Multiplanar realignment for unstable Hangman’s fracture with Posterior C2-3 fusion: A prospective series
Introduction
Hangman’s fractures (bilateral fracture of pars interarticularis) constitute about 20% of all C2 injuries [1]. While most of undisplaced/ minimally displaced (≪3 mm), non angulated (≪11) fractures (i.e. Levine and Edwards type I) heal well with rigid immobilisation alone, unstable type II, IIa and III require surgical fixation [[1], [2], [3], [4]]. Of the standard (anterior and posterior) fixation techniques that are described, no consensus exists on the preferred approach [2,[5], [6], [7]]. Some have described combined fixation for Hangman’s fractures [8]. The anterior approach deals with the C2-3 dislocation without addressing the fractured fragments. Of late, the apparently motion-preserving direct pars screw technique has also been advocated and overzealously used [9]. Nevertheless, it’s presumed efficacy and long term outcome is debatable [3,10]. This procedure may not effective as it does not address the C2-3 instability resulting from soft tissue injury. Moreover, biomechanical studies in cadavers suggest that posterior C2-3 fusion possibly has an edge over the other described techniques [11]. Very few papers have reported on the patients who underwent posterior C2-3 fixation [6,7]. However the analysis and discussion about multiplanar dislocations of fracture fragments and its realignment is lacking.
In such context, we intended to study the clinical and radiological (from the perspective of multiplanar displacement) outcome of patients with Hangman’s fracture managed by posterior C2-3 fusion.
Section snippets
Clinico-radiological assessment
From January 2015 to June 2016, we prospectively studied 9 patients of unstable Hangman fractures (type II and IIA) managed in our institute. The diagnosis was made based on plain cervical spine radiography and/or reconstructed computed tomography (CT). The images were studied for the fracture type and associated cervical spine injuries. The mal-alignment of fractured fragments was evaluated in axial, coronal and sagittal planes (Fig. 1, Fig. 2, Fig. 3). In axial plane, a line was drawn along
Results
Table 1 summarizes the clinico-radiological data of patients. The mean age of patients was 42.4 ± 10.6 year s (range, 26 to 62). There were 7 male and 2 female. Seven (77.8%) patients sustained trauma following road traffic accident (RTA). In 2 (22.2%) patients, the mode of injury was self fall. Neck pain was the predominant complaint and was present in all. The mean VAS score before surgery was 8.1 ± 1.1. All were neurologically normal except one who belonged to American Spinal Injury
Discussion
The optimal management of unstable hangman’s fracture (Edward Levine type II, II A and III) remains controversial [[1], [2], [3],[5], [6], [7]]. Different authors recommend various surgical approaches with arguments in favour of each of them [[5], [6], [7], [8]]. The available options include anterior C2-3 discectomy with fusion, posterior C2-3 fusion and recently pars pedicle screw alone. Combined anterior & posterior fixations have also been performed [8]. Though not preferable, some even
Conclusion
C2-3 fusion appears to be an effective method to deal not only with the fractured segments but also the associated discoligamentous instability. It achieves correction in multiple planes. Besides, the fracture/ dislocation at adjacent levels can also be simultaneous managed. It provides significant pain relief with a stable fixation and good bony fusion.
Funding
No funding was received for this article.
Compliance with Ethical Requirements
The procedures performed were in accordance with the ethical standards of the institutional ethics committee and with the 1964 Helsinki declaration and its later amendments. Informed consent was obtained from all the patients included in the study.
Conflicts of interest
The authors declare that they have no conflict of interest.
Acknowledgements
Nil
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