Motion Preserving Surgery Using O-Arm for Unstable Hangman Fracture

 

 Buy Article Permissions and Reprints

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.

• References

• 1 Hadley MN, Browner C, Sonntag VKH. Axis fractures: a comprehensive review of management and treatment in 107 cases. Neurosurgery 1985; 17 (02) 281-290
  CrossrefPubMedGoogle Scholar
• 2 Roda JM, Castro A, Blázquez MG. Hangman’s fracture with complete dislocation of C-2 on C-3. Case report. J Neurosurg 1984; 60 (03) 633-635
  CrossrefPubMedGoogle Scholar
• 3 Benzel EC, Hart BL, Ball PA, Baldwin NG, Orrison WW, Espinosa M. Fractures of the C-2 vertebral body. J Neurosurg 1994; 81 (02) 206-212
  CrossrefPubMedGoogle Scholar
• 4 Hu Y, Yuan ZS, Kepler CK, Dong WX, Sun XY, Zhang J. Comparison of occipitocervical and atlantoaxial fusion in treatment of unstable Jefferson fractures. Indian J Orthop 2017; 51 (01) 28-35
  CrossrefPubMedGoogle Scholar
• 5 Peev NA. Understanding the statics and dynamics of the subaxial cervical segments, following C1-C2 fusion. World Neurosurg 2016; 87: 621-623
  CrossrefPubMedGoogle Scholar
• 6 Schneider RC, Livingston KE, Cave AJ, Hamilton G. “Hangman’s fracture” of the cervical spine. J Neurosurg 1965; 22: 141-154
  CrossrefPubMedGoogle Scholar
• 7 Effendi B, Roy D, Cornish B, Dussault RG, Laurin CA. Fractures of the ring of the axis. A classification based on the analysis of 131 cases. J Bone Joint Surg Br 1981; 63-B (03) 319-327
  CrossrefPubMedGoogle Scholar
• 8 Levine AM, Edwards CC. The management of traumatic spondylolisthesis of the axis. J Bone Joint Surg Am 1985; 67 (02) 217-226
  CrossrefPubMedGoogle Scholar
• 9 Coric D, Wilson JA, Kelly Jr. DL. Treatment of traumatic spondylolisthesis of the axis with nonrigid immobilization: a review of 64 cases. J Neurosurg 1996; 85 (04) 550-554
  CrossrefPubMedGoogle Scholar
• 10 Li XF, Dai LY, Lu H, Chen XD. A systematic review of the management of hangman’s fractures. Eur Spine J 2006; 15 (03) 257-269
  CrossrefPubMedGoogle Scholar
• 11 Longo UG, Denaro L, Campi S, Maffulli N, Denaro V. Upper cervical spine injuries: indications and limits of the conservative management in Halo vest. A systematic review of efficacy and safety. Injury 2010; 41 (11) 1127-1135
  CrossrefPubMedGoogle Scholar
• 12 Duggal N, Chamberlain RH, Perez-Garza LE, Espinoza-Larios A, Sonntag VK, Crawford NR. Hangman’s fracture: a biomechanical comparison of stabilization techniques. Spine 2007; 32 (02) 182-187
  CrossrefPubMedGoogle Scholar
• 13 Rajasekaran S, Vidyadhara S, Shetty AP. Iso-C3D fluoroscopy-based navigation in direct pedicle screw fixation of Hangman fracture: a case report. J Spinal Disord Tech 2007; 20 (08) 616-619
  CrossrefPubMedGoogle Scholar
• 14 Sugimoto Y, Ito Y, Shimokawa T, Shiozaki Y, Mazaki T. Percutaneous screw fixation for traumatic spondylolisthesis of the axis using iso-C3D fluoroscopy-assisted navigation (case report).. Minim Invasive Neurosurg 2010; 53 (02) 83-85
  Article in Thieme ConnectPubMedGoogle Scholar
• 15 Mueller CA, Roesseler L, Podlogar M, Kovacs A, Kristof RA. Accuracy and complications of transpedicular C2 screw placement without the use of spinal navigation. Eur Spine J 2010; 19 (05) 809-814
  CrossrefPubMedGoogle Scholar
• 16 Ma W, Xu R, Liu J. et al. Posterior short-segment fixation and fusion in unstable Hangman’s fractures. Spine 2011; 36 (07) 529-533
  CrossrefPubMedGoogle Scholar
• 17 Xie N, Khoo LT, Yuan W. et al. Combined anterior C2-C3 fusion and C2 pedicle screw fixation for the treatment of unstable hangman’s fracture: a contrast to anterior approach only. Spine 2010; 35 (06) 613-619
  CrossrefPubMedGoogle Scholar
• 18 Ying Z, Wen Y, Xinwei W. et al. Anterior cervical discectomy and fusion for unstable traumatic spondylolisthesis of the axis. Spine 2008; 33 (03) 255-258
  CrossrefPubMedGoogle Scholar
• 19 Chittiboina P, Wylen E, Ogden A, Mukherjee DP, Vannemreddy P, Nanda A. Traumatic spondylolisthesis of the axis: a biomechanical comparison of clinically relevant anterior and posterior fusion techniques. J Neurosurg Spine 2009; 11 (04) 379-387
  CrossrefPubMedGoogle Scholar
• 20 Wilson AJ, Marshall RW, Ewart M. Transoral fusion with internal fixation in a displaced hangman’s fracture. Spine 1999; 24 (03) 295-298
  CrossrefPubMedGoogle Scholar
• 21 Tuite GF, Papadopoulos SM, Sonntag VK. Caspar plate fixation for the treatment of complex hangman’s fractures. Neurosurgery 1992; 30 (05) 761-764 discussion 764–765
  PubMedGoogle Scholar
• 22 Karimi-Nejad A. Surgical management of cervical spine injuries. Neurosurg Rev 1989; 12 (Suppl. 01) 525-535
  CrossrefPubMedGoogle Scholar
• 23 Leconte P. Fracture et luxation des deux premières vertèbres cervicales In: Judet R. ed. Luxation Congenénitale de la Hanche: Fractures du Cou-de-pied Rachis Cervical. Actualités de Chirurgie Orthopédique de l’Hôpital Raymond- Poincaré. Paris: Masson et Cie; 1964: 147-166
• 24 Bristol R, Henn JS, Dickman CA. Pars screw fixation of a hangman’s fracture: technical case report. Neurosurgery 2005; 56 (Suppl. 01) E204-discussion E204
  PubMedGoogle Scholar
• 25 ElMiligui Y, Koptan W, Emran I. Transpedicular screw fixation for type II Hangman’s fracture: a motion preserving procedure. Eur Spine J 2010; 19 (08) 1299-1305
  CrossrefPubMedGoogle Scholar
• 26 Samaha C, Lazennec JY, Laporte C, Saillant G. Hangman’s fracture: the relationship between asymmetry and instability. J Bone Joint Surg Br 2000; 82 (07) 1046-1052
  CrossrefPubMedGoogle Scholar
• 27 Verheggen R, Jansen J. Hangman’s fracture: arguments in favor of surgical therapy for type II and III according to Edwards and Levine. Surg Neurol 1998; 49 (03) 253-261 discussion 261–262
  CrossrefPubMedGoogle Scholar
• 28 Mammis A, Yanni DS, Thaker NG, Goldstein IM. Reduction of displaced Hangman’s fracture by compression across crossed translaminar screws. J Clin Neurosci 2012; 19 (04) 582-584
  CrossrefPubMedGoogle Scholar
• 29 Ludwig SC, Kowalski JM, Edwards II CC, Heller JG. Cervical pedicle screws: comparative accuracy of two insertion techniques. Spine 2000; 25 (20) 2675-2681
  CrossrefPubMedGoogle Scholar
• 30 Yukawa Y, Kato F, Ito K. et al. Placement and complications of cervical pedicle screws in 144 cervical trauma patients using pedicle axis view techniques by fluoroscope. Eur Spine J 2009; 18 (09) 1293-1299
  CrossrefPubMedGoogle Scholar
• 31 Richter M, Amiot LP, Neller S, Kluger P, Puhl W. Computer-assisted surgery in posterior instrumentation of the cervical spine: an in-vitro feasibility study. Eur Spine J 2000; 9 (Suppl. 01) S65-S70
  CrossrefPubMedGoogle Scholar
• 32 Tian W, Weng C, Liu B. et al. Posterior fixation and fusion of unstable Hangman’s fracture by using intraoperative three-dimensional fluoroscopy-based navigation. Eur Spine J 2012; 21 (05) 863-871
  CrossrefPubMedGoogle Scholar
• 33 Ito Y, Sugimoto Y, Tomioka M, Hasegawa Y, Nakago K, Yagata Y. Clinical accuracy of 3D fluoroscopy-assisted cervical pedicle screw insertion. J Neurosurg Spine 2008; 9 (05) 450-453
  CrossrefPubMedGoogle Scholar
• 34 Tjardes T, Shafizadeh S, Rixen D. et al. Image-guided spine surgery: state of the art and future directions. Eur Spine J 2010; 19 (01) 25-45
  CrossrefPubMedGoogle Scholar