Primary surgical management by reduction and fixation of unstable hangman's fractures with discoligamentous instability or combined fractures

Clinical article

Jun Jae Shin Department of Neurosurgery, Sanggye Paik Hospital, Inje University College of Medicine, Seoul;
Department of Neurosurgery, Stanford University School of Medicine, Stanford, California

Search for other papers by Jun Jae Shin in
jns
Google Scholar
PubMed
Close
 M.D., Ph.D.
,
Sang Hyun Kim Department of Neurosurgery, Ajou University School of Medicine, Suwon;

Search for other papers by Sang Hyun Kim in
jns
Google Scholar
PubMed
Close
 M.D., Ph.D.
,
Yong Eun Cho Department of Neurosurgery, Spine Hospital, Kangnam Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea; and

Search for other papers by Yong Eun Cho in
jns
Google Scholar
PubMed
Close
 M.D., Ph.D.
,
Samuel H. Cheshier Department of Neurosurgery, Stanford University School of Medicine, Stanford, California

Search for other papers by Samuel H. Cheshier in
jns
Google Scholar
PubMed
Close
 M.D., Ph.D.
, and
Jon Park Department of Neurosurgery, Stanford University School of Medicine, Stanford, California

Search for other papers by Jon Park in
jns
Google Scholar
PubMed
Close
 M.D., F.R.C.S.C.
Restricted access

Purchase Now

USD  $45.00

Spine - 1 year subscription bundle (Individuals Only)

USD  $392.00

JNS + Pediatrics + Spine - 1 year subscription bundle (Individuals Only)

USD  $636.00
USD  $45.00
USD  $392.00
USD  $636.00
Print or Print + Online Sign in

Object

Several controversial issues arise in the management of unstable hangman's fractures. Some surgeons perform external reduction and immobilize the patient's neck in a halo vest, while others perform surgical reduction and internal fixation. The nonsurgical treatments with rigid collar or halo vest immobilization present problems, including nonunion, pseudarthrosis, skull fracture, and scalp laceration and may also fail to achieve anatomical realignment of the local C2–3 kyphosis. With recent advances in surgical technique and technology, surgical intervention is increasingly performed as the primary treatment in high cervical fractures. The outcomes of such surgeries are often superior to those of conservative treatment. The authors propose that surgical intervention as a primary management for hangman's fracture may avoid risks inherent in conservative management when severe circumferential discoligamentous instability is present and may reduce the risk of catastrophic results at the fracture site.

The purposes of this study were to assess fracture healing following expedient reduction and surgical fixation and to propose a guideline for treatment of unstable hangman's fractures.

Methods

From April 2006 to December 2011, the authors treated 105 patients with high cervical fractures. This study included 23 (21.9%) of these patients (15 men and 8 women; mean age 46.4 years) with Type II, IIa, and III hangman's fractures according to the Levine and Edwards classification. The patient's age, sex, mechanism of injury, associated injuries, neurological status, and complications were ascertained. The authors retrospectively assessed the clinical outcome (Neck Disability Index), radiological findings (disc height, translation, and angulation), and bony healing.

Results

The average follow-up period was 28.9 months (range 12–63.2 months). The overall average Neck Disability Index score at the time of this study was 6.6 ± 2.3. The average duration of hospitalization was 20.3 days, and fusion was achieved in all cases by 14.8 ± 1.6 weeks after surgery, as demonstrated on dynamic radiographs and cervical 3D CT scans.

The mean pretreatment translation was 6.9 ± 3.2 mm, and the mean postoperative translation was 1.6 ± 1.8 mm (mean reduction 5.2 ± 3.1 mm). The initial angulation was 4.7° ± 5.3° and the postoperative angulation was 2.5° ± 1.8° (mean reduction 6.1° ± 5.3°). The preoperative and postoperative values for translation and angulation differed significantly (p < 0.05). The overall C2–3 disc height was 6.7 ± 1.2 mm preoperatively, whereas 3 months after surgery it was 6.4 ± 1.1 mm. These values did not differ significantly (p = 0.0963).

Conclusions

The authors observed effective reduction and bony healing in cases of unstable hangman's fractures after fixation, and all patients experienced favorable clinical outcomes with neck pain improvement. The protocols allowed for physiological reconstruction of the fractured deformities and avoided external fixation. The authors suggest that posterior reduction and screw fixation should be used as a primary treatment to promote stability of hangman's fracture in the presence of discoligamentous instability or combined fractures.

Abbreviations used in this paper:

ACDF = anterior cervical discectomy and fusion; ASIA = American Spinal Injury Association; MEP = motor evoked potential.
  • Collapse
  • Expand
  • 1

    Chittiboina P, , Wylen E, , Ogden A, , Mukherjee DP, , Vannemreddy P, & Nanda A: Traumatic spondylolisthesis of the axis: a biomechanical comparison of clinically relevant anterior and posterior fusion techniques. Laboratory investigation. J Neurosurg Spine 11:379387, 2009

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 2

    Coric D, , Wilson JA, & Kelly DL Jr: Treatment of traumatic spondylolisthesis of the axis with nonrigid immobilization: a review of 64 cases. J Neurosurg 85:550554, 1996. (Erratum in J Neurosurg 85: 1198, 1996)

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 3

    Duggal N, , Chamberlain RH, , Perez-Garza LE, , Espinoza-Larios A, , Sonntag VK, & Crawford NR: Hangman's fracture: a biomechanical comparison of stabilization techniques. Spine (Phila Pa 1976) 32:182187, 2007

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 4

    Effendi B, , Roy D, , Cornish B, , Dussault RG, & Laurin CA: Fractures of the ring of the axis. A classification based on the analysis of 131 cases. J Bone Joint Surg Br 63-B:319327, 1981

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 5

    ElMiligui Y, , Koptan W, & Emran I: Transpedicular screw fixation for type II Hangman's fracture: a motion preserving procedure. Eur Spine J 19:12991305, 2010

  • 6

    Hadley MN, , Browner C, & Sonntag VK: Axis fractures: a comprehensive review of management and treatment in 107 cases. Neurosurgery 17:281290, 1985

  • 7

    Isolated fractures of the axis in adults. Neurosurgery 50:3 Suppl S125S139, 2002

  • 8

    Leconte P, Fracture et luxation des deux premières vertèbres cervicales. Judet R: Luxation Congenénitale de la Hanche: Fractures du Cou-de-pied Rachis Cervical. Actualités de Chirurgie Orthopédique de l'Hôpital Raymond-Poincaré Paris, Masson et Cie, 1964. 147166

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 9

    Levine AM, & Edwards CC: The management of traumatic spondylolisthesis of the axis. J Bone Joint Surg Am 67:217226, 1985

  • 10

    Li XF, , Dai LY, , Lu H, & Chen XD: A systematic review of the management of hangman's fractures. Eur Spine J 15:257269, 2006

  • 11

    Liu J, , Li Y, & Wu Y: One-stage posterior C2 and C3 pedicle screw fixation or combined anterior C2-C3 fusion for the treatment of unstable hangman's fracture. Exp Ther Med 5:667672, 2013

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 12

    Ludwig SC, , Kowalski JM, , Edwards CC II, & Heller JG: Cervical pedicle screws: comparative accuracy of two insertion techniques. Spine (Phila Pa 1976) 25:26752681, 2000

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 13

    Ma W, , Xu R, , Liu J, , Sun S, , Zhao L, & Hu Y, et al.: Posterior short-segment fixation and fusion in unstable Hangman's fractures. Spine (Phila Pa 1976) 36:529533, 2011

  • 14

    Müller EJ, , Wick M, & Muhr G: Traumatic spondylolisthesis of the axis: treatment rationale based on the stability of the different fracture types. Eur Spine J 9:123128, 2000

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 15

    Panjabi MM, & White AA III: Basic biomechanics of the spine. Neurosurgery 7:7693, 1980

  • 16

    Rajasekaran S, , Vidyadhara S, & Shetty AP: Iso-C3D fluoroscopy-based navigation in direct pedicle screw fixation of Hangman fracture: a case report. J Spinal Disord Tech 20:616619, 2007

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 17

    Roda JM, , Castro A, & Blázquez MG: Hangman's fracture with complete dislocation of C-2 on C-3. Case report. J Neurosurg 60:633635, 1984

  • 18

    Samaha C, , Lazennec JY, , Laporte C, & Saillant G: Hangman's fracture: the relationship between asymmetry and instability. J Bone Joint Surg Br 82:10461052, 2000

  • 19

    Schneider RC, , Livingston KE, , Cave AJ, & Hamilton G: “Hangman's fracture” of the cervical spine. J Neurosurg 22:141154, 1965

  • 20

    Shin JJ, , Kim SJ, , Kim TH, , Shin HS, , Hwang YS, & Park SK: Optimal use of the halo-vest orthosis for upper cervical spine injuries. Yonsei Med J 51:648652, 2010

  • 21

    Tian W, , Weng C, , Liu B, , Li Q, , Hu L, & Li ZY, et al.: Posterior fixation and fusion of unstable Hangman's fracture by using intraoperative three-dimensional fluoroscopy-based navigation. Eur Spine J 21:863871, 2012

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 22

    Tuite GF, , Papadopoulos SM, & Sonntag VKH: Caspar plate fixation for the treatment of complex hangman's fractures. Neurosurgery 30:761765, 1992

  • 23

    Vaccaro AR, , Madigan L, , Bauerle WB, , Blescia A, & Cotler JM: Early halo immobilization of displaced traumatic spondylolisthesis of the axis. Spine (Phila Pa 1976) 27:22292233, 2002

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 24

    Verheggen R, & Jansen J: Hangman's fracture: arguments in favor of surgical therapy for type II and III according to Edwards and Levine. Surg Neurol 49:253262, 1998

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 25

    Watanabe M, , Nomura T, , Toh E, , Sato M, & Mochida J: Residual neck pain after traumatic spondylolisthesis of the axis. J Spinal Disord Tech 18:148151, 2005

  • 26

    Wilson AJ, , Marshall RW, & Ewart M: Transoral fusion with internal fixation in a displaced hangman's fracture. Spine (Phila Pa 1976) 24:295298, 1999

  • 27

    Xu H, , Zhao J, , Yuan J, & Wang C: Anterior discectomy and fusion with internal fixation for unstable hangman's fracture. Int Orthop 34:8588, 2010

Metrics

All Time Past Year Past 30 Days
Abstract Views 1763 202 10
Full Text Views 298 36 1
PDF Downloads 438 38 0
EPUB Downloads 0 0 0