Anterior cervical discectomy and fusion plus plating for unstable Hangman's fractures / 中华创伤杂志

Objective To investigate the clinical effectiveness of anterior cervical discectomy and fusion (ACDF)plus plating in the treatment of unstable Hangman's fractures.Methods A retrospective case series study was carried out to analyze 12 patients who received ACDF plus plate internal fixation for unstable Hangman's fracture admitted to Sir Run Run Shaw Hospital affiliated to Zhejiang University School of Medicine from July 2014 to July 2018.There were nine males and three females,aged 24-70 years with an average of 46.2 years.According to Levine-Edwards typing,there were seven patients of type Ⅱ,four patients of type Ⅱ A and one patient of type Ⅲ.There were two patients of grade D and 10 patients of grade E according to the American Spinal Injury Association (ASIA) classification.The operation time,intraoperative blood loss and the operational complications were recorded.At 3 days,1,3,6,12 and 24 months after operation,the height of intervertebral disc,physiological curvature of cervical spine,fracture healing and bone graft fusion were evaluated.The recovery of neurological function was assessed by ASIA,and the neck pain relief and function improvement was assessed by visual analogue scale (VAS) and the neck disability index (NDI).Results All patients were followed for 6-48 months(mean,27.7 months).The operation time ranged from 50-100 minutes,with an average of 72.5 minutes.The intraoperative blood loss was 30-120 ml (mean,65.8 ml).No serious complications occurred during and after operation.Two patients had dysphagia after operation,and the symptoms were relieved at the follow-up of 3 months.All patients achieved bony fusion of C2-3 within the 6 month follow-up.No subsidence or migration of cages and significant loss of intervertebral space height were observed.The patient's neck and occipital pain was relieved obviously,and the flexion,extension and rotation of cervical spine were good.The neurologic dysfunction of two patients of ASIA Grade D recovered after surgery,and the final ASIA grade was E.The VAS score was decreased from 5.0 (4.0,6.0)points preoperatively to 1.0(0,1.0)points at the last follow-up (P ＜0.01).The NDI score was improved from (28.5 ± 6.4) points preoperatively to (5.3 ± 2.7) points at the last follow-up (P＜0.01).Conclusion ACDF combined with plate internal fixation can provide immediate postoperative stability,high fusion rate,less complications,less pain,and satisfactory function recovery.

Clinical efficacy of anterior cervical plate fixation for type II and type II A Hangman’s fracture / 医学研究生学报

Objective　There are still disputes about the clinical treatment of type II and type II A Hangman’s fracture. The article aimed to explore the clinical efficacy of anterior cervical plate fixation for type II and type II A Hangman’s fracture.　Methods　Seventeen patients with type II and type II A Hangman’s fracture combined with intervertebral disc injury were analyzed in our department from January 2013 to August 2017, including 12 males and 5 females, aged from 27 to 76 years old, with an average age of 54.9 years. The operative time and intraoperative blood loss and postoperative drainage were recorded. The effectiveness was evaluated using visual analogue scale (VAS) for occipitocervical pain, and the Neck Disability Index (NDI) score for cervical vertebra function. Radiological indices (C2/3 local kyphotic angle, C2 translation) and bone graft fusion were evaluated by X-ray.　Results　All the patients were followed up successfully. No cerebrospinal fluid leakage occurred during the operation. There were no broken nails, broken slab, and loose internal fixation. All the patients were almost free from occipitocervical pain and neurological function of all patients improved partially. The VAS and NDI scores were significantly improved at 3 months after operation and one year when compared with preoperative scores (P<0.05). The C2/3 local kyphotic angle was corrected significantly with the mean preoperative 12.24±2.17 degrees, initial postoperative -2.12±3.20 degrees and the latest follow-up -1.88±2.67 degrees respectively (P<0.05). The C2 translation was also corrected significantly with the mean preoperative 3.47±1.46 mm, initial postoperative 1.02±0.63 mm, and the latest follow-up 1.21±0.56 mm respectively (P<0.05). All the patients had good bone graft fusion.　Conclusion　For type II and type II A Hangman’s fracture, the method of anterior cervical plate fixation can effectively restore cervical curvature and reconstruct cervical stability, which is featured by the advantage of less trauma, fewer complications and faster recovery.

Surgical treatment of atypical unstable Hangman fracture in elderly osteoporotic patients / 中国骨伤

OBJECTIVE@#To explore the clinical effect of operative reduction and internal fixation in treating atypical unstable Hangman fracture in elderly osteoporotic patients.@*METHODS@#The clinical data of 9 elderly osteoporotic patients with atypical unstable Hangman fracture treated from December 2012 to December 2017 were retrospectively analyzed. There were 5 males and 4 females with an average age of 72.7 years (range 65 to 79) old. The fracture line was located on bilateral inferior articular surface or lamina with anterior dislocation of axis in 3 cases (similar to Levine-Edwards type II); one side of the fracture line was located on the lower articular surface and opposite side involved on the upper articular surface and the body of axis with atlantoaxial lateral mass dislocation in 4 cases; the fracture line was located at the pedicle of the axis, transverse foramen and posterior inferior wall of the vertebral body, accompanying by anterior and posterior longitudinal ligaments and C₂-C₃ intervertebral disc injury resulted in C₂-C₃ intervertebral instability in 2 cases. According to ASIA grade of spinal cord injury, 2 cases were grade D and 7 cases were grade E. Preoperative JOA scores were 9 to 11 points with an average of 9.8 points. All patients underwent routinely skull traction for reduction. Three patients with anterior dislocation of axis were treated with stage I anterior-posterior internal fixation and 6 patients with simple posterior pedicle screw fixation. Postoperative JOA score, ASIA system and the imaging data were used to evaluate clinical effects.@*RESULTS@#All patients were followed up from 12 to 20 months with an average of 18 months. The neck pain disappeared after operation and cervical spine movement was well in all patients. The improvement rate of JOA at 3 months after operation was 75% to 87.5%. Two cases of ASIA grade D fully recovered to grade E. All fractures healed at 6 to 12 months after operation. Except one case occurred superior laryngeal nerve injury and had a complete recovery after 3 months, the other patients had no complications like spinal cord and vertebral artery injury, plate screw loosening and wound infection.@*CONCLUSIONS@#According to the type of atypical unstable Hangman fracture in elderly osteoporotic patients, choosing a reasonable and personalized surgical plan can achieve immediate cervical stability and well reduction, which is beneficial for early ambulation and quick rehabilitation.

Finite element analysis on anterior and posterior internal fixation for treating type ⅡHangman’s fracture / 医用生物力学

Objective To evaluate biomechanical differences between anterior titanium plate internal fixation and posterior pedicle screw internal fixation for treating type Ⅱ unstable Hangman’s fracture by finite element analysis. Methods An intact finite element model of the upper cervical spine (C0-3) was established and validated, and an unstable model was also established. Two different internal fixation models, i.e. anterior titanium plate+Cage with bone graft (Plate+Cage) and C2 pedicle screws+C3 lateral mass screws (C2PS+C3LMS) were established, respectively, based on the unstable model. The vertical load of 40 N was applied on the occiput to simulate head weight and 1.5 N•m torque was applied on the occiput to simulate loading conditions of flexion, extension, lateral bending and rotation. Range of motion (ROM) of C2-3, force pathway and strain at the fractured line were calculated and analyzed. ResultsCompared with the unstable model, the Plate+Cage model could decrease the ROM by 92.4%, 97.1%, 96.5% and 90.0%, while the C2PS+C3LMS model could decrease the ROM by 88.6%, 90.2%, 95.7% and 90.3%, in flexion, extension, lateral bending and axial rotation, respectively. The maximum stress of the Plate+Cage model was smaller than that of the C2PS+C3LMS model under 4 loading conditions. Conclusions The anterior Plate+Cage fixation possesses better stability than the posterior C2PS+C3LMS fixation in flexion and extension, while both fixation methods show similar stability in lateral bending and axial rotation. The anterior Plate+Cage fixation is more reasonable in structure and stress distributions, and can achieve reduction, decompression, fixation and fusion in one step, thus it is an effective operative procedure for treating typeⅡ Hangman’s fracture.

C1-C3 Lateral Mass Screw-Rod Fixation and Fusion for C2 Pathologies and Hangman's Fractures

STUDY DESIGN: Retrospective clinical study. PURPOSE: We report our experience of eight patients treated with C1-C3 lateral mass rod-screw stabilization and fusion in the treatment of Hangman's fracture and other axis pathologies. OVERVIEW OF LITERATURE: Different surgical approaches, both anterior and posterior, have been described for treating Hangman's fracture and other pathologies where surgery is indicated. METHODS: All patients who underwent surgical treatment for Hangman's fracture and axial pathology where C1-C3 lateral mass screw-rod stabilization and fusion done, following reduction of the fracture or removal of the pathology were included in this series. The recorded patient management data was retrospectively studied. RESULTS: There were 8 cases in total. All were male, with an average age of 40.75 years. Hangman's fracture occurred in 6 cases (75%), one with metastatic squamous cell carcinoma and the remaining with plasmocytoma. Among the Hangman's fractures 4 (66.66%) had no neuro-deficit. Reduction and bilateral C1-C3 lateral mass screw and rod fixation with posterior fusion by bone graft was performed in all cases. In 2 cases, a C2 body tumor was removed transorally. All patients with neuro-deficit fully recovered, except one who expired in the early post-operative period. Rest of all patients were leading a normal life till last follow up. CONCLUSIONS: Although the number of cases was very small with a relatively short follow up period, C1 and C3 lateral mass screw-rod fixation followed by fusion showed promise as an effective and biomechanically sound way for the treatment of properly selected Hangman's fracture cases, and may also be suitable in other axial pathologies.

Posterior C2-C3 Fixation for Unstable Hangman's Fracture

OBJECTIVE: This is a retrospective review of 13 unstable Hangman's fractures who underwent posterior C2-3 fixation to describe clinical outcomes with a literature review. METHODS: Thirteen patients for unstable Hangman's fracture were enrolled between July 2007 and June 2010 were included in this study. The medical records of all patients were reviewed. Concurrently, clinical outcomes were evaluated using Neck Disability Index (NDI) scores and Visual Analogue Scale (VAS) scores during preoperative and postoperative follow up period. Plain radiographs were obtained on postoperative 1day, 1week, and then at 1, 2, 6, and 12 months. CT was done at postoperative 12 months in all patients for evaluation of bone fusion. The mean period of clinical follow-up was 17 months. RESULTS: Mean age were 43 years old. Bone fusion was recognized in all cases at the final follow-up. The average preoperative VAS score for neck pain was 8.3+/-1.1, while the final follow-up VAS score was 2.07+/-0.8 (p<0.001). The average immediate postoperative NDI was 84% points and final NDI was 22% points (p<0.001). There were one case of infection and 1 case of screw loosening. CONCLUSION: In the treatment of the patients with unstable Hangman's fracture, posterior C2-C3 fusions is effective and curative treatments to achieve cervical spinal stability.

Percutaneous Pedicle Screw Fixation of a Hangman's Fracture Using Intraoperative, Full Rotation, Three-dimensional Image (O-arm)-based Navigation: A Technical Case Report

Surgical treatment of a hangman's fractures is technically demanding, even when using the standard open procedure. In this case report, a type II hangman's fracture was treated by percutaneous posterior screw fixation, without a midline incision, using intraoperative, full rotation, three-dimensional (3D) image (O-arm)-based navigation. A 48-year-old woman was injured in a motor vehicle accident and diagnosed with a unilateral hangman's fracture associated with subluxation of the C2 vertebral body on C3. After attaching the reference arc of the 3D-imaging system to the headholder, the cervical spine was screened using an O-arm without anatomical registration. Drilling and screw fixation were performed using a guide tube while referring to the reconstructed 3D-anatomical views. The operation was successfully completed without technical difficulties or neurovascular complications. This percutaneous procedure requires less dissection of normal tissue, which may allow earlier recovery. However, further validation of this procedure for its effectiveness and safety is required.

Effects of anterior fusion and posterior internal fixation on stability of upper cervical vertebra in type II Hangman fracture / 医用生物力学

Objective To evaluate biomechanical properties of internal fixation after C3 corpectomy and C2-4 anterior fusion with Zephir plate in reconstructing stability of the upper cervical vertebra, and compare them with conventionally used anterior internal fixation after C2-3 intervertebral fusion and posterior internal fixation by C2 transpedicle screws. MethodsSix fresh human upper cervical vertebra specimens (including C2-4) were divided into five groups: the intact specimen group(control group), the incision of the C2-3 group (Hangman group), the posterior internal fixation by C2 transpedicle screw group (posterior fixation group), the anterior internal fixation after C2-3 intervertebral fusion with Zephir plate group (anterior fixation group), and the internal fixation after C3 corpectomy and C2-4 anterior fusion with Zephir plate group (C2-4 incision +internal fixation group). Range of motion (ROM) of the C2-3 and C3-4 segments was tested respectively under 0.5, 1.5 and 2.5 N•m moment by measurement system for three-dimensional spinal movement, and the statistical analysis was also conducted. Results(1) C2-3 segment: ROM of anterior fixation group and C2-4 incision +internal fixation group was significantly smaller than that of Hangman group and posterior fixation group in all six directions under various loading conditions (P<0.05); there was no significant difference between anterior fixation group and C2-4 incision +internal fixation group. ROM of posterior fixation group was larger than that of intact group in all six directions under various loading conditions (P<0.05); There was no significant difference in flexion and extension direction under all loading conditions between posterior fixation group and Hangman group, but significant difference was found in left/right and right/left axial rotation and under 2.5 N•m moment between posterior fixation group and Hangman group (P<0.05). (2) C3-4 segment: there was no significant difference in ROM in six directions under various loading conditions among all groups except for C2-4 incision +internal fixation group. ROM of C2-4 incision +internal fixation group was significantly smaller than that of other groups in all six direction (P<0.05). Although ROM of anterior fixation group was slightly larger than that of Hangman group and posterior fixation group, the difference was not statistically significant. Conclusions From the view of biomechanics, internal fixation after C3 corpectomy and C2-4 anterior fusion with Zephir plate is a better surgical option for stabilizing the fracture than that of posterior internal fixation by C2 transpedicle screws to treat type II Hangman fracture with C2-3 intervertebral disc injury.

Pedicle screw fixation in treatment of acute Hangmans fracture and spinal cord injury / 中华创伤骨科杂志

Objective To evaluate the clinical outcomes of pedicle screw fixation in the treatment of Hangmans fracture. Methods The 15 patients who had been treated for acute Hangmans fracture in our department after 1999 were retrospectively analyzed. 4 of them were type I, and 11 type II. All the patients presented symptoms of nerve system at different degrees. They were treated with AO pure titanium cortex screw through isthmus after skull traction replacement. Results All the patients were followed up for 12 to 60 months. According to Frankle classification, 6 cases of Grade D and 5 cases of Grade C recovered up to Grade E, 2 cases of Grade C recovered to Grade D, 1 case of Grade B recovered to Grade C and 1 case of Grade B recovered to Grade D. X ray showed all the fractures healed up without vertebra artery injury or other complications. Conclusion The outcomes of pedicle screw fixation and reduction in treatment of acute Hangmans fracture are satisfactory, for the clinic technique promotes functional recovery of spinal cord, decreases the rate of infection and scarcely affects the function of upper cervical spine.

The C2,3 pedicle-lateral mass plate fixation in the treatment of unstable Hangman's fractures / 中华创伤骨科杂志

Objective To study the feasibility and clinical results of C2, 3 pedicle-lateral mass plate fixation in the treatment of unstable Hangman's fractures. Methods From March 1999 to July 2005, 25 cases of unstable Hangman's fracture were treated surgically using the C2, 3 pedicle-lateral mass plate. All the cases were followed up for the healing of bone and function of the cervical vertebrate. Results The average follow-up period was 38 months. Twenty-three cases had a perfect reduction. Three cases had kyphosis deformity. There were no other complications related to the operation. AH the cases had a perfect early fusion of the C2 pedicle isthmus and long-term stability of C2, 3 intervertebral space. The clinic results were good. Conclusion Since the C2, 3 pedicle-lateral mass fixation can provide immediate reduction and satisfactory biomechanical stability, it is a good device for unstable Hangman s fractures.

Posterior Short Segment Fixation and Fusion in a Displaced Hangman's Fracture

Although most cases of C2 traumatic spondylolisthesis, a so called Hangman's fracture, can be managed by a closed reduction and immobilization, surgery should be considered in the cases of non-reducible fractures or a recurrent subluxation. This report details our recent experience with the surgical treatment of a Type II Hangman's fracture after an unsuccessful closed reduction. Advantage and the technique of the posterior short segment fixation are discussed.

Direct Reduction and Fixation for Unstable Hangman's Fracture with Posterior Lateral Mass Plating: Report of 4 Cases

While most patients with hangman's fracture could be effectively managed with non-operative treatment, surgical intervention should be considered in unstable hangman's fracture with severe C2-3 dislocation or angulation. Author modified the posterior lateral mass plating techinic for the unstable hangman's fracture. While the C3 screw fixation was done with usual manner, author applied the long lag screw instead of usual short- or medium-sized screw through the isthmus of C2 for direct reduction and fixation of fractured segment. It is similar to anterior screw fixation for odontoid type II fracture in terms of simutaeneous reduction and fixation. Besides these procedure interfacetal fusion and ligamentoplasty were added in C2-3 articulation. Surgical point of view was discussed with literature review.

Anterior Interbody Fusion through the Retropharyngeal Approach for Hangman's Fracture: Report of 2 Cases

Most patients with hangman's fracture frequently responded to consertvative therapy consisted of skeletal traction and halo vest, and surgery to stabilize or reduce further injury is seldom necessary. But occasionally operative stabilization may be necessary and can be achiveed satisfactorilly through anterior or posterior approach. Anterior interbody fusion at the G2-3 interspace has advantages of immediate bony stabilization with preservation of rotatory motion compared with posterior approach.

Clinical Review of the Isolated Acute Axis Fracture

A series of 26 patients of acute axis fractures were treated at the Wonkwang Medical Center, Wonkwang University between January, 1988 and December, 1992. The medical records and roentgenograms of these 26 patients were reviewed in detail. Follow-up data were available for all of the cases. for a median duration of 25.6 months(range 3 months to 5years). There were 8 hangman's fractures(31%), 10 odontoid type II fractures(38%), 6 odontoid type III fractures(23%), 2 miscellanous fractures(8%). The odontoid type II fracture was the most common axis fracture and the most common cause of injury was motor-vehicle accident followed by fall, Hangman's fracture, odontoid type II, miscellanous fracture were effectively treated with external stabilization. In the 10 odontoid type II fractures, 7 patients were treated by external stabilization and 3 were by early surgical stabilization. Among the external stabilization group, the fusion failure occured 2 of the displacement of 4mm or greater in the initial treatment.

Analysis of Upper Cervical Injuries

During the past five years we have treated twenty-seven cases of upper cervical injury among total three hundred and seventeen spine injuries. A follow-up study has done on twenty-one upper cervical injuries and the result is reported. The incidence of upper cervical injury was 8.5% of the total spine injury and 17.5% of the cervical injury. Almost all of the injuries(95.2%) were caused by traffic accidents and falls. The types of injury were odontoid fracture(38.1%), hangman's fracture(28.6%), atlanto-axial instability(19.1%), tear drop fracture of the axis(9.5%), and Jefferson's fracture(4.8%). Chief complaints on admission were motor weakness(57.1%), neck pain with limitted range of motion(42.9%), and sensory disturbance was noted in six cases of the motor weakness group(28.6%). Out of twenty-one cases, operative fixation was performed in eight cases with good result in five(62.5%) and thirteen patients were treated conservatively with eleven cases(84.6%) of good result. In chronic nonunited or malnunited cases, it seems to be safer to fuse the level both by anterior and posterior routes than by either route alone because it is not always stable and needs long period of immobilization.

The hangman’s fracture.

Eleven patients with hangman’s fracture admitted into Siriraj Hospital Between 1978 and 1984 were studied and analysed. Automobile accident (73%) and falling (18%) were the most common causes of this injury. The mechanism of the injury was acute hyperextension of the head on the upper cervical spinal. Because the fracture occurring at the greatest anteroposterior diameter of the cervical spine canal, the spinal cord injury was rarely associated with this lesion. Radiographic findings of the hangman’s fracture were bilateral fracture of the pedicles of the axis with or without anterior dislocation of C2 on C3. The degree of displacement varied from minimal to severe. However the posterior fragment usually retained its normal relationship to the posterior arch of C3. Retropharyngeal soft tissue swelling served as a general clue to the presence of this injury and an avulsion fracture or compression of the anterosuperior margin of the body of C3 was an additional finding of the lesion. Differential diagnosis of the hangman’s fracture should be made from the congenital spondylolisthesis of the axis.

Traumatic Spondylolisthesis of the Axis / 대한정형외과학회잡지

Twelve patient with fracture of the neural arch of the axis (hangman's fracture or traumatic spondylolisthesis of the axis) were treated at Kangnam St. Mary's Hospital between 1980 and 1986. There were three type I fractures, seven type II fractures, and two type III fracture. Non of these patients had neurological damage. Seven patients (five in type II and two in type III) in this series, underwent anterior interbody fusion operation between axis and third cervical vertebra following 6 weeks of cervical traction. The remaining five patients were treated conservatively by cervicel traction in the bed. Average follow up period was 24 months. The mean duration of fracture union was 10 weeks after trauma in 3 cases of type I and twelve weeks after trauma in 2 cases of type II which were treated conservatively. Otherwise in 5 cases of type II and two cases of type III which were taken anterior interbody fu sion, the mean duration of fracture union was 8 weeks in type II and 10 weeks in type III after surgery. All regained a stability of the cervical spines. Because the fracture healing of the neural arch invariably occurred through this study, it is felt that anterior interbody fusion between axis and third cervical vertebra is necessary surgical.procedure to gain the early stability if there is an evidence of persistant instability between axis and third cervical verbebrae even after 6 weeks of conservative traction treatment.