Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_6029_Библиотеки_им_академика_М_И_Перельмана.pdf
178
11 Odontoid Process Fractures
79. Saur, K., Sames, M.: Results of the treatment of odontoid
fractures by osteosynthesis with a single axial screw. Acta
Chir Orthop Traumatol Cech 75, 48–51 (2008)
80. Schatzker, J., Rorabeck, C.H., Waddell, J.P.: Fractures of the
dens (odontoid process). An analysis of thirty-seven cases. J
Bone Joint Surg Br 53, 392–405 (1971)
81. Schatzker, J., Rorabeck, C.H., Waddell, J.P.: Non-union of
the odontoid process. An experimental investigation. Clin
Orthop Relat Res 108, 127–137 (1975)
82. Schneider, A.M., Hipp, J.A., Nguyen, L., et al.: Reduction in
head and intervertebral motion provided by 7 contemporary
cervical orthoses in 45 individuals. Spine (Phila Pa 1976)
32, E1–E6 (2007)
83. Scott, E.W., Haid Jr., R.W., Peace, D.: Type I fractures of the
odontoid process: implications for atlanto-occipital instability. Case report. Neurosurg 72, 488–492 (1990)
84. Seybold, E.A., Bayley, J.C.: Functional outcome of surgically and conservatively managed dens fractures. Spine (Phila
Pa 1976) 23, 1837–1845 (1998). discussion 1845–1836
85. Shalayev, S.G., Mun, I.K., Mallek, G.S., et al.: Retrospective
analysis and modifications of retractor systems for anterior
odontoid screw fixation. Neurosurg Focus 16, 1–4 (2004)
86. Streli, R.: Kompressionosteosynthese bei Fracturen und
Pseudoarthrosen des Dens Epistrophei. Z Orthop 119, 675–
676 (1981)
87. Strohm, P.C., Muller Ch, A., Kostler, W., et al.: Halo-fixator
vest – indications and complications. Zentralbl Chir 132,
54–59 (2007)
88. Stulik, J., Suchomel, P., Lukas, R., et al.: Primary osteosynthesis of the odontoid process: a multicenter study. Acta
Chir Orthop Traumatol Cech 69, 141–148 (2002)
89. Subach, B.R., Morone, M.A., Haid Jr., R.W., et al.:
Management of acute odontoid fractures with single-screw
anterior fixation. Neurosurgery 45, 812–819 (1999). discussion 819–820
90. Suchomel, P.: Analysis of the causes of failure in the treatment of simple traumatic epidural hematomas. Rozhl Chir
69, 649–654 (1990)
91. Suchomel, P., Taller, S., Lukas, R., et al.: Surgical treatment
of fractures of the odontoid process. Rozhl Chir 79, 301–308
(2000)
92. Tashjian, R.Z., Majercik, S., Biffl, W.L., et al.: Halo-vest
immobilization increases early morbidity and mortality in
elderly odontoid fractures. J Trauma 60, 199–203 (2006)
93. Tippets, R.H., Alvis, M.A.: Treatment of axis fractures. In:
Menezes, A.H., Sonntag, V.K.H. (eds.) Principles of spinal
surgery, pp. 871–883. McGraw-Hill, New York (1996)
94. Traynelis, V.C.: Evidence-based management of type II
odontoid fractures. Clin Neurosurg 44, 41–49 (1997)
95. Waddell, J.P., Reardon, G.P.: Atlantoaxial arthrodesis to
treat odontoid fractures. Can J Surg 26(255–257), 260
(1983)
96. Weller, S.J., Malek, A.M., Rossitch Jr., E.: Cervical spine
fractures in the elderly. Surg Neurol 47, 274–280 (1997).
discussion 280–271
Fractures of the Ring of Axis (Hangman Type Fractures)
P. Suchomel and J. Hradil
12
Hangman’s fracture [83] is an eponym referring to a
bilateral fracture of the C2 partes interarticularis.
Schneider’s expressive term was brought to describe a
seemingly uniform C2 fracture pattern. Unfortunately,
its similarity to the result of proper judicial hanging is
misleading. The vast majority of authors observed that
contemporary trauma results in a much more graphical
complexity of these injuries and is usually a result of
much different biomechanical forces. Nonetheless, the
term has a long history and has been used for many
years. As such, it cannot be formally replaced. Rather
than that, there is space for expanding its meaning. The
way it is used in contemporary literature abandons original presumptions. It usually encapsulates all radiographic
alternatives of the “classical” fracture pattern as well as
a full spectrum of associated discoligamentous injuries.
Several terminological alternatives that can be
traced in the literature:
Fracture of the ring of axis (Effendi)
Traumatic spondylolisthesis of axis (Garber)
Fracture of the middle column of C2 (Roy-Camile)
Pedicular fracture of the axis (Borne)
Fracture of the neural arch of the axis (Brashear)
Fracture of the axis arch (Marar)
12.1 History
Hanging as a capital punishment has been practised
from biblical times. One of the earliest studies by WoodJones investigates a series of 101 excavated bodies of
P. Suchomel and J. Hradil
Department of Neurosurgery,
Neurocenter, Regional Hospital Liberec,
Husova St. 10, 46063 Liberec, Czech Republic
Nubians executed by Romans in late Roman Byzantine
times. The victims, found with rope remnants still
around their neck, usually suffered a fracture across the
skull base, most probably as a result of “long drop” with
subaural knot placement [101]. In England, hanging
was introduced by Angles, Saxons, and Jutes around
449 AD. During a reign of Henry VIII, over 72,000 of
his subjects were executed. Hanging involved posterior
placement of the knot and very short (zero) drop.
Victims often struggled violently before succumbing
[53]. The same results could, unfortunately, be seen
even in more recent executions with subaural knot
placement and such cases started intense debates concerning a proper technique of hanging. There is a record
of a survivor who was suspended for 15 min [19].
Introduction of a “long drop” dates back to 1784. It
was a very effective technique, but several victims were
decapitated during public executions. Rev. Prof.
Haungton [42] was the first to publish standards on
length of the drop and other parameters, quoting on
fracture dislocation of second cervical vertebra. Subaural
knot placement was a matter of tradition for executioners, and even official recommendations advocating submental placement [62], had no effect on the practice.
Colonel Marshall was surprised to find out, that subaural knot technique was, in his own words, “in full swing”
as late as in 1913. In fact, things did not change substantially until abolition of capital punishment in United
Kingdom in 1965. Due to these circumstances and contrary to common belief, hangman’s fracture caused
death in as low as 19% of the hanged convicts [44].
The primary anatomical paper comes from Dr.
Frederick Wood-Jones (1913), who investigated bodies
of criminals hanged at Rangoon central jail [101].
According to his observations, submental knot placement and a proper technique of “long drop” lead to a
quick and uneventful death. Violent hyperextension and
P. Suchomel and O. Choutka, Reconstruction of Upper Cervical Spine and Craniovertebral Junction,
DOI: 10.1007/978-3-642-13158-5_12, © Springer-Verlag Berlin Heidelberg 2011
179
180
12 Fractures of the Ring of Axis (Hangman Type Fractures)
traction produced a fracture through both partes interacticulares of axis and C2/3 disk disruption. Body of C2
along with dens, atlas, and the head moved cranially,
leaving posterior part of the axis attached to the rest of
the spine. His paper was the first to show drawings of the
fracture and to describe the lethal mechanism in detail.
Probably the first real trauma case was published by
Clarke [14]. His description of C2 fracture survivor who
fell out of the tree suggests it could be a case of hangman’s fracture. Grogono, in 1954, published first radiographs of fractured posterior arch of C2 in a tetraplegic
trauma victim [39]. He noticed similarity with the pattern
described by Wood-Jones. Later on, several authors also
commented on the similarity of their observations [35,
70, 74, 77]. It was Schneider (1965) who provided an
expressive eponym “Hangman’s fracture” for eight victims of MVA [83]. French authors adopted the term but
they use more precise “la fracture du pendu”, as, it is in
fact, a fracture of a “hangee,” not a hangman [78–80].
In 1962, Robert Judet placed first “transpedicular”
axis screw (Christian Mazel – personal communication) published by LeConte in 1964 [54] and Découlx
(1968) reported on anterior fixation technique for C2/3
space [22]. Cornish (1968) was the first and for a long
time the only, advocate of surgical treatment in Englishspeaking literature [18].
The majority of publications reported more or less
solitary cases, mostly as part of a larger series of cervical spine trauma. Vichard (1981) found 229 cases of
fractures of the pars interarticularis published before
1981 [95]. Treatment was non-surgical in 165 cases
and surgical in 64 (25 posterior fusion, 14 anterior
fusion, and 25 direct screw fixation of the pars). No
concise classification has been proposed nor has there
been recognition of any varieties of the injury even in
several larger and specific series [7, 18, 23, 60] until
1981, when Francis and Effendi published large sets
(123 and 131 cases, respectively) [27, 33].
Francis adopted criteria based on biomechanical
cadaveric studies by White and Panjabi [98, 99]. Authors
developed a system of five categories. However, it was
Effendi’s work that became widely accepted and extensively used in further reports. Effendi et al. divided fractures into three basic categories according to radiological
appearance and estimated corresponding (in)stability.
The series clearly showed complex fracture patterns
including cases of marked asymmetry and infractions
into facet joints and C2 body as detected on tomograms.
Several traumatic mechanisms were taken into account
and thoroughly discussed. As in many other papers, the
term “hangman’s fracture” was criticized as misleading.
Authors suggest “fracture of the ring of axis,” which is
probably the most suitable alternative.
French authors mostly used a classification of C2
middle column fractures by Roy-Camille [78–80],
which includes combination of arch-dens trauma. In
1985, Levine and Edwards modified Effendi’s system
by identifying a biomechanically distinct type IIa category [56]. They also specified maximum displacement of type I injury (3 mm). Although based on plain
films/tomograms and lacking any direct confirmation
of a proclaimed presence/absence of discoligamentous
injury, this classification is the most frequently used in
recent publications. We also use the Levin and Edward
system at our department (Figs. 12.1–12.4).
Introduction of CT and MRI confirmed high variability of fracture patterns and soft tissue injury [82]
and led to more individual evaluations of stability as
well as specific treatment rationales. However, no classification system with respect to CT and/or MRI findings has been put to practice so far.
There are over 200 articles, book chapters or other
cited sources on the topic [52]. Unfortunately, the majority of these works come from pre-CT and pre-MRI era.
Even the most recent sources rely on classifications,
results, and recommendations based solely on these
reports. The principles derived from these sources
were hardly ever analyzed or updated. Nonetheless,
they are widely accepted and very seldom questioned.
Fig. 12.1 Levine type I fracture
12.2 Classifications
Fig. 12.2 Levine Type II fracture in three different patients. (a) Flexion and dislocation. (b) Extension and dislocation (note fracture
of posterior ring of atlas). (c) Angular instability without dislocation
181
Fig. 12.3 CT 3D reconstruction of Levine type II fracture
Spine surgery is heading in the direction of evidence
and maximally objective evaluation. Verbal shortcuts
of evaluation, such as “good fusion,” “acceptable
result,” “no significant pain,” are typical for the majority of articles in the twentieth century and these results
need to be reconsidered using contemporary optics.
For proper evaluation and evidence of any kind, multicenter-controlled cohort evaluations including CT and
MRI findings are absolutely mandatory. Even though
there are reports of very good design, the pitfalls of old
classifications, traditionalistic setting of treatment
options, and short follow-ups do not (and cannot) provide valid evidence.
Fig. 12.4 Levine type IIa fracture, kyphotic position susceptible
of PLL injury (confirmed by MRI and peroperative discography)
12.2 Classifications
12.2.1 Effendi
Type I: Isolated hairline fractures of the ring of the
axis with minimal displacement of the body of C2.
The fracture may involve any part of the ring of the
axis and may extend anteriorly into the body of C2.
The fracture line is then oblique, involving usually
one or rarely both postero-inferior corners of the
body. The disc space below the axis is normal and
stable.
182
12 Fractures of the Ring of Axis (Hangman Type Fractures)
Type II: Displacement of the anterior fragment, with
an abnormal disc below the axis. The body of the axis
may be displaced in extension, flexion or obvious
forward olisthesis.
Type III: Displacement of the anterior fragment with
the body of the axis in the flexed position; but in addition, the facet joints at C2-3 are dislocated and locked.
A type III lesion must be suspected when the body of
the axis is in a position of flexion; it has not been seen
when it is in a position of extension or of forward
olisthesis.
12.2.2 Francis
Grade I displacement of <3.5 mm and angulation <11°
Grade II displacement <3.5 mm and angulation >11°
Grade III displacement >3.5 mm and <0.5 vertebral
width and angulation <11°
Grade IV displacement of >3.5 and <0.5 vertebral
width and angulation >11°
Grade V disc disruption
12.2.3 Levine and Edwards
Type I: all nondisplaced fractures and all fractures that
showed no angulation and less than 3 mm of displacement (pure hyperextension-axial loading).
Type II: Significant displacement (3.5 mm) and angulation (11°) (combination of hyperextension-axial
loading with secondary flexion-compression).
Type IIa: minimum degree of displacement combined
with severe angulation (flexion-distraction).
Type III unilateral or bilateral facet dislocation in addition to the posterior element fractures (flexioncompression)
endplate and upper endplate of C3. The criteria apply
even on dynamic radiograph.
Type 2: unstable fractures with either more than 2 mm
AT or more than 5° of angulation or both.
Type 3: middle column fracture with dislocation of C2
facet joints over C3.
Type 4: middle column fracture with dens fracture.
12.3 Etiology and Epidemiology
Axis fractures consist of approximately 20% of all
acute cervical spine fractures. Around 14–16% of axis
fractures are combined with atlantal injury. Hangman’s
fractures represent 20% of C2 trauma and male/female
ratio is approximately 1.6. Most of the cases come
from high velocity accidents, i.e., motor vehicle (50–
80%), falls from height (14–25%), diving (1–4%), and
other more specific causes [27, 33, 38, 58, 88]. Serious
head or chest injury can be seen in up to 43% of cases,
polytrauma in general is present in 10–56% admissions [52, 67]. The exact numbers are influenced by
population, environment and as such, there can be substantial differences between reports. In general, the
spectrum of fractures changes with lifestyle of the
population and available diagnostic possibilities. It
surely changes in time. Data are closely connected
with automotive industry and safety designs involved
[55, 102]. The incidence does not seem do decrease
with airbag use, it may even be slightly increased due
to this otherwise valuable technology [59].
In our series of 40 cases treated surgically [88],
there was a male/female ratio of 1.86, mean age
44 years (18–79), and combined fracture with C1 in
17.5%. We found Levine-Edwards type I in 5 cases,
type II in 25 cases, and no case of type III fracture.
12.4 Symptoms and Signs
12.2.4 Roy-Camille Classification of C2
Middle Column Fractures
Type 1: stable fracture with less than 2 mm of anterior
translation (AT) and less than 5° of regional angulation
rheumatoid arthritis, which is an angle defined by C2
In isolated Hangman’s fractures, the symptoms are
often limited to neck pain, stiffness or transient “electricity-like” whole body irritations. Permanent neurological deficits are very rare [38, 58, 88]. It is appropriate
to cite the work of Marar [60] here as it belongs to one
of the most misinterpreted of all. Marar claims at least
some cord involvement in 11 out of 15 of his patients,
12.5 Radiology
183
Fig. 12.5 Different atypical fracture patterns where the “natural
enlargement” of canal by fracture is not true. (a) The arch is not
really disconnected – fracture of posterior caudal C2 wall. (b)
which is considered an extremely high number by many
authors. But he considers purely sensory disturbances,
too. This applies not only to six of his patients that
recovered fully in 24 h, but also to all other recovering
fully until 1 month. In his series, there was no permanent neurological injury! Discrepancy could be at least
partially assigned to the level of detail during neurological examination and honest reporting of even slightest
signs of cord involvement. DeLorme [23] reports neurological deficit in roughly 1/3 of his 40 cases, and 1/3
of these remained permanent; Muller [67] reports 10.3%
neurological deficits, all of them present in patients with
type II injury and displacement more than 4 mm.
The patients often lack any objective evidence of
cord involvement and they are happy to have “just neck
pain.” This can create certain bias. In our experience,
50% of the patients recall feelings of “electricity going
through their body” with more or less rapid recovery.
However, this information needs a direct question.
Patients seldom report this actively as these symptoms
no longer exist on admission. Unfortunately no study
evaluating electrophysiological functions of spinal
cord after such an event is available.
There are series of radiological examination of fatal
craniospinal trauma victims, showing surprisingly high
incidence of C2 fractures [1, 21]. Alker [1] found that
39% victims who died solely as a result of neck injury
had C2 fracture. Study of Bucholz [9] on over 170 cadavers of multiple trauma victims concludes that severe neurological injury is a frequent complication of Hangman’s
fracture, and usually is incompatible with survival.
Schneider [83] quoted on “roomingness” of the upper
cervical canal and “death-averting decompression of
Bilateral symmetric anterior spurs, any dislocation can cause
compression. (c) Unilateral anterior spur
the upper cervical cord accomplished by lesion itself.”
This is true of Hangman’s fracture in its classical form,
however, frequent “atypical” patterns (Fig. 12.5) show
clear potential to compress on medulla at the moment
of injury or in case of significant dislocation at any
time thereafter [87].
It is likely that the zone between instant death and
symptom-free survival is narrow here and a marked
neurological deficit in a survivor is a very rare result
under these circumstances.
12.5 Radiology
Definition of hangman’s fracture is somewhat misty as
it evolves in time and so is the radiological description.
There are long discussions about which fracture pattern still represents a hangman’s fracture (“typical” or
“atypical”) [45]. The axis ring ruptures vary between
two extremes – the fracture through the C2 body
(Fig. 12.6) and distant fracture of the arch (Fig. 12.7).
The most important radiographic features are usually derived from existing classification systems (see
above). Thus, radiology is focused only on films.
Although currently inevitable, more advanced modalities (dynamic films/CT/MRI) have not been used for
classification purposes up to the present.
The initial pattern is a bilateral fracture through
pars interarticularis (between superior and inferior
facet joints). Many authors report fractures of the
“pedicle” [5, 6, 11]. However, pars interarticularis is
not identical with the pedicle of the axis as we have
184
12 Fractures of the Ring of Axis (Hangman Type Fractures)
emphasized previously. True fractures of the pedicle of
axis are very rare. There are only unilateral cases
reported with various fracture lines through the other
side of the axis ring and only extreme conditions can
provide such a result [44].
Fig. 12.6 Axial CT scan showing the fracture of the C2 ring
extending into the verberal body
The combination of original fracture site and symmetry is actually rare (Fig. 12.8). The fracture line
most often involves posterior cortex of the axis body,
facet joints and it can extend into vertebral foramina
(Fig. 12.9). There are numerous reports, which do not
quote on such alternative patterns but they clearly show
them in presented radiolographic documentation [8,
37, 63, 102]. It can be only hypothesized, how many
cases with “atypical” patterns were actually present in
the series published in pre-CT era.
The most common “alternative” pattern is a fracture
line invasion into posterior cortical wall of C2 body [2,
9, 11, 27, 30, 61, 64, 85, 88, 97]. The extent of C2 body
infraction depends on trauma mechanism and also on
the local anatomy of the posterior wall. The cortex is
thick in lateral and inferior areas and gets narrow medially and cranially. The result is an incomplete fracture
line above the inferior portion of the posterior axis
wall. CT-scan shows disruption of the “inner cortical
ring” close to the midline, and a characteristic picture
of bilateral “spurs” (Fig. 12.5). These can be of various
sizes and they are often asymmetric [85, 97]. The ultimate form is a complete avulsion of the posterior wall
[88, 96]. The majority of cases have their true fracture
site more anteriorly compared to the pattern described
by Wood-Jones and “revived” by Schneider. This often
leads to another very common finding: superior facet
Fig. 12.7 Plain lateral film showing distant fracture of the arch
(only one side)
Fig. 12.8 CT of a rare symmetric transisthmic pattern of hang-
man’s fracture
12.5 Radiology
Fig. 12.9 CT showing
fracture line reaching the FT.
(a) Bilateral FT fracture
involvement. (b) Another
patient fracture through FT
seen on sagittal
reconstruction
185
joint involvement [18, 27, 82, 88]. Such patterns are
routinely seen on 3D CT reconstructions (Fig. 12.9b),
and they were confirmed also on autopsy findings in
the past [85]. The extension of fracture line into vertebral artery (VA) foramina is not an exception [18, 88].
However, there are only several reports on serious VA
injury [58, 71]. Fracture through superior facet joint
should be considered unstable and reposition is likely
to be essential for a good, long-term functional outcome [52] as in any other intra-articular fractures in
human body.
The majority of fractures are essentially asymmetric. The above-mentioned variants can be present unilaterally with the other side harboring a “classical”
fracture of the pars. Up to 50% of cases can display
such pattern [82] and they are likely to be produced
due to rotation before or during the trauma impact.
However, asymmetric fractures can very often be produced without any asymmetric loading or rotation in
laboratory conditions [90]. It should be mentioned that
no classification system deals with asymmetry or rotation. All are 30+ years old and rely on plain films that
simply cannot demonstrate such features.
The radiographic “span” of hangman’s fracture is
limited anteriorly with deeper involvement into axis
body, where it can merge with type III dens fractures,
according to Anderson-D’Alonso. Posterior border
seems to be inferior facet joint. Fractures located bilaterally more posteriorly (neural arch, behind the joint)
have no significant effect on C2/3 stability and form a
separate category of C2 trauma.
Cautions is necessary when evaluating radiographs
of children. Normally, neurocentral synchondroses
ossify between 3 and 7 years of age [86]; however,
persistent synchondroses or primary spondylolyses (as
seen in pyknodysostosis or Crouzon disease) can occur
and these can mimic hangman’s fracture. On the other
hand, there are reports of traumatic lesions in infants
under 1 or 2 years of age [32], mostly as a result of
child abuse. Dynamic radiographs, CT, MRI, clinical
findings, and history of trauma are necessary to distinguish developmental conditions from their traumatic
counterparts.
Hangman’s fracture is, of course, not only a fracture
but frequently (types II and III) a complex soft tissue
injury, too. This aspect, if present, is actually very
important for treatment planning. At the time of impact,
C2/3 disc is put to high levels of mechanical stress that
often lead to its injury, which allows more or less
dislocation/angulation of both adjacent vertebrae.
“Slipping” of the axis over C3 is a base for Garber’s
term “traumatic spondylolisthesis.” However, only rare
cases of atraumatic axis olistheses and C2/3 dislocations without any fracture have been reported and
quoted [15, 29, 68].
In case of significant C2/3 displacement and especially angulation, at least one of anterior or posterior longitudinal ligaments is likely to be injured. Definitions of
(in)stability vary widely even in recent literature [57].
The majority of hangman’s fractures result from extension and axial loading (typical pattern in MVA). Injury to
anterior longitudinal ligament is the most common finding (Levine type II). Flexion distraction mechanisms, that
lead to type IIa and type III patterns, are accompanied by
injured PLL. Absence of any support in flexion renders
this condition highly unstable (Fig. 12.10). Traction is
hazardous in case of type IIa injury [26, 46, 47] as it wid-
ens the fracture gap and increases angulation. The soft
186
Fig. 12.10 Levine type II with distractive dislocation, severe
ligamentous injury (no traction!)
tissue injury can involve additional elements, such as
capsulae of C2/3 facet joints in type III injury, nuchal
ligament, and the conditions become far more complex in
combined atlanto-dental injuries.
Mechanisms able to produce a true hangman’s fracture by traction-extension are very rare today [26, 81,
102]. Contemporary suicidal attempts are usually short
drops resulting mostly in reflective cardiac arrest or
asphyxia, rather than cervical spine injury [45].
Slipping under the safety belt during a car accident is
possible but happens rarely with modern car designs.
In addition to static features of the injury, it is essential to emphasize the necessity of dynamic film evaluation. Major classifications include this modality to
rule out type II unstable fractures that are spontaneously reduced. They resemble type I injury, which can
also be easily overlooked on plain films [99].
Nonetheless, negative radiographs of active and/or
passive flexion-extension are not an absolute proof of
stability due to possible stabilizing effects of reflex
muscle spasms. Dynamic MRI would be of a high
value here, assessing soft tissue behavior, but this technology is still far from abundant at the present time.
The structural incompetence of anterior and posterior
longitudinal ligaments can be verified by C2/3 discography also.
Unfortunately, studies with long-term follow-up are
very rare. Contrary to findings in short periods of time,
authors show degenerative changes in C2/3 level [7,
12 Fractures of the Ring of Axis (Hangman Type Fractures)
89], that can even lead to “spontaneous” fusion of the
segment after several years [7]. Those who use external immobilization techniques report significant percentages of fusion with residual dislocation [38].
12.6 Treatment Strategy
First of all, it is necessary to emphasize that there is no
class I or II evidence for the treatment guidelines or
recommendations of hangman’s facture available in
the literature.
According to reviews by Koller [50, 52], more than
50 authors present approx. 40 different concepts for
therapy of hangman’s fracture. Many of them conclude
that primary surgical treatment of the fracture is not
necessary for successful result [10, 17, 29, 30, 38, 41,
60, 65, 72, 76, 84, 85, 93, 104] and advocate various
types of external immobilization. Other authors are in
favor of early surgical approach at least in unstable
ones [6, 12, 34, 40, 48, 49, 52, 61, 66, 75, 89, 91, 94],
reporting favorable result, better fracture alignment,
substantial reduction of treatment period, and early
mobilization with better quality of life.
Historically, conservative treatment dominated the
field. Most often, dislocated fractures were reduced by
traction first and then patients placed to brace. There
are plenty of external rigid [4, 29, 30, 41, 60, 84, 93] or
in some cases non-rigid [17, 67] immobilization techniques, ranging from sand-bag support [92] through
soft/hard collars, traction devices, plaster supports of
various designs, up to SOMI braces and halo systems.
Although there are extensive reviews and meta-analyses available [10, 17, 38, 96], the definition of success-
ful treatment of hangman’s fracture is usually quite
vague in both older and recent publications and it is
most often set equal to fusion (usually, without any
definition) [16, 96]. Fusion refers to the site of a fracture, and not to the condition of C2/3 disc space and
overall sagittal cervical alignment. However, the fracture site is probably of lesser importance than is the
type and extent of displacement and associated soft tissue injury [25].
Perfect Complete reduction of dislocated fracture
cannot be achieved by halo immobilization in all
cases. Nearly all later publications admit recurrence
of anterior translation of up to 60% and angulation of
up to 40% of the initial status prior to reduction by
12.6 Treatment Strategy
187
traction [56]. Fusion in displacement of up to 5 mm
can be seen with halo-vest immobilization as was
documented by Coric [17]. Authors often claim that
healing in displaced position is not harmful. However,
there is a lack of self-evaluation data to support such
statement. Malalignment and sagittal profile distortion
represents terrain prone to secondary degenerative
changes, including disc osteochondrosis, osteophyte
formation, and calcification (Fig. 12.11). Delayed
spontaneous C2/C3 fusions based on degeneration
can be seen as documented in follow-ups lasting at
least several years [7, 89]. Considering a frequent
involvement of C1/C2 joint, it is highly questionable
to claim this result to be a success. Motion restriction
and especially pain are usually fairly interpreted or
even completely omitted in many studies on both surgical [6] and conservative treatments [10, 17, 41, 72,
73, 96]. It can only by hypothesized why there is no
significant pain and limited range of motion, whereas
in many other conditions involving C1/2 osteochondrosis, significant pain can be observed [28, 31, 103].
Ubiquitous lack of longer follow-up may surely be a
factor. Only recently, there are studies of a high methodological level providing evidence that malunion in
C2 fractures has a strong association with development of atlantoaxial osteoarthritis, significant impact
on clinical outcomes, and both total and atlantoaxial
neck rotations [51].
Any type of halo immobilization suffers from inherent problems, such as pin loosening, infection of various
degrees including epidural abscess, pressure sores, lack
of compliance by patient, breathing problems, pneumonia, and transient or permanent loss of range of motion
[36]. Also, the halo-vest competence to sufficiently stabilize the upper cervical spine (UCS) is questionable.
Current biomechanical works report the sagittal and
coronal “snaking” of UCS fixed in halo [43].
Crutchfield [20], satisfied with his invention,
claimed that “traction leaves few, if any, indications for
surgery” in cervical spine trauma. This is still perfectly
true, as nearly all fractures can be treated by simple
traction, immobilization with bedrest, and without
necessity of surgery. Obviously, it is not a necessity of
surgery, but it is a benefit of the patient, what really
matters. Yet another aspect is, choice of the patient. In
our practice, an average 6-day hospital stay involving
1-h routine anterior surgery clearly wins over 3 months
in halo-vest.
Advancements in spine surgery in the past 10–20
years inevitably lead to conclusion that treatment recommendation of old studies (including all ground
works for classification systems) cannot be fully taken
Fig. 12.11 Hangman’s type II fracture treated conservatively in
halo-vest. (a) Axial CT scan showing healed fracture in malposition. (b) Plain lateral radiogram depicting the deformity, note the
fusion of C2-3. (c) Flexion on plain film confirming fixed deformity (Courtesy of Prof. Robert Veres, Budapest)