Posterior C2-C3 Fixation for Unstable Hangman's Fracture

Direct Transpedicular C2 Fixation for the Surgical Management of Hangman's Fractures: A "Second Youth" for the Judet Approach

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.

Comparison of C2-3 Pedicle Screw Fixation With C2 Spinous Muscle Complex and Iliac Bone Graft for Instable Hangman Fracture

Purpose: To compare the effect between C2 spinous muscle complex graft and iliac bone graft in C2-3 pedicle screw fixation for instable Hangman fracture. Using axial spinous muscle complex instead of iliac bone for instable Hangman fracture can decrease neck pain, bone donor site complication, and operation time.

Method: The outcomes of C2-3 pedicle screw fixation with C2 spinous muscle complex were compared with iliac bone graft in 18 and 21 patients with instable Hangman fracture. The mean age was 49.1 ± 15.8 years in the complex group and 55.3 ± 12.2 years in the Iliac group, and the mean time to surgery of the patients was 3.3 ± 0.6 days in the complex group and 3.6 ± 0.9 days in the iliac group. Outcome measures including operation time, blood loss, visual analog scale (VAS) for pain, Japanese orthopedic association score (JOA), American spine injure association classification (ASIA), and bone fusion time were collected from medical records. In addition, the postoperative complications were also recorded.

Results: There were significant differences in operation time and interoperative blood loss between the two groups (P < 0.01). Also a significant difference was found in VAS score and JOA score between the two groups (P = 0.0012 and P < 0.001, respectively) at 1-month follow-up, whereas, no significant difference was found at other visit time. In the final visit, all patients showed good bone fusion, and two patients shows incision edema and exudation in the iliac group.

Conclusion: C2-3 pedicle screw fixation with C2 spinous muscle complex graft maybe a feasible and safe procedure for instable Hangman fracture.

Unstable Hangman Fracture Complicated by Vertebral-Venous Fistula: Surgical Considerations and Review of Literature

BACKGROUND

Hangman fracture or traumatic spondylolisthesis of the axis associated with a traumatic vertebral venous fistula (VVF) is a rare entity and sparsely reported in literature. Standard recommendations for management of such rare and complex scenarios are not available and hence the strategy has to be individualized on a case-by-case basis.

METHODS

We report a 70-year-old man having an unstable hangman fracture with VVF. Both pathologies were simultaneously managed uniquely. The VVF was managed by endovascular occlusion. The fracture was managed by anterior fusion alone as posterior fusion was deemed riskier in the aftermath of a recently occluded VVF. The patient had good neck function and bony fusion at 1-year follow-up.

CONCLUSION

This case report emphasizes the need for timely recognition and management of a VVF, which can rarely coexist with hangman fracture, and discusses the interesting surgical paradigms in the management. We also present a review of literature.

Unstable Hangman's fracture: Anterior or posterior surgery?

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.

Management of Hangman's Fractures: A Systematic Review

BACKGROUND

Traumatic spondylolisthesis of the axis, is a common cervical spine fracture; however, to date there is limited data available to guide the treatment of these injuries. The purpose of this review is to provide an evidence-based analysis of the literature and clinical outcomes associated with the surgical and nonsurgical management of hangman's fractures.

METHODS

A systematic literature search was conducted using PubMed (MEDLINE) and Scopus (EMBASE, MEDLINE, COMPENDEX) for all articles describing the treatment of hangman's fractures in 2 or more patients. Risk of nonunion, mortality, complications, and treatment failure (defined as the need for surgery in the nonsurgically managed patients and the need for revision surgery for any reason in the surgically managed patients) was compared for operative and nonoperative treatment methods using a generalized linear mixed model and odds ratio analysis.

RESULTS

Overall, 25 studies met the inclusion criteria and were included in our quantitative analysis. Bony union was the principal outcome measure used to assess successful treatment. All studies included documented fracture union and were included in statistical analyses. The overall union rate for 131 fractures treated nonsurgically was 94.14% [95% confidence interval (CI), 76.15-98.78]. The overall union rate for 417 fractures treated surgically was 99.35% (95% CI, 96.81-99.87). Chance of nonunion was lower in those patients treated surgically (odds ratio, 0.12; 95% CI, 0.02-0.71). There was not a significant difference in mortality between patients treated surgically (0.16%; 95% CI, 0.01%-2.89%) and nonsurgically (1.04%; 95% CI, 0.08%-11.4%) (odds ratio, 0.15; 95% CI, 0.01-2.11). Treatment failure was less likely in the surgical treatment group (0.12%; 95% CI, 0.01%-2.45%) than the nonsurgical treatment group (0.71%; 95% CI, 0.28%-15.75%) (odds ratio 0.07; 95% CI, 0.01-0.56).

CONCLUSION

Hangman's fractures are common injuries, and surgical treatment leads to an increase in the rate of osteosynthesis/fusion without significantly increasing the rate of complication. Both an anterior and a posterior approach result in a high rate of fusion, and neither approach seems to be superior.

Burden of Surgical Site Infections Associated with Select Spine Operations and Involvement of Staphylococcus aureus

BACKGROUND

Spine operations may be indicated for treatment of diseases including vertebral injuries, degenerative spinal conditions, disk disease, spinal misalignments, or malformations. Surgical site infection (SSI) is a clinically important complication of spine surgery. Staphylococcus aureus, including methicillin-resistant Staphylococcus aureus (MRSA), is a leading cause of post-spinal SSIs.

METHODS

PubMed and applicable infectious disease conference proceedings were searched to identify relevant published studies. Overall, 343 full-text publications were screened for epidemiologic, mortality, health care resource utilization, and cost data on SSIs associated with specified spine operations.

RESULTS

Surgical site infection rates were identified in 161 studies from North America, Europe, and Asia. Pooled average SSI and S. aureus SSI rates for spine surgery were 1.9% (median, 3.3%; range, 0.1%-22.6%) and 1.0% (median, 2.0%; range, 0.02%-10.0%). Pooled average contribution of S. aureus infections to spinal SSIs was 49.3% (median, 50.0%; range, 16.7%-100%). Pooled average proportion of S. aureus SSIs attributable to MRSA was 37.9% (median, 42.5%; range, 0%-100%). Instrumented spinal fusion had the highest pooled average SSI rate (3.8%), followed by spinal decompression (1.8%) and spinal fusion (1.6%). The SSI-related mortality rate among spine surgical patients ranged from 1.1%-2.3% (three studies). All studies comparing SSI and control cohorts reported longer hospital stays for patients with SSIs. Pooled average SSI-associated re-admission rate occurring within 30 d from discharge ranged from 20% to 100% (four studies). Pooled average SSI-related re-operation rate was 67.1% (median, 100%; range, 33.5%-100%). According to two studies reporting direct costs, spine surgical patients incur approximately double the health care costs when they develop an SSI.

CONCLUSIONS

Available published studies demonstrate a clinically important burden of SSIs related to spine operations and the substantial contribution of S. aureus (including MRSA). Preventive strategies aimed specifically at S. aureus SSIs could reduce health care costs and improve patient outcomes for spine operations.

Operative strategy and clinical outcomes of ROI-C(TM) fusion device in the treatment of Hangman's fracture

OBJECTIVE

to compare the clinical outcomes of anterior fusion with ROI-C(TM) and titanium plate in the treatment of Hangman's fractures.

METHODS

From Dec 2005 to Jan 2015, a total of 21 patients with Hangman's fracture, who underwent anterior internal fixation with titanium plate or ROI-C(TM), were retrospectively reviewed. All patients underwent anteroposterior, lateral, and flexion-extension radiography and computed tomography of cervical spine preoperatively and postoperatively at 3 days and 3 months. Cervical visual analog scale (VAS) score, Bazaz dysphagia score, angular displacement (AD), horizontal displacement (HD), fusion rate, and blood loss were measured.

RESULTS

The VAS and Bazaz dysphagia score at postoperative 3 days were significantly lower in ROI-C(TM) group, as compared to titanium plate group (P<0.05). AD and HD were significantly decreased in both groups after operation (P<0.05). The postoperative rate of complete reduction of spondylolisthesis was significantly higher in ROI-C(TM) group than that in titanium plate group (P<0.05). The operative time and blood loss was significantly decreased in ROI-C(TM) group, as compared to titanium plate group (P<0.05).

CONCLUSION

ROI-C(TM) device showed superiority to titanium plate in the treatment of Hangman's fractures, suggesting that anterior operation with ROI-C(TM) device may be a better choice for treating Hangman's fractures.