Key words: Axis; Spinal Fractures; Internal Fixators; Biomechanics

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

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. 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. 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). 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.

Osteosynthesis a physiological way of managing Hangman's fracture

Most of the Hangman's fractures are treated conservatively. Surgical indication is only in type IIA and III fractures. There are many ways of fixing fractured spine either by anterior or posterior. Osteosynthesis of C2 pedicle by transpedicular screw in type IIA is a newer concept started by Judet by putting appropriate length of screws in C2 pedicle, so the fracture reduces and anatomical motion will remain intact. In fact it is a more physiological concept of fixing.1 I am doing by open method with exposure of C2 bilaterally and putting appropriate screws in the fracture. It gives proper reduction, compression and immediate stabilization of fracture.

Halo Vest treatment of upper cervical vertebral fracture

Objective: In this study we aimed to investigate the ef­ficacy, long term result and associated complications of Halo Vest treatment for patients with upper cervical spine fractures. Methods: This study included 13 patients (11 men and 2 women) who applied Halo Vest treatment for traumatic upper cervical vertebral fracture between 2006 and 2011. We reviewed the radiological and clinical findings of pa­tients before and after the treatment. Results: Six of 13 patients had odontoid type 3 fracture, 2 patients had odontoid type 2 fracture with C1 type 1 fracture, 2 patients had odontoid type 2 fracture with Jef­ferson fracture, one patient had type 2 hangman fracture and two patients had unclassified C2 corpus fractures. The mean follow-up time with Halo Vest was 14 weeks (10-21 weeks). Ten patients had bone fusion and the mean time of bone fusion was 12 weeks. Conclusions: Halo Vest treatment for upper cervical spine fracture is a safe and effective method but the pa­tients comfort and satisfaction are low.

Determining Optimal C2 Pedicle Screw Placement and Length in Patients with Axis Traumatic Spondylolisthesis: A Case Series

We sought to determine the optimal placement and screw length for C2 pedicle screw fixation to compare with recommendations in literature. Nine patients were included in this study and underwent C2 pedicle instrumentation either for a hangman's fracture as part of C2 pedicle–C3 lateral mass fixation or for C2–C3 subluxation. All nine patients had good postoperative improvement with satisfactory fracture consolidation. Mediolateral and rostrocaudal angulations of the inserted screws were not consistent with the traditional angulations of 20 degrees in each plane due to the fracture lines and the anatomical variations. Because the frequent observation of the bony anatomical variations and the lines of fractures brought about by trauma, a shift from the classic 20 degrees of angulation in both trajectories has been concluded. But still fixed angles of angulations cannot be generalized. As a consequence, accurate preoperative planning can be obtained by computed tomography with three-dimensional images so that it gives the surgeon a good prediction of the best length of utilized screws in the procedure and the best angulations for safety of the neighboring neurovascular structures.

Postmortem multislice computed tomography (pmMSCT) imaging of hangman’s fracture

First described in 1965, avulsion of the neural arch from the vertebral body of the axis (C2) as a sequel to violent and rapid hyperextension of the head was termed hangman's fracture because of its similarity to the injury observed after judicial hanging. Since diagnosing such a fracture at autopsy is difficult because of its anatomic position, accurate determination of features of a hangman's fracture in cases of non-judicial hanging has not been systematically elucidated. We performed a prospective autopsy study visualizing hangman's fractures in 32 cases of hanging using postmortem multislice computed tomography (pmMSCT). A hangman's fracture with a fracture of the vertebral arch adjacent to the C2 vertebral body was only detected in one case (3.1 %). In this case a rarely observed longer drop with a lateral knot was used. Although a hangman's fracture was invariably observed bilaterally in previously reported cases, our case revealed a unilateral fracture at the side corresponding to the location of the knot. Out of the three types of hangman's fracture, pmMSCT is especially useful for detecting type 1 (nonangulated, undisplaced C2 with a normal disk at C2/C3). Also, pmMSCT is superior to conventional radiography in diagnosis, especially when the fracture is extending into the transverse foramen. In conclusion, pmMSCT imaging is useful for detecting hangman's fracture in hanging cases. Accumulating more evidence through pmMSCT will allow clarification of the actual incidence and circumstantial findings of hangman's fracture that have been controversially debated for many decades in the forensic community.

Double Hangmanʼs Fracture

Clinical case report and review of the literature. To report a very rare case of bipedicular fracture of C2, C3 along with traumatic spondylolisthesis of the C2, C3 vertebral bodies together over C4 without any neurological deficits. Cervical spine injury is a potentially fatal and debilitating incident because of the risk of damage of the cervical spinal cord. Hangman's fracture comprises 4% to 7% of all traumatic cervical spine fractures. Attempting closed reduction in a neurologically intact patient may cause the development of new deficits during time of traction, especially in the case of compromised neural canal. The management should be aimed at providing a stable well-aligned spine without causing any new neurological deficits. A 35-year-old female had a motor vehicle accident and her forehead collided against the ground, causing hyperextension-compression type injury of the cervical spine that resulted in complaints of neck pain on movement. Cervical spine plain radiographs revealed spondylolisthesis of C2, C3 vertebral bodies together over C4 with bipedicular fracture of C2, C3. A computed tomographic scan confirmed these fractures. Magnetic resonance imaging further demonstrated spondylolisthesis without any spinal cord compression or signal abnormality. An anterior C2, C3 and C3-C4 cervical fusion was performed with iliac crest tricortical strut grafting and anterior cervical plating. The patient was turned to a prone position on the striker bed and posterior fixation was performed with lateral mass screws of C1 and C5. Reduction of the spondylolisthesis was achieved with gradual cervical traction in an awake intubation followed by 360º of fusion with both anterior and posterior fixation. Bipedicular fracture of C2, C3 along with traumatic spondylolisthesis of the C2, C3 vertebral bodies together over C4 without any neurological deficits is very rare injury and needs methodical 360º fixation.

Management of Acute Combination Fractures of the Atlas and Axis in Adults

Standards There is insufficient evidence to support treatment standards. Guidelines There is insufficient evidence to support treatment guidelines. Options Treatment of atlas-axis combination fractures based primarily on the specific characteristics of the axis fracture is recommended. External immobilization of most C1--C2 combination fractures is recommended. C1--Type II odontoid combination fractures with an atlantodens interval of 5 mm or more and C1--hangman's combination fractures with C2--C3 angulation of 11 degrees or more should be considered for surgical stabilization and fusion. In some cases, the surgical technique must be modified as a result of loss of the integrity of the ring of the atlas.

One-stage posterior C2 and C3 pedicle screw fixation or combined anterior C2-C3 fusion for the treatment of unstable hangman’s fracture

The present study aimed to evaluate the effect of using one-stage posterior C2 and C3 pedicle screw fixation or combined anterior C2-C3 fusion in the treatment of unstable hangman’s fracture. A total of 13 patients with unstable hangman’s fractures underwent C2 and C3 pedicle screw fixation, lamina interbody fusion or combined anterior C2-C3 fusion and imaging examinations to evaluate the fracture fixation and healing condition at three days and three months following surgery. Postoperative X-ray and computed tomography (CT) results showed high fracture reduction, good internal fixation position and reliable fracture fixation. The three-month postoperative CT showed good vertebral fracture healing. C2 and C3 pedicle screw fixation has a good curative effect in the treatment of unstable hangman’s fracture. The direct fixation of the fracture enables early ambulation by the patients.

Posterior C2-C3 Fixation for Unstable Hangman's Fracture.

ObjectiveThis is a retrospective review of 13 unstable Hangman's fractures who underwent posterior C2-3 fixation to describe clinical outcomes with a literature review.MethodsThirteen patients for unstable Hangman's fracture were enrolled between July 2007 and June 2010 were included in this study. The medical records of all patients were reviewed. Concurrently, clinical outcomes were evaluated using Neck Disability Index (NDI) scores and Visual Analogue Scale (VAS) scores during preoperative and postoperative follow up period. Plain radiographs were obtained on postoperative 1day, 1week, and then at 1, 2, 6, and 12 months. CT was done at postoperative 12 months in all patients for evaluation of bone fusion. The mean period of clinical follow-up was 17 months.ResultsMean age were 43 years old. Bone fusion was recognized in all cases at the final follow-up. The average preoperative VAS score for neck pain was 8.3±1.1, while the final follow-up VAS score was 2.07±0.8 (p<0.001). The average immediate postoperative NDI was 84% points and final NDI was 22% points (p<0.001). There were one case of infection and 1 case of screw loosening.ConclusionIn the treatment of the patients with unstable Hangman's fracture, posterior C2-C3 fusions is effective and curative treatments to achieve cervical spinal stability.

A new technique in the surgical treatment of Hangman's fractures: Neurospinal Academy (NSA) technique.

Context:Treatment of Hangman's fractures is still controversial. Hangman's fractures Type II and IIA are usually treated with surgical procedures.Aim:This study aims at describing the Neurospinal Academy (NSA) technique as an attempt to achieve an approximation of the fracture line to the axis body, which may be used for Type II and IIA patients with severe displacement and angulation.Settings and Design:NSA technique both pars or pedicle screws are placed bicortically to ensure that anterior surface of C2 vertebral body will be crossed 1-2 mm. A rod is prepared in suitable length and curve to connect the two screws. For placing the rod, sufficient amount of bone is resected from the C2 spinous process. C2 vertebral body is pulled back by means of the screws that crossed the anterior surface of C2 vertebral body.Materials and Methods:Hangman II and IIA patient are treated with NSA technique.Result:Angulated and tilted C2 vertebral body was pulled back and approximated to posterior elements.Conclusions:In Hangman's fractures Type II and IIA with severe vertebral body and pedicle displacement, NSA technique is an effective and reliable treatment alternative for the approximation of posterior elements to the C2 vertebral body, which is tilted, angulated, and dislocated.

Fractures of the cervical spine

OBJECTIVES:The aim of this study was to review the literature on cervical spine fractures.METHODS:The literature on the diagnosis, classification, and treatment of lower and upper cervical fractures and dislocations was reviewed.RESULTS:Fractures of the cervical spine may be present in polytraumatized patients and should be suspected in patients complaining of neck pain. These fractures are more common in men approximately 30 years of age and are most often caused by automobile accidents. The cervical spine is divided into the upper cervical spine (occiput-C2) and the lower cervical spine (C3-C7), according to anatomical differences. Fractures in the upper cervical spine include fractures of the occipital condyle and the atlas, atlanto-axial dislocations, fractures of the odontoid process, and hangman's fractures in the C2 segment. These fractures are characterized based on specific classifications. In the lower cervical spine, fractures follow the same pattern as in other segments of the spine; currently, the most widely used classification is the SLIC (Subaxial Injury Classification), which predicts the prognosis of an injury based on morphology, the integrity of the disc-ligamentous complex, and the patient's neurological status. It is important to correctly classify the fracture to ensure appropriate treatment. Nerve or spinal cord injuries, pseudarthrosis or malunion, and postoperative infection are the main complications of cervical spine fractures.CONCLUSIONS:Fractures of the cervical spine are potentially serious and devastating if not properly treated. Achieving the correct diagnosis and classification of a lesion is the first step toward identifying the most appropriate treatment, which can be either surgical or conservative.

Management of Hangman's Fractures and a Subaxial Compression Fracture in Two Children With Osteogenesis Imperfecta

Cervical spine fractures in osteogenesis imperfecta are rare. The purpose of this article is to describe the successful outcomes of the nonoperative and operative treatment of C2 pars fracture and operative treatment of C7 compression fracture in two children with osteogenesis imperfecta. Patient 1, a 22-month-old female, had a C2 pars fracture managed nonoperatively with a cervical orthosis. Patient 2, a 15-year-old male, had concurrent C2 pars and C7 compression fractures; the C2 pars fractures were treated operatively via a posterior approach and open reduction and internal fixation, and the C7 compression fracture was treated via a C7 corpectomy, iliac crest strut autograft, and anterior plating from C6 to T1. Patient 1 had delayed union but complete healing at latest follow-up (31 months postpresentation). At latest follow-up, patient 2 remained asymptomatic.

Anterior C3 corpectomy and fusion for complex Hangman’s fractures

The aim of this study was to assess the effectiveness and feasibility of anterior C3 corpectomy and fusion with screw-plate fixation of C2-4 for the treatment of Hangman's fracture in which spinal cord compression comes from the posterosuperior part of C3 vertebral body and the intervertebral disc injury at the C2-3 level. From August 2000 to December 2005, 11 patients (eight males and three females) with traumatic spondylolisthesis of the axis underwent the above surgery. Neurological status was evaluated by the Japanese Orthopaedic Association Score (JOA score). The fusion of the graft, healing of the fracture, and range of motion of the whole cervical spine were examined according to X-ray imaging. No patient received blood transfusion. There was no deterioration of the neurological function in any case postoperatively. The mean JOA score was significantly improved from 9.1 ± 2.3 preoperatively to 14.8 ± 1.2 at the 12-month postoperative visit. All patients were relieved of axial pain. Imaging evaluation confirmed a high fusion rate and healing rate in all patients. No patient complained of limited mobility of the cervical spine in flexion, extension and rotation. No graft or plate-related complication was observed in any patients during the whole follow-up period. The only postoperative complication was trouble in swallowing liquids in two cases which resolved three months after surgery without any treatment. Anterior C3 corpectomy and fusion may prove to be safe and applicable for the treatment of complex Hangman's fractures.

Management of hangman’s fracture with percutaneous transpedicular screw fixation

This study describes a percutaneous technique for C2 transpedicular screw fixation and evaluates its safety and efficacy in the treatment of patients with hangman's fracture. Ten patients with hangman's fracture were treated by percutaneous C2 transpedicular screw fixation. There are six males and four females, who were, based on the classification of Levine and Edwards, sorted as follows: type I fracture, three cases; type II, five cases; type IIa, two cases. The causes of injury were road traffic accident in six patients and falling injury in four patients. Other associated lesions included rib fractures (7 patients), head injuries (4 patients), and fractures of extremities (6 patients). The new technique was performed successfully in all cases. The average operation time was 98 min (range 60-130 min) and the estimated blood loss was 25 ml (range 15-40 ml). No complications such as vascular or neural structures injuries were found intraoperatively. Postoperative CT scans demonstrated that 17 (85 %) of 20 screws were placed satisfactorily, and 3 (15 %) screws showed perforations of the pedicle wall (<2 mm). These patients were asymptomatic and no further intervention was required postoperatively. After 8-25 months follow-up (mean 15.3 months), solid fusion was demonstrated by computed tomography. All cases got well-sagittal alignment and no angulation or dislocation was found at the segment of C2-C3. There was no loss of fixation. Clinical examination showed a full range of motion in the neck in all patients. The fluoroscopically assisted percutaneous C2 transpedicular screw fixation method is a technically feasible and minimally invasive technique for hangman's fracture.

An Evidence-Based Medicine Process to Determine Outcomes After Cervical Spine Trauma

A systematic review of the available medical literature from 1980 to 2010 was conducted and combined with expert opinion from a recent survey of experts regarding cervical spine fractures. Using an objective, hierarchical approach, the best available evidence is presented for health-related quality-of-life outcomes for these injuries. To provide an evidence-based set of guidelines for cervical spine injuries in order to reduce variability in the information given to patients and their families. Patients' expectations regarding quality-of-life outcomes are highly dependent on the information provided by surgeons early in the treatment course. Our previous work has demonstrated that there is substantial variability in what surgeons tell patients regarding outcomes of cervical spine injuries, thus patients' expectations will differ and outcomes vary. Four common cervical spine injuries (C1 burst, Hangman fracture, odontoid fracture, and unilateral facet fracture) treated both surgically and nonsurgically were considered. We assessed the evidence regarding 5 health-related quality-of-life outcomes: time to return to work, activity level, hospital stay, the proportion of patients who are pain free and patients who have regained full range of motion at 1 year after the injury. Published outcome data were available for most injuries. Using consensus expert opinion and the literature, answers to each question were achieved. Overall, expert opinion was relatively homogeneous across injury types, suggesting that experts do not distinguish between specific injuries when advising patients of expected outcomes such as pain. By overcoming gaps in the literature with consensus expert opinion, our study provides surgeons and others with evidence-based medicine guidelines for patient-centered outcomes after cervical spine injury. This information can be presented to patients to frame expectations of typical outcomes during and after treatment to optimize patient care and quality of life.

Management of C2 fractures using Iso-C3D guidance: a single institution's experience

About 20 % of cervical fractures involve the C2 vertebra. Many surgical techniques have been proposed according to the type of fracture. However, morbidity and mortality of these procedures is often high, which can be attributed to the old age and significant co-morbidities of the affected population and the complex anatomy of C2. To target the latter, several authors have applied iso-C(3D) guidance for most of the common techniques. We here present our experience using a fixed protocol and iso-C(3D) guidance in all cases of traumatic C2 fractures. Sixteen patients were operated upon between April 2011 and April 2012 using Iso-C(3D) guidance, following a fixed routine protocol. The screw position was verified by CT-scanning. Intraoperative and clinical parameters were evaluated. Six patients received anterior lag-screw fixation of odontoid fractures. Two underwent isolated posterior lag-screw fixation of hangman's fracture. C1 and/or C3 lateral mass, and/or C2 isthmic screws were placed in eight patients. No screw had to be revised, 3 minor breachings of the cortical bone of <2 mm were observed.The same standard protocol for draping, registration of the navigation and Iso-C(3D) guided drilling could be applied for anterior and posterior procedures, leaving only two variables. This led to rapid acceptance of the technique among OR-staff and surgeons, who felt comfortable with iso-C(3D) guidance after only five cases. Iso-C(3D) guidance is a safe and straightforward technique for anterior and posterior screw placement in the upper cervical spine.

Results of Direct Repair of Type 2 Hangman Fracture Using Iso-C3D Navigation

Prospective Study. To study the results of direct repair of type 2 hangman fracture using Iso-C3D navigation. Direct fixation of axis pedicle fracture gives biomechanically stronger stability and early mobilization. These fixations are technically demanding. Very few cases of direct fixation using Iso-C3D navigation are reported. We report the largest series of directly fixed hangman fractures so far. Twenty type 2 hangman fractures (18 men and 2 women), in age group of 17-63 years (average, 38 y), were treated by posterior direct repair using Judet screws under Iso-C3D navigation. Twelve had road traffic accident, 7 had fallen from height, and 1 had direct injury to head. Nine had limb or pelvic fractures. Eighteen patients had normal, 2 had ASIA D, and 1 had ASIA B neurology. With no intraoperative complications, 18 patients underwent bilateral pedicle fixation and 2 underwent unilateral fixation, with an average blood loss of 220 mL. Average follow-up was 29 months. Postoperative images showed good reduction with union in an average of 8 weeks. Average anterior translation of 3.2 mm preoperatively was reduced to 1.0 mm postoperatively. Computed tomography axial cuts distance with an average of 3.57 mm on right side and 3.66 mm on left side were reduced to 0.40 and 0.46 mm postoperatively. Two cases presenting with pseudoarthrosis showed consolidation after 25 weeks of surgery. Visual analog score of 7 preoperatively reduced to 1 by 8 weeks, 0 by 20 weeks postoperatively, except in 2 patients. In one patient, screws were removed after 8 months postoperatively and in other patient pain subsided gradually by 7 months. According to Myung-Sang Moon Assessment Criteria, 14 had excellent, 3 had good, 2 had fair, and 1 had poor results. P value was significant for visual analog score and postoperative reduction distance. Use of Iso-C navigation allows safe direct fixation of hangman fractures.

Surgical Strategies in Craniovertebral Junction Lesions

Objective: Outcome analysis of surgical management in craniovertebral junction (CVJ) lesions (trauma, congenital anomalies [CA], and rheumatoid arthritis [RA]). Methods: Sixty-three patients with CVJ pathology underwent surgery between 1998 and 2011. Trauma occurred in 49 cases, CA in 3, and RA in 11. Diagnostics consisted of neuro-orthopedic status assessment and neuroimaging. Patients were divided into two groups according to dominating clinical syndromes (DCSs): Group I was neurologically complicated with spinal cord compression, group 2 was orthopedically complicated with unstable injuries and high risk of secondary neuro-orthopedic lesions. Results: Group I (24 patients) with spinal cord compression had absolute indications for surgery, including myelopathic syndrome. These patients underwent single, two-stage surgery including spinal cord decompression and fixation. The first stage was decompression. The decompression target was chosen by compression direction as follows: Anterior decompression was done in cases with anterior compression (transoral-transpharyngeal approach), posterior decompression was done in cases with posterior compression. Group II (39 patients) had unstable injuries with high risk of secondary neuro-orthopedic lesions. The fixation method was chosen differentially. In cases of acute dental fracture, cannulated fixation was used; for atlanto-occipital dislocation, craniocervical fixation was used; for transarticular C1-C2, in case of Hangman's fracture, ACDF C2-C3 was used. Eighty-two percent of patients had follow-up from 1 year up to 5 years. We achieved positive outcome in 94.3% of patients. Three of 63 patients after surgery (4.6%) had complications. Conclusion: Spinal cord compression is an absolute indication for surgery. Wide bone resection requires safe internal fixation. Surgery in patients with instability without myelopathic manifestations provides possibilities for better functional outcomes in a shorter time.

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.