Anterior-only stabilization using cage versus plating with bone autograft for the treatment of type II/IIA Hangman’s fracture combined with intervertebral disc injury

Abstract

BackgroundAnterior C2/3 discectomy and interbody fusion (ACDF) with plating is increasingly performed as the primary treatment of unstable Hangman’s fracture; however, plate-related complications, such as screw back-out, plate fracture and soft-tissue injury, is not uncommon. Polyetheretherketone (PEEK) cage has now been developed to provide initial stability before fusion; however, whether and how ACDF with PEEK cage offer better clinical results compared with ACDF with plating in management of Hangman’s fracture remains unknown. This study compares the efficacy of ACDF with plating to that of ACDF with PEEK cage in management of type II/IIA Hangman’s fractures (according to Levine and Edwards classification) retrospectively.MethodsFrom February 2006 to March 2012, a total of 21 patients with type II/IIA Hangman’s fractures combined with intervertebral disc injury underwent ACDF with PEEK cage, and 28 patients underwent ACDF with plating. Perioperative parameters were compared. The average follow-up period was 50.3 months (range 27–76 months). The clinical outcome (visual analog scale (VAS), American Spinal Injury Association (ASIA) scale, and clinical post-traumatic neck score (PTNC)) and radiological outcome (translation of C2, local kyphotic angle (LKA), and fusion status of C2/3) was compared retrospectively.ResultsThe operative time and blood loss were significantly less in the ACDF with cage group compared with that in the ACDF with plating group (P < 0.05). All patients showed neurological recovery and achieved solid fusion. There were no significant differences in the clinical and radiological outcomes at final follow-up between groups, except in the LKA and the correction loss rate of LKA which were higher in the ACDF with plating group (P < 0.05). Donor-site pain occurred in two patients (10.1%) within 6 months after operation in the ACDF with plating group and none in the ACDF with cage group. All patients recovered without any adverse effects.ConclusionsACDF with PEEK cage is effective and reliable in management of type II/IIA Hangman’s fractures and is more cost-effective due to shorter operative time and less blood loss requirements.

The Impact Plate Application on the Sagittal Plane Correction after Anterior Cervical Discectomy and Fusion Compared to Stand Alone Cage.

“…In previous studies, it has been shown that the cage alone technique is a less costly approach. 24 However, since complication rates and reoperation rates are variable in different studies, a clear cost analysis is hard to extrapolate. The UK published paper carried a cost analysis for multiple approaches to cervical radiculopathy, which included cage only and cage and plate constructs.…”

Surgical Management of Hangman’s Fracture: A Systematic Review

“…Authors describing the approach in this systematic review referred to a transverse skin incision at the midpoint between the angle of the jaw and thyroid cartilage 17,32,44,45,56,57 ; others included in this review 18,31 and in the wider literature 58 described a "high retropharyngeal," "submandibular," or "high anterior cervical" approach, which may involve an incision closer to the mandible; others described a more longitudinal skin incision from the angle of the jaw to the hyoid bone. 46,48,49 After skin and platysma incision, all authors used the fascial planes of the neck to retract the sternocleidomastoid and carotid sheath laterally and enter the retropharyngeal space to expose the prevertebral fascia. 58 Structures at risk via this approach include the carotid sheath, recurrent laryngeal nerve, esophagus, trachea, hypoglossal, and facial nerves; however, the majority of the approach relies on opening fascial places and minimizing the soft tissue and muscle damage.…”

“…Most authors described continuing traction intraoperatively, most commonly with a Mayfield clamp. Techniques to reduce any outstanding displacement intraoperatively included adjusting the angle of the Mayfield clamp under fluoroscopic guidance 19,37,41,47 ; reducing the fracture by extending the neck and pushing the body of C2 33,46,48 ; and using Caspar distractors. 46,50,51 In the posterior approach, when threading pedicle screws across a fracture site, the screws compressed the fracture.…”

“…Techniques to reduce any outstanding displacement intraoperatively included adjusting the angle of the Mayfield clamp under fluoroscopic guidance 19,37,41,47 ; reducing the fracture by extending the neck and pushing the body of C2 33,46,48 ; and using Caspar distractors. 46,50,51 In the posterior approach, when threading pedicle screws across a fracture site, the screws compressed the fracture. 37,47 Jain et al, in describing the anterior approach, commented on whether screw purchase was unicortical or bicortical using unicortical locking screws 49 ; other authors describing both anterior and posterior approaches emphasized that great care was taken not to penetrate the far cortex when inserting screws.…”

C2–C3 Anterior Cervical Discectomy and Fusion (ACDF) for Hangman's Fractures with C2 Posterior Dislocation: A Modified Classification of Hangman's Fractures and Technical Notes

“…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 (PCDF) with C2 pedicle and C3 lateral mass screws [1]. Both an anterior and a posterior approach result in a high rate of fusion [22], but C2-C3 ACDF seems to be superior to posterior approach as it is less invasive, simpler procedure, fewer complications, direct access to the main pathology and effectively restore cervical lordosis [21,[30][31][32][33].…”