Abstract
Background Traumatic cervical spine fractures with dislocation are often caused by high-energy injuries, typically from motor vehicle accidents. Hangman’s fracture constitutes 4% to 5% of cervical fractures and is usually accompanied by anteroposterior dislocation and/or neurological deficits. However, lateral vertebral dislocation without neurological symptoms is extremely rare. We present a case of C2 to C3 lateral dislocation with C3 fracture in a patient who only reported neck pain and limited mobility.
Methods This study reports a case of a 42-year-old woman who presented with neck pain after a traffic accident. The patient remained fully conscious throughout the incident, and the patient did not experience any loss of consciousness. Preoperative imaging clearly revealed a split fracture of the right C3 body-pedicle junction and the right vertebral plate, along with anterolateral dislocation of the C2 vertebral body. After a closed reduction of the affected segment, an anterior cervical discectomy and fusion (ACDF) was performed to restore segmental stability of the C2 to C3 level.
Results A satisfied closed reduction was achieved after a fixed cervical traction. An ACDF was performed to successfully restore the segmental stability of the C2 to C3 level without surgical-related complications. The patient reported alleviation of neck pain (visual analog scale score decreased from 7 preoperatively to 2 postoperatively). Postoperative imaging revealed a satisfactory reduction of fracture-dislocation. At a 2-month follow-up after discharge, the patient had returned to work.
Conclusion This case demonstrates the feasibility of ACDF as a standalone approach for treating single-stage cervical fractures with associated lateral dislocation following precise and sustained traction reduction. Compared with posterior or combined approaches, the anterior-only technique offers significant advantages, providing a minimally invasive alternative for the management of complex cervical spine trauma.
Clnical Relevance This case highlights that prompt recognition and surgical stabilization of C3 vertebral body fracture with C2–C3 spondylolisthesis can prevent neurological deterioration and improve functional recovery. It provides practical evidence to support early surgical decision-making in rare but severe cervical spine injuries.
Level of Evidence 5.
Introduction
Traumatic cervical spine fractures with dislocation are a major focus in spine surgery due to their complex anatomy and the risk of catastrophic neurological injury. Approximately 2% to 3% of all trauma patients experience cervical spine fractures and/or dislocations.1 Based on the affected segment, cervical spine fractures are classified into upper cervical (C1–C2) and lower cervical (C3–C7) fractures, with nearly two-thirds occurring in the subaxial cervical region.2
As to the junction of the upper and lower cervical spine, the most common injury of the C2 to C3 segment is hangman’s fracture, which is characterized by traumatic spondylolisthesis of the axis. hangman’s fracture is usually caused by a hyperextension-distraction injury and is a fracture of the C2 pedicle combined with C2 body dislocation onto the C3 body.3 Upper cervical spine fractures, exemplified by hangman’s fracture, are classified in various ways.4 The most widely used classification of traumatic spondylolisthesis of the axis is that proposed by Effendi and workmates; their classification was modified by Levine and Edward to focus on the injury mechanism and the degree of angular deviation and translational deviation of C2 to C3.5 In theoretical terms, intervertebral dislocation can occur in any plane.6 However, reports of C2 to C3 lateral dislocation combined with C3 vertebra fracture are even rarer.7
From a biomechanical perspective, the core injury mechanism in traumatic cervical spine fractures involves the cervical spine being subjected to additional force vectors along the longitudinal axis. The injury mechanism can be categorized into hyperextension-traction and hyperextension-compression injuries. Traction injuries are commonly seen in “judicial hangings,” where complete rupture of all ligamentous structures can occur, leading to severe instability and typically causing fatal C2-level spinal cord injury. Compression injuries are more commonly seen in traffic accidents, particularly when a passenger’s forehead impacts the windshield. These injuries are often accompanied by multiple fractures of adjacent spinous processes or lower cervical vertebrae, ultimately leading to ligamentous rupture and severe cervical instability.8
This study presents the case of a 42-year-old female patient who suffered a severe C3 fracture, splintering with traumatic C2 to C3 lateral dislocation in a car accident. The patient’s only complaint was neck pain without any sensory or motor deficits. This case is unique in that the patient suffered a severe cervical fracture-dislocation without accompanying neurologic injury, which provides important clinical insight into the diagnosis and management of such injuries.
Report of Case
Presentation
A 42-year-old female patient with neck pain after a motor vehicle accident was admitted into the emergency room. The patient was seated in the rear passenger seat and, due to inertia, struck the windshield. Throughout the incident, the patient remained fully conscious with no signs of loss of consciousness or neurological deficits. A thorough neurological examination revealed no significant sensory, motor, or reflex abnormalities. The patient complained of persistent neck pain with significantly reduced cervical range of motion. The lateral view of the x-ray suggested an anterior dislocation of the C2 body and a suspicious pedicle fracture. A follow-up computed tomography (CT) image clearly displayed a split fracture of the right C3 body-pedicle junction and the right vertebral plate. An obvious C2 to C3 listlessness and the right facet joint subluxation were observed. The C2 body was dislocated anterolaterally onto the right aspect of the C3 body. Magnetic resonance imaging (MRI) displayed the prevertebral space hematoma but dismissed C2 to C3 space and disc-ligamentous complex injury. A C3 to C4 disc herniation was also found in the MRI (Figure 1). A CT angiography was also performed to exclude the malformation of the vertebral artery.
Lateral cervical plain radiograph (A), anteroposterior cervical plain radiograph (E), sagittal computed tomography (CT) (B), and CT cervical vertebrae 3D reconstruction (C) revealed significant intervertebral dislocation at the C2 to C3 level (blue arrowhead). Axial (D), CT cervical vertebrae 3D reconstruction (G), and coronal CT (F) CT revealed a split fracture of the right C3 body-pedicle junction and the right vertebral plate (blue arrowhead). Sagittal magnetic resonance imaging scan (H) displayed the prevertebral space hematoma and dismissed C2 to C3 space and disc-ligamentous complex (DLC) injury. C3 to C4 disc herniation was also found (blue arrowhead).
Perioperative Treatment
After admission into the ward, preoperative skull traction with 4 kg was performed to facilitate preoperative reduction of C2 to C3.9 The effect of traction was evaluated using x-ray imaging. After a detailed preoperative preparation, an anterior surgical plan was made to restore the normal alignment and stability of the upper cervical spine.
After general anesthesia, the patient was placed in a supine position with slight extension of the neck and proper fixation of the shoulder (Figure 2A). We performed a fixed cranial traction, not continuous traction, to avoid potential strain of the spinal cord after intraoperative reduction or release (Figure 2B). Intraoperative neurophysiological monitoring was employed throughout the procedure to minimize the risk of potential neurological complications due to surgical manipulation. Intraoperative fluoroscopy suggested an ideal C2 to C3 reduction was achieved, and an anterior cervical discectomy and fusion (ACDF) involving C2 to C3 and C3 to C4 was successfully performed by using an anterior incision (Figure 2C–E). Intraoperative fluoroscopy demonstrated that satisfactory intervertebral fusion and fixation were achieved (Figure 2F).
Slight extension of the neck and proper fixation of the shoulder (A). A fixed cranial traction to avoid potential strain of the spinal cord after intraoperative reduction or release (B) (red arrowhead). Intraoperative fluoroscopy suggested an ideal C2 to C3 reduction was achieved (C and D). The preoperative approach incision for anterior cervical discectomy and fusion (ACDF) at the C2 to C3 and C3 to C4 levels (E). Intraoperative fluoroscopy shows satisfactory intervertebral fusion and fixation results (F).
The patient had no surgery-related injuries. The patient remained hemodynamically stable and fully conscious after surgery. Surgical dressings were changed regularly, and the cervical incision showed good healing without signs of bleeding or infection. Upon regaining consciousness from anesthesia, the patient reported significant relief of neck pain, with the visual analog scale (VAS) score decreasing from 7 preoperatively to 3 postoperatively. Mild dysphagia was noted, but there was no hoarseness, and no sensory or motor deficits were observed in the limbs. The Table summarizes the comparison of preoperative and postoperative scores for the VAS, modified Japanese Orthopedic Association survey, Neck Disability Index, and the 36-Item Short Form Health Survey (SF-36). Postoperative x-ray and CT imaging showed a very satisfactory reduction and almost complete realignment in all planes of C2 to C3 (Figure 3A–G). The postoperative MRI indicated that a perfect decompression of the cervical spinal cord was achieved (Figure 3H). On postoperative day 2, the patient began ambulating with a cervical collar, and dysphagia resolved. The patient recovered well, had no handicap, and was very satisfied with the treatment outcome. The patient was discharged on postoperative day 5 with instructions to continue wearing the cervical collar and to attend regular follow-up visits.
Lateral cervical plain radiographs (A), sagittal computed tomographic (CT) image (B), and CT cervical vertebrae 3D reconstruction (C) revealed realignment of C2 to C3 body. Axial cut (D), anteroposterior (AP) x-ray image (E), coronal cut (F), and CT cervical vertebrae 3D reconstruction (G) showing realignment of facets and the fractured fragments. The postoperative magnetic resonance imaging (MRI) (H) indicated that a perfect decompression of the cervical spinal cord was achieved.
Comparison of preoperative and postoperative VAS, NDI, mJOA, and SF-36 scores.
Follow-Up and Outpatient Visits After Discharge
The patient was re-evaluated 1 month later and reported mild neck pain, with daily pain duration not exceeding 1 hour. Sensation and motor function in all limbs were normal, and no abnormal signs were observed. At 3 months postinjury, the patient reported complete resolution of neck pain and was able to perform some household activities. By the second month, she had already returned to work, although her working hours and intensity had not yet reached the level prior to the injury. At the 5-month follow-up, the patient reported no recurrence of neck pain, cervical mobility had returned to normal, and she had fully resumed her work with working hours and intensity comparable to preinjury level levels.
Discussion
Cervical spine injuries can be classified into C1 to C2 injuries and lower cervical spine injuries.10 The atlantoaxial joint, which forms the upper cervical spine, primarily facilitates head rotation. In the lower cervical spine, the C4 to C5 and C5 to C6 segments exhibit the greatest mobility, whereas the C2 to C3 segment has the least movement, making it the most stable joint. The C2 to C3 junction represents a unique transitional region, and due to its minimal mobility, injuries at this level are exceedingly rare.7
As to traumatic spondylolisthesis of the axis, the most commonly used classification was Levine and Edward classification.5 According to this classification, type I, type II, and atypical fractures were stable fractures; therefore, nonsurgical treatment like external fixation can achieve good long-term outcomes. However, for unstable type IIa, type III, and atypical fractures, surgical treatment is recommended.11 As to the preoperative imaging performance for the current case, the proper classification for her was type IIa. Hence, an ACDF was performed for this patient.
Based on studies of the injury mechanisms and biomechanics of cervical spine trauma, it has been shown that if extension or flexion forces are applied to the head, accompanied by axial traction or compression, there may be suspicion of traumatic cervical spondylolisthesis.8 In this motor vehicle accident, the patient was subjected to inertial forces, being thrown forward from the rear seat, with the head striking the windshield. Given the presence of a skin laceration in the parietal region of the patient’s head, it was reasonable to assume that the fracture with dislocation was caused by an extension-compression mechanism, as extension injuries are associated with damage to the anterior portion of the C2 to C3 intervertebral disc. However, the lateral dislocation at C2 to C3 corroborated that the injury did not originate from unidirectional extension-compression forces but may have involved lateral shearing and compressive forces.1 When the cervical vertebral body experiences compressive forces on the ipsilateral side, it can cause a fracture and lead to dispersion and dislocation on the contralateral side.12 In this case, the compressive force likely resulted in a C3 fracture and its outward displacement.7 Fortunately, this outward displacement helped to increase the diameter of the spinal canal, thereby preventing injury to the spinal cord. This also explains why the patient did not experience any neurological deficits.13
In the treatment of hangman’s fracture, anterior cervical, posterior cervical, and combined operations can be used as effective treatment options. Due to the significant heterogeneity and frequent intervertebral dislocation associated with such injuries, it is necessary to develop a personalized surgical protocol strictly based on the fracture dislocation type to achieve a precise balance between anatomic reduction and functional recovery. However, each of the 3 surgical options has its own indications and advantages and disadvantages.14
Why Choose an Isolated Anterior Approach?
Before the surgery, through cranial traction, it was confirmed that the lateral displacement of the affected segment had been reduced (Figure 2C–D; prerequisite), and the fracture fragments had not invaded the spinal canal. A simple anterior approach surgery was sufficient to achieve decompression and fusion, and posterior surgery was not necessary. Regarding the benefits of posterior surgery vs risks of trauma, although posterior surgery provides stronger stability, it is associated with larger surgical incisions, muscle dissection, increased risks of bleeding and infection, and a higher economic burden on the patient’s family. Considering the stability in this case and the patient’s postoperative needs, the preferred choice was ACDF, which was deemed more reasonable. A review of the relevant literature indicates that, in the management of both typical and atypical hangman’s fractures, posterior approaches are used in approximately 33% of type IIA or type III cases, while anterior approaches are employed in about 51% of cases. For unstable fracture patterns, the anterior approach is generally considered the preferred option.15 Two days postoperatively, the patient’s neck VAS score decreased from 7 preoperatively to 3, and by the day of discharge, the VAS score had dropped to 2. However, postoperative CT revealed mild residual displacement between the vertebral bodies (Figure 3C). If an anterior-posterior combined approach had been used during the surgery, a more precise restoration of the cervical spine anatomy could have been achieved.16
The Advantages and Disadvantages of ACDF
ACDF offers several significant advantages, including (1) effective restoration and maintenance of cervical lordosis, improving spinal alignment and biomechanics; (2) less postoperative pain and a shorter time to pain-free recovery compared with posterior approaches; (3) minimal surgical trauma, with significantly reduced intraoperative blood loss and postoperative drainage; (4) direct anterior decompression of lesions such as herniated discs or anteriorly displaced bone fragments; (5) shorter operative time and greater surgical efficiency; (6) less disruption to soft tissues, leading to faster postoperative recovery. In this case report, the patient had no neurological deficits, and the anterior cervical approach allowed for direct decompression, thereby preventing neurological deterioration. Therefore, when appropriately indicated, ACDF is a safe, minimally invasive, and effective surgical option.15
Posterior surgery can directly reduce dislocation and provide greater structural stability, which is particularly beneficial for patients with poor bone quality, such as those with ankylosing spondylitis or osteoporosis. Combined anterior-posterior surgery offers the strongest fixation and can improve fusion rates when treating cervical dislocations.17 However, for this patient—who was 42 years old, neurologically intact, and without a history of the aforementioned conditions—an anterior approach was a more prudent choice due to its less invasive nature and lower risk of postoperative wound complications.
While ACDF is a widely accepted and effective anterior cervical procedure, attention must still be paid to its postoperative complications. The most common complications include self-limiting dysphagia, surgical site hematoma, airway-related issues, voice changes, and implant failure, with an overall complication rate reported between 13% and 19%. Among these, dysphagia (1.7%–9.5%) and hematoma (0.4%–5.6%) are considered the most significant, primarily due to the surgical proximity to critical structures such as the pharynx, trachea, esophagus, and neurovascular bundles.16
Why Was an ACDF Surgery Performed at the C2 to C4 Levels?
Preoperative MRI revealed disruption of the C2 to C3 DLC and disc herniation at the C3 to C4 level, indicating that fusion at the C3 to C4 segment was not only reasonable but also essential.
In certain clinical and radiological scenarios, one surgical approach may prove to be more advantageous than another. Therefore, when facing patients with various types of cervical spine injuries, spine surgeons should be proficient in both individual surgical techniques and combined procedures, ultimately providing patients with a more satisfactory treatment experience.
Conclusion
Based on the analysis of this case and a review of the literature, we believe that, provided successful closed reduction is achieved, isolated ACDF can be considered the preferred surgical approach for C2 to C3 facet lateral dislocation combined with C3 vertebral body fracture. This procedure, through direct decompression of the anterior column and bony fusion between the vertebrae, effectively restores the biomechanical stability of the cervical spine. Relevant studies have confirmed its significant advantages, including minimal intraoperative trauma (average blood loss <50 mL) and high preservation of cervical rotational function postoperatively, making it particularly suitable for high-energy injury cases without neurological impairment. This case demonstrates that a standalone ACDF can serve as an effective and feasible treatment strategy, helping to fill a gap in the limited existing literature. It also highlights the importance and efficacy of sustained preoperative traction reduction in patients without significant neurological deficits. That being said, ACDF should not be considered the standard treatment for C2 to C3 lateral dislocation with concomitant C3 vertebral fracture. In other clinical settings, posterior or combined approaches may provide more appropriate surgical strategies tailored to individual patient needs. The choice of approach remains a subject of debate and depends on multiple factors, requiring a case-by-case evaluation. The significance of this case report lies in offering a successful example that may serve as a valuable reference for spine surgeons when encountering similar complex cases in the future.
Footnotes
Funding The authors received no financial support for the research, authorship, and/or publication of this article.
Declaration of Conflicting Interests The authors report no conflicts of interest in this work.
Patient Consent for Publication In the submitted manuscript, the patient has consented to the use of her medical case data (including medical history, imaging data such as x-rays, CT scans, and MRI) as well as related surgical photos for publication in an academic journal. We confirm that all personally identifiable information has been removed from this manuscript to protect the patient's privacy.
Disclosures Each author certifies that he has no commercial associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the present article.
- This manuscript is generously published free of charge by ISASS, the International Society for the Advancement of Spine Surgery. Copyright © 2025 ISASS. To see more or order reprints or permissions, see http://ijssurgery.com.
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