Unstable Hangman's Fracture Research Articles

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

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. 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. 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. 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.

Percutaneous Fixation of Levine-Edwards Type II Hangman's Fractures Under the Guidance of an Orthopedic Robot.

There is no consensus regarding the optimal treatment for unstable hangman's fractures. Conservative treatment, although time-consuming and associated with complications such as nonunion, neck stiffness, and pseudarthrosis formation, is still preferred by many surgeons. With the development of minimally invasive techniques, surgical treatment is trending in recent years. We have proposed a minimally invasive, robot-assisted technique for the treatment of Levine-Edwards (L-E) type II hangman's fractures; this could improve the patients' quality of life. Five patients with L-E type II hangman's fractures were treated operatively initially. After closed reduction, the C2 pedicle screws were inserted percutaneously with the guidance of the orthopedic surgical robot. The positions of pedicle screws were verified by intraoperative 3-dimensional C-arm fluoroscopy. Regular follow-ups were performed to evaluate the radiological and functional outcomes. Postoperatively, all the fractures have healed with an average healing time of 3.5 months, the functional outcomes were satisfactory at last follow-up, and there was no neurovascular injury associated with this technique. The 3D-fluoroscopy-based, robot-assisted C2 pedicle screw fixation is a safe, precise, and feasible method for the initial treatment of L-E type II hangman's fractures. [Orthopedics. 2023;46(1):59-63.].

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

Opinions vary regarding optimal treatment of unstable hangman's fractures. Recent technological advances have allowed short segment, motion preserving fixation, even in complex cases. The aim of the study was to demonstrate C1-C2 motion-preserving short-segment fusion in hangman's fracture and the evolution of technique from pedicle realignment to pedicle reformation in complex fractures with resorbed/destroyed C2 pedicles. This was a retrospective study. Patients operated by a single surgeon at a tertiary level center from 2012 to 2018 were included. The type of fracture, operating time, and blood loss was recorded. Neurologic deficits were recorded using the American Spinal Injury Association scale with regular clinicoradiologic follow-up. Nine patients (8 male), with a mean age of 36 ± 16.9 years were included. In the initial 7 patients, C2 pedicle screw, C3-C4 lateral mass screw, and rod fixation was done. The last 2 patients were complex neglected injuries, with 1 having severe angulation and displacement and the other having spondyloptosis with C2 body placed anterior to C4 body. In both these patients, direct C2 body screw were placed and pedicle reconstruction was done. Mean follow up was 41.4 ± 29.8 months. All 5 patients with preoperative neurologic deficits had improvement in power. C1-C2 joint motion was preserved in all. All patients had bony fusion. Preservation of motion at the C1-C2 joint should be the goal in all surgically managed hangman's fracture patients. The technique of C2 pedicle reconstruction can be utilized for the same in old neglected hangman's fractures.

Simplified four-step retropharyngeal approach for the upper cervical spine: technical note.

In this paper, we propose a simplified four-step retropharyngeal approach, whose aim is getting straight to the upper cervical spine minimizing complications. While the classical retropharyngeal approach includes about 11 steps, ours is a four-step approach: patient positioning, skin-platysma incision, hyoid bone superolateral dissection and retropharyngeal blunt exposure. We avoid several steps of the classical anterior retropharyngeal approach, particularly dissection of submandibular gland, facial veins, external carotid artery and thyroid artery, bellies of the digastric muscle, hypoglossal nerve, thyrohyoid membrane and the internal branch of superior laryngeal nerve. We have adopted this technique for five patients: two patients had a C2-C3 herniated disk with myelopathy, two patients had unstable Hangman fracture with no bone fusion after 2-month treatment with rigid collar, and one patient had a C2-C3 osteophyte with dysphagia. The intraoperative time needed for reaching the retropharyngeal space was 15 (first case), 9 (second case), 7min (third case-illustrative case-and fourth case), 8min (fifth case). No complications occurred. Our simplification, avoiding several steps, is simple, effective, safe, and rapid and requires a simple learning curve.

How Does Cervical Sagittal Balance Change After Hangman Fracture Treated with Anterior or Posterior Approach Surgery?

To assess and compare clinical outcomes and sagittal balance after unstable hangman fracture between C2-C3 anterior discectomy and fusion (ACDF) and posterior C2-C3 short-segment fixation and fusion. A total of 45 patients underwent ACDF (20 patients) and posterior C2-C3 short-segment fixation and fusion (25 patients) between March 2005 and June 2013. Visual analog scale, Neck Disability Index, Odom grading system, American Spinal Injury Association Impairment Scale (AIS), C2-C3 angle, displacement of C2-C3 (DC2-C3), occiput-C2 angle (O-C2 angle), cervical lordosis (CL), and C2-C7 sagittal vertical axis (cSVA) were assessed preoperatively and at final follow-up. The follow-up duration was 20.0 months (range, 18.0-21.0 months) in the anterior group and 19.0 months (range, 18.0-20.0 months) in the posterior group. Satisfactory bony fusions were achieved in 2 groups. The VAS score and NDI score were significantly lower than their respective preoperative score in each group (P < 0.001), whereas there was no difference between 2 groups (P= 0.78; P= 0.85). A statistically significant decrease of O-C2 angle and cSVA between preoperative and postoperative data was found in each group (P < 0.001), and CL increased statistically (P < 0.001). For O-C2 angle, CL, and cSVA, the changes of parameters after the posterior approach were more significant than after the anterior approach (P < 0.05). Both anterior and posterior surgical techniques are effective for unstable hangman fracture and both can restore the sagittal balance of the cervical spine. Furthermore, the posterior approach has an advantage over the anterior approach in promoting recovery of cervical sagittal balance.

Anterior cervical discectomy and fusion plus plating for unstable Hangman's fractures

Objective To investigate the clinical effectiveness of anterior cervical discectomy and fusion (ACDF)plus plating in the treatment of unstable Hangman's fractures. Methods A retrospective case series study was carried out to analyze 12 patients who received ACDF plus plate internal fixation for unstable Hangman's fracture admitted to Sir Run Run Shaw Hospital affiliated to Zhejiang University School of Medicine from July 2014 to July 2018. There were nine males and three females, aged 24-70 years with an average of 46.2 years. According to Levine-Edwards typing, there were seven patients of type Ⅱ, four patients of type Ⅱ A and one patient of type Ⅲ. There were two patients of grade D and 10 patients of grade E according to the American Spinal Injury Association (ASIA) classification. The operation time, intraoperative blood loss and the operational complications were recorded. At 3 days, 1, 3, 6, 12 and 24 months after operation, the height of intervertebral disc, physiological curvature of cervical spine, fracture healing and bone graft fusion were evaluated. The recovery of neurological function was assessed by ASIA, and the neck pain relief and function improvement was assessed by visual analogue scale (VAS) and the neck disability index (NDI). Results All patients were followed for 6-48 months(mean, 27.7 months). The operation time ranged from 50-100 minutes, with an average of 72.5 minutes. The intraoperative blood loss was 30-120 ml (mean, 65.8 ml). No serious complications occurred during and after operation. Two patients had dysphagia after operation, and the symptoms were relieved at the follow-up of 3 months. All patients achieved bony fusion of C2-3 within the 6 month follow-up. No subsidence or migration of cages and significant loss of intervertebral space height were observed. The patient's neck and occipital pain was relieved obviously, and the flexion, extension and rotation of cervical spine were good. The neurologic dysfunction of two patients of ASIA Grade D recovered after surgery, and the final ASIA grade was E. The VAS score was decreased from 5.0 (4.0, 6.0)points preoperatively to 1.0(0, 1.0)points at the last follow-up (P<0.01). The NDI score was improved from (28.5±6.4)points preoperatively to (5.3±2.7)points at the last follow-up (P<0.01). Conclusion ACDF combined with plate internal fixation can provide immediate postoperative stability, high fusion rate, less complications, less pain, and satisfactory function recovery. Key words: Axis; Decompression, surgical; Fracture fixation, internal; Hangman's fracture

Analysis of the Cervical Sagittal Alignment in Patients with Unstable Hangman Fracture Under C2∼3 Anterior Discectomy and Fusion

To investigate the changes in the sagittal parameters of the cervical spine and the clinical efficacy of C2∼3 anterior cervical discectomy and fusion (ACDF) combined with internal fixation for unstable hangman's fractures. The clinical data of 46 patients with unstable hangman's fractures treated with both C2∼3 ACDF combined with internal fixation between May 2012 and May 2017 were analyzed retrospectively. The upper cervical angle (C0∼2), the forward translation of the C2 vertebral body (C2-T), C2∼3 local kyphosis angle (C2∼3 LK), C2∼7 cervical curvature (C2∼7 CC), C2 sagittal vertical axis (C2-SVA), and T1 slope angle (T1S) were compared preoperatively, postoperatively, and at the last follow-up to evaluate the clinical therapeutic effects. A total of 46 patients were followed-up for an average of 16 months. No aggravation of the spinal cord, nerve injury, cerebrospinal fluid leakage, or other complications occurred. Six patients had American Spinal Injury Association (ASIA) grade C preoperatively; 4 improved to grade E, and 2 improved to grade D postoperatively. Twelve patients with ASIA grade D preoperatively improved to grade E postoperatively. C0∼2, C2-T, C2∼3 LK, C2∼7 CC, and C2-SVA measurements were significantly improved postoperatively and at the last follow-up, but there was no significant change in T1S between preoperative and postoperative values. For patients with unstable hangman's fractures, C2∼3 ACDF combined with internal fixation can achieve immediate stability of the upper cervical vertebrae, effectively correct the forward displacement and angulation of C2, and restore the sagittal balance of the cervical spine. The rate of osseous intervertebral fusion is high, and there are few complications. This method can effectively promote the recovery of spinal nerve function and preserve the motor function of the cervical vertebrae.

Surgical treatment of atypical unstable Hangman fracture in elderly osteoporotic patients

To explore the clinical effect of operative reduction and internal fixation in treating atypical unstable Hangman fracture in elderly osteoporotic patients. The clinical data of 9 elderly osteoporotic patients with atypical unstable Hangman fracture treated from December 2012 to December 2017 were retrospectively analyzed. There were 5 males and 4 females with an average age of 72.7 years (range 65 to 79) old. The fracture line was located on bilateral inferior articular surface or lamina with anterior dislocation of axis in 3 cases (similar to Levine-Edwards type II); one side of the fracture line was located on the lower articular surface and opposite side involved on the upper articular surface and the body of axis with atlantoaxial lateral mass dislocation in 4 cases; the fracture line was located at the pedicle of the axis, transverse foramen and posterior inferior wall of the vertebral body, accompanying by anterior and posterior longitudinal ligaments and C₂-C₃ intervertebral disc injury resulted in C₂-C₃ intervertebral instability in 2 cases. According to ASIA grade of spinal cord injury, 2 cases were grade D and 7 cases were grade E. Preoperative JOA scores were 9 to 11 points with an average of 9.8 points. All patients underwent routinely skull traction for reduction. Three patients with anterior dislocation of axis were treated with stage I anterior-posterior internal fixation and 6 patients with simple posterior pedicle screw fixation. Postoperative JOA score, ASIA system and the imaging data were used to evaluate clinical effects. All patients were followed up from 12 to 20 months with an average of 18 months. The neck pain disappeared after operation and cervical spine movement was well in all patients. The improvement rate of JOA at 3 months after operation was 75% to 87.5%. Two cases of ASIA grade D fully recovered to grade E. All fractures healed at 6 to 12 months after operation. Except one case occurred superior laryngeal nerve injury and had a complete recovery after 3 months, the other patients had no complications like spinal cord and vertebral artery injury, plate screw loosening and wound infection. According to the type of atypical unstable Hangman fracture in elderly osteoporotic patients, choosing a reasonable and personalized surgical plan can achieve immediate cervical stability and well reduction, which is beneficial for early ambulation and quick rehabilitation.

Nouvelle technique de traitement chirurgical des fractures bipédiculaires de C2 par vissage pédiculaire et contre pulsion antérieure

The treatment of hangman's fracture is controversial. If treated with a traditional surgical procedure, there will likely be many complications, such as kyphosis, pseudarthrosis and nonunion. Our present study aims to describe a bucking bar method with pedicle screw fixation to treat hangman's fracture. Thirty-two patients with an unstable hangman's fracture who underwent posterior C2-3 pedicle lag screw fixation surgery assisted by a bucking bar between May 2004 and Jan 2017 were evaluated. All the participating patients were successfully treated using this novel technique, and follow-up revealed anatomical fusion in 27 patients, incomplete fusion in 4 patients, and C2-3 angular deformity healing in 1 patient. No patient developed throat wall edema or pseudomembrane formation. Satisfactory reduction, fixation and fusion of C2 pedicle fractures can be achieved using a pedicle screw assisted with the transoral bucking bar technique. Level of evidenceIV, retrospective case-series study.

A novel technique using a pedicle screw and bucking bar for the treatment of hangman's fracture

The treatment of hangman's fracture is controversial. If treated with a traditional surgical procedure, there will likely be many complications, such as kyphosis, pseudarthrosis and nonunion. Our present study aims to describe a bucking bar method with pedicle screw fixation to treat hangman's fracture. Thirty-two patients with an unstable hangman's fracture who underwent posterior C2-3 pedicle lag screw fixation surgery assisted by a bucking bar between May 2004 and Jan 2017 were evaluated. All the participating patients were successfully treated using this novel technique, and follow-up revealed anatomical fusion in 27 patients, incomplete fusion in 4 patients, and C2-3 angular deformity healing in 1 patient. No patient developed throat wall edema or pseudomembrane formation. Satisfactory reduction, fixation and fusion of C2 pedicle fractures can be achieved using a pedicle screw assisted with the transoral bucking bar technique. Level of evidenceIV, retrospective case-series study.

Motion Preserving Surgery Using O-Arm for Unstable Hangman Fracture

Abstract Aim To evaluate clinical outcomes, radiological findings (displacement and angulation), and bony fusion in cases of unstable hangman’s fracture. Introduction Hangman fracture, also known as traumatic spondylolisthesis of axis vertebra, is classically defined as bilateral pars interarticularis fracture of axis vertebra. Opinions vary regarding optimal treatment of unstable hangman’s fractures. Some authors have recommended use of rigid orthosis, whereas others have recommended internal fixation. The peculiar anatomy of the upper cervical spine is highly variable, and presence of surrounding neurovascular structures makes axis pedicle screw fixation even more technically challenging. The advent of intraoperative three-dimensional navigation systems facilitates safe and accurate instrumentation. Materials and Methods This article analyzes patients operated for type II and IIa hangman’s fractures during the period from September 2011 to August 2018 by two neurosurgeons. The patients’ age, sex, mechanism of injury, associated injuries, and neurologic status were noted. The authors retrospectively assessed the clinical outcome, radiological findings (displacement and angulation), and bony fusion. Result Eighteen patients with age ranging from 17 to 81 years, were operated using computed tomography-based (O-arm) navigation. Accuracy of screw insertion, preoperative and postoperative displacement, and angulation of C2 over C3 were evaluated. Bony fusion was assessed in all patients. A total of 92 screws were inserted: 36 screws in C2 pedicle, 34 in C3 lateral mass, 20 in C4 lateral mass, and 2 in C5 lateral mass. Of these 92 screws, 36 C2 pedicle screws were inserted under O-arm guidance. The mean preoperative C2–C3 displacement was 4.5 ± 2.1 mm, and the mean postoperative displacement was 1.8 ± 1.1 mm with a mean reduction of 2.7 ± 1.4 mm. The mean preoperative C2–C3 angulation was 10.2 ± 7.6 degrees and the postoperative angulation was 2.52 ± 4.62 degrees with a mean reduction of 8.2 ± 11.6 degrees. Screw malplacement was seen in two C2 pedicle screws (2/36, 5.5%). All C2 pedicle screw breaches were of grade 2. Excellent anatomical reduction in all cases could be achieved as established by the improvement in morphological parameters of fracture. Conclusion This series using O-arm in unstable hangman fracture demonstrates that intraoperative O-arm-based navigation is a safe, accurate, and effective tool for screw placement in patients with unstable hangman fracture.

Unstable Hangman's fracture: Anterior or posterior surgery?

Context:Literature evaluating the efficacy and long-term clinico-radiological outcomes of anterior cervical discectomy and fusion (ACDF) and posterior fixation at C2–C3 for the treatment of unstable hangman's fractures is scanty.Aims:The aim of this study is to compare the efficacy, clinical-radiological outcomes, and complications of ACDF and posterior fixation techniques performed for unstable hangman's fractures.Settings and Design:The study design involves retrospective comparative study.Subjects and Methods:This study conducted from 2012 to 2018 included 21 patients with unstable hangman's fracture (Levine and Edwards Type II, IIa and III). All patients were divided into two groups based on the approach taken for fracture fixation (Group A-anterior approach and Group B-posterior approach). Peri-operative clinical, radiological parameters, postoperative complications, and outcomes were evaluated and compared in both the groups.Statistical Analysis Used:Chi-square test and Student's t-test were used.Results:The mean age was 39.8 ± 4.5 years in-group A and 41.3 ± 6.7 years in-group B. The male patients outnumbered the female patients and road traffic accident was the most common cause of unstable fractures. There were statistical significant differences in surgical time (P = 0.15), operative blood loss, pain-free status postsurgery, and hospital stay (P = 0.15) between two groups. No statistically significant differences noted in clinic-radiological outcomes in the form of visual analog scale and fusion rate at final follow-up between two groups at final follow-up.Conclusions:The unstable hangman's fractures can be effectively managed with both anterior and posterior approaches with comparable clinico-radiological outcome. A minimally invasive nature, earlier pain-free status, early mobilization with reduced hospitalization make the ACDF efficacious, particularly in cases with no medullary canal in C2 pedicles and traumatic C2–3 disc herniation with listhesis compressing the spinal cord.

Management of occipitocervical junction and upper cervical trauma.

Objective:The treatment modality of occipitocervical junction (OCJ) and upper cervical traumas carries great importance because of unique form of bone, complex ligamentous, and neurovascular structure.Materials and Methods:Eighty-eight patients were admitted to Mersin University Department of Neurosurgery between January 2007 and January 2017 for injuries of the OCJ and upper cervical spine and evaluated retrospectively. In the group, there were 60 male, 28 female patients in the mean age of 42.9 (18–87) years. Among those, 2 occipital condyle fractures, 28 C1 fractures (26 isolated and 2 with transverse ligament injury), 9 combined C1/C2 fractures, 6 rotatory C1/C2 dislocations, and 43 C2 fractures (32 odontoid, 5 Hangman's, and 6 miscellaneous fractures) were diagnosed. In addition to clinical cases, ten cadavers were used to study the OCJ in a step-wise manner.Results:Occipital condyle fractures, isolated C1 fractures, and rotatory C1/C2 dislocations were treated conservatively. Two patients with C1 fracture including transverse ligament injury were operated in one of the methods of C1–C2 fusion which is posterior sublaminar wiring. Five patients having Type II odontoid fracture were treated surgically. One instable Hangman's fracture patient was treated as anterior cervical discectomy and fusion.Conclusions:Cases with isolated C1 fracture with intact transverse ligament should be conservatively treated without surgical approach. Atlas fractures with transverse ligament rupture, odontoid Type II fractures with dislocation >6 mm, and unstable Hangman's fractures required surgical treatment. Vital neurovascular, ligamentous, and accompanying bone structures should be evaluated for diagnosis and treatment modality. In addition, patient's health status, patient's treatment preference, and surgical team experience are the affecting factors for the decision of surgery.

Residual Deformity After Anterior Cervical Discectomy and Fusion for Unstable Hangman's Fractures.

Anterior cervical discectomy and fusion (ACDF) is a commonly used surgery for unstable hangman's fractures. This study investigated the rate of residual deformity after ACDF for these fractures and the effect of residual deformity on clinical and radiologic outcomes. A retrospective analysis of 28 patients with unstable hangman's fractures treated with ACDF was undertaken. The angulation and anterior translation between C2-C3 were measured on lateral radiographs at the time of admission, after skull traction, in the initial postoperative period, and at final follow-up. Residual deformity after surgery was defined as significant angulation (≥6°) and/or translation (≥3 mm). Patients were divided into 2 groups: with and without residual deformity. Follow-up evaluation included clinical and radiologic outcomes. Mean follow-up time was 22 months. The group with residual deformity included 7 patients with an angulation of ≥11° and/or translation of ≥4 mm after skull traction. The remaining 21 patients without residual deformity had an angulation of <11° and translation of <4 mm after skull traction. Neck pain and neurologic deficits improved significantly in all patients after surgery. No significant changes of alignment of middle and lower cervical vertebrae were observed. Residual deformity after ACDF for unstable hangman's fractures is not rare, and it seems to have no significant effect on clinical outcome during short-term follow-up. A severe deformity between C2-C3 after skull traction may be a predictor of residual deformity.

Evaluation of Correction of Radiologic Parameters (Angulation and Displacement) and Accuracy of C2 Pedicle Screw Placement in Unstable Hangman's Fracture with Intraoperative Computed Tomography-Based Navigation.

Opinions vary regarding optimal treatment of unstable hangman's fractures, including rigid orthosis and internal fixation. The anatomy of upper cervical spine is complex. The advent of intraoperative 3-dimensional navigation systems facilitates safe and accurateinstrumentation. To evaluate radiologic parameters of fracture morphology in unstable hangman's fracture in preoperative and postoperative period and accuracy of inserting axis pedicle screws by using intraoperative computed tomography-based navigation. Fifteen patients with unstable hangman's fractures with age ranging from 17 years to 81 years were operated using computed tomography-based navigation from September 2011 to march 2016. Patient's age, sex, mechanism of injury, associated injuries, and neurologic status were noted. Clinical outcome, accuracy of screw insertion, preoperative and postoperative displacement, and angulation of C2 over C3 and bony fusion were assessed. Overall, 76 screws were inserted including 30 screws in C2 pedicle with 2 (2/60; 6.7%) malplaced screws in C2 pedicle. Mean follow-up period was 34 ± 18 months (range 7-80 months). Mean hospital stay was 12.8 ± 2.4 days. Mean preoperative and postoperative displacements were 4.09 mm ± 1.78 mm and 1.82 mm ± 1.14 mm respectively with a mean reduction of 2.27 mm ± 1.49 mm. Mean preoperative angulation was 7.23° ± 11.96° and postoperative angulation was 2.32° ± 4.77° with a mean reduction of 5.11° ± 11.96°. Bony fusion was achieved and rotation was preserved at C1-C2 joint in all cases. Intraoperative O-arm-based navigation is a safe, accurate, and effective tool for screw placement in patients with unstable hangman fracture and achieves good anatomical reduction.

CT analysis of anatomical variation and injury affecting posterior pedicle screw fixation for unstable Hangman fractures

The aim of this study was to evaluate the anatomical variations and injuries in patients with unstable Hangman fractures that affected the posterior pedicle screw placement of C2 to C3 and retrospectively review our experience with management of these fractures. Clinical data were reviewed in 72 patients with unstable Hangman fractures, especially using 3-dimensional computed tomography (3D-CT) scan to identify the presence of anatomical variations or injuries and analyzing the treatment strategies we used. Twenty-two patients (22/72, 30.6%) with 39 (C2 or C3) risk factors were not fit for safe C2 to C3 pedicle screw placement, due to factors such as small pedicle size of C2 or C3, high-riding vertebral arteries, fractured fragments encased into vertebral canal, or transverse process foramen of C2, sclerotic pedicles and pedicle fractures of C3. One or more than one of these risk factors could pose more risks of arterial or neural structures damages to pedicle screw fixation for unstable Hangman fractures. Individualized treatment plans were made to minimize the risks of surgery for the 22 patients. There is a high incidence of anatomical variations and injuries in the C2 to C3 region in patients with unstable Hangman fractures that affect the pedicle screw placement. Preoperative evaluation of these conditions using 3D-CT scans is of paramount importance to avoid and decrease operative complications and to choose appropriate surgical techniques.

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.

A novel technique for unstable Hangman’s fracture: lag screw-rod (LSR) technique

The goal of the study was to describe the lag screw-rod (LSR) technique for the treatment of unstable Hangman's fracture as an attempt to pull C2 vertebral body back to posterior elements easily and immobilize C2 relative to C3 simultaneously. Twenty-one patients with unstable Hangman's fracture were treated with the LSR technique from January 2008 to October 2014. The clinical and radiological records were reviewed retrospectively. The angulation and displacement of C2 on C3 were evaluated. Complications, neck pain, neurological improvement, and fusion rate were assessed. The LSR technique was used for C2-C3 pedicle fixation and fusion in all the patients. The C2 vertebral body was pulled back to posterior elements successfully. The angulation and displacement of C2 on C3 were rectified obviously. No intra-operative or post-operative spinal cord or vertebral injury was observed. Visual analogue scale (VAS) scores for neck pain decreased gradually after operation. The patients with spinal cord injury were recovered at final following up. All patients achieved bony fusion without internal fixation failures. The LSR technique is an effective and reliable treatment for unstable Hangman's fractures. The technique has the advantages of pulling back the C2 vertebral body back to posterior elements easily and immobilizing C2 relative to C3 simultaneously.

CT Analysis of Anatomical Variation and Injury Affecting Posterior Pedicle Screw Fixation for Unstable Hangman's Fractures

Introduction The aim of this study was to evaluate the anatomical variations and injuries in patients with unstable Hangman's fractures that affected the posterior pedicle screw (PS) placement of C2-C3 and retrospectively review our experience with management of these fractures. Material and Methods Clinical data were reviewed in 72 patients with unstable hangman's fractures, especially using three-dimensional computed tomography (3D-CT) scan to identify the presence of anatomical variations or injuries and analyzing the treatment strategies we used. Results Twenty-two patients(22/72,30.6%) with 39(C2 or C3) risk factors were not fit for safe C2–3 PS placement, due to factors such as small pedicle size of C2 or C3, high-riding vertebral arteries, fractured fragments encased into vertebral canal or transverse process foramen of C2, sclerotic pedicles and pedicle fractures of C3. One or more than one of these risk factors could pose more risks of arterial or neural structures damages in PS fixation for unstable Hangman's fractures. Individualized treatment plans were made to minimize the risks of surgery for the 22 patients. Conclusion There is a high incidence of anatomical variations and injuries in the C2- C3 region in patients with unstable Hangman's fractures that affect the PS placement. Preoperative evaluation of these conditions using 3D-CT scans is of paramount importance to avoid and decrease operative complications and to choose appropriate surgical techniques.

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.