Individual Surgical Strategy Using Posterior Lag Screw–Rod Technique for Unstable Atypical Hangman's Fracture Based on Different Fracture Patterns

doi:10.1016/j.wneu.2018.07.285

World Neurosurgery

Volume 119, November 2018, Pages e848-e854

https://doi.org/10.1016/j.wneu.2018.07.285 Get rights and content

Highlights

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A retrospective analysis of 23 patients with unstable AHF was performed.
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Satisfactory reduction and bony union were demonstrated on postoperative radiographs.
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Neck pain and neurologic deficits improved significantly in all patients after operation.
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For surgical treatment of unstable AHF, focusing on different fracture patterns may be necessary.
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Using surgical strategies based on different fracture patterns, posterior C2-C3 LSR technique may be an effective option.

Objective

The literature on surgical management of atypical hangman's fracture (AHF) is sparse. The aim of this study was to describe an individual surgical strategy using a lag screw–rod technique for treatment of unstable AHF based on different fracture patterns.

Methods

A retrospective analysis of 23 patients with unstable AHF was performed. Fractures were classified into 3 patterns: A, 1 fracture line through 1 side of C2 body obliquely and another through pars interarticularis on the other side; B, 1 fracture line through 1 side of C2 body obliquely and another through contralateral lamina; C, bilateral oblique fracture lines through posterior cortex of C2 on different sides. Posterior C2-C3 pedicle screw fixation and fusion using a lag screw–rod technique with different surgical strategies for each fracture pattern was used for all patients. Complications, neck pain, neurologic status, reduction of anterior translation and angulation between C2 and C3, and fusion rate were evaluated.

Results

No technique-related complications (e.g., spinal cord or nerve injury caused by malposition of screws) occurred. Mean follow-up time was 37 months. Satisfactory reduction and bony union were demonstrated on postoperative radiographs. Neck pain and neurologic deficits caused by C2 injury improved significantly in all patients after operation. No graft or implant-related complications were observed in patients during the entire follow-up period.

Conclusions

Using individual surgical strategies based on different fracture patterns, the posterior C2-C3 lag screw–rod technique may be an effective and reliable option for unstable AHF.

Introduction

In 1985, Levine and Edwards¹ modified the classification of Effendi et al. and published the most widely accepted categorization for hangman's fracture.2, 3 The Levine-Edwards classification not only affords a clear picture of the mechanism of injury but also guides the proper treatment for each lesion type.1, 2, 3, 4 However, this classification usually focuses on bilateral pars fractures of C2 and does not focus on fractures involving the posterior cortex of C2 on 1 or both sides. Starr and Eismont⁵ first formally focused on atypical hangman's fracture (AHF) in their series of 19 hangman's fractures in 1993, and they defined AHF as hangman's fracture with fracture involving the posterior cortex of C2. Although the literature demonstrates that AHF has a high incidence with a variety of manifestations, literature focusing on surgical management of these fractures is sparse.5, 6, 7, 8 We reported our experience with posterior C2-C3 pedicle fixation and fusion using a lag screw–rod (LSR) technique for unstable hangman's fractures, which demonstrated a good result.⁹ To evaluate the feasibility of the posterior C2-C3 LSR technique for treatment of unstable AHF, we reviewed the data of 23 patients with unstable AHF treated with this technique. To our knowledge, this is the first report focusing on a surgical strategy using the C2-C3 LSR technique for unstable AHF.

Section snippets

Patients

This study was approved by the local institutional review board. A retrospective analysis of 23 patients with unstable AHF was performed. AHF was defined as hangman's fracture with fracture occurring through the posterior cortex of C2 on 1 or both sides.⁵ The diagnosis was confirmed with the combination of x-rays, three-dimensional computed tomography, and magnetic resonance imaging of the cervical spine. All 23 cases were treated using posterior C2-C3 pedicle fixation and fusion using the LSR

Results

Clinical data of the 23 patients are listed in Table 1. There were 18 male and 5 female patients, and the average age was 42.7 years (range, 15–74 years). The causes of injuries were falls (14 cases), motor vehicle accidents (4 cases), and others (5 cases). Associated injuries were reported in 11 (47.8%) of 23 cases. Combined injuries included head injury (3 cases, 2 with minor and 1 with major head injuries), subaxial cervical spine injuries (2 cases), thoracolumbar vertebral fractures (2

Discussion

The literature focusing on surgical management of AHF is sparse.5, 6, 7, 8 Because of small patient numbers, neither Burke and Harris⁷ nor Starr and Eismont⁵ analyzed the treatment strategy of AHF. Samaha et al.⁶ reported 13 AHFs among 24 hangman's fractures in their series and concluded that the features of AHF did not affect the outcomes of treatment and should not influence decisions in treatment, but they did not report a specific surgical technique or strategy. More recently, Al-Mahfoudh

Conclusions

For surgical treatment of unstable AHF, focusing on different fracture patterns may be necessary. Considering the limitation of this present study by its retrospective nature and small number of cases, we cautiously suggest that the posterior C2-C3 LRS technique with different key points for each fracture pattern may be an effective and reliable option for most cases of unstable AHF.

Acknowledgments

We thank the staff and patients for their contributions and participation in this study.

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Citation Excerpt :
However, the limitations of Levine-Edwards classification are: It underestimates the greater diversity of fractures location. The result of this study and some other studies showed that the typical fractures were rare, and a variety of location and pattern of the fracture lines in such fractures [5,9,12–15]. On the other hand, it mainly focuses on the displacement and angulation at C2/3 level and pays less attention to the axis ring itself.
Recently research reports show that the anatomical location and pattern of fracture lines in axis ring fractures are variety, however, no studies focusing on these topics have published so far. The objective of this study is to observe the radiological features of axis ring fractures with multicenter data.
We reviewed the clinical notes and imaging studies of axis ring fractures in our prospectively maintained database. Specially, CT scans and three-dimensional reconstructed images of the cervical spine were used to observe: the incidence of different anatomical structures injuries, location of fracture lines, and fracture pattern.
Two hundred and seventeen patients with axis ring fractures were included. There were total 438 fracture lines on the axis ring, and the incidence of fractures of superior articular facet and/or posterior wall of C2 body, pediculoisthmic component (PIC), inferior articular facet, and lamina fracture, were 49.1%, 27.6%, 13.7%, and 9.6%, respectively. The most common fracture pattern (145 cases) was one fracture line through superior articular facet and/or posterior wall of C2 body on one side and another through the neural arch on the other side. The remaining fracture patterns included bilateral fracture lines through superior articular facet and/or posterior wall of C2 body (35 cases), bilateral PIC fractures (16 cases), and others (21 cases). A supplementary classification of axis ring fractures taking into account the anatomical areas, features, and probable mechanism was proposed.
The anatomical location and pattern of fracture lines in axis ring fractures were more complex than expected. This study might help in understanding of radiological features of such fractures, and choosing the proper treatment.
C2–C3 Anterior Cervical Diskectomy and Fusion for Hangman's Fractures with C2 Posterior Dislocation: Technical Notes
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Citation Excerpt :
Nonoperative treatment with immobilization with either a cervical collar or halo vest is our choice for stable hangman’s fractures or for patients with surgical contraindications.21-23 Surgical stabilization techniques through anterior, posterior, and combined anteroposterior approaches have been reported for treating unstable hangman’s fractures.1,24-29 Surgical options for unstable hangman’s fractures through anterior approaches rely on a C2-C3 ACDF, while posterior approaches mainly rely on a C2–C3 posterior cervical decompression and fusion with C2 pedicle and C3 lateral mass screws.1
The overwhelming majority of hangman’s fractures cause anterior dislocation of C2. Hangman’s fracture with C2 posterior dislocation is extremely rare; only 1 pediatric case was reported in 2018 to date. This kind of injury cannot be cataloged using current classification schemes, and no established treatment recommendations exist. The purpose of this article is to report a rare case of a hangman's fracture with C2 posterior dislocation, which does not fit into existing classification systems and discuss management technical notes to avoid pitfalls.
We describe this case, review relevant literature, and share our experience.
A 31-year-old male sustained a hangman’s fracture with C2 posterior dislocation after he fell into a 50-cm deep roadside ditch when riding a motorcycle. Radiograph and computed tomography on admission showed fractures through both pars of C2 and C2 posterior dislocation. Magnetic resonance imaging on admission showed high T2-weighted signal intensity of cervical spinal cord and compression of the cervical spinal cord by posterior dislocation of the C2 vertebral body. A C2-3 anterior cervical diskectomy and fusion was performed. At 6 months after operation, bony fusion was achieved and magnetic resonance imaging showed the T2-weighted signal hyperintensity of cervical spinal cord before surgery disappeared.
C2–C3 anterior cervical diskectomy and fusion is recommended for hangman's fractures with C2 posterior dislocation. Traction before surgery is not recommended.
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: Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

: Guangzhou Li and Qing Wang are co–first authors.

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Original ArticleIndividual Surgical Strategy Using Posterior Lag Screw–Rod Technique for Unstable Atypical Hangman's Fracture Based on Different Fracture Patterns

Highlights

Objective

Methods

Results

Conclusions

Introduction

Section snippets

Patients

Results

Discussion

Conclusions

Acknowledgments

World Neurosurg

The management of traumatic spondylolisthesis of the axis

J Bone Joint Surg Am

Anterior cervical discectomy and fusion for unstable traumatic spondylolisthesis of the axis

Spine (Phila Pa 1976)

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

Spine (Phila Pa 1976)

A systematic review of the management of hangman’s fractures

Eur Spine J

Atypical hangman’s fracture

Spine (Phila Pa 1976)

Hangman’s fracture: the relationship between asymmetry and instability

J Bone Joint Surg Br

Acute injuries of the axis vertebra

Skeletal Radiol

Management of typical and atypical hangman’s fractures

Global Spine J

A novel technique for unstable hangman’s fracture: lag screw-rod (LSR) technique

Eur Spine J

Validation of the American Spinal Injury Association (ASIA) motor score and the National Acute SpinalCord Injury Study (NASCIS) motor score

Spine (Phila Pa 1976)

Original Article
Individual Surgical Strategy Using Posterior Lag Screw–Rod Technique for Unstable Atypical Hangman's Fracture Based on Different Fracture Patterns