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Transoral Approach With Reverse Pedicle Screw Technique for the Treatment of Chronic Levine-Edwards Type III Hangman’s Fracture: A Case Report, Surgical Technique, and Literature Review

  • International Journal of Spine Surgery
  • August 2026,
  • 20
  • (4)
  • 582-590;
  • DOI: https://doi.org/10.14444/8867

Abstract

Background The optimal surgical strategy for unstable hangman’s fractures remains controversial, particularly in cases where posterior fixation is unsuitable and evidence for alternative approaches is lacking.

Case Presentation A 58-year-old man presented with a C2 vertebral body fracture, right C2 pedicle fracture, and concurrent C2/C3 disc injury, which manifested as a chronic fracture (4 weeks after trauma). Despite multiple courses of conservative treatment and use of a cervicothoracic orthosis, fracture displacement progressed. No significant neurological deficits were noted. The fracture was reduced and stabilized via a transoral approach using a bilateral reverse pedicle screw technique with cortical bone compression screws. A 2-cm incision was made, with a total surgical duration of 1 hour and intraoperative blood loss of 20 mL; no neurovascular injuries occurred. Immediate intraoperative fracture reduction and fixation were achieved, and no postoperative infections were observed. Postoperatively, the patient wore a cervical collar, initiated neck rehabilitation at 48 hours, and resumed daily activities within 1 week. The visual analog scale score decreased from 4 (preoperatively) to 0 (1 week postoperatively), the Japanese Orthopedic Association score improved from 11 to 16, and the Neck Disability Index score decreased from 28% to 6%. Follow-up computed tomographic imaging demonstrated satisfactory fusion.

Conclusion The minimally invasive transoral approach combined with reverse pedicle screw fixation is an effective surgical option for treating Levine and Edwards type III chronic hangman’s fracture. This study provides a reference for optimizing surgical strategies in the management of upper cervical trauma.

Clinical Relevance This case report demonstrates that the minimally invasive transoral reverse pedicle screw technique is a safe and effective alternative for treating chronic, unstable hangman’s fractures, particularly in patients for whom posterior fixation is unsuitable or motion preservation is desired. The findings may help expand the surgical armamentarium for upper cervical trauma.

Level of Evidence 4.

Background

Hangman’s fracture (HF), or traumatic spondylolisthesis of the axis, was first described and termed by Schneider in 1965.1 It involves fractures of the superior and inferior articular processes of the C2 vertebra, resulting from hyperextension, hyperflexion, and axial loading forces. These injuries are often accompanied by ligamentous and disc damage, leading to C2 to C3 instability. HF accounts for 23% to 27% of all axis fractures. The management of HF is primarily guided by fracture classification, with the Levine-Edwards system being the most widely adopted.2

Unstable HF generally requires surgical intervention, though the optimal surgical approach remains controversial. Historically, posterior C2 pedicle screw fixation was considered the gold standard, as it enables direct fracture compression, anatomical reduction, and preservation of cervical motion.3 However, this technique has notable limitations: open posterior dissection carries a risk of C2 nerve root irritation and venous plexus disruption, leading to high rates of persistent postoperative occipital neuralgia.4 While navigation-assisted percutaneous screw placement may mitigate some risks, its accuracy is compromised in highly unstable fractures and may even exacerbate fracture displacement during screw insertion (Figure 1).5 For patients with traumatic disc herniation causing spinal cord compression, Verheggen and Jansen advocated for C2 to C3 anterior cervical discectomy and fusion (ACDF).6 ACDF allows direct disc excision and fusion via a natural anatomical plane, minimizing intraoperative blood loss.7 However, it is associated with risks such as dysphagia and donor-site morbidity from autogenous iliac bone grafting.8 Additionally, ACDF is ineffective for unstable axis fractures with pedicle displacement. To address these limitations—while achieving anatomical fixation, avoiding posterior neurovascular complications, preserving C1 to C3 motion, and reducing ACDF-related morbidity—we employed the transoral reverse pedicle screw technique with cortical compression screws for a chronic Levine and Edwards type III HF in April 2025. This report details the case and provides a review of relevant literature.

Imaging of a prior case treated with a standard posterior approach. Postoperative sagittal (A) and axial (B-D) CT images demonstrate exacerbated fracture displacement secondary to screw insertion (C).
Figure 1

Imaging of a prior case treated with a standard posterior approach. Postoperative sagittal (A) and axial (B-D) CT images demonstrate exacerbated fracture displacement secondary to screw insertion (C).

Case Presentation

General Information

A 58-year-old man presented with neck pain and restricted range of motion 1 month after falling down a flight of stairs (from the second to the first floor) and landing on his right head. Immediately after the trauma, he developed severe neck pain and marked motion restriction. No loss of consciousness, limb sensory/motor deficits, perianal sensory loss, or bowel/bladder dysfunction was reported. Initial cervical computed tomography (CT) at a local hospital revealed a C2 fracture (Figure 2A–B). He was referred to an orthopedic specialist, who initiated conservative management with a cervical collar. One month later, cervical radiographs showed progressive fracture displacement (Figure 2C–D). Persistent pain prompted further evaluation, leading to admission to our spine surgery department. The patient had good general health and a history of chronic snoring. Physical examination revealed a mild antalgic gait while wearing the cervical collar. No obvious cervical deformity was noted; tenderness was present at the C2 spinous process and paraspinal regions (+). Upper limb sensation and tone were normal, with bilateral muscle strength graded 5/5. Upper limb reflexes were +++ on the left and ++ on the right, with a positive bilateral Hoffmann’s sign. Cervical CT with sagittal bone window reconstruction confirmed a fracture involving the posterior left C2 vertebral body and right C2 pedicle, accompanied by anterior C2 displacement and angulation. MRI demonstrated a C2 fracture-dislocation and diffuse edema in the C2 to C7 interspinous ligaments. The final diagnosis was chronic Levine and Edwards type III HF (Figures 2 and 3).

Preoperative imaging demonstrating an anteriorly displaced C2 fracture. (A and B) Initial computed tomography (CT) images at the time of injury. (C and D) Cervical radiographs obtained 1 month after the injury. (E–P) Imaging studies acquired during the current admission. (E and F) Anteroposterior and lateral cervical radiographs. (G and H) Flexion and extension cervical radiographs. (I) Sagittal CT reconstruction revealing significant C2 anterior displacement and C2–C3 dislocation. (J–L) Axial CT slices showing increased fracture displacement compared with initial imaging, with no evidence of fracture healing. (M–P) Sagittal and axial MRI sequences demonstrating no spinal cord compression.
Figure 2

Preoperative imaging demonstrating an anteriorly displaced C2 fracture. (A and B) Initial computed tomography (CT) images at the time of injury. (C and D) Cervical radiographs obtained 1 month after the injury. (E–P) Imaging studies acquired during the current admission. (E and F) Anteroposterior and lateral cervical radiographs. (G and H) Flexion and extension cervical radiographs. (I) Sagittal CT reconstruction revealing significant C2 anterior displacement and C2–C3 dislocation. (J–L) Axial CT slices showing increased fracture displacement compared with initial imaging, with no evidence of fracture healing. (M–P) Sagittal and axial MRI sequences demonstrating no spinal cord compression.

Preoperative computed tomography angiography for evaluating risks related to transoral approach. The course of the internal carotid artery was unremarkable, confirming a relatively safe surgical corridor for the transoral approach.
Figure 3

Preoperative computed tomography angiography for evaluating risks related to transoral approach. The course of the internal carotid artery was unremarkable, confirming a relatively safe surgical corridor for the transoral approach.

Surgical Technique

General anesthesia was administered, and the patient was placed in a supine position with the neck maintained in a fixed extended posture. The surgeon, positioned cephalad, prepared the oral cavity using povidone-iodine. A Codman retractor was used to achieve adequate exposure of the operative field. After confirming the C1 to C2 anatomical location via C-arm fluoroscopy, a 20-mm midline longitudinal incision was made in the posterior pharyngeal wall. Prevertebral muscles were dissected using bipolar electrocautery to expose the anterior C2 vertebral body. A nerve dissector was used to expose a 7-mm segment of the odontoid base. The screw entry point was marked 6 mm caudal and 6 mm lateral to the medial border of the C2 lateral mass articulation. A 2.00-mm drill was used to create a cortical entry hole, angled 20° caudally and laterally. An awl was advanced 2.7 mm into the vertebral bone in a controlled manner. A guidewire was inserted, and its position was confirmed via C-arm fluoroscopy. The awl was then advanced further until a loss of resistance was appreciated. Two 40 × 3.5-mm cortical bone compression screws were inserted sequentially. Clear tactile feedback confirmed fracture compression during screw tightening. C-arm fluoroscopy verified satisfactory fracture reduction and implant position. The naso-oropharynx was irrigated repeatedly with povidone-iodine. The muscular and mucosal layers were closed with absorbable sutures. The total duration of exposure and fixation was 1 hour with intraoperative blood loss of 20 mL (Figure 4).

Intraoperative details. (A) Cortical bone compression screws utilized in the procedure. (B) Intraoperative patient positioning. (C) Preoperative 3-dimensional (3D) anatomical model for surgical planning of screw trajectory. (D and E) Intraoperative anteroposterior and lateral fluoroscopic images. (F) Intraoperative photograph demonstrating satisfactory screw fixation.
Figure 4

Intraoperative details. (A) Cortical bone compression screws utilized in the procedure. (B) Intraoperative patient positioning. (C) Preoperative 3-dimensional (3D) anatomical model for surgical planning of screw trajectory. (D and E) Intraoperative anteroposterior and lateral fluoroscopic images. (F) Intraoperative photograph demonstrating satisfactory screw fixation.

Postoperative Management

The patient was intubated and monitored in the intensive care unit for 24 hours, followed by successful extubation. Enteral nutrition was administered via a nasogastric tube for 7 days. Prophylactic anticoagulation, broad-spectrum antibiotics, and analgesics were prescribed. Cervical collar-assisted rehabilitation was initiated on postoperative day 2, and ambulation was started on day 3. The patient wore the cervical collar for 3 months, with instructions to avoid strenuous neck activities. Imaging obtained at 1 week postoperatively is shown in Figure 5.

Postoperative imaging at 1 wk. (A and B) Axial computed tomography (CT) views demonstrating optimal screw positioning. (C and D) Sagittal CT reconstructions showing satisfactory fracture reduction and compression at 1-wk postoperative imaging.
Figure 5

Postoperative imaging at 1 wk. (A and B) Axial computed tomography (CT) views demonstrating optimal screw positioning. (C and D) Sagittal CT reconstructions showing satisfactory fracture reduction and compression at 1-wk postoperative imaging.

Follow-up

Follow-up radiographs and CT scans at 1 and 3 months postoperatively showed progressive fracture healing (Figures 6 and 7). The patient remained asymptomatic, with excellent functional outcomes.

Postoperative follow-up imaging at 1 mo. (A–D) Anteroposterior, lateral, flexion, and extension cervical radiographs. (E–H) Sagittal computed tomography (CT) views. (I) Axial CT view demonstrating fracture line blurring.
Figure 6

Postoperative follow-up imaging at 1 mo. (A–D) Anteroposterior, lateral, flexion, and extension cervical radiographs. (E–H) Sagittal computed tomography (CT) views. (I) Axial CT view demonstrating fracture line blurring.

Postoperative follow-up imaging at 3 mo. (A) Anteroposterior cervical radiograph. (B and C) Flexion and extension cervical radiographs. (D–H) Computed tomography images demonstrating bony union of the right C2 pedicle fracture and blurring of the fracture line involving the left posterior C2 vertebral body.
Figure 7

Postoperative follow-up imaging at 3 mo. (A) Anteroposterior cervical radiograph. (B and C) Flexion and extension cervical radiographs. (D–H) Computed tomography images demonstrating bony union of the right C2 pedicle fracture and blurring of the fracture line involving the left posterior C2 vertebral body.

Discussion

Schneider first described and termed “hangman’s fracture” in 1965; this injury is also referred to as “axis ring fracture” or traumatic spondylolisthesis of the axis.9 It accounts for 4% to 7% of all spinal fractures and 20% to 22% of cervical fractures.10 Effendi et al proposed a classification system for HF in 1981,11 which was later modified by Levine in 1985 into the widely used 4-type system based on injury mechanism.2 Type I fractures are stable and managed nonoperatively with a rigid cervical collar,12 while types II, IIA, and III involve significant flexion forces leading to C2 to C3 disc injury and require surgical stabilization.13

Surgical options for unstable HF include posterior and anterior approaches.14 Posterior C2 pedicle screw fixation was once considered ideal for achieving anatomical reduction via screw thread compression while preserving motion. However, the inability to achieve bicortical fixation often limits effective compression and may exacerbate displacement (Figure 1). Type III fractures with C2 to C3 instability—particularly those involving the posterior inferior corner of C2—often require more extensive fusion constructs. In current practice, posterior C1 to C2 fusion (Harms technique) remains the prevalent choice for unstable HF, especially in elderly patients, due to its rigid stability and high fusion rates. However, it sacrifices C1 to C2 rotation and carries risks associated with posterior dissection. Posterior C1 to C3 fixation represents a common and biomechanically robust option, especially in cases with severe discoligamentous disruption or atlantoaxial instability.15 Open posterior surgery carries a risk of C2 nerve root irritation and venous plexus injury, which contribute to persistent postoperative neck pain.16–19 While navigation can facilitate percutaneous screw placement, its accuracy is unreliable in highly unstable fractures.5

Anteriorly, Verheggen and Jansen advocated for ACDF in HF patients with traumatic disc herniation causing spinal cord compression.6 ACDF allows direct disc excision and fusion via an anatomical plane, with reduced intraoperative blood loss.20 However, high cervical ACDF is associated with a risk of dysphagia, and autologous iliac bone grafting may cause donor-site morbidity.7 Studies have shown that patients with HF treated with ACDF have significantly higher postoperative visual analog scale scores compared with those undergoing posterior fixation.3

Standalone C2 fracture fixation stabilizes the injury while preserving segmental motion. The transoral approach has been reported for the treatment of atlas fractures using screw-wire or plate systems.21,22 Posterior lag screws have been used for minimally displaced anterior C1 ring fractures and coronally split lateral mass fractures to prevent degenerative changes and displacement.23–27 Kandziora et al defined safe zones for C1/C2 screw insertion.28 With advances in surgical techniques and instrumentation, the complication rate of transoral procedures has decreased.29–33

Anterior reverse pedicle screw fixation has been reported in selected atlas fractures and atlantoaxial dislocations, but not in chronic unstable Levine and Edwards type III HF.34–36 The trajectory of the axis reverse pedicle screw is consistent with that of the conventional posterior axis pedicle screw; theoretically, their biomechanical stability is comparable, making this approach the optimal internal fixation method for axis stabilization and distinctly superior to anterior vertebral body screws or articular process screws of the axis.37 Anatomical studies confirmed the feasibility and safe corridors for transoral C2 pedicle screw placement, providing key parameters for entry points, trajectories, and pedicle dimensions.38,39 Nevertheless, these studies focused principally on atlantoaxial instability or odontoid pathologies rather than HF. Moreover, updated classifications, which differentiate “full-length” from “short-course” reverse pedicle screws based on caudal inclination, have refined the biomechanical basis for anterior C2 fixation.40

In the present case, we applied bilateral bicortical compression screws to address type III injury-specific challenges: anteroposterior instability, rotational displacement, and persistent fracture gap. Bilateral fixation enhances rotational control and load-sharing vs unilateral placement; the anterior-to-posterior trajectory enables direct interfragmentary compression, improving stability and osseous union. This approach is further supported by contemporary literature underscoring the critical role of preoperative CT-based planning and patient-specific trajectory selection in mitigating vertebral artery injury risk.41,42 Given the chronic nature of the fracture and the significant fracture gap, full-length bicortical compression screws (40 mm) were essential for achieving complete reduction (Figure 4A). Postoperative CT imaging clearly showed that the screw tips protruded 3 mm beyond the posterior margin of the C2 articular processes, confirming successful bicortical compression fixation. The posterior aspect of the C2 pedicle is covered by thick soft tissues, including the semispinalis cervicis muscle, inferior obliquus capitis muscle, and nuchal ligament. Imaging analysis revealed a soft tissue thickness of approximately 5 mm posterior to the pedicle in this patient, confirming that the 3-mm screw protrusion remained within safe limits. Postoperative imaging, including coronal CT reconstructions and CT angiography, demonstrated a minimal breach of the right screw into the transverse foramen without compromising the vertebral artery, confirming the safety of the procedure (Figure 8). This innovative technique overcomes the limitations of isolated posterior or anterior approaches, establishing it as a promising solution for unstable axis fractures.

Postoperative imaging demonstrating screw position and vertebral artery integrity. (A and B) Coronal computed tomography reconstructions reveal minimal breach of the right reverse pedicle screw into the transverse foramen (yellow arrow). (C and D) Computed tomography angiography confirms the patency and preserved anatomical course of the vertebral artery (blue arrow).
Figure 8

Postoperative imaging demonstrating screw position and vertebral artery integrity. (A and B) Coronal computed tomography reconstructions reveal minimal breach of the right reverse pedicle screw into the transverse foramen (yellow arrow). (C and D) Computed tomography angiography confirms the patency and preserved anatomical course of the vertebral artery (blue arrow).

Key advantages of our transoral approach include minimal tissue disruption (facilitating faster exposure and reduced swelling), shorter postoperative intubation times, and a potentially lower infection risk compared with traditional transoral procedures. Compared with posterior transpedicular compression screw fixation, the anterior approach minimizes the risk of fracture fragment displacement during screw insertion—since the dense posterior musculoligamentous complex may act as a fulcrum. Furthermore, the relatively thin soft tissue envelope anterior to the C1 to C2 complex poses a risk: excessively long bicortical screws placed posteriorly may breach the anterior pharyngeal wall, causing oropharyngeal contamination. Critically, the transoral anterior approach eliminates this concern, allowing surgeons to confidently select screws of sufficient length to achieve secure bicortical compression fixation without risking visceral injury.

Specific perioperative risks must be considered. Studies indicate that approximately 4.2% of patients develop acute airway obstruction due to retropharyngeal edema, requiring delayed extubation.43 More severe complications include retropharyngeal infection with tissue loss, which may necessitate complex reconstruction. Postoperative infection rates (4%–7%) are comparable to those of other spinal surgeries when performed by experienced surgeons.44 Notably, transoral procedures performed by experienced surgeons do not carry higher mortality or morbidity rates than other established spinal surgical approaches.35 In the present case, manual placement of the right pedicle screw adjacent to the laminar fracture failed to perfectly traverse the fracture line. While bilateral fixation controlled rotational instability and facilitated early (4 weeks) healing, this highlights the complexity of transoral upper cervical anatomy and the limitations of C-arm fluoroscopy. It underscores the need for enhanced intraoperative guidance—such as intraoperative CT and real-time navigation—to ensure precise screw placement.

Conclusion

The innovative transoral reverse pedicle screw fixation technique is an effective surgical option for chronic unstable axis fractures. In this case of Levine and Edwards type III chronic HF, the technique achieved anatomical reduction, bony fusion, and preservation of cervical motion.

Footnotes

  • Funding This study was supported by Tianjin Key Medical Discipline (Specialty) Construction Project (TJYXZDXK-064B).

  • Declaration of Conflicting Interests The authors report no conflicts of interest in this work.

  • Patient Consent The patient gave informed written consent for the publication of personal and clinical data and images in this report.

  • Ethics Approval This case report did not undergo formal ethics committee review. The patient identifiers have been removed from imaging and clinical data to ensure anonymity. Written informed consent for publication was obtained from the patient.

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In this Issue

International Journal of Spine Surgery

Vol. 20, Issue 4

1 Aug 2026

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Keywords

transoral, pedicle screw, hangman’s fracture, C2 vertebra, axis