Abstract
Purpose
The purpose of this study was to assess the efficacy and accuracy of posterior screw fixation for unstable Hangman’s fracture using intraoperative 3D fluoroscopy-based navigation.
Methods
14 patients with unstable Hangman’s fractures (11 males and 3 females), ranging in age from 21 to 59 years, received posterior fixation assisted by an intraoperative 3D fluoroscopy-based navigation system: 11 Levine–Edwards type II and three type IIA cases. The American Spine Injury Association grade was D in 2 and E in 12 cases.
Results
Operation time was 110 min (range 90–140 min). Hospital stay was 7.6 days (range 5–12 days). All the patients were observed for an average of 28.8 months (range 15–50 months). No screw-related injury to nerve, or vertebral artery was observed intraoperatively. An average of four screws/patient were inserted. Pedicle screws were placed into C2 and C3, and 5 screws were into the lateral mass of C3. Screw placement accuracy was evaluated using postoperative CT, according to the modified classification of Gertzbein and Robbins; one screw was grade 2 in C2, and three screws were grade 2 in the pedicle of C3. No grade 3 misplacement or clinical deficits were noted. C3 lateral mass screws were successfully inserted. Neck pain was relieved in each case. Neurologic status improved from D to E in 2 cases. Solid fusion was demonstrated in all the cases by static and dynamic films during the final follow-up.
Conclusions
This case series demonstrates that intraoperative 3D fluoroscopy-based navigation is a safe, accurate, and effective tool for screw placement in patients with unstable Hangman’s fracture.
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References
Schneider RC, Livingston KE, Cave AJ, Hamilton G (1965) “Hangman’s Fracture” of the cervical spine. J Neurosurg 22:141–154. doi:10.3171/jns.1965.22.2.0141
Li XF, Dai LY, Lu H, Chen XD (2006) A systematic review of the management of hangman’s fractures. Eur Spine J 15:257–269. doi:10.1007/s00586-005-0918-2
Levine AM, Edwards CC (1985) The management of traumatic spondylolisthesis of the axis. J Bone Joint Surg Am 67:217–226
Yukawa Y, Kato F, Ito K, Horie Y, Hida T, Nakashima H, Machino M (2009) Placement and complications of cervical pedicle screws in 144 cervical trauma patients using pedicle axis view techniques by fluoroscope. Eur Spine J 18:1293–1299. doi:10.1007/s00586-009-1032-7
Tjardes T, Shafizadeh S, Rixen D, Paffrath T, Bouillon B, Steinhausen ES, Baethis H (2010) Image-guided spine surgery: state of the art and future directions. Eur Spine J 19:25–45. doi:10.1007/s00586-009-1091-9
Rajasekaran S, Vidyadhara S, Shetty AP (2007) Iso-C3D fluoroscopy-based navigation in direct pedicle screw fixation of hangman fracture: a case report. J Spinal Disord Tech 20:616–619. doi:10.1097/BSD.0b013e318074f978
Sugimoto Y, Ito Y, Shimokawa T, Shiozaki Y, Mazaki T (2010) Percutaneous screw fixation for traumatic spondylolisthesis of the axis using iso-C3D fluoroscopy-assisted navigation (case report). Minim Invasive Neurosurg 53:83–85. doi:10.1055/s-0030-1247503
Gertzbein SD, Robbins SE (1990) Accuracy of pedicular screw placement in vivo. Spine (Phila Pa 1976) 15:11–14
Mueller CA, Roesseler L, Podlogar M, Kovacs A, Kristof RA (2010) Accuracy and complications of transpedicular C2 screw placement without the use of spinal navigation. Eur Spine J 19:809–814. doi:10.1007/s00586-010-1291-3
Effendi B, Roy D, Cornish B, Dussault RG, Laurin CA (1981) Fractures of the ring of the axis. A classification based on the analysis of 131 cases. J Bone Joint Surg Br 63-B:319–327
Ying Z, Wen Y, Xinwei W, Yong T, Hongyu L, Zhu H, Qinggang Z, Weihong Z, Yonggeng C (2008) Anterior cervical discectomy and fusion for unstable traumatic spondylolisthesis of the axis. Spine (Phila Pa 1976) 33:255–258. doi:10.1097/BRS.0b013e31816233d0
Xie N, Khoo LT, Yuan W, Ye XJ, Chen DY, Xiao JR, Ni B (2010) 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 (Phila Pa 1976). doi:10.1097/BRS.0b013e3181ba3368
Ma W, Xu R, Liu J, Sun S, Zhao L, Hu Y, Jiang W, Liu G, Gu Y (2011) Posterior short-segment fixation and fusion in unstable Hangman’s fractures. Spine (Phila Pa 1976) 36:529–533. doi:10.1097/BRS.0b013e3181d60067
Tuite GF, Papadopoulos SM, Sonntag VK (1992) Caspar plate fixation for the treatment of complex hangman’s fractures. Neurosurgery 30:761–764 (discussion 764–765)
Wilson AJ, Marshall RW, Ewart M (1999) Transoral fusion with internal fixation in a displaced hangman’s fracture. Spine (Phila Pa 1976) 24:295–298
Muller EJ, Wick M, Muhr G (2000) Traumatic spondylolisthesis of the axis: treatment rationale based on the stability of the different fracture types. Eur Spine J 9:123–128
Bristol R, Henn JS, Dickman CA (2005) Pars screw fixation of a hangman’s fracture: technical case report. Neurosurgery 56:204 (discussion E204)
ElMiligui Y, Koptan W, Emran I (2010) Transpedicular screw fixation for type II Hangman’s fracture: a motion preserving procedure. Eur Spine J 19:1299–1305. doi:10.1007/s00586-010-1401-2
Samaha C, Lazennec JY, Laporte C, Saillant G (2000) Hangman’s fracture: the relationship between asymmetry and instability. J Bone Joint Surg Br 82:1046–1052
Verheggen R, Jansen J (1998) Hangman’s fracture: arguments in favor of surgical therapy for type II and III according to Edwards and Levine. Surg Neurol 49:253–261 (pii:S0090-3019(97)00300-5, discussion 261–262)
Duggal N, Chamberlain RH, Perez-Garza LE, Espinoza-Larios A, Sonntag VK, Crawford NR (2007) Hangman’s fracture: a biomechanical comparison of stabilization techniques. Spine (Phila Pa 1976) 32:182–187. doi:10.1097/01.brs.0000251917.83529.0b
Nottmeier EW, Foy AB (2008) Placement of C2 laminar screws using three-dimensional fluoroscopy-based image guidance. Eur Spine J 17:610–615. doi:10.1007/s00586-007-0557-x
Richter M, Amiot LP, Neller S, Kluger P, Puhl W (2000) Computer-assisted surgery in posterior instrumentation of the cervical spine: an in vitro feasibility study. Eur Spine J 9(Suppl 1):65–70
Gebhard FT, Kraus MD, Schneider E, Liener UC, Kinzl L, Arand M (2006) Does computer-assisted spine surgery reduce intraoperative radiation doses? Spine (Phila Pa 1976) 31:2024–2027. doi:10.1097/01.brs.0000229250.69369.ac (discussion 2028)
Beck M, Mittlmeier T, Gierer P, Harms C, Gradl G (2009) Benefit and accuracy of intraoperative 3D-imaging after pedicle screw placement: a prospective study in stabilizing thoracolumbar fractures. Eur Spine J 18:1469–1477. doi:10.1007/s00586-009-1050-5
Ito Y, Sugimoto Y, Tomioka M, Hasegawa Y, Nakago K, Yagata Y (2008) Clinical accuracy of 3D fluoroscopy-assisted cervical pedicle screw insertion. J Neurosurg Spine 9:450–453. doi:10.3171/SPI.2008.9.11.450
Sugimoto Y, Ito Y, Tomioka M, Shimokawa T, Shiozaki Y, Mazaki T, Tanaka M (2010) Vertebral rotation during pedicle screw insertion in patients with cervical injury. Acta Neurochir (Wien) 152:1343–1346. doi:10.1007/s00701-010-0665-y
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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 21, 863–871 (2012). https://doi.org/10.1007/s00586-011-2085-y
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DOI: https://doi.org/10.1007/s00586-011-2085-y