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Li G, Wang Q. Detailed observation of anatomical location and pattern in Hangman's fracture based on computed tomography three-dimensional reconstruction. J Orthop Surg Res 2023; 18:136. [PMID: 36823607 PMCID: PMC9948456 DOI: 10.1186/s13018-023-03622-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 02/15/2023] [Indexed: 02/25/2023] Open
Abstract
OBJECTIVE To observe the precise anatomical location and pattern of the fracture lines in Hangman's fracture. METHODS Three-dimensional computed CT images of 210 patients with Hangman's fracture were collected. According to the involvement of anatomical structures, the injuries were classified into facet joint injury and pure bony injury. The C2 ring was also divided into: anterior, middle, and posterior elements. The anatomical structures involvement and fracture patterns were observed. RESULT Total 520 anatomical structures injuries were involved in 210 patients Hangman's fractures, including 298 facet joints injuries (57.3%) and 222 bony injuries (42.7%). The most common facet joints injury was superior articular facet injury of C2, and the most common pure bony injury was pediculoisthmic component fracture. The injuries of anterior element (60.6%) were more common than that of middle (20.4%) or posterior (19.0%) element. One injury in anterior element on one side and another injury located in the anterior, middle or posterior element other side was the most common fracture pattern. Injury of middle element on one side with another injury located in the middle or posterior element could be also observed. CONCLUSION In Hangman's fractures, fracture lines could occur in any part of C2 ring. Facet joints injuries were more common than pure bony injuries, and the injuries of anterior element were also more common than that of middle or posterior element. The high prevalence of facet joints injuries means that most of Hangman's fractures may be involved with intra-articular injuries.
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Affiliation(s)
- Guangzhou Li
- Department of Orthopeadics (Spine Surgery), The Affiliated Hospital of Southwest Medical University, No. 25 Taiping Street, Luzhou, 646000, Sichuan Province, China
| | - Qing Wang
- Department of Orthopeadics (Spine Surgery), The Affiliated Hospital of Southwest Medical University, No. 25 Taiping Street, Luzhou, 646000, Sichuan Province, China.
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Tang YX, Peng SL, Chen YW, Huang HM, Shih CT. Evaluating the contact anatomy and contact bone volume of spinal screws using a novel drilled surface image. PLoS One 2023; 18:e0282737. [PMID: 37036863 PMCID: PMC10085035 DOI: 10.1371/journal.pone.0282737] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Accepted: 02/21/2023] [Indexed: 04/11/2023] Open
Abstract
Intraoperative navigation systems have been widely applied in spinal fusion surgery to improve the implantation accuracy of spinal screws using orthogonal tomographic and surface-rendering imaging. However, these images contain limited anatomical information and no information on bone volume contact by the implanted screw, which has been proven to affect the stability of implanted screws. This study proposed a novel drilled surface imaging technique that displays anatomical integration properties to calculate the contact bone volume (CBV) of the screws implanted along an implantation trajectory. A cylinder was used to represent the area traversed by the screws, which was manually rotated and translated to a predetermined implantation trajectory according to a vertebra model obtained using computed tomography (CT) image volumes. The drilled surface image was reconstructed by interpolating the CT numbers at the predefined sampling points on the cylinder surface. The anatomical integration property and CBV of the screw implanted along the transpedicular trajectory (TT) and cortical bone trajectory (CBT) were evaluated and compared. The drilled surface image fully revealed the contact anatomical structure of the screw under the trajectories, improving the understanding of the anatomical integration of the screw and surrounding tissues. On average, the CBV of the CBT was 30% greater than that of the TT. The proposed drilled surface image may be applied in preoperative planning and integrated into intraoperative navigation systems to evaluate the anatomical integration and degree of bone contact of the screw implanted along a trajectory.
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Affiliation(s)
- Yun-Xuan Tang
- Department of Radiology, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan
- Department of Medical Imaging and Radiological Technology, Yuanpei University of Medical Technology, Hsinchu, Taiwan
| | - Shin-Lei Peng
- Department of Biomedical Imaging and Radiological Science, China Medical University, Taichung, Taiwan
| | - Yi-Wen Chen
- Graduate Institute of Biomedical Sciences, China Medical University, Taichung, Taiwan
- x-Dimension Center for Medical Research and Translation, China Medical University Hospital, Taichung, Taiwan
- 3D Printing Medical Research Institute, Asia University, Taichung, Taiwan
| | - Hsiang-Ming Huang
- Department of Neurosurgery, China Medical University Hsinchu Hospital, Hsinchu, Taiwan
| | - Cheng-Ting Shih
- Department of Biomedical Imaging and Radiological Science, China Medical University, Taichung, Taiwan
- x-Dimension Center for Medical Research and Translation, China Medical University Hospital, Taichung, Taiwan
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Certo F, Altieri R, Garozzo M, Visocchi M, Barbagallo GMV. Direct Transpedicular C2 Fixation for the Surgical Management of Hangman's Fractures: A "Second Youth" for the Judet Approach. ACTA NEUROCHIRURGICA. SUPPLEMENT 2023; 135:291-299. [PMID: 38153484 DOI: 10.1007/978-3-031-36084-8_45] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2023]
Abstract
PURPOSE The optimal management of hangman's fractures is controversial and the standard of care has been neither established nor supported by strong evidence. The Judet approach has been introduced in 1970 as surgical option to treat selected cases of hangman's fractures, harboring the advantage to preserve motion of the craniovertebral junction and to restore the C2 vertebra anatomy by insertion of transpedicular screws through the fracture line. This paper reviews the literature on hangman's fractures surgically managed by Judet approach, and reports two new illustrative cases. METHODS The PubMed database was searched for the review process. After initial screening of abstracts and papers, 13 manuscripts were included in the present review.Two cases of hangman's fractures, a Levine-Edwards type I and a type IIA, respectively, treated with direct transpedicular C2 screw fixation are reported. Surgical steps of the Judet approach are also described. RESULTS Our literature review revealed that the technique described by Judet is gaining appeal only in recent years and there is no consensus on surgical indications.No surgery-related complications were observed in the two reported cases. Patients experienced a significant reduction of neck pain postoperatively. Motion of craniovertebral junction was preserved in both patients at 3-, 6-, and 12-month follow-ups. CONCLUSIONS Direct transpedicular osteosynthesis of C2-pars interarticularis fracture has been already demonstrated as effective in type II and IIA hangman's fractures. The application of such technique in selected patients with atypical type I fractures should also be considered in order to achieve early mobilization and avoid external fixation.
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Affiliation(s)
- Francesco Certo
- A.O.U. Policlinico "G. Rodolico - San Marco" University Hospital, Catania, Italy
| | - Roberto Altieri
- A.O.U. Policlinico "G. Rodolico - San Marco" University Hospital, Catania, Italy
| | - Marco Garozzo
- A.O.U. Policlinico "G. Rodolico - San Marco" University Hospital, Catania, Italy
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Kalnev M, Uchikov P, Kehayov I. Clinical Behavior of General Practitioners for Patients who Underwent an Operative or Conservative Treatment for a Craniocervical Fracture. Open Access Maced J Med Sci 2022. [DOI: 10.3889/oamjms.2022.9923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Craniocervical fractures are socially important pathology. They represent one-third of the fractures in the cervical region. It is typical that elderly patients suffer from low-energy traumas such as falls, while younger patients suffer from high-energy traumas such as motor vehicle accidents, sport falls and etc. Craniocervical fractures are associated with an increased risk of craniocervical instability or neurological deficit. Primary therapeutic options depend on the type of fracture. Predictors of nonunions are the displacement of fractures, patients’ age, and comorbidities. The observership of the general practitioner in the postoperative period or the period of cervical immobilization could recognize possible malpositioning of the instrumentation, nonunion of the fracture, malsanation of the wound, and possible complications in case of the external immobilization. There is a lack of information on that topic. The goal of the paper is to summarise the most common fractures of the craniocervical region, their etiology, and treatment options and to present the results of our study of patients who underwent operative treatment for craniocervical fracture(s). Mastering the details, the treatment options, and the possible complication of the fractures in the craniocervical region, general practitioners could play an important role in the treatment of patients.
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Foster MA, Gridley DG, Lettieri SC, Feiz-Erfan I. Brown-Sequard syndrome associated with hangman fracture after blunt trauma: A case report. Surg Neurol Int 2022; 13:150. [PMID: 35509566 PMCID: PMC9062955 DOI: 10.25259/sni_897_2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2021] [Accepted: 03/31/2022] [Indexed: 11/04/2022] Open
Abstract
Background:
The association of Brown-Sequard syndrome (BSS) and hangman fracture (HF) is rarely reported.
Case Description:
We present a case of a 28-year-old female with a HF sustained after a motor vehicle accident and BSS. Diagnosis was established based on typical loass of motor function ipsilaterally and loss of pain and temperature sensation contralaterally. Furthermore, magnetic resonance imaging delineated the location of the injury to the right side of the spinal cord at cervical level 2. Near-complete neurological recovery was achieved after anterior fusion and fixation at cervical level 2–3 after 8 months of follow-up.
Conclusion:
HF from blunt trauma can be directly associated with BSS. Surgery was effective and associated with a near-complete resolution of symptoms.
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Affiliation(s)
| | - Daniel Gene Gridley
- Department of Radiology, Valleywise Health Medical Center, Phoenix, Arizona, United States,
| | | | - Iman Feiz-Erfan
- Division of Neurosurgery, Valleywise Health Medical Center, Phoenix, Arizona, United States
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Anterior C2-3 fusion surgery alone for highly displaced Hangman's fracture with severe angulation of C2-3 of more than 30°. Clin Neurol Neurosurg 2021; 206:106701. [PMID: 34049751 DOI: 10.1016/j.clineuro.2021.106701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Revised: 04/28/2021] [Accepted: 05/12/2021] [Indexed: 11/20/2022]
Abstract
BACKGROUND Highly displaced Hangman's fracture is a very rare and extremely unstable fracture of the C2 axis. Combined anteroposterior or posterior long-segment fusion surgery is typically performed for the treatment of highly displaced Hangman's fracture. However, these kinds of surgeries increase the risk of complications, loss of motion, and hospital costs. OBJECTIVE We sought to investigate the surgical outcomes of anterior C2-3 fusion surgery alone for highly displaced Hangman's fractures with severe angulation of C2-3 by more than 30° and discoligamentous injury. METHODS A total of five patients (four men and one woman) were included in this study with a mean age of 40.4 years (range, 26-70 years). The mean follow-up period after surgery was 37.2 months (range, 12-96 months). The fracture characteristics, treatment methods, and outcomes were retrospectively analyzed. RESULTS All five patients had type II Hangman's fractures (according to the Levine and Edwards classification scheme). None of the included patients had neurologic deficit or other spine injury but all patients had complete C2-3 discoligamentous injury. Before surgery, all patients successfully achieved closed reduction by skull traction, followed by C2-3 anterior decompression and fusion (ACDF) with plating. For interbody grafting, three patients received a polyetheretherketone (PEEK) cage filled with an autogenous cancellous iliac bone graft and two received autogenous tricortical iliac bone grafts. Severe angulation (39.2° vs. 3.0°, P < 0.001) and severe displacement (76.1% vs. 4.0%, P < 0.001) of C2-3 were both significantly corrected after surgery. All patients had achieved solid fusion at last follow-up. In terms of clinical outcomes, the mean neck pain visual analog scale score was significantly improved (8.6 points vs. 1.8 points, P < 0.001). The mean neck disability index value was also significantly improved (45.4 points vs. 13.0 points, P < 0.01). According to Odom's criteria, all patients achieved satisfactory outcomes. No major complications occurred. One patient complained of dysphagia, but recovered after three months with conservative treatment. CONCLUSIONS Preoperative closed reduction and anterior C2-3 fusion surgery alone should be considered as a less-invasive and useful surgical option for highly displaced Hangman's fracture with severe angulation of C2-3, which is an extremely unstable fracture of the C2 axis.
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Sawarkar D, Agrawal M, Singh PK, Mishra S, Agrawal D, Kumar A, Verma S, Doddamani R, Meena R, Garg K, Gurjar H, Chandra PS, Kale SS. Evolution to Pedicle Reformation Technique in Surgical Management of Hangman's Fracture. World Neurosurg 2021; 149:e481-e490. [PMID: 33567364 DOI: 10.1016/j.wneu.2021.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Revised: 01/31/2021] [Accepted: 02/01/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND Opinions vary regarding optimal treatment of unstable hangman's fractures. Recent technological advances have allowed short segment, motion preserving fixation, even in complex cases. The aim of the study was to demonstrate C1-C2 motion-preserving short-segment fusion in hangman's fracture and the evolution of technique from pedicle realignment to pedicle reformation in complex fractures with resorbed/destroyed C2 pedicles. METHODS This was a retrospective study. Patients operated by a single surgeon at a tertiary level center from 2012 to 2018 were included. The type of fracture, operating time, and blood loss was recorded. Neurologic deficits were recorded using the American Spinal Injury Association scale with regular clinicoradiologic follow-up. RESULTS Nine patients (8 male), with a mean age of 36 ± 16.9 years were included. In the initial 7 patients, C2 pedicle screw, C3-C4 lateral mass screw, and rod fixation was done. The last 2 patients were complex neglected injuries, with 1 having severe angulation and displacement and the other having spondyloptosis with C2 body placed anterior to C4 body. In both these patients, direct C2 body screw were placed and pedicle reconstruction was done. Mean follow up was 41.4 ± 29.8 months. All 5 patients with preoperative neurologic deficits had improvement in power. C1-C2 joint motion was preserved in all. All patients had bony fusion. CONCLUSIONS Preservation of motion at the C1-C2 joint should be the goal in all surgically managed hangman's fracture patients. The technique of C2 pedicle reconstruction can be utilized for the same in old neglected hangman's fractures.
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Affiliation(s)
- Dattaraj Sawarkar
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - Mohit Agrawal
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - Pankaj Kumar Singh
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India.
| | - Shashwat Mishra
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - Deepak Agrawal
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - Amandeep Kumar
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - Satish Verma
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - Ramesh Doddamani
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - Rajesh Meena
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - Kanwaljeet Garg
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - Hitesh Gurjar
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - Poodipedi S Chandra
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - Shashank S Kale
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
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Liao S, Jung MK, Hörnig L, Grützner PA, Kreinest M. Injuries of the upper cervical spine—how can instability be identified? INTERNATIONAL ORTHOPAEDICS 2020; 44:1239-1253. [DOI: 10.1007/s00264-020-04593-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Accepted: 04/27/2020] [Indexed: 10/24/2022]
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9
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Tulip-Screw Head Disjunction from Posterior C2 Fracture Fixation Instrumentation. Case Rep Orthop 2020; 2020:5824383. [PMID: 32158578 PMCID: PMC7060438 DOI: 10.1155/2020/5824383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Accepted: 02/10/2020] [Indexed: 11/23/2022] Open
Abstract
This report presents an unusual case of instrumentation failure after posterior fixation of a C2 fracture and reviews currently available treatment alternatives. The patient, a 53-year-old female, initially presented to the emergency department at an outside facility with acute alcohol intoxication and acute neck pain following a fall from a ladder. CT demonstrated bilateral C2 pars fractures and unstable posteroinferior displacement of the posterior elements. She underwent an emergent C2 open-reduction internal fixation (ORIF) at the outside facility with 3.5 mm polyaxial synapse pedicle screws (DePuy Synthes, Switzerland). There were no known complications and the patient was discharged. Two years after the index operation, cervical CT scan at a different facility revealed that although the fracture was fully healed, bilateral tulip caps had detached from the pedicle screw heads at C2. All implants were removed without postoperative complications. Industry review of alternate lag screws approved for the cervical spine demonstrated that there is not currently an ideal implant for fixation of C2 fractures without fusion. Cannulated trauma screws, which are low profile and would have avoided the instrumentation failure seen here, are not currently FDA approved for the cervical spine.
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10
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Patel JYK, Kundnani VG, Kuriya S, Raut S, Meena M. Unstable Hangman's fracture: Anterior or posterior surgery? JOURNAL OF CRANIOVERTEBRAL JUNCTION AND SPINE 2020; 10:210-215. [PMID: 32089613 PMCID: PMC7008659 DOI: 10.4103/jcvjs.jcvjs_112_19] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Accepted: 12/18/2019] [Indexed: 12/03/2022] Open
Abstract
Context: Literature evaluating the efficacy and long-term clinico-radiological outcomes of anterior cervical discectomy and fusion (ACDF) and posterior fixation at C2–C3 for the treatment of unstable hangman's fractures is scanty. Aims: The aim of this study is to compare the efficacy, clinical-radiological outcomes, and complications of ACDF and posterior fixation techniques performed for unstable hangman's fractures. Settings and Design: The study design involves retrospective comparative study. Subjects and Methods: This study conducted from 2012 to 2018 included 21 patients with unstable hangman's fracture (Levine and Edwards Type II, IIa and III). All patients were divided into two groups based on the approach taken for fracture fixation (Group A-anterior approach and Group B-posterior approach). Peri-operative clinical, radiological parameters, postoperative complications, and outcomes were evaluated and compared in both the groups. Statistical Analysis Used: Chi-square test and Student's t-test were used. Results: The mean age was 39.8 ± 4.5 years in-group A and 41.3 ± 6.7 years in-group B. The male patients outnumbered the female patients and road traffic accident was the most common cause of unstable fractures. There were statistical significant differences in surgical time (P = 0.15), operative blood loss, pain-free status postsurgery, and hospital stay (P = 0.15) between two groups. No statistically significant differences noted in clinic-radiological outcomes in the form of visual analog scale and fusion rate at final follow-up between two groups at final follow-up. Conclusions: The unstable hangman's fractures can be effectively managed with both anterior and posterior approaches with comparable clinico-radiological outcome. A minimally invasive nature, earlier pain-free status, early mobilization with reduced hospitalization make the ACDF efficacious, particularly in cases with no medullary canal in C2 pedicles and traumatic C2–3 disc herniation with listhesis compressing the spinal cord.
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Affiliation(s)
| | - Vishal G Kundnani
- Bombay Hospital and Medical Research Centre, Mumbai, Maharashtra, India
| | - Suraj Kuriya
- Department of Spine, Mumbai Institute of Spine Surgery, Bombay Hospital and Medical Research Centre, Mumbai, Maharashtra, India
| | - Saijyot Raut
- Bombay Hospital and Medical Research Centre, Mumbai, Maharashtra, India
| | - Mohit Meena
- Bombay Hospital and Medical Research Centre, Mumbai, Maharashtra, India
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Schonauer C, Tessitore E, de Falco R, Maione M, Certo F, Barbagallo G. Surgical Decision-Making in Cranio-Vertebral Junction Trauma: A Case Illustrated Chapter. SURGERY OF THE CRANIO-VERTEBRAL JUNCTION 2020:319-326. [DOI: 10.1007/978-3-030-18700-2_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
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12
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Yang Y, Dai L, Ma L, Gao X, Liu H. Incidence of dysphagia and dysphonia after Hangman's fractures: Evidence from 93 patients. Medicine (Baltimore) 2018; 97:e13552. [PMID: 30544470 PMCID: PMC6310564 DOI: 10.1097/md.0000000000013552] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
This research aims to explore the accurate incidence, severity and outcomes of dysphagia and dysphonia after Hangman fractures.A total of 93 patients were included in this study and clinical data were reviewed. The Bazaz grading system (0-None; 1-Mild; 2-Moderate; 3-Severe) was used for dysphagia evaluation and the Voice Handicap Index-10 used to evaluate dysphonia. In all of the patients, evaluation of dysphagia and dysphonia was performed preoperatively and at 1 week, 1 month, 3, 6, and 12 months after surgery. SPSS 22.0 software (SPSS Inc, Chicago, IL) was used for all statistical analyses.Posttraumatic immediate dysphagia was found in 8 patients and posttraumatic immediate dysphonia was observed in 3 patients. The incidence of dysphagia was 22.6% at the 1st week, 16.1% at the 1st month, and 9.7% at the 3rd month of follow-up. The incidence of dysphonia was 24.5% at the 1st week, 11.3% at the 1st month, and 3.8% at the 3rd month of follow-up.Posttraumatic immediate dysphagia and dysphonia occurred and the anterior surgical approach was associated with a higher incidence of dysphagia compared to posterior surgery and nonoperative patients. Most dysphagia and dysphonia were mild and gradually decreased during the subsequent 3 months after surgery. Future prospective, randomized studies with larger sample sizes are required to validate these data.
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Affiliation(s)
- Yi Yang
- Department of Orthopedics, West China Hospital
| | - Lijuan Dai
- College of Computer Science, Sichuan University, Chengdu, Sichuan Province, China
| | - Litai Ma
- Department of Orthopedics, West China Hospital
| | - Xinlin Gao
- Department of Orthopedics, West China Hospital
| | - Hao Liu
- Department of Orthopedics, West China Hospital
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Soliman MAR, Kwan BYM, Jhawar BS. Minimally Invasive Unilateral Percutaneous Transfracture Fixation of a Hangman's Fracture Using Neuronavigation and Intraoperative Fluoroscopy. World Neurosurg 2018; 122:90-95. [PMID: 30391610 DOI: 10.1016/j.wneu.2018.10.140] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Revised: 10/20/2018] [Accepted: 10/22/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Traumatic spondylolisthesis or hangman's fracture is a common cervical spine fracture. Most cases of traumatic spondylolisthesis are treated nonoperatively with external immobilization. The indications for surgery have generally included fracture instability or failed nonoperative management. Operative stabilization can be performed through either anterior or posterior approaches and has generally required instrumentation using open methods. We propose a technique for surgical repair of hangman's fracture that is minimally invasive and motion preserving using recent advances in 3-dimensional image-guidance technology. We believe this method represents another option in the treatment of hangman's fractures, because it allows for immediate stabilization, prompt recovery, and quick mobilization. CASE DESCRIPTION We present the case of 2 patients with hangman's fractures who had undergone surgical unilateral transfixation with minimally invasive percutaneous screw placement. In both cases, we used 3-dimensional neuronavigation and bidirectional intraoperative fluoroscopy. The operative time from incision to closure was <30 minutes. Preparation and positioning after intubation varied from 40 to 150 minutes. No intraoperative complications occurred. Both patients were discharged within 48 hours postoperatively. The follow-up examinations at 3 months, 12 months, and 5 years revealed healthy bony fusion on computed tomography imaging and an excellent clinical recovery. CONCLUSION We have provided 2 examples in which minimally invasive unilateral fixation of hangman's fractures proved to be safe and effective. In both cases, the patients were immediately relieved of their pain, quickly mobilized, and promptly discharged. The achievement of successful fusion confirmed at the follow-up examinations.
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Affiliation(s)
| | - Benjamin Y M Kwan
- Department of Neurosurgery, Windsor Regional Hospital, Western University, Windsor, Ontario, Canada
| | - Balraj S Jhawar
- Department of Neurosurgery, Windsor Regional Hospital, Western University, Windsor, Ontario, Canada
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Scholz M, Kandziora F, Kobbe P, Matschke S, Schleicher P, Josten C. Treatment of Axis Ring Fractures: Recommendations of the Spine Section of the German Society for Orthopaedics and Trauma (DGOU). Global Spine J 2018; 8:18S-24S. [PMID: 30210957 PMCID: PMC6130108 DOI: 10.1177/2192568217745061] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
STUDY DESIGN Narrative literature review and expert recommendation. OBJECTIVE To establish treatment recommendations for axis ring fractures based on the knowledge of the experts of the Spine Section of the German Society for Orthopaedics and Trauma. METHODS This recommendation summarizes the knowledge of the experts of the Spine Section of the German Society for Orthopaedics and Trauma with regard to the treatment of axis ring fractures based on a narrative literature review. RESULTS Typical "hangman's fractures" with bilateral separation of the neural arch from C2 and atypical "hangman's fractures" with irregular fracture morphology are described. Computed tomography is the "gold" standard used to detect and analyse these fractures adequately. Furthermore, the detection of vertebral artery integrity is necessary. To classify axis ring fractures, the Levine-Edwards or Josten classification is recommended. In particular, the integrity of the C2/3 disc and the integrity of the anterior longitudinal ligament are used to determine the treatment strategy. While Levine-Edwards type I and type IIA (Josten type 1 and 2) fractures should be treated conservatively, Levine type II and type III (Josten type 3 and 4) fractures should be treated operatively. Levine-Edwards type II fractures will be predominately treated by anterior C2/3 fusion. Levine-Edwards type III fractures have to be primary reduced, if an anterior fusion is planned (anterior cervical discectomy and fusion [ACDF] C2/3). If a closed reduction of a type III fracture is impossible, an open reduction and posterior fixation/fusion is the treatment of choice. CONCLUSION Conservative treatment is predominantly reserved for Levine-Edwards I and IIA fractures. Operative treatment should be performed in case of Levine-Edwards II and III fractures.
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Affiliation(s)
- Matti Scholz
- BG Unfallklinik Frankfurt am Main gGmbH, Frankfurt am Main, Germany,Matti Scholz, BG Unfallklinik Frankfurt am Main gGmbH, Friedberger Landstraße 430, 60389 Frankfurt am Main, Germany.
| | - Frank Kandziora
- BG Unfallklinik Frankfurt am Main gGmbH, Frankfurt am Main, Germany
| | | | - S. Matschke
- BG Klinik Ludwigshafen, Ludwigshafen, Germany
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Abstract
Cervical spine injuries are frequent and often caused by a blunt trauma mechanism. They can have severe consequences, with a high mortality rate and a high rate of neurological lesions.Diagnosis is a three-step process: 1) risk assessment according to the history and clinical features, guided by a clinical decision rule such as the Canadian C-Spine rule; 2) imaging if needed; 3) classification of the injury according to different classification systems in the different regions of the cervical spine.The urgency of treatment is dependent on the presence of a neurological lesion and/or instability. The treatment strategy depends on the morphological criteria as defined by the classification. Cite this article: EFORT Open Rev 2018;3 DOI: 10.1302/2058-5241.3.170076.
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Affiliation(s)
- Philipp Schleicher
- Zentrum für Wirbelsäulenchirurgie und Neurotraumatologie, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Germany
| | - Andreas Pingel
- Zentrum für Wirbelsäulenchirurgie und Neurotraumatologie, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Germany
| | - Frank Kandziora
- Zentrum für Wirbelsäulenchirurgie und Neurotraumatologie, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Germany
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16
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Intraoperative Navigation Is Associated with Reduced Blood Loss During C1-C2 Posterior Cervical Fixation. World Neurosurg 2017; 107:574-578. [PMID: 28842229 DOI: 10.1016/j.wneu.2017.08.051] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2017] [Revised: 08/08/2017] [Accepted: 08/10/2017] [Indexed: 01/29/2023]
Abstract
OBJECTIVE Traumatic injuries, degenerative/rheumatologic conditions, tumors, or infections of the upper cervical spine may in certain circumstances require surgical stabilization. C1 lateral mass screws (Harms technique) in combination with C2 instrumentation (pars, pedicle, translaminar screws) have become a mainstay of surgical treatment. The surgical anatomy of the C1 lateral mass can be challenging especially with the robust venous plexus that often causes significant bleeding with exposure of the C1-C2 articular complex. The purpose of this study was to examine whether the use of navigation reduced intraoperative blood loss during atlantoaxial fixation. METHODS We reviewed our institutional experience with atlantoaxial instrumentation with and without navigation from 2007 to 2016. We limited our cases to those requiring C1-C2 stabilization in traumatic and degenerative cases and not as part of more extensive surgical stabilizations. We identified 45 consecutive patients and compared intraoperative blood loss, need for transfusion, and time of procedure with and without the use of navigation. RESULTS There was a significant reduction in the amount of intraoperative blood loss in the navigated (n = 20) versus non-navigated cases (n = 25). In addition, although the navigated cases initially were longer, currently there is no significant difference in the length of the cases. CONCLUSIONS In our series, surgical navigation significantly reduced blood loss compared with non-navigated cases without increasing surgical time or risk of complication. Furthermore, navigation has the potential to reduce operative times due to a reduction in blood loss.
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Radovanovic I, Urquhart JC, Rasoulinejad P, Gurr KR, Siddiqi F, Bailey CS. Patterns of C-2 fracture in the elderly: comparison of etiology, treatment, and mortality among specific fracture types. J Neurosurg Spine 2017; 27:494-500. [PMID: 28820364 DOI: 10.3171/2017.3.spine161176] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Previous studies have focused on Type II odontoid fractures and have failed to report on the effect of other C-2 fracture types on treatment and outcome. The purpose of this study was to compare patient characteristics, cause of injury, predisposing factors to fracture, treatments, and mortality rates among C-2 fracture types in a cohort of elderly patients 70 years of age and older. METHODS A retrospective cohort study design was used. Patients who sustained a C-2 fracture between 2002 and 2011 and who were admitted to the authors' Level 1 trauma center were identified using the Discharge Abstract Database and the International Statistical Classification of Diseases and Related Health Problems (ICD-10) code S12.1. Fractures were classified as odontoid Type I, II, or III; hangman's; C-2 complex (hangman's appearance on sagittal images, Type III odontoid on coronal cuts); and other (miscellaneous). Age, sex, predisposing factors to falls, cause of injury, treatment, presence of autofusion in the subaxial cervical spine, and mortality rates were compared between fracture patterns. RESULTS One hundred forty-one patients were included; their mean age was 82 years. Fractures included Type II odontoid (57%), complex (19%), Type III odontoid (11%), hangman's (8%), and other (5%). Falls from a standing height accounted for 47% of injuries, and 65% of patients had ≥ 3 risk factors for falls. Subaxial autofusion was more common in odontoid fractures (p = 0.002). Treatment was mainly nonoperative (p < 0.0001). The 1-year mortality rate was 27%. Four patients died of spinal cord injury. CONCLUSIONS Although not as common as Type II odontoid fractures, other C-2 fractures including hangman's, complex, and Type III odontoid fractures accounted for close to half of the injuries in the study cohort. There were few differences between the fracture types with respect to cause of injury, predisposing factors, or mortality rate. However, surgical treatment was more common for Type II odontoid fractures.
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Affiliation(s)
- Ingrid Radovanovic
- Division of Orthopaedics, Department of Surgery, Schulich School of Medicine and Dentistry, The University of Western Ontario.,London Health Sciences Center, London, Ontario, Canada
| | - Jennifer C Urquhart
- Lawson Health Research Institute; and.,London Health Sciences Center, London, Ontario, Canada
| | - Parham Rasoulinejad
- Division of Orthopaedics, Department of Surgery, Schulich School of Medicine and Dentistry, The University of Western Ontario.,London Health Sciences Center, London, Ontario, Canada
| | - Kevin R Gurr
- Division of Orthopaedics, Department of Surgery, Schulich School of Medicine and Dentistry, The University of Western Ontario.,London Health Sciences Center, London, Ontario, Canada
| | - Fawaz Siddiqi
- Division of Orthopaedics, Department of Surgery, Schulich School of Medicine and Dentistry, The University of Western Ontario.,London Health Sciences Center, London, Ontario, Canada
| | - Christopher S Bailey
- Division of Orthopaedics, Department of Surgery, Schulich School of Medicine and Dentistry, The University of Western Ontario.,London Health Sciences Center, London, Ontario, Canada
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18
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Zeden JP, Müller JU, El Refaee EAM, Schroeder HWS, Pillich DT. Neuronavigation and 3D fluoroscopy-guided lag screw reduction and osteosynthesis for traumatic spondylolistheses of the axis: a path worth exploring? Neurosurg Focus 2017; 43:E2. [PMID: 28760039 DOI: 10.3171/2017.5.focus17201] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE In traumatic spondylolistheses of the axis, there is a marked heterogeneity of the observed injury patterns, with a wide range of the severity-from stable fractures, which can be treated conservatively with very good success, to highly unstable fractures, which should be treated surgically. A number of classification systems have been devised to assess the instability of the injuries and to derive a corresponding therapy recommendation. In particular, the results and recommendations regarding medium-severity cases are still inconclusive. Minimally invasive percutaneous procedures performed using modern techniques such as 3D fluoroscopy and neuronavigation have the potential for improvements in the therapeutic outcome and procedural morbidity against open surgical procedures and conservative therapy. METHODS A minimally invasive method using 3D fluoroscopy and neuronavigation for percutaneous lag screw osteosynthesis of the pars interarticularis was performed in 12 patients with a Levine-Edwards Type II fracture. Ten patients had an isolated hangman's fracture and 2 patients had an additional odontoid fracture of the axis (Type II according to the Anderson and D'Alonzo classification system). Complications, operating parameters, screw positions, and bony fusion were evaluated for the description and evaluation of the technique. RESULTS In 6 men and 6 women, percutaneous lag screw osteosynthesis was performed successfully. Correct placement could be verified postoperatively for all inserted screws. In the case series, nonunion was not observed. In all patients with a complete follow-up, a bony fusion, an intact vertebral alignment, and no deformity could be detected on CT scans obtained after 3 months. CONCLUSIONS The percutaneous pars interarticularis lag screw osteosynthesis is a minimally invasive and mobility-preserving surgical technique. Its advantages over alternative methods are its minimal invasiveness, a shortened treatment time, and high fusion rates. The benefits are offset by the risk of injury to the vertebral arteries. The lag screw osteosynthesis is only possible with Levine-Edwards Type II fractures, because the intervertebral joints to C-3 are functionally preserved. A further development and evaluation of the operative technique as well as comparison with conservative and alternative surgical treatment options are deemed necessary.
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Affiliation(s)
- Jan-Philip Zeden
- Department of Neurosurgery, University Medicine Greifswald, Germany; and
| | - Jan-Uwe Müller
- Department of Neurosurgery, University Medicine Greifswald, Germany; and
| | - Ehab Ahmed Mohamed El Refaee
- Department of Neurosurgery, University Medicine Greifswald, Germany; and.,Department of Neurosurgery, Cairo University, Cairo, Egypt
| | | | - Dirk T Pillich
- Department of Neurosurgery, University Medicine Greifswald, Germany; and
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19
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The spectrum of traumatic injuries at the craniocervical junction: a review of imaging findings and management. Emerg Radiol 2017; 24:377-385. [DOI: 10.1007/s10140-017-1490-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2016] [Accepted: 02/14/2017] [Indexed: 12/15/2022]
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20
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Taif S, Menon VK, Alrawi A, Alnuaimi AS, Mollahalli KK, Al Ghafri K. Imaging findings of flexion type of hangman's fracture; an attempt for a more objective evaluation with newly introduced scoring system. Br J Radiol 2016; 90:20160793. [PMID: 27885837 DOI: 10.1259/bjr.20160793] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE To identify the flexion type of hangman's fracture on imaging studies. METHODS 38 cases of hangman's fracture were retrospectively studied and categorized into flexion and non-flexion groups. Plain radiograph, CT and MRI of these patients were evaluated; 13 radiological parameters that might define flexion injuries were measured. The data were statistically analyzed to identify good criteria and to rank them according to their importance in predicting flexion. RESULTS Seven radiological criteria that have the highest correlation with flexion injury were identified. These are C2-3 lower end-plate angle, C2-3 posterior body angle, interspinous angle, disc disruption (MRI), widening of interspinous distance, disruption of the posterior ligamentous complex (MRI) and angle at the fracture site. Scoring 1 point for each positive criterion, a total score of 4 predicts flexion injury with 100% sensitivity and 96.9% specificity. Score of 5 has 83.3% sensitivity and 100% specificity. CONCLUSION Flexion hangman's injury can be diagnosed by the presence of four out of seven radiological criteria in the newly introduced scoring system. The authors believe that this method may help spinal surgeons in their selection of therapeutic strategy. Advances in knowledge: This study introduces fast, simple and more objective imaging criteria for the diagnosis of flexion hangman's injury and separates it from the non-flexion pattern.
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Affiliation(s)
- Sawsan Taif
- 1 Department of Radiology, Khoula Hospital, Muscat, Oman
| | | | - Asif Alrawi
- 3 James Cook University Hospital, South Tees Hospital, NHS, Middlesbrough, UK
| | - Ahmed S Alnuaimi
- 4 Department of Community Medicine, Baghdad College of Medicine, Baghdad, Iraq
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21
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Abstract
A fracture through the pars interarticularis of the axis is colloquially known as the ‘hangman’s fracture’. The origin of the name is self-explanatory; however, in modern times the hangman’s fracture is rarely seen in suicide by hanging. This short article aimed at the non-spinal surgeon will take the reader through a brief timeline from the days of capital punishment to the modern day road traffic collision and the management of the hangman’s fracture.
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Affiliation(s)
| | | | - K Porter
- Major Trauma Service, Queen Elizabeth Hospital Birmingham, UK
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22
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Pesce A, Frati A, Caruso R, Wierzbicki V, Raco A. Morgagni Spine Fractures-Dislocations per Anatomen Indagatis: Since the Dawn of Modern Medicine A Taxonomy and Pathomorphology Problem. World Neurosurg 2016; 96:171-176. [PMID: 27609446 DOI: 10.1016/j.wneu.2016.08.115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2016] [Revised: 08/23/2016] [Accepted: 08/26/2016] [Indexed: 11/17/2022]
Abstract
The aim of this study is to retrieve and bring back to light a part of the astonishing and painstaking work of the legendary Italian father of modern pathology Giovanni Battista Morgagni, concerning one of most discussed topics in spine surgery: spine fractures-dislocations. All the excerpts selected for this study are contained in De sedibus et causis morborum per anatomen indagatis, the summa maxima of the entire production of Morgagni. This treatise encloses the enormous experience of Morgagni in anatomic dissections and pathologic investigations. With the aid of a strict dissection and description methodology, Morgagni identified and described many of the most important aspects of spinal fractures-dislocations, from the importance of the mechanism of injury, to the relevance of ligamentous complex, or the risk of posttraumatic kyphosis and the clinical expression of spinal cord injury.
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Affiliation(s)
- Alessandro Pesce
- A.O. "Sant'Andrea", Neurosurgery Division, Rome, Italy; NESMOS Department, "Sapienza" University, Rome, Italy.
| | - Alessandro Frati
- NESMOS Department, "Sapienza" University, Rome, Italy; IRCCS "Neuromed", Pozzilli, Isernia, Italy
| | - Riccardo Caruso
- NESMOS Department, "Sapienza" University, Rome, Italy; Rome Army Hospital "Celio", Neurosurgery Division, Dipartimento Scienze Neurosensoriali, Rome, Italy
| | - Venceslao Wierzbicki
- Rome Army Hospital "Celio", Neurosurgery Division, Dipartimento Scienze Neurosensoriali, Rome, Italy
| | - Antonino Raco
- A.O. "Sant'Andrea", Neurosurgery Division, Rome, Italy; NESMOS Department, "Sapienza" University, Rome, Italy
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23
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Wang JH, Daniels AH, Palumbo MA, Eberson CP. Cervical Traction for the Treatment of Spinal Injury and Deformity. JBJS Rev 2016; 2:01874474-201405000-00004. [PMID: 27500609 DOI: 10.2106/jbjs.rvw.m.00108] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Joanne H Wang
- Hasbro Children's Hospital, 2 Dudley Street, Suite 200, Providence, RI, 02903
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Abstract
Study Design Retrospective study of a prospectively maintained database. Objective Our aim was to retrospectively review management and outcomes of patients with low-grade hangman's fractures, specifically looking at differences in outcomes between collars and halo immobilization. We also studied fracture patterns and their treatment outcomes. Methods Forty-one patients with hangman's fractures were identified from 105 patients with axis fractures between 2007 and 2013. Typical hangman's fractures were defined as traumatic spondylolisthesis of the axis causing a bilateral pars interarticularis fracture. Fractures involving the posterior cortex of C2 on one or both sides or an asymmetrical pattern were defined as atypical. Results There were 41 patients with a mean age of 59 years, with 13 (31.7%) typical and 28 (68.2%) atypical fractures. There were 22 (53.6%) type 1 fractures, 7 (41.4%) type 2 fractures, and 2 (4.9%) type 2a fractures in this series. Cervical collars were used to manage 11 patients (27% of all patients with hangman's fractures) and halo orthosis was used in 27 (65.8%). Three (7.3%) patients underwent surgical fixation of the fracture. Bony union was achieved in all patients on radiologic follow-up. Permanent neurologic deficit occurred in one patient due to associated injuries. Neck pain and stiffness were reported more commonly in the atypical group, but this finding was not statistically significant. Conclusions The majority of hangman type fractures can be treated nonoperatively. We found no difference in outcomes between a rigid collar or halo immobilization for treatment of low-grade fractures. Radiologic follow-up is essential to identify cases of nonunion.
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Abstract
Acute management of hangman fracture is well described; however the surgical management of neglected hangman fracture has not been described in literature. We report the surgical management of an untreated hangman's fracture. A 30-year-old male had fallen from a tree 12 weeks back. Patient presented with cervical myelopathy and restricted neck movements. Radiographs and computed tomography (CT) scan revealed fracture of pars interarticularis of axis with Grade III C2-C3 spondylolisthesis with localized kyphosis of 33°. Gentle reduction under general anesthesia (GA) failed to improve the alignment. Patient was operated in three stages in a single setting. In Stage I, release of contracted anterior structures and C2-C3 discectomy was done in supine position followed by C2-C3 posterior fixation and fusion in Stage II. C2-C3 interbody bone grafting and anterior plating completed the third stage. C2-C3 interbody fusion was seen at 5 months and a CT scan at 18 months postoperative confirmed fusion and maintenance of alignment. The satisfactory outcome in our patient leads us to believe that anterior-posterior-anterior is the appropriate surgical approach for treatment of such patients.
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Affiliation(s)
- Sudhir Kumar Srivastava
- Department of Orthopaedics, Seth G.S. Medical College and K.E.M Hospital, Parel, Mumbai, Maharashtra, India
| | - Rishi Anil Aggarwal
- Department of Orthopaedics, Seth G.S. Medical College and K.E.M Hospital, Parel, Mumbai, Maharashtra, India
| | - Pradip Sharad Nemade
- Department of Orthopaedics, Seth G.S. Medical College and K.E.M Hospital, Parel, Mumbai, Maharashtra, India
| | - Sunil Krishna Bhoale
- Department of Orthopaedics, Seth G.S. Medical College and K.E.M Hospital, Parel, Mumbai, Maharashtra, India
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26
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Menon KV, Taif S. Detailed description of anatomy of the fracture line in hangman's injury: a retrospective observational study on motor vehicle accident victims. Br J Radiol 2015; 89:20150847. [PMID: 26607649 DOI: 10.1259/bjr.20150847] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE To study the precise location of fracture line in hangman's fracture to determine the fracture patterns, symmetry and involvement of different vertebral elements. METHODS 32 cases of hangman's fractures were retrospectively evaluated. All patients presented with motor vehicle accidents. CT scans were studied to accurately localize the fracture lines. Symmetry of fracture lines on both sides was assessed, and involvement of the vertebral bodies, lamina, facet joints and foramen transversarium was also determined. RESULTS 20 patients showed asymmetric fracture locations, 13 of them had a unilateral pedicle fracture and a contralateral pars fracture which comprised the most common injury pattern (40% of cases). Less frequent combinations for the two sides of asymmetric C2 ring disruption include pars-vertebral body (3 patients), pedicle-vertebral body (2 patients) and pedicle-lamina (2 patients). 12 patients showed symmetrical fractures (5 through the pars and 7 through the pedicles). Vertebral body and facet joint involvement were demonstrated in 15 (47%) and 16 (50%) cases, respectively. 18 cases had fractures extending into the foramen transversarium (56%). In total, 26 fracture lines primarily affected the pars (40%) and 31 affected the pedicles (49%). CONCLUSION Asymmetric hangman's fracture is more common with the usual pattern being fracture pedicle on one side and pars on the other followed by the symmetric bilateral pedicle and bilateral pars fractures. Fracture lines running into the transverse foramen and facet joints are very frequent as well as those involving the vertebral bodies. ADVANCES IN KNOWLEDGE There is controversy in literature regarding the fracture locations in hangman's injury owing to lack of studies that address this subject. This article is the first to describe precisely the anatomical locations and patterns of this injury.
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Affiliation(s)
- K Venugopal Menon
- 1 Orthopaedics Department, Khoula Hospital, Mina al Fahal, Muscat, Sultanate of Oman
| | - Sawsan Taif
- 2 Department of Radiology, Khoula Hospital, Mina al Fahal, Muscat, Sultanate of Oman
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27
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Iizuka H, Tomomatsu Y, Sorimachi Y, Ara T, Mieda T, Iizuka Y, Takagishi K. Clinical findings of conservative cases with a coronally oriented vertical fracture of the posterior region of the C2 vertebral body. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2015; 25:110-114. [DOI: 10.1007/s00586-015-4187-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/09/2015] [Revised: 08/05/2015] [Accepted: 08/06/2015] [Indexed: 12/29/2022]
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Abstract
Study Design Narrative review. Objective To elucidate the current concepts in diagnosis and treatment of traumatic spondylolisthesis of the axis. Methods Literature review using PubMed, Google Scholar, and Cochrane databases. Results The traumatic spondylolisthesis of the axis accounts to 5% of all cervical spine injuries and is defined by a bilateral separation of the C2 vertebral body from the neural arch. The precise location of the fracture line may vary widely. For understanding the pathobiomechanics, the involvement of the C2-C3 disk is essential. Although its synonym "hangman's fracture" suggests an extension moment as primary injury mechanism, flexion moments are also proven to cause such fracture morphology. The axial force vector (distraction versus compression) is thought to have a significant effect on the neurologic involvement. The most widely accepted classifications, according to Effendi and modified by Levine, regard the displacement of the C2 vertebral body and possible locking of the facet joints. For decisions on conservative versus surgical therapy, a definitive statement about the stability is essential. The stability is determined by involvement of the C2-C3 disk and longitudinal ligaments, which frequently cannot be assessed by X-ray or computed tomography alone. The assessment of this soft tissue injury therefore requires additional imaging either by magnetic resonance imaging to display the disk and longitudinal ligaments or dynamic fluoroscopy to assess functional behavior of the C2-C3 motion segment. If stability is proven, an immobilization of the cervical spine in a semirigid cervical collar is sufficient. Unstable lesions require surgical stabilization. The standard procedure is an anterior C2-C3 diskectomy and fusion, because of the lower morbidity of the anterior approach and the motion preservation between C1 and C2. In rare cases (irreducible locked facet joints, the necessity of decompression of the vertebral artery, contraindication for anterior approach), a posterior approach is sometimes necessary. Isolated direct screw osteosynthesis is of little value, because it only makes sense in cases with an intact C2-C3 disk, which is usually regarded as stable and therefore might be treated conservatively. Conclusions Overall, the clinical evidence regarding traumatic spondylolisthesis of the axis is very low and mainly based on small case series, expert opinion, laboratory findings, and theoretical considerations.
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Affiliation(s)
- Philipp Schleicher
- Zentrum für Wirbelsäulenchirurgie und Neurotraumatologie, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Frankfurt am Main, Germany,Address for correspondence Dr. med. Philipp Schleicher Zentrum für Wirbelsäulenchirurgie und NeurotraumatologieBerufsgenossenschaftliche Unfallklinik Frankfurt am MainFriedberger Landstrasse 430, 60389 Frankfurt am MainGermany
| | - Matti Scholz
- Zentrum für Wirbelsäulenchirurgie und Neurotraumatologie, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Frankfurt am Main, Germany
| | - Andreas Pingel
- Zentrum für Wirbelsäulenchirurgie und Neurotraumatologie, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Frankfurt am Main, Germany
| | - Frank Kandziora
- Zentrum für Wirbelsäulenchirurgie und Neurotraumatologie, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Frankfurt am Main, Germany
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Krylov VV, Grin' AA, Lutsik AA, Parfenov VE, Dulaev AK, Manukovskii VA, Konovalov NA, Perl'mutter OA, Safin SM, Kravtsov MN, Manashchuk VI, Rerikh VV. [Recommended protocol for treating complicated and uncomplicated acute spinal injury in adults (Association of Neurosurgeons of Russia). Part 2]. ZHURNAL VOPROSY NEĬROKHIRURGII IMENI N. N. BURDENKO 2015; 79:83-89. [PMID: 25909749 DOI: 10.17116/neiro201579183-89] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- V V Krylov
- Sklifosovsky Research Institute of emergency care, Moscow; Evdokimov Moscow state medical dental University
| | - A A Grin'
- Sklifosovsky Research Institute of emergency care, Moscow; Evdokimov Moscow state medical dental University
| | - A A Lutsik
- Novokuznetsk Academy of Postgraduate Education
| | - V E Parfenov
- Dzhanelidze Research Institute of Emergency Care, St. Petersburg, Russia
| | - A K Dulaev
- Dzhanelidze Research Institute of Emergency Care, St. Petersburg, Russia
| | - V A Manukovskii
- Dzhanelidze Research Institute of Emergency Care, St. Petersburg, Russia
| | | | - O A Perl'mutter
- Nizhegorodsky Research Institute of Traumatology and Orthopedics, Nizhny Novgorod
| | | | | | | | - V V Rerikh
- Novosibirsk research Institute of Traumatology, Orthopedics, Neurosurgery
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The surgical management of traumatic lower cervical spondylolisthesis with posterior percutaneous pedicle screw fixation. Asian Spine J 2015; 9:271-5. [PMID: 25901240 PMCID: PMC4404543 DOI: 10.4184/asj.2015.9.2.271] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2014] [Revised: 09/26/2014] [Accepted: 10/16/2014] [Indexed: 12/03/2022] Open
Abstract
We reported a technical report of traumatic lower cervical spondylolisthesisca used by bilateral pedicle fracture, without neurological compression. The patient was treated with the minimally invasive technique of percutaneous pedicle screw fixation. Fracture healing and normal cervical motion were confirmed by plain films and physical examinations on the 18-monthpostoperatively. The technique of percutaneous pedicle screw fixation might be an alternative strategy for the treatment of traumatic lower cervical spondylolisthesis with pedicle fracture.
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Li Z, Li F, Hou S, Zhao Y, Mao N, Hou T, Tang J. Anterior discectomy/corpectomy and fusion with internal fixation for the treatment of unstable hangman's fractures: a retrospective study of 38 cases. J Neurosurg Spine 2015; 22:387-93. [PMID: 25635631 DOI: 10.3171/2014.11.spine13959] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECT
The object of this study was to describe the authors' method of anterior discectomy/corpectomy and fusion combined with internal fixation for the treatment of unstable hangman's fractures and to evaluate the clinical and radiological outcomes.
METHODS
This study included 38 consecutive patients who underwent surgery for unstable hangman's fractures between July 2002 and October 2011 and were followed up for more than 2 years. The patients were 18 women and 20 men with a mean age of 42.8 years (range 20–69 years). The fracture resulted from a fall in 9 patients, a motor vehicle accident in 21 patients, and a motorcycle accident in 8 patients. The Levine-Edwards classification was Type II in 13 patients, Type IIA in 20 patients, and Type III in 5 patients. All patients underwent anterior C2–3 intervertebral disc excision or C-3 corpectomy, decompression and reduction, interbody implantation of an autologous iliac bone graft, and internal fixation with a titanium plate. Pain was assessed before and after surgery using a visual analog scale (VAS). Myelopathy was graded using the Japanese Orthopaedic Association (JOA) score. Patient satisfaction with the surgery was assessed using Odom's grading system. Anteroposterior, lateral, and dynamic (flexion/extension) radiographs were obtained during the follow-up period. Two-dimensional CT studies with sagittal and coronal reconstructions were routinely performed.
RESULTS
The mean follow-up period was 49.2 months (range 24–132 months). There was a significant decrease between the preoperative and final follow-up VAS scores (mean [SD] 7.56 ± 1.52 vs 2.36 ± 1.25, p < 0.05) and a significant increase between the preoperative and final follow-up JOA scores (12.58 ± 1.34 vs 16.13 ± 1.17, p < 0.05). Postoperative radiographs showed satisfactory reduction of the fracture in all cases. Postoperative complications included transient neurological deficits (3 cases), hematoma (2 cases), temporary dysphagia (5 cases), temporary hoarseness (2 cases), prolonged pain at the iliac crest donor site (4 cases), and wound infection at the iliac crest donor site (2 cases). Solid fusion was achieved in 94.7% of patients at the final follow-up.
CONCLUSIONS
Anterior discectomy/corpectomy and fusion combined with internal fixation is a safe and effective procedure for the treatment of unstable hangman's fractures.
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Affiliation(s)
- Zhonghai Li
- 1Department of Orthopaedics, First Affiliated Hospital of PLA General Hospital, Beijing; and
| | - Fengning Li
- 2Department of Orthopedics, First Affiliated Hospital of PLA Second Military Medical University, Shanghai, The People's Republic of China
| | - Shuxun Hou
- 1Department of Orthopaedics, First Affiliated Hospital of PLA General Hospital, Beijing; and
| | - Yantao Zhao
- 1Department of Orthopaedics, First Affiliated Hospital of PLA General Hospital, Beijing; and
| | - Ningfang Mao
- 2Department of Orthopedics, First Affiliated Hospital of PLA Second Military Medical University, Shanghai, The People's Republic of China
| | - Tiesheng Hou
- 2Department of Orthopedics, First Affiliated Hospital of PLA Second Military Medical University, Shanghai, The People's Republic of China
| | - Jiaguang Tang
- 1Department of Orthopaedics, First Affiliated Hospital of PLA General Hospital, Beijing; and
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Brotis AG, Paraskevi TM, Tsitsopoulos P, Tasiou A, Fotakopoulos G, Fountas KN. An evidence-based approach towards the cranio-cervical junction injury classifications. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2015; 24:931-9. [DOI: 10.1007/s00586-015-3877-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/01/2014] [Revised: 02/07/2015] [Accepted: 03/11/2015] [Indexed: 12/12/2022]
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Joaquim AF, Ghizoni E, Tedeschi H, Yacoub ARD, Brodke DS, Vaccaro AR, Patel AA. Upper cervical injuries: Clinical results using a new treatment algorithm. JOURNAL OF CRANIOVERTEBRAL JUNCTION AND SPINE 2015; 6:16-20. [PMID: 25788816 PMCID: PMC4361833 DOI: 10.4103/0974-8237.151585] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Introduction: Upper cervical injuries (UCI) have a wide range of radiological and clinical presentation due to the unique complex bony, ligamentous and vascular anatomy. We recently proposed a rational approach in an attempt to unify prior classification system and guide treatment. In this paper, we evaluate the clinical results of our algorithm for UCI treatment. Materials and Methods: A prospective cohort series of patients with UCI was performed. The primary outcome was the AIS. Surgical treatment was proposed based on our protocol: Ligamentous injuries (abnormal misalignment, facet perched or locked, increase atlanto-dens interval) were treated surgically. Bone fractures without ligamentous injuries were treated with a rigid cervical orthosis, with exception of fractures in the dens base with risk factors for non-union. Results: Twenty-three patients treated initially conservatively had some follow-up (mean of 171 days, range from 60 to 436 days). All of them were neurologically intact. None of the patients developed a new neurological deficit. Fifteen patients were initially surgically treated (mean of 140 days of follow-up, ranging from 60 to 270 days). In the surgical group, preoperatively, 11 (73.3%) patients were AIS E, 2 (13.3%) AIS C and 2 (13.3%) AIS D. At the final follow-up, the American Spine Injury Association (ASIA) score was: 13 (86.6%) AIS E and 2 (13.3%) AIS D. None of the patients had neurological worsening during the follow-up. Conclusions: This prospective cohort suggested that our UCI treatment algorithm can be safely used. Further prospective studies with longer follow-up are necessary to further establish its clinical validity and safety.
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Affiliation(s)
- Andrei F Joaquim
- Department of Neurosurgery, State University of Campinas, Campinas, São Paulo, Brazil
| | - Enrico Ghizoni
- Department of Neurosurgery, State University of Campinas, Campinas, São Paulo, Brazil
| | - Helder Tedeschi
- Department of Neurosurgery, State University of Campinas, Campinas, São Paulo, Brazil
| | - Alexandre R D Yacoub
- Department of Neurosurgery, State University of Campinas, Campinas, São Paulo, Brazil
| | - Darrel S Brodke
- Department of Orthopaedics, University of Utah, Salt Lake City, Utah, USA
| | - Alexander R Vaccaro
- Department of Orthopaedics, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Alpesh A Patel
- Department of Orthopaedic Surgery, Northwestern University, Chicago, Illinois, USA
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Wei F, Pan X, Zhou Z, Cui S, Zhong R, Wang L, Gao M, Chen N, Liang Z, Zou X, Huang S, Liu S. 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. J Orthop Surg Res 2015; 10:33. [PMID: 25879225 PMCID: PMC4362826 DOI: 10.1186/s13018-015-0164-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2014] [Accepted: 01/14/2015] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND Anterior 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. METHODS From 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. RESULTS The 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. CONCLUSIONS ACDF 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.
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Affiliation(s)
- Fuxin Wei
- Department of Spine Surgery, The First Affiliated Hospital and Orthopedic Research Institute of Sun Yat-sen University, Guangzhou, China.
| | - Ximin Pan
- Department of Radiology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.
| | - Zhiyu Zhou
- Department of Spine Surgery, The First Affiliated Hospital and Orthopedic Research Institute of Sun Yat-sen University, Guangzhou, China. .,The Medical School of Shenzhen University, Shenzhen, China.
| | - Shangbin Cui
- Department of Spine Surgery, The First Affiliated Hospital and Orthopedic Research Institute of Sun Yat-sen University, Guangzhou, China.
| | - Rui Zhong
- Department of Spine Surgery, The First Affiliated Hospital and Orthopedic Research Institute of Sun Yat-sen University, Guangzhou, China.
| | - Le Wang
- Department of Spine Surgery, The First Affiliated Hospital and Orthopedic Research Institute of Sun Yat-sen University, Guangzhou, China.
| | - Manman Gao
- Department of Spine Surgery, The First Affiliated Hospital and Orthopedic Research Institute of Sun Yat-sen University, Guangzhou, China.
| | - Ningning Chen
- Department of Spine Surgery, The First Affiliated Hospital and Orthopedic Research Institute of Sun Yat-sen University, Guangzhou, China.
| | - Zijian Liang
- Department of Spine Surgery, The First Affiliated Hospital and Orthopedic Research Institute of Sun Yat-sen University, Guangzhou, China.
| | - Xuenong Zou
- Department of Spine Surgery, The First Affiliated Hospital and Orthopedic Research Institute of Sun Yat-sen University, Guangzhou, China.
| | - Sheng Huang
- Department of Spine Surgery, The First Affiliated Hospital and Orthopedic Research Institute of Sun Yat-sen University, Guangzhou, China.
| | - Shaoyu Liu
- Department of Spine Surgery, The First Affiliated Hospital and Orthopedic Research Institute of Sun Yat-sen University, Guangzhou, China.
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Anterior Cervical Discectomy and Fusion Versus Posterior Fixation and Fusion of C2–3 for Unstable Hangman’s Fracture. ACTA ACUST UNITED AC 2015; 28:E61-6. [DOI: 10.1097/bsd.0000000000000150] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Krylov VV, Grin AA, Lutsyk AA, Parfenov VE, Dulaev AK, Manukovskiy VA, Konovalov NA, Perl'mutter OA, Safin SM, Kravtsov MN, Manashchuk VI, Rerikh VV. An advisory protocol for treatment of acute complicated and uncomplicated spinal cord injury in adults (association of neurosurgeons of the Russian Federation). Part 3. ZHURNAL VOPROSY NEIROKHIRURGII IMENI N. N. BURDENKO 2015; 79:97-110. [PMID: 26146049 DOI: 10.17116/neiro201579297-110] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Affiliation(s)
- V V Krylov
- Sklifosovsky Research Institute of Emergency Care, Moscow, Russia; Evdokimov Moscow State Medical Dental University, Moscow, Russia
| | - A A Grin
- Sklifosovsky Research Institute of Emergency Care, Moscow, Russia; Evdokimov Moscow State Medical Dental University, Moscow, Russia
| | - A A Lutsyk
- Novokuznetsk Academy of Postgraduate Education, Novokuznetsk, Russia
| | - V E Parfenov
- Dzhanelidze Research Institute of Emergency Care, St. Petersburg, Russia
| | - A K Dulaev
- Dzhanelidze Research Institute of Emergency Care, St. Petersburg, Russia
| | - V A Manukovskiy
- Dzhanelidze Research Institute of Emergency Care, St. Petersburg, Russia
| | | | - O A Perl'mutter
- Nizhegorodsky Research Institute of Traumatology and Orthopedics, Nizhny Novgorod, Russia
| | - Sh M Safin
- National Neurosurgical Centre, Ufa, Russia
| | - M N Kravtsov
- Kirov Military Medical Academy, St. Petersburg, Russia
| | | | - V V Rerikh
- Novosibirsk Research Institute of Traumatology, Orthopedics, Neurosurgery, Novosibirsk, Russia
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Axis ring fractures due to simulated head impacts. Clin Biomech (Bristol, Avon) 2014; 29:906-11. [PMID: 25042350 DOI: 10.1016/j.clinbiomech.2014.06.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2014] [Revised: 06/27/2014] [Accepted: 06/30/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND We investigated mechanisms of axis ring fractures due to simulated head impacts. METHODS Our model consisted of a human upper cervical spine specimen (occiput through C3) mounted to a surrogate torso mass on a sled and carrying a surrogate head. We divided 13 specimens into 3 groups based upon head impact location: upper forehead in the midline, upper lateral side of the forehead, and upper lateral side of the head. Post-impact fluoroscopy and anatomical dissection documented the injuries. Average occurrence times of the peak loads and accelerations were statistically compared (P<0.05) using ANOVA and Bonferroni pair-wise post-hoc tests. FINDINGS Of the 13 upper cervical spines tested, 5 specimens sustained axis ring fractures with the most common mechanism being impact to the upper left lateral side of the forehead. The first local force peaks at the impact barrier and neck and all peak head accelerations occurred between 18.0 and 22.8 ms, significantly earlier than the absolute force peaks. The average peak neck loads reached 1761.2N and the axis ring fractures occurred within 50 ms. INTERPRETATION We observed asymmetrical fractures of the axis ring including fractures of the superior and inferior facets, laminae, posterior wall of the vertebral body, pars interarticularis, and pedicles. The fracture patterns were related to the morphology of the axis as a transitional vertebra of the upper cervical spine. Understanding the mechanisms of axis ring fractures may help in choosing the optimal reduction technique and stabilization method based upon the specific fracture pattern.
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Dalbayrak S, Yaman O. A coinsidence, a chance or a misfortune? Hangman's fracture. Neurol Neurochir Pol 2014; 48:305-7. [DOI: 10.1016/j.pjnns.2014.07.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2014] [Revised: 06/09/2014] [Accepted: 07/02/2014] [Indexed: 11/26/2022]
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Hur H, Lee JK, Jang JW, Kim TS, Kim SH. Is it feasible to treat unstable hangman’s fracture via the primary standard anterior retropharyngeal approach? EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2014; 23:1641-7. [DOI: 10.1007/s00586-014-3311-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/13/2013] [Revised: 03/02/2014] [Accepted: 04/09/2014] [Indexed: 11/30/2022]
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Dalbayrak S, Yaman O, Yılmaz M. A new technique in the surgical treatment of Hangman's fractures: Neurospinal Academy (NSA) technique. JOURNAL OF CRANIOVERTEBRAL JUNCTION AND SPINE 2014; 4:59-63. [PMID: 24744563 PMCID: PMC3980557 DOI: 10.4103/0974-8237.128529] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Context: Treatment of Hangman's fractures is still controversial. Hangman's fractures Type II and IIA are usually treated with surgical procedures. Aim: This study aims at describing the Neurospinal Academy (NSA) technique as an attempt to achieve an approximation of the fracture line to the axis body, which may be used for Type II and IIA patients with severe displacement and angulation. Settings and Design: NSA technique both pars or pedicle screws are placed bicortically to ensure that anterior surface of C2 vertebral body will be crossed 1-2 mm. A rod is prepared in suitable length and curve to connect the two screws. For placing the rod, sufficient amount of bone is resected from the C2 spinous process. C2 vertebral body is pulled back by means of the screws that crossed the anterior surface of C2 vertebral body. Materials and Methods: Hangman II and IIA patient are treated with NSA technique. Result: Angulated and tilted C2 vertebral body was pulled back and approximated to posterior elements. Conclusions: In Hangman's fractures Type II and IIA with severe vertebral body and pedicle displacement, NSA technique is an effective and reliable treatment alternative for the approximation of posterior elements to the C2 vertebral body, which is tilted, angulated, and dislocated.
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Affiliation(s)
- Sedat Dalbayrak
- Department of Neurosurgery, Neurospinal Academy, Istanbul, Turkey
| | - Onur Yaman
- Clinic of Neurosurgery, Tepecik Education and Training Hospital, Izmir, Turkey
| | - Mesut Yılmaz
- Department of Neurosurgery, Neurospinal Academy, Istanbul, Turkey
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Joaquim AF, Ghizoni E, Tedeschi H, Lawrence B, Brodke DS, Vaccaro AR, Patel AA. Upper cervical injuries - a rational approach to guide surgical management. J Spinal Cord Med 2014; 37:139-51. [PMID: 24559418 PMCID: PMC4066422 DOI: 10.1179/2045772313y.0000000158] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
CONTEXT The complex anatomy and the importance of ligaments in providing stability at the upper cervical spine region (O-C1-C2) require the use of many imaging modalities to evaluate upper cervical injuries (UCI). While separate classifications have been developed for distinct injuries, a more practical treatment algorithm can be derived from the injury pattern in UCI. OBJECTIVE To propose a practical treatment algorithm to guide treatment based on injuries characteristic of UCI. METHODS A literature review was performed on the Pubmed database using the following keywords: (1) "occipital condyle injury"; (2) "craniocervical dislocation or atlanto-occipital dislocation or craniocervical dislocation"; (3) "atlas fractures"; and (4) "axis fractures". Just articles containing the diagnosis, classification, and treatment of specific UCI were included. The data obtained were analyzed by the authors, dividing the UCI into two groups: Group 1 - patients with clear ligamentous injury and Group 2 - patients with fractures without ligament disruption. RESULTS Injuries with ligamentous disruption, suggesting surgical treatment, include: atlanto-occipital dislocation, mid-substance transverse ligament injury, and C1-2 and C2-3 ligamentous injuries. In contrast, condyle, atlas, and axis fractures without significant displacement/misalignment can be initially treated using external orthoses. Odontoid fractures with risk factors for non-union are an exception in Group 2 once they are better treated surgically. Patients with neurological deficits may have more unstable injuries. CONCLUSIONS Ascertaining the status of relevant ligamentous structures, fracture patterns and alignment are important in determining surgical compared with non-surgical treatment for patients with UCI.
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Affiliation(s)
- Andrei F. Joaquim
- Department of Neurosurgery, State University of Campinas, UNICAMP, Campinas-SP, Brazil,Correspondence to: Andrei F. Joaquim, Neurosurgery Division, State University of Campinas, 13083-970, Campinas-SP, Brazil. E-mail:
| | - Enrico Ghizoni
- Department of Neurosurgery, State University of Campinas, UNICAMP, Campinas-SP, Brazil
| | - Helder Tedeschi
- Department of Neurosurgery, State University of Campinas, UNICAMP, Campinas-SP, Brazil
| | - Brandon Lawrence
- Department of Orthopaedics, University of Utah, Salt Lake City, UT, USA
| | - Darrel S. Brodke
- Department of Orthopaedics, University of Utah, Salt Lake City, UT, USA
| | | | - Alpesh A. Patel
- Department of Orthopaedic Surgery, Northwestern University, Chicago, IL, USA
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Ferro FP, Borgo GD, Letaif OB, Cristante AF, Marcon RM, Iutaka AS. Traumatic spondylolisthesis of the axis: epidemiology, management and outcome. ACTA ORTOPEDICA BRASILEIRA 2014; 20:84-7. [PMID: 24453586 PMCID: PMC3718423 DOI: 10.1590/s1413-78522012000200005] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/02/2011] [Accepted: 09/05/2011] [Indexed: 01/24/2024]
Abstract
Objective To evaluate cases of traumatic spondylolisthesis of the axis and describe them in
relation to epidemiology, classification, neurological deficit, healing time and
treatment method. Method A retrospective analysis of the medical records of patients treated between 2002 and
2010 at IOT-FMUSP. Inclusion criteria: pars interarticularis fracture of C2. Results 68% were male patients, with a mean age of 39.1 years. We used the classification by
Effendi, modified by Levine-Edwards. Type I fractures were observed in five patients
(31.2%) and type II in eight patients (50%). Only three patients (18%) had type IIa
fracture. There were no cases of type III. Mechanism: Eight car accidents and four
falls. Other mechanisms: being run over, and diving accidents. Treatment with halo
traction was used in eleven patients, using minerva cast and halo-cast. Healing time:
3.6 months. Follow-up time: 9.6 months. Discussion In general, hangman fracture has a good prognosis, which is confirmed by our results.
There was no need for surgery in any of the cases. The incidence of neurological deficit
is low. No patient had unstable fracture (type III). Conclusion This paper suggests that traumatic spondylolisthesis of the axis continues to be an
injury that is successfully treated by conservative treatment in most cases.
Level of Evidence -IV, Case series.
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Krylov VV, Grin' AA, Lutsik AA, Parfenov VE, Dulaev AK, Manukovskiĭ VA, Konovalov NA, Perl'mutter OA, Safin SM, Kravtsov MN, Manashchuk VI, Rerikh VV. [A protocol recommended for treating acute complicated and uncomplicated spinal injuries in adult patients (Association of Neurosurgeons of Russia). Part 1]. ZHURNAL VOPROSY NEIROKHIRURGII IMENI N. N. BURDENKO 2014; 78:60-67. [PMID: 25809171 DOI: 10.17116/neiro201478660-67] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- V V Krylov
- NII skoroĭ pomoshchi im. N.V. Sklifosovskogo, Moskva; Moskovskiĭ gosudarstvennyĭ mediko-stomatologicheskiĭ universitet im. A.I. Evdokimova
| | - A A Grin'
- NII skoroĭ pomoshchi im. N.V. Sklifosovskogo, Moskva; Moskovskiĭ gosudarstvennyĭ mediko-stomatologicheskiĭ universitet im. A.I. Evdokimova
| | - A A Lutsik
- Novokuznetskaia akademiia poslediplomnogo obrazovaniia
| | - V E Parfenov
- NII skoroĭ pomoshchi im. I.I. Dzhanelidze, Sankt-Peterburg
| | - A K Dulaev
- NII skoroĭ pomoshchi im. I.I. Dzhanelidze, Sankt-Peterburg
| | | | - N A Konovalov
- NII neĭrokhirurgii im. akad. N.N. Burdenko RAMN, Moskva
| | - O A Perl'mutter
- Nizhegorodskiĭ NII travmatologii i ortopedii, Nizhniĭ Novgorod
| | - Sh M Safin
- Respublikanskiĭ neĭrokhirurgicheskiĭ tsentr, Ufa
| | - M N Kravtsov
- Voenno-meditsinskaia akademiia im. S.M. Kirova, Sankt-Peterburg
| | | | - V V Rerikh
- Novosibirskiĭ NII travmatologii, ortopedii, neĭrokhirurgii
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Fogeltanz KA, Ditty MD, Pursel KJ. Hangman’s fracture presenting to chiropractic clinic as benign neck pain: a case report. J Chiropr Med 2013; 12:201-6. [DOI: 10.1016/j.jcm.2013.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2012] [Revised: 07/16/2013] [Accepted: 08/15/2013] [Indexed: 11/16/2022] Open
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Ryken TC, Hadley MN, Aarabi B, Dhall SS, Gelb DE, Hurlbert RJ, Rozzelle CJ, Theodore N, Walters BC. Management of Isolated Fractures of the Axis in Adults. Neurosurgery 2013; 72 Suppl 2:132-50. [DOI: 10.1227/neu.0b013e318276ee40] [Citation(s) in RCA: 71] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Affiliation(s)
- Timothy C. Ryken
- Iowa Spine & Brain Institute, University of Iowa, Waterloo/Iowa City, Iowa
| | - Mark N. Hadley
- Division of Neurological Surgery and Children's Hospital of Alabama, University of Alabama at Birmingham, Birmingham, Alabama
| | - Bizhan Aarabi
- Department of Neurosurgery and University of Maryland, Baltimore, Maryland
| | - Sanjay S. Dhall
- Department of Neurosurgery, Emory University, Atlanta, Georgia
| | - Daniel E. Gelb
- Department of Orthopaedics, University of Maryland, Baltimore, Maryland
| | - R. John Hurlbert
- Department of Clinical Neurosciences, University of Calgary Spine Program, Faculty of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Curtis J. Rozzelle
- Division of Neurological Surgery, Children's Hospital of Alabama, University of Alabama at Birmingham, Birmingham, Alabama
| | - Nicholas Theodore
- Division of Neurological Surgery, Barrow Neurological Institute, Phoenix, Arizona
| | - Beverly C. Walters
- Department of Neurosciences, Inova Health System, Falls Church, Virginia
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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 2013; 5:667-672. [PMID: 23408668 PMCID: PMC3570178 DOI: 10.3892/etm.2013.898] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2012] [Accepted: 01/04/2013] [Indexed: 11/15/2022] Open
Abstract
The present study aimed to evaluate the effect of using one-stage posterior C2 and C3 pedicle screw fixation or combined anterior C2-C3 fusion in the treatment of unstable hangman’s fracture. A total of 13 patients with unstable hangman’s fractures underwent C2 and C3 pedicle screw fixation, lamina interbody fusion or combined anterior C2-C3 fusion and imaging examinations to evaluate the fracture fixation and healing condition at three days and three months following surgery. Postoperative X-ray and computed tomography (CT) results showed high fracture reduction, good internal fixation position and reliable fracture fixation. The three-month postoperative CT showed good vertebral fracture healing. C2 and C3 pedicle screw fixation has a good curative effect in the treatment of unstable hangman’s fracture. The direct fixation of the fracture enables early ambulation by the patients.
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Affiliation(s)
- Jingchen Liu
- Department of Spine Surgery, The First Hospital of Jilin University, Changchun, Jilin 130021, P.R. China
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Wang C, Ma H, Yuan W, Wang X, Chen H, Wu X. Anterior C3 corpectomy and fusion for complex Hangman's fractures. INTERNATIONAL ORTHOPAEDICS 2012. [PMID: 23180098 DOI: 10.1007/s00264-012-1703-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
PURPOSE The aim of this study was to assess the effectiveness and feasibility of anterior C3 corpectomy and fusion with screw-plate fixation of C2-4 for the treatment of Hangman's fracture in which spinal cord compression comes from the posterosuperior part of C3 vertebral body and the intervertebral disc injury at the C2-3 level. METHODS From August 2000 to December 2005, 11 patients (eight males and three females) with traumatic spondylolisthesis of the axis underwent the above surgery. Neurological status was evaluated by the Japanese Orthopaedic Association Score (JOA score). The fusion of the graft, healing of the fracture, and range of motion of the whole cervical spine were examined according to X-ray imaging. RESULTS No patient received blood transfusion. There was no deterioration of the neurological function in any case postoperatively. The mean JOA score was significantly improved from 9.1 ± 2.3 preoperatively to 14.8 ± 1.2 at the 12-month postoperative visit. All patients were relieved of axial pain. Imaging evaluation confirmed a high fusion rate and healing rate in all patients. No patient complained of limited mobility of the cervical spine in flexion, extension and rotation. No graft or plate-related complication was observed in any patients during the whole follow-up period. The only postoperative complication was trouble in swallowing liquids in two cases which resolved three months after surgery without any treatment. CONCLUSIONS Anterior C3 corpectomy and fusion may prove to be safe and applicable for the treatment of complex Hangman's fractures.
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Affiliation(s)
- Cong Wang
- Department of Orthopedics, Second Military Medical University, Shanghai, China
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Goldschlager T, Leach JCD, Williamson OD, Malham GM. Oblique axis body fracture--pitfalls in management. Injury 2012; 43:505-8. [PMID: 20466369 DOI: 10.1016/j.injury.2010.04.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2009] [Accepted: 04/12/2010] [Indexed: 02/02/2023]
Abstract
BACKGROUND Transverse fractures through the body of the axis, rather than at the base of the odontoid are uncommon and management with an external orthosis is usually recommended. Oblique fractures through the body of the axis accompanying a hangman's fracture have not been reported and are not described as part of any classification system. Such fractures may be at high risk for treatment failure in an external orthosis. CASE DESCRIPTION We report on a case of an oblique axis fracture that failed treatment with external orthosis. Posterior instrumented fusion was employed successfully using a C1-C3 and C4 poly axial screw rod construct. Frameless stereotaxy and a biomodel were useful surgical adjuncts. Twelve month follow up revealed bony union in an asymptomatic patient. CONCLUSIONS Oblique fractures of the body of the axis can displace in a halo-thoracic orthosis. Serial radiological review is required to detect displacement prior to fracture union. Oblique fractures of the body of the axis can be managed surgically with preservation of atlanto-occipital motion, resulting in satisfactory clinical and radiological outcomes.
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Affiliation(s)
- Tony Goldschlager
- Department of Neurosurgery, The Alfred Hospital, Victoria 3181, Australia.
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Ramieri A, Domenicucci M, Landi A, Rastelli E, Raco A. Conservative treatment of neural arch fractures of the axis: computed tomography scan and X-ray study on consolidation time. World Neurosurg 2011; 75:314-9. [PMID: 21492736 DOI: 10.1016/j.wneu.2010.09.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2010] [Accepted: 09/10/2010] [Indexed: 02/07/2023]
Abstract
BACKGROUND Computed tomography (CT) scan and X-ray study on consolidation time of C2 neural arch fractures treated conservatively were examined. METHODS A prospective study was undertaken: 28 conservatively treated fractures of the neural arch of the axis (11 hanged-man type I, 5 type II, and 12 miscellaneous fractures) were monitored during the period of orthosis by means of CT scan and plain X-rays performed on admission, and then at intervals between 2 and 120 days afterward. In patients treated with a halo vest (20 cases), a CT scan of the skull was performed to make sure that the pins were correctly positioned and to evaluate the osteolytic processes at the pin-bone interface. RESULTS Two patients died as a result of other severe brain or thoracoabdominal injuries, and the remaining 26 fractures healed in an average time of 109 days (range 90-120). The process of bone consolidation was documented in detail by CT, which showed how the newly formed osteofibrous tissue (iso-hypodense) progressively filled the interfragmentary space. In 2 cases of cranial pin loosening, CT demonstrated an osteolytic rim at the interface, which prompted early removal of the halo system. At clinical follow-up (mean 32 months; range 24-84), functional status was evaluated: all of the patients were neurologically intact with the exception of one, who presented with persistent paresthesias. The most frequent disturbance was cervical pain (12 cases, 46%). CONCLUSIONS CT with two- and three-dimensional reconstructed images has been shown to be the most reliable method for clarifying the evolution of bone consolidation and to show any osteolytic processes at the pin-bone interface during halo vest immobilization. Follow-up results of our series suggest that surgical treatment would not have improved the quality of life in these patients.
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