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  • Failure of Anterior Cervical Fusion for the Treatment of Hangman’s Fracture with Atypical Features - An Analysis of Three Cases

    Final Number:

    Zaid Aljuboori MD; Maxwell Boakye MD

    Study Design:
    Clinical Research

    Subject Category:
    Spine: Open Surgery

    Meeting: Congress of Neurological Surgeons 2019 Annual Meeting

    Introduction: Hangman’s fracture is a fracture of bilateral pars interarticularis of the axis. The mechanism is hyperexten¬sion with axial loading. Most hangman’s fractures can be treated using external immobilization. Surgery is reserved for fractures that fail immobilization, disc disruption, displacement, or neurological injury. Surgi¬cal options are anterior C2-3 anterior cervical discectomy and fusion (ACDF) or posterior (C1-3) spinal fusion. Both have comparable outcomes. Here we present a series of cases with hangman’s fractures with atypical features that failed C2-3 ACDF.

    Methods: Case 1: A 48 years old female with hangman’s fracture (left pars & right pedicle) after motor vehicle accident. She underwent C2-3 ACDF. On 2 months follow up X-rays showed new C2-3 anterolisthesis (9mm) with nonunion. The patient underwent a C3 corpectomy with C2-4 arthrodesis followed by a C1-C4 posterior instrumentation. Case 2: A 54 years old male with hangman’s (bilateral pedicular involvement) and C1 bilateral posterior arch fractures after a bike accident. The C2-3 disc was disrupted. He underwent C2-3 ACDF. Immediate postoperative x-rays showed worsening of C2-3 anterolisthesis. He underwent a C1-C3 posterior instrumentation. Case 3: A 69 years old male with hangman’s fracture (right pedicle & left pars) after a motor vehicle accident. The C2-3 disc was disrupted. He underwent C2-3 ACDF. Immediate postoperative x rays showed worsening of C2-3 anterolisthesis. He underwent a C1-C3 posterior instrumentation.

    Results: Cases 1,2,3 were followed up with x-rays as follows: 8,12, 3 months respectively. X-rays showed stable instrumentation and solid bony fusion.

    Conclusions: Anterior approach can be used for the treatment of some hangman’s fractures. Here we present cases that failed anterior fusion. We hypothesize that the presence of unilateral or bilateral pedicular involvement (atypical features) may lead to failure of anterior approach and that posterior fusion is indicated.

    Patient Care: We strongly believe that this abstract will raise awareness of this potential surgical complication among practicing neurosurgeons. We hope this further studies will be conducted to validate our findings will which results in a change in the treatment paradigms of hangman's fractures.

    Learning Objectives: 1. Hangman’s fracture with atypical features is recognizable on imaging 2. Treatment paradigm for hangman’s fracture with atypical features differs from that for typical hangman’s. 3. There is limited data on the best treatment option for hangman’s with atypical features.

    References: 1. Garber JN. Abnormalities of the atlas and axis vertebrae—congenital and traumatic. JBJS. 1964 Dec 1;46(8):1782-91. 2. Duggal N, Chamberlain RH, Perez-Garza LE, Espinoza-Larios A, Sonntag VK, Crawford NR. Hangman’s fracture: a biomechanical comparison of stabilization techniques. Spine. 2007 Jan 15;32(2):182-7. 3. White AA, Panjabi MM. Clinical biomechanics of the spine. Philadelphia: Lippincott; 1990 Jan 1. 4. Haughton S. IV. On hanging, considered from a mechanical and physiological point of view. The London, Edinburgh, and Dublin Philosophical Magazine and Journal of Science. 1866 Jul 1;32(213):23-34. 5. Wood-Jones F. The ideal lesion produced by judicial hanging. The Lancet. 1913 Jan 4;181(4662):53. 6. Schneider RC, Livingston KE, Cave AJ, Hamilton G. “Hangman's fracture” of the cervical spine. Journal of neurosurgery. 1965 Feb;22(2):141-54. 7. Francis WR, Fielding JW, Hawkins RJ, Pepin J, Hensinger RO. Traumatic spondylolisthesis of the axis. Bone & Joint Journal. 1981 Aug 1;63(3):313-8. 8. Effendi B, Roy D, Cornish B, Dussault RG, Laurin CA. Fractures of the ring of the axis. A classification based on the analysis of 131 cases. Bone & Joint Journal. 1981 Aug 1;63(3):319-27. 9. Levine AM, Edwards CC. The management of traumatic spondylolisthesis of the axis. The Journal of bone and joint surgery. American volume. 1985 Feb;67(2):217-26. 10. van der Horst A, Lippross S, Dunn RN. Traumatic spondylolisthesis of the axis: Surgical indication and outcomes. SA Orthopaedic Journal. 2013 Jan;12(2):46-51.

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