Are C2 pars-pedicle screws alone for type II Hangman's fracture overrated?

https://doi.org/10.1016/j.clineuro.2015.11.019Get rights and content

Highlights

  • Multiple options are available for management of Type II Hangman Fractures.

  • C2 pars-pedicle screws alone have been used in recent past, but exact translation is not clear.

  • Such technique in translation >4.5 mm has shown persistent angular instability, focal kyphosis or C2–3 fusion.

  • For Type II hangman fracture with translation >4.5 mm, C2–3 fusion may be better.

Abstract

Background/object

The recent trend for treatment of certain cases of type II Hangman's fracture has been towards motion preserving surgery. This is claimed to be achieved with placement of pedicle screws across the fracture fragments. However, the long term outcome in clinical scenario is not yet clear, neither are the factors determining suitability of such a technique.

Materials and methods

We have retrospectively analyzed the results of 11 patients of type II Hangman's fracture, according to the extent of translation. Nine patients underwent stabilization of fracture with C2 pedicle screws and 2 were managed with halo immobilization. The conservative management failed in one and this patient underwent internal fixation using pars-pedicle screw as well. The long term clinical and radiological (CT and dynamic X-rays) outcome was analyzed.

Results

All patients including the one with halo immobilization, showed solid fusion across the fracture fragments. With the exception of one patient none had any clinical symptoms. This lone patient complained of restricted neck movements. Three different types of radiological results were observed. Two patients with translation >8 mm showed C2–3 body fusion. Three of 6 patients with minimal translational (3–4 mm) showed facet fusion. Three patients with moderate translational dislocation (4.5–5.5 mm) showed persisting C2–3 angular instability.

Conclusions

The C2 pedicle screw is a good technique for osteosynthesis. However, the claimed long term advantage of motion segment preservation with this technique remains doubtful. It may be suitable for those fractures with minimal translation (<4 mm), where the superiority of surgery, itself, over external immobilization is questionable. C2–3 fusion is preferable for those fractures with translation >4 mm as these are unstable and C2 pedicle screws alone are likely to have less desirable results.

Introduction

Hangman's fracture or traumatic spondylolisthesis of axis is defined as bilateral fracture of C2 pars interarticularis [1]. These injuries often present without neurological deficits. The fracture is further classified and treated depending on the displacement and relationship between C2 and C3 [1]. Type I fractures (those with displacement <3 mm), are often managed conservatively. Type III fractures, with C2–3 subluxation require C2–3 fusion [2]. The treatment options are variable in Type II (translational movement >3 mm) and Type IIa (angular displacement >11°). Various options from conservative management to internal fixation of fracture fragments and C2–3 fusion have been described for Type II Hangman's fracture [2], [3], [4], [5].

The recent trend for ‘selected’ cases of type II Hangman's fracture is towards internally fixing the fracture fragments alone with C2 pars-pedicle (i.e. beginning in pars and passing through pedicle) screws [4], [5], [6]. It apparently preserves mobility and is safe with intraoperative imaging and navigation. Infact, percutaneous screw fixation has been tried with success [5], [6]. However, the case selection criterion for such a technique is not clear. Additionally little has been discussed about the long term results with such motion segment preserving surgery. Cadaveric studies do not recommend such fixation [7]. However, clinical data on this is sparse. We have discussed our experience and long term outcome with Type II Hangman's fracture, most of which were managed with C2 pars-pedicle screw. The inference drawn from our results may help in choosing the appropriate procedure.

Section snippets

Materials and methods

A proper informed consent was obtained from all patients prior to intervention. Surgery was offered to all patients but 2 patients chose Halo immobilization.

Clinical data: Eleven patients with Type II Hangman's fracture managed in 2 institutes, between June 2012 and May 2014 were included in this retrospective study. The age group varied between 13 and 60 years. Nine patients had sustained motor vehicle accidents and the remaining 2 had suffered a fall from height. All of them had presented

Results

The clinico-radiological data has been summarized in Table 1.

Clinical data: The neck pain improved in all patients. Ten patients were asymptomatic during follow up. One patient complained of restricted neck movements. None of them had any new neurological deficits (JOAS 17/17 both before and after surgery).

Radiological data: The preoperative X rays showed displacement ranging from 3.5 to 9.3 mm. Minimal translation (<4 mm) was noted in 6 patients, moderate (4.5–5.5 mm) in 3 patients and severe

Discussion

The treatment options for Type II Hangman's fracture are variable [1], [2], [3], [4], [8]. Both external immobilization and internal fixation has been tried with apparently good results. Halo immobilization following reduction has been shown to successfully unite the fracture fragments in 3–4 months [3]. Internal fixation techniques vary from anterior C2–3 fusion, posterior C2–3 fusion to C2 pars-pedicle screw alone. The anterior approach stabilizes the fractured unit by C2–3 discectomy and

Conflict of interest

The authors have no financial disclosures to be made and there is no conflict of interest. The authors have no personal, financial or institutional interest in any material, devices or drugs mentioned.

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