Multiplanar realignment for unstable Hangman’s fracture with Posterior C2-3 fusion: A prospective series

doi:10.1016/j.clineuro.2018.03.024

Clinical Neurology and Neurosurgery

Volume 169, June 2018, Pages 133-138

https://doi.org/10.1016/j.clineuro.2018.03.024 Get rights and content

Highlights

•
Standard approach for fixation of unstable Hangman’s fracture remains unsettled.
•
We present a short series of Hangman’s treated by posterior C2-3 fixation.
•
Most of the patients showed malalignment of fractured segments in various planes.
•
Posterior fixation offers excellent multiplanar fractural realignment and fusion.
•
It also addresses the soft tissue elements involved in pathogenesis of Hangman’s.

Abstract

Objective

There is lack of consensus on the preferred approach for unstable Hangman’s fracture. The associated soft tissue injuries apart from apparent bony injury add to the complexity of dislocation and needs to be addressed. Here, we evaluated the clinico-radiological characteristics and outcome of patients managed by posterior C2-3 fusion.

Patients & methods

Nine patients with unstable Hangman’s fracture (type II and IIA) were prospectively studied. The displacement of fractured fragments and C2-3 dislocation was studied in multiple planes. C2 pars-pedicle screw was placed to bring fractured fragments together (lag effect), which was then fused with C3 lateral masses to achieve multiplanar realignment. Clinical outcome was assessed in terms of pain (VAS score) and neurological status after surgery. Patient’s clinico-radiological status was followed up at regular intervals.

Results

Pain was the predominant symptom (VAS: 8.1 ± 1.1). Only one had neurological deficit (ASIA- D). Mean VAS score improved significantly in postoperative period (1.2 ± 1.6). About two-third (66.7%) had atypical Hangman’s. In six, fractured segments were malaligned in multiple planes. Axial rotation, lateral translation and superior translation (over-riding) of fragments were seen in 4, 4 and 3 patients respectively. Two had adjacent level injuries. Reduction and realignment of fractured fragments as well as C2-3 in multiple planes could be achieved in all. Follow-up varied from 6 to 22 months (mean, 12.8 ± 5.7). Bony fusion was evident in 9 to 12 months. Three patients showed mild curvature change in subaxial spine.

Conclusion

The fractures fragments may be dislocated in axial (rotation and lateral translation) apart from antero-posterior plane. It is important to study the radiology in various planes. Posterior C2-3 fusion is an effective way to achieve good realignment of bony fragments in all planes. It also addresses the instability resulting from soft tissue injury.

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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Cited by (15)

Application of novel self-designed surgical tools for the safe C2 pedicle screw placement in 12 patients with Hangman fracture
2023, Asian Journal of Surgery
A Novel Pedicle Screw Design with Variable Thread Geometry: Biomechanical Cadaveric Study with Finite Element Analysis
2023, World Neurosurgery
Pedicle screw fixation provides one of the most stable spinal constructs. Their designs together with osseous characteristics have been known to influence the screw-bone interplay during surgical maneuvers and thereafter the fusion process. Various technical modifications to enhance screw performance have been suggested. This study evaluated the pull-out strength and axial stiffness of a novel pedicle screw design with variable thread geometry and pitch.
The newly designed triple threaded pedicle screw is tapered, and has unique out-turned flanges to hold the cancellous bone and a finer pitch at its distal and proximal end to engage the cortical bone. Five lumbar and 4 lower thoracic cadaveric vertebrae were divided into hemivertebrae. A standard cancellous pedicle screw and the newly designed pedicle screw were inserted into each hemivertebra. Axial stiffness and peak pull-out force between the screw types were compared; a finite element analysis was also performed to additionally compare the pull out under toggle forces.
In cadaveric study, the axial stiffness of the new screw was significantly better than that of the standard screw. However, the peak load between the screws was not statistically different. Finite element analyses suggested lesser stress at bone-implant interface for the new screw along with better axial stiffness under both co-axial and toggle forces.
Our novel pedicle screw design with variable thread geometry demonstrates greater axial stiffness compared with the standard screws, and therefore is likely to withstand a greater surgical manipulation.
Anterior C2-3 fusion surgery alone for highly displaced Hangman's fracture with severe angulation of C2-3 of more than 30°
2021, Clinical Neurology and Neurosurgery
Citation Excerpt :
The preferred surgical approach for unstable Hangman’s fracture remains controversial. Anterior, posterior, and combined anteroposterior approaches can be used during surgical treatment for unstable Hangman’s fracture [9–15]. In cases with C2-3 angulation, displacement, or discoligamentous injury, C2-3 ACDF with plating is preferred as a less-invasive surgery for direct decompression, correction of angulation and displacement, and stable fixation [9–11].
Highly displaced Hangman’s fracture is a very rare and extremely unstable fracture of the C2 axis. Combined anteroposterior or posterior long-segment fusion surgery is typically performed for the treatment of highly displaced Hangman’s fracture. However, these kinds of surgeries increase the risk of complications, loss of motion, and hospital costs.
We sought to investigate the surgical outcomes of anterior C2-3 fusion surgery alone for highly displaced Hangman’s fractures with severe angulation of C2-3 by more than 30° and discoligamentous injury.
A total of five patients (four men and one woman) were included in this study with a mean age of 40.4 years (range, 26–70 years). The mean follow-up period after surgery was 37.2 months (range, 12–96 months). The fracture characteristics, treatment methods, and outcomes were retrospectively analyzed.
All five patients had type II Hangman’s fractures (according to the Levine and Edwards classification scheme). None of the included patients had neurologic deficit or other spine injury but all patients had complete C2-3 discoligamentous injury. Before surgery, all patients successfully achieved closed reduction by skull traction, followed by C2-3 anterior decompression and fusion (ACDF) with plating. For interbody grafting, three patients received a polyetheretherketone (PEEK) cage filled with an autogenous cancellous iliac bone graft and two received autogenous tricortical iliac bone grafts. Severe angulation (39.2° vs. 3.0°, P < 0.001) and severe displacement (76.1% vs. 4.0%, P < 0.001) of C2-3 were both significantly corrected after surgery. All patients had achieved solid fusion at last follow-up. In terms of clinical outcomes, the mean neck pain visual analog scale score was significantly improved (8.6 points vs. 1.8 points, P < 0.001). The mean neck disability index value was also significantly improved (45.4 points vs. 13.0 points, P < 0.01). According to Odom’s criteria, all patients achieved satisfactory outcomes. No major complications occurred. One patient complained of dysphagia, but recovered after three months with conservative treatment.
Preoperative closed reduction and anterior C2-3 fusion surgery alone should be considered as a less-invasive and useful surgical option for highly displaced Hangman’s fracture with severe angulation of C2-3, which is an extremely unstable fracture of the C2 axis.
Evolution to Pedicle Reformation Technique in Surgical Management of Hangman's Fracture
2021, World Neurosurgery
Citation Excerpt :
Unstable hangman's fractures of the C2 vertebra require surgical fixation. The choice of surgical approach remains controversial, with both anterior and posterior approaches being recommended.1-8 Posterior cervical fusion with C2 pedicle screw (PS) is the most direct method to reduce and fix the fracture segments.
Opinions vary regarding optimal treatment of unstable hangman's fractures. Recent technological advances have allowed short segment, motion preserving fixation, even in complex cases. The aim of the study was to demonstrate C1-C2 motion-preserving short-segment fusion in hangman's fracture and the evolution of technique from pedicle realignment to pedicle reformation in complex fractures with resorbed/destroyed C2 pedicles.
This was a retrospective study. Patients operated by a single surgeon at a tertiary level center from 2012 to 2018 were included. The type of fracture, operating time, and blood loss was recorded. Neurologic deficits were recorded using the American Spinal Injury Association scale with regular clinicoradiologic follow-up.
Nine patients (8 male), with a mean age of 36 ± 16.9 years were included. In the initial 7 patients, C2 pedicle screw, C3-C4 lateral mass screw, and rod fixation was done. The last 2 patients were complex neglected injuries, with 1 having severe angulation and displacement and the other having spondyloptosis with C2 body placed anterior to C4 body. In both these patients, direct C2 body screw were placed and pedicle reconstruction was done. Mean follow up was 41.4 ± 29.8 months. All 5 patients with preoperative neurologic deficits had improvement in power. C1-C2 joint motion was preserved in all. All patients had bony fusion.
Preservation of motion at the C1-C2 joint should be the goal in all surgically managed hangman's fracture patients. The technique of C2 pedicle reconstruction can be utilized for the same in old neglected hangman's fractures.
How Does Cervical Sagittal Balance Change After Hangman Fracture Treated with Anterior or Posterior Approach Surgery?
2020, World Neurosurgery
Citation Excerpt :
Controversy remains on the choice of surgical approach. According to the Levine-Edwards classification, for the same type of patients, the choice of surgical approach varied.7,8,35-37 For example, we performed ACDF for those with serious C2-C3 disc shown by MRI; however, some other surgeons prefer a posterior approach.35-37
To assess and compare clinical outcomes and sagittal balance after unstable hangman fracture between C2-C3 anterior discectomy and fusion (ACDF) and posterior C2-C3 short-segment fixation and fusion.
A total of 45 patients underwent ACDF (20 patients) and posterior C2-C3 short-segment fixation and fusion (25 patients) between March 2005 and June 2013. Visual analog scale, Neck Disability Index, Odom grading system, American Spinal Injury Association Impairment Scale (AIS), C2-C3 angle, displacement of C2-C3 (D_C2-C3), occiput-C2 angle (O-C2 angle), cervical lordosis (CL), and C2-C7 sagittal vertical axis (cSVA) were assessed preoperatively and at final follow-up.
The follow-up duration was 20.0 months (range, 18.0–21.0 months) in the anterior group and 19.0 months (range, 18.0–20.0 months) in the posterior group. Satisfactory bony fusions were achieved in 2 groups. The VAS score and NDI score were significantly lower than their respective preoperative score in each group (P < 0.001), whereas there was no difference between 2 groups (P = 0.78; P = 0.85). A statistically significant decrease of O-C2 angle and cSVA between preoperative and postoperative data was found in each group (P < 0.001), and CL increased statistically (P < 0.001). For O-C2 angle, CL, and cSVA, the changes of parameters after the posterior approach were more significant than after the anterior approach (P < 0.05).
Both anterior and posterior surgical techniques are effective for unstable hangman fracture and both can restore the sagittal balance of the cervical spine. Furthermore, the posterior approach has an advantage over the anterior approach in promoting recovery of cervical sagittal balance.
Analysis of the Cervical Sagittal Alignment in Patients with Unstable Hangman Fracture Under C2∼3 Anterior Discectomy and Fusion
2020, World Neurosurgery
Citation Excerpt :
Anterior cervical surgery has little effect on the range of motion of the cervical vertebrae, and the incidence of surgical complications is lower.8-10 Although the posterior approach leads to full exposure and fixes the columns through pedicle screw fixation, the fixation has been shown to be stronger with the posterior approach than with the anterior plate; however, screw placement is more complicated with anterior fixation, increasing the risk of vertebral artery and spinal cord injury and poorer reduction.8,11,12 Despite the numerous reports on the injury mechanism and clinical treatment of hangman's fracture, the optimal treatment strategy remains controversial.13
To investigate the changes in the sagittal parameters of the cervical spine and the clinical efficacy of C2∼3 anterior cervical discectomy and fusion (ACDF) combined with internal fixation for unstable hangman's fractures.
The clinical data of 46 patients with unstable hangman's fractures treated with both C2∼3 ACDF combined with internal fixation between May 2012 and May 2017 were analyzed retrospectively. The upper cervical angle (C0∼2), the forward translation of the C2 vertebral body (C2-T), C2∼3 local kyphosis angle (C2∼3 LK), C2∼7 cervical curvature (C2∼7 CC), C2 sagittal vertical axis (C2-SVA), and T1 slope angle (T1S) were compared preoperatively, postoperatively, and at the last follow-up to evaluate the clinical therapeutic effects.
A total of 46 patients were followed-up for an average of 16 months. No aggravation of the spinal cord, nerve injury, cerebrospinal fluid leakage, or other complications occurred. Six patients had American Spinal Injury Association (ASIA) grade C preoperatively; 4 improved to grade E, and 2 improved to grade D postoperatively. Twelve patients with ASIA grade D preoperatively improved to grade E postoperatively. C0∼2, C2-T, C2∼3 LK, C2∼7 CC, and C2-SVA measurements were significantly improved postoperatively and at the last follow-up, but there was no significant change in T1S between preoperative and postoperative values.
For patients with unstable hangman's fractures, C2∼3 ACDF combined with internal fixation can achieve immediate stability of the upper cervical vertebrae, effectively correct the forward displacement and angulation of C2, and restore the sagittal balance of the cervical spine. The rate of osseous intervertebral fusion is high, and there are few complications. This method can effectively promote the recovery of spinal nerve function and preserve the motor function of the cervical vertebrae.

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Multiplanar realignment for unstable Hangman’s fracture with Posterior C2-3 fusion: A prospective series

Highlights

Abstract

Objective

Patients & methods

Results

Conclusion

Introduction

Section snippets

Clinico-radiological assessment

Results

Discussion

Conclusion

Funding

Compliance with Ethical Requirements

Conflicts of interest

Acknowledgements

Clin Neurol Neurosurg

Management of Typical and Atypical Hangman’s Fractures

Global Spine J

A systematic review of the management of hangman’s fractures

Eur Spine J

Traumatic Spondylolisthesis of the Axis Vertebra in Adults

Global Spine J

Early halo immobilization of displaced traumatic spondylolisthesis of the axis

Spine (Phila Pa 1976)

Anterior discectomy/corpectomy and fusion with internal fixation for the treatment of unstable hangman’s fractures: a retrospective study of 38 cases

J Neurosurg Spine

Posterior short-segment fixation and fusion in unstable Hangman’s fractures

Spine (Phila Pa 1976)