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

Abstract

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.

Neuronavigation and 3D fluoroscopy–guided lag screw reduction and osteosynthesis for traumatic spondylolistheses of the axis: a path worth exploring?

“…15 On the contrary, Shin et al described posterior reduction and screw fixation as a primary treatment strategy in all patients with hangman's fracture of all grades. 19 It was previously reported that stable fractures (L-E Type I) and certain adequately reduced L-E Type II fractures are generally treated with brace therapy involving a rigid cervical collar or halo immobilization.…”

Minimally invasive percutaneous screw fixation of traumatic spondylolisthesis of the axis

“…20,23 A recent paper by Shin et al advocates for the early use of surgical fixation of hangman's fractures because of high rates of nonunion and pseudarthrosis, along with patient dissatisfaction associated with long-term rigid cervical collar and halo use. 27 Shin et al suggested the use of posterior reduction and screw fixation as a primary treatment for hangman's fractures of all grades. As such, surgical stabilization, including minimally invasive direct percutaneous fracture fixation, is a potentially useful adjunct in the proper management algorithm.…”

“…Although we still recommend nonoperative management when possible, Shin et al have advocated for the use of early surgical intervention. 27 If patients are carefully selected and intraoperative neuronavigation is used, this technique seems to be a safe and effective method for the treatment of traumatic spondylolisthesis of the axis.…”

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

“…3,8,13,15,[17][18][19]21,23,25,28,31,33,34 Posterior surgery was previously performed using C1-3 wire fixation, but this technique requires postoperative halo vest immobilization and sacrifices atlantoaxial function. 13 Bristol et al 3 treated the atlantoaxial isthmus fracture by direct screw fixation to retain atlantoaxial function.…”