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
188
12 Fractures of the Ring of Axis (Hangman Type Fractures)
into account. A fracture-dislocation of C3/4 level in an
otherwise healthy person would be treated by anterior
surgery and fusion today. It becomes very hard to find
a reasonable argument against the use of the same
principle for C2/3 intervertebral space. Nonetheless,
even in this era, there are authors in favor of primary
conservative treatment of all variants including highly
unstable fractures [17]. There are reports of successful
treatment of complete C2/3 dislocations by halo immobilization [76].
On the other hand, some of the authors with extensive experience with conservative approach were very
satisfied with technical accessibility, immediate segmental stability, and excellent results of primary surgery and proposed it at least as a fully acceptable
alternative [91].
There are many types and extents of surgical treatment in the literature. Most exotic variants are either
insufficient, or overtreating, or both [8].
Four viable options of surgical treatment are available today:
Anterolateral approach with bone graft (auto/
allograft) fixed by plate and screws (best bicortical) is
the first option. Even back in 1970, Norrel reports five
cases of unstable hangman’s fracture treated by anterior dowel fusion and average hospital stay of mere
10 days [69]. We reported average hospital stay of 6 to
8 days (polytrauma excluded) including preoperative
fracture-reduction by halo-traction [88]. The wound
complications and infection is rare in contemporary
cervical spine surgery and mostly equals to zero [50,
88]. Although there are some variants, such as tran-
soral approach for C2-3 fusion [100], proper use of
anterolateral technique is straightforward, routine, and
hardly ever brings problems or complications [50, 52,
88]. Patients are usually advised to wear hard collar for
various periods of time after surgery usually depending
on the severity concomitant to soft tissue injury. There
are also recent studies showing sufficient biomechanical parameters of fixation using simple anterior plate
even with non-constrained monocortical screws [13].
Posterior approach can be primarily used in cases
of otherwise irreducible locked facets (type III). The
purpose of surgery can be limited to facet joint reposition with subsequent anterior fixation, or posterior fixations of various extents can follow. Posterior C2-C3
screw-rod fixation is biomechanically superior to anterior plate stabilization in lateral bending and axial rotation [24]. Considering available clinical series where
majority of surgeries were performed with anterior
fixation [50, 52, 88, 91], it is again the necessity of
significant muscle dissection that renders posterior
approach less favorable at least in the treatment of
fractures other than type III.
Combined approach is reasonable in highly unstable injuries where both anterior and posterior fixation
techniques can be associated to provide stable 360°
construct; for example, type III injury reduced and
fixed posteriorly with subsequent anterior disc removal
and fusion.
Direct pars fixation, according to Judet, is a specific
alternative applicable to cases with limited discoligamentous injury. As in other posterior C2 screw techniques, it is often feared as risky because of potential
VA injury. Image guidance is of little use here [3], since
the fragments are often dislocated and/or can be displaced during the procedure, thus making the C2 fiducial registration impossible. Posterior transpedicular/
transisthmic screw can be introduced by “free hand”
safely if individual anatomy, fracture morphology, and
preoperative radiologic workup are respected, as
described in the previous chapter. However, posterior
screw placement performed under direct CT-guidance
is not only safer but in addition, can directly show the
desired compression of the fracture [89].
12.7 Our Preference
All patients with suspected C-spine injury admitted to our
hospital, proceeded directly from the place of accident,
through the emergency department to spiral CT first,
without plain films. Those referred from other hospitals
mostly come with plain films and CT images already
obtained. If further algorithm is not changed because
of concomitant injuries and a hangman type fracture is
diagnosed, we obtain an MRI in all cases to assess the
extent of soft tissue damage and establish the status of
radiographic neural compromise. Although MRI is considered unnecessary by some authors, particularly in the
absence of neurologic deficit, we prefer to obtain it. In
type I fractures (non-displaced) the eventual C2-3 disc
damage can be confirmed, occasionally the disruption of
anterior or posterior longitudinal ligament can be seen,
and also the coincident injury to other disc levels can be
excluded (Fig. 12.12). This algorithm is easily followed
in our hospital where MRI is available 24 h a day.
12.7 Our Preference
189
Fig. 12.13 The same patient as Fig. 12.12. Dislocation of frac-
ture during extension. Notice the posterior atlas ring fracture
Fig. 12.12 MRI in T2 sequence of type I Hangman’s fracture.
Clearly visible tear of ALL and anterior disc at C2-3 level and
canal compromise by degenerative disc disease at C5-6 and
C6-7 levels
Further workup is modified according to the
type of injury. There is no need for further investigation in dislocated type II and III fractures as they are
directly indicated for adequate traction/reduction followed by surgical stabilization.
If an isolated hangman fracture without translational or angular dislocation is confirmed and no
compression of spinal cord exists, then the major
issue is to decide whether the fracture is stable and
well configured and if it can be treated conservatively. Bone abruption of anterior C2 edge and/or
concomitant fractures (often, posterior C1 arch) can
strengthen our inkling for potential instability. Also,
MR evidence of ligamentous or disc injury can raise
our suspicion but the true stability cannot be accurately confirmed unless there is movement visible on
flexion-extension lateral projections (Fig. 12.13). In
cooperating conscious patients without neurological
deficit, we always perform a manual surgeon-guided
flexion and extension under fluoroscopy (possible
also lying on the side) and document the extreme
positions (Fig. 12.14). Not only the patient’s status,
but also radiographic findings can be a limitation of
dynamic imaging. The patient should be carefully
evaluated for presence of previously described anterior spurs and/or incomplete ring fractures, which
could cause compression during head manipulation.
If the fracture is considered stable and there is less
than 3 mm of inter-fragmental distance on initial axial
CT scan, we recommend the use of a hard cervical
collar for 3 months with regular CT follow-up to
monitor fracture healing. The treatment is finished
when there is no visible fracture line on axial CT
images and confirmed stability on dynamic films.
Occasionally, this can take more than 3 months
(Fig. 12.15).
If, despite dynamic stability, the fracture gap is
more than 3 mm on axial CT, we discuss with the
patient the option of direct CT-guided posterior osteosynthesis (Fig. 12.16). Depending on his/her decision, we perform the fixation or continue with
Philadelphia collar or SOMI brace and careful
follow-up.
In initially displaced fractures or those with instability on dynamic films, we always recommend surgical treatment. In cases of marked dislocation, we
apply halo-ring and traction of 2–5 kg (with
190
Fig. 12.14 Non-displaced
fracture with abruption of
anterior C2 edge. (a) Neutral
position. (b) Flexion.
(c) Extension revealing
angular instability. (d) Final
treatment with anterior graft
and plate fixation
12 Fractures of the Ring of Axis (Hangman Type Fractures)
12.7 Our Preference
ab
Fig. 12.15 Still apparent facture line after 4 month of Philadelphia
collar support
191
exception of total disruption – some type Levine IIa,
where more gentle manipulation allows preoperative
reduction). The majority of displaced fractures can
be reduced overnight. Reducible cases are treated
by anterior approach with discectomy, auto/allogenic
bone graft, plate and bicortical screw fixation.
Posterior approach is reserved for complicated cases
irreducible by simple traction and more complex
C1-2 injury.
Although infrequent, there are borderline cases
where the decision for surgery is controversial. In
such cases, we usually proceed with operative intervention and check the disc and ligament integrity
with intraoperative discography. So far, in all these
operated cases, we were able to confirm a contrast
leak either through anterior or posterior longitudinal
ligament (Fig. 12.17).
Fig. 12.16 CT guided direct osteosynthesis of hangman’s fracture according to Judet. (a) Initial CT scan. (b) Fracture gap disap-
pearance after tightening of the lag screws
192
a
c
b
d
12 Fractures of the Ring of Axis (Hangman Type Fractures)
Fig. 12.17 Borderline instability of hangman’s fracture. (a) Axial CT showing hairline fracture. (b) Dynamic investigation – flexion.
(c) Dynamic investigation extension. (d) Peroperative discography confirming the morphological incompetence of PLL
References
ab
a b
Fig. 12.18 (a) extension ,
(b) flexion
193
Fig. 12.19 (a) extension,
(b) flexion
All patients are followed for at least 2 years to
establish long-term stability and the influence on
adjacent segments; however, the patient response
rate, as in other trauma groups, is limited (Figs. 12.18
and 12.19).
We always consider treatment prioritization in polytrauma patients. Without neurological compromise,
definite surgical treatment of hangman’s fracture can
always be postponed until other life-threatening situations are addressed and patient stabilized.
References
1. Alker Jr., G.J., Oh, Y.S., Leslie, E.V.: High cervical spine
and craniocervical junction injuries in fatal traffic accidents:
a radiological study. Orthop Clin North Am 9, 1003–1010
(1978)
2. Andrews, R.J.: Hangman’s fractures involving the body of
C2. Neurosurgery 27, 845–846 (1990)
3. Arand, M., Hartwig, E., Kinzl, L., et al.: Spinal navigation in
cervical fractures–a preliminary clinical study on Judetosteosynthesis of the axis. Comput Aided Surg 6, 170–175
(2001)
194
12 Fractures of the Ring of Axis (Hangman Type Fractures)
4. Baumgarten, M., Mouradian, W., Boger, D., et al.: Computed
axial tomography in C1-C2 trauma. Spine (Phila Pa 1976)
10, 187–192 (1985)
5. Benzel, E.C.: Anatomic consideration of C2 pedicle screw
placement. Spine (Phila Pa 1976) 21, 2301–2302 (1996)
6. Borne, G.M., Bedou, G.L., Pinaudeau, M.: Treatment of
pedicular fractures of the axis. A clinical study and screw
fixation technique. J Neurosurg 60, 88–93 (1984)
7. Brashear Jr., R., Venters, G., Preston, E.T.: Fractures of the
neural arch of the axis. A report of twenty-nine cases. J Bone
Joint Surg Am 57, 879–887 (1975)
8. Bridwell, K.H.: Treatment of a markedly displaced hangman’s fracture with a luque rectangle and a posterior fusion
in a 71-year-old man. Case report. Spine (Phila Pa 1976) 11,
49–52 (1986)
9. Bucholz, R.W.: Unstable hangman’s fractures. Clin Orthop
Relat Res 154, 119–124 (1981)
10. Bucholz, R.D., Cheung, K.C.: Halo vest versus spinal fusion
for cervical injury: evidence from an outcome study. J
Neurosurg 70, 884–892 (1989)
11. Burke, J.T., Harris Jr., J.H.: Acute injuries of the axis vertebra. Skeletal Radiol 18, 335–346 (1989)
12. Chen, X.S., Jia, L.S., Cao, S.F., et al.: Diagnosis and surgical
management of Hangman’s fracture combined with intervertebral disc injury. Zhonghua Wai Ke Za Zhi 42, 712–715
(2004)
13. Chittiboina, P., Wylen, E., Ogden, A., et al.: Traumatic spondylolisthesis of the axis: a biomechanical comparison of
clinically relevant anterior and posterior fusion techniques. J
Neurosurg Spine 11, 379–387 (2009)
14. Clarke, A.P.: Fracture of the cervical vertebrae. JAMA 3,
390–391 (1884)
15. Colangelo, E.J.: Cervicocranium and the aviator’s protective helmet. Aviat Space Environ Med 46, 1263–1264
(1975)
16. Cooper, P.R., Maravilla, K.R., Sklar, F.H., et al.: Halo immobilization of cervical spine fractures. Indications and results.
J Neurosurg 50, 603–610 (1979)
17. Coric, D., Wilson, J.A., Kelly Jr., D.L.: Treatment of traumatic spondylolisthesis of the axis with nonrigid immobilization: a review of 64 cases. J Neurosurg 85, 550–554
(1996)
18. Cornish, B.L.: Traumatic spondylolisthesis of the axis. J
Bone Joint Surg Br 50, 31–43 (1968)
19. Crook, G.T.: The complete newgate calendar, vol. 2, p. 181.
Navarre Society, London (1926)
20. Crutchfield, W.G.: Skeletal traction in treatment of injuries
to the cervical spine. JAMA 155, 29–32 (1954)
21. Davis, D., Bohlman, H., Walker, A.E., et al.: The pathological findings in fatal craniospinal injuries. J Neurosurg 34,
603–613 (1971)
22. Decoulx, P., Decoulx, J., Duquennoy, A., et al.: Fractures
and luxations of the cervical spine. Indications and technic
of anterior arthrodesis (especially C.2-C.3)]. J Chir (Paris)
96, 423–437 (1968)
23. DeLorme, T.L.: Axis-pedicle fractures. J Bone Joint Surg Br
49, 1472 (1967)
24. Duggal, N., Chamberlain, R.H., Perez-Garza, L.E., et al.:
Hangman’s fracture: a biomechanical comparison of stabilization techniques. Spine (Phila Pa 1976) 32, 182–187
(2007)
25. Dussault, R.G., Effendi, B., Roy, D., et al.: Locked facets
with fracture of the neural arch of the axis. Spine (Phila Pa
1976) 8, 365–367 (1983)
26. Edgar, M.A., Fisher, T.R., McSweeney, T., et al.: Tetraplegia
from hangman’s fracture: report of a case with recovery.
Injury 3, 199–202 (1972)
27. Effendi, B., Roy, D., Cornish, B., et al.: Fractures of the ring
of the axis. A classification based on the analysis of 131
cases. J Bone Joint Surg Br 63-B, 319–327 (1981)
28. Ehni, G., Benner, B.: Occipital neuralgia and the C1-2
arthrosis syndrome. J Neurosurg 61, 961–965 (1984)
29. Elliott Jr., J.M., Rogers, L.F., Wissinger, J.P., et al.: The
hangman’s fracture. Fractures of the neural arch of the axis.
Radiology 104, 303–307 (1972)
30. Fielding, J.W., Francis, W.R., Hawkins, R.J., et al.: Traumatic
spondylolisthesis of the axis. Clin Orthop Relat Res 239,
48–52 (1982)
31. Finn, M., Fassett, D.R., Apfelbaum, R.I.: Surgical treatment
of nonrheumatoid atlantoaxial degenerative arthritis producing pain and myelopathy. Spine (Phila Pa 1976) 32, 3067–
3073 (2007)
32. Finnegan, M.A., McDonald, H.: Hangman’s fracture in an
infant. Can Med Assoc J 127, 1001–1002 (1982)
33. Francis, W.R., Fielding, J.W., Hawkins, R.J., et al.: Traumatic
spondylolisthesis of the axis. J Bone Joint Surg Br 63-B,
313–318 (1981)
34. Fuentes, S., Metellus, P., Dufour, H., et al.: Traumatic spondylolisthesis of the axis: arguments in favor of surgical management after analysis of 8 patients. Neurochirurgie 49,
25–30 (2003)
35. Garber, J.N.: Abnormalities of the Atlas and Axis Vertebrae–
Congenital and Traumatic. J Bone Joint Surg Am 46, 1782–
1791 (1964)
36. Garfin, S.R., Botte, M.J., Waters, R.L., et al.: Complications
in the use of the halo fixation device. J Bone Joint Surg Am
68, 320–325 (1986)
37. Gerlock Jr., A.J., Mirfakhraee, M.: Computed tomography
and hangman’s fractures. South Med J 76, 727–728 (1983)
38. Greene, K.A., Dickman, C.A., Marciano, F.F., et al.: Acute
axis fractures. Analysis of management and outcome in 340
consecutive cases. Spine (Phila Pa 1976) 22, 1843–1852
(1997)
39. Grogono, B.J.S.: Injuries of the atlas and axis. J Bone Joint
Surg Br 36-B, 397–410 (1954)
40. Guiot, B., Fessler, R.G.: Complex atlantoaxial fractures. J
Neurosurg Spine 91, 139–143 (1999)
41. Hadley, M.N., Browner, C., Sonntag, V.K.: Axis fractures: a
comprehensive review of management and treatment in 107
cases. Neurosurgery 17, 281–290 (1985)
42. Haughton, S.: On hanging, considered from a mechanical
and physiological point of view. Philos Mag J Sci 32, 23–34
(1866)
43. Ivancic, P.C., Beauchman, N.N., Tweardy, L.: Effect of halovest components on stabilizing the injured cervical spine.
Spine (Phila Pa 1976) 34, 167–175 (2009)
44. James, R., Nasmyth-Jones, R.: The occurrence of cervical
fractures in victims of judicial hanging. Forensic Sci Int 54,
81–91 (1992)
45. Jarolimek, A.M., Coffey, C.C., Sandler, C.M., et al.: Imaging
of upper cervical spine injuries – part III: C2 bellow the
dens. Appl Radiol 33, 9–21 (2004)
References
195
46. Jeanneret, B., Magerl, F., Ward, J.C.: Overdistraction: a hazard of skull traction in the management of acute injuries of
the cervical spine. Arch Orthop Trauma Surg 110, 242–245
(1991)
47. Jeffreys, E.: Disorders of the cervical spine, p. 60.
Butterworths, London (1980)
48. Junge, A., El-Sheik, M., Celik, I., et al.: Pathomorphology,
diagnosis and treatment of “hangman’s fractures”.
Unfallchirurg 105, 775–782 (2002)
49. Kocis, J., Wendsche, P., Visna, P., et al.: Traumatic spondylolisthesis of the axis. Acta Chir Orthop Traumatol Cech
70, 214–218 (2003)
50. Koller, H.: The unstable traumatic spondylolisthesis C2/3.
Akt Traumatol 35, 183–202 (2005)
51. Koller, H., Acosta, F., Forstner, R., et al.: C2-fractures: part
II. A morphometrical analysis of computerized atlantoaxial
motion, anatomical alignment and related clinical outcomes.
Eur Spine J 18, 1135–1153 (2009)
52. Koller, H., Kathrein, A.: Letter to the editor concerning: a
systematic review of the management of hangman’s fractures by Xin-Feng Li et al. Eur Spine J 15, 257–269 (2006).
Eur Spine J 15:1415–1418; author reply 1419–1421
53. Laurence, J.: A history of capital punishment, p. 42.
Sampson, London (1926)
54. Leconte, P.: Fracture et luxation des deux premieres vertebres
cervicales. In: Judet, R. (ed.) Luxation Congenitale de la
Hanche. Fractures du Cou-de-pied Rachis Cervical. Actualites
de Chirurgie Orthopedique de l’Hospital Raymond-Poincare,
vol. 3, pp. 147–166. Masson et Cie, Paris (1964)
55. Lesoin, F., Thomas, C.E., Lozes, G., et al.: Has the
safety-belt replaced the hangman’s noose? Lancet 1, 1341
(1985)
56. Levine, A.M., Edwards, C.C.: The management of traumatic
spondylolisthesis of the axis. J Bone Joint Surg Am 67, 217–
226 (1985)
57. Li, X.F., Dai, L.Y., Lu, H., et al.: A systematic review of the
management of hangman’s fractures. Eur Spine J 15, 257–
269 (2006)
58. Lohnert, J., Latal, J.: Fracture of the axis–surgical treatment.
II. Axial isthmus. Acta Chir Orthop Traumatol Cech 60,
47–50 (1993)
59. Maiman, D.J., Larson, S.J.: Management of odontoid fractures. Neurosurgery 11, 471–476 (1982)
60. Marar, B.C.: Fracture of the axis arch. “Hangman’s fracture”
of the cervical spine. Clin Orthop Relat Res 106, 155–165
(1975)
61. Marotta, T.R., White, L., TerBrugge, K.G., et al.: An unusual
type of hangman’s fracture. Neurosurgery 26, 848–850
(1990). discussion 850–841
62. Marshal, J.J.: Judicial executions. Brit Med J 2, 779–782
(1888)
63. McCall, I., el Masri, W., Jaffray, D.: Hangman’s fracture in
ankylosing spondylitis. Injury 16, 483–484 (1985)
64. Mirvis, S.E., Young, J.W., Lim, C., et al.: Hangman’s fracture: radiologic assessment in 27 cases. Radiology 163,
713–717 (1987)
65. Mollan, R.A., Watt, P.C.: Hangman’s fracture. Injury 14,
265–267 (1982)
66. Moon, M.S., Moon, J.L., Moon, Y.W., et al.: Traumatic
spondylolisthesis of the axis: 42 cases. Bull Hosp Jt Dis 60,
61–66 (2001)
67. Muller, E.J., Wick, M., Muhr, G.: Traumatic spondylolisthesis of the axis: treatment rationale based on the stability
of the different fracture types. Eur Spine J 9, 123–128
(2000)
68. Nordstrom, R.E., Lahdenranta, T.V., Kaitila, I.I., et al.:
Familial spondylolisthesis of the axis vertebra. J Bone Joint
Surg Br 68, 704–706 (1986)
69. Norrell, H., Wilson, C.B.: Early anterior fusion for injuries
of the cervical portion of the spine. JAMA 214, 525–530
(1970)
70. Norton, W.L.: Fractures and Dislocations of the Cervical
Spine. J Bone Joint Surg Am 44, 115–139 (1962)
71. Okuchi, K., Fujioka, M., Konobu, T., et al.: A case of
Hangman’s fracture associated with vertebral arteriovenous
fistula treated with trapping. No Shinkei Geka 22, 55–59
(1994)
72. Pepin, J.W., Hawkins, R.J.: Traumatic spondylolisthesis of
the axis: Hangman’s fracture. Clin Orthop Relat Res 157,
133–138 (1981)
73. Pinczewski, L., Taylor, T.K., Ryan, M.D.: Hangman’s fracture: nonoperative management with the halocast. Aust N Z
J Surg 53, 71–76 (1983)
74. Ramadier, J.O., Bombart, M.: Fractures and dislocations of
the cervical spine without spinal cord lesion. I. Generalities.
Lesions of the 21st vertebrae. 52 cases. Rev Chir Orthop
Reparatrice Appar Mot 49, 741–764 (1963)
75. Reynier, Y., Lena, G., Diaz-Vazquez, P., et al.: Evaluation of
138 fractures of the cervical spine during a recent 5-year
period (1979 to 1983). Therapeutic approaches. Neurochirurgie
31, 153–160 (1985)
76. Roda, J.M., Castro, A., Blazquez, M.G.: Hangman’s fracture
with complete dislocation of C-2 on C-3. Case report. J
Neurosurg 60, 633–635 (1984)
77. Rogers, W.A.: Fractures and dislocations of the cervical
spine; an end-result study. J Bone Joint Surg Am 39-A, 341–
376 (1957)
78. Roy-Camille, R., de la Caffiniére, J.H., Saillant, G.: Les
traumatismes du rachis cervical superieur C1-C2. Masson et
Cie, Paris (1973)
79. Roy-Camille, R., Saillant, G.: Surgery of the cervical spine.
4. Osteosynthesis of the upper cervical spine. Nouv Presse
Med 1, 2847–2849 (1972)
80. Roy-Camille, R., Saillant, G.: Spinal injuries without neurologic complications. Int Orthop 8, 155–162 (1984)
81. Saldeen, T.: Fatal neck injuries caused by use of diagonal
safety belts. J Trauma 7, 856–862 (1967)
82. Samaha, C., Lazennec, J.Y., Laporte, C., et al.: Hangman’s
fracture: the relationship between asymmetry and instability.
J Bone Joint Surg Br 82, 1046–1052 (2000)
83. Schneider, R.C., Livingston, K.E., Cave, A.J., et al.:
“Hangman’s fracture” of the cervical spine. J Neurosurg 22,
141–154 (1965)
84. Seljeskog, E.L., Chou, S.N.: Spectrum of the hangman’s
fracture. J Neurosurg 45, 3–8 (1976)
85. Sherk, H.H., Howard, T.: Clinical and pathologic correlations in traumatic spondylolisthesis of the axis. Clin Orthop
Relat Res 174, 122–126 (1983)
86. Smith, J.T., Skinner, S.R., Shonnard, N.H.: Persistent synchondrosis of the second cervical vertebra simulating a
hangman’s fracture in a child. Report of a case. J Bone Joint
Surg Am 75, 1228–1230 (1993)
196
12 Fractures of the Ring of Axis (Hangman Type Fractures)
87. Starr, J.K., Eismont, F.J.: Atypical hangman’s fractures.
Spine (Phila Pa 1976) 18, 1954–1957 (1993)
88. Suchomel, P., Hradil, J., Barsa, P., et al.: Surgical treatment
of fracture of the ring of axis – “hangman’s fracture”. Acta
Chir Orthop Traumatol Cech 73, 321–328 (2006)
89. Taller, S., Suchomel, P., Lukas, R., et al.: CT-guided internal
fixation of a hangman’s fracture. Eur Spine J 9, 393–397
(2000)
90. Teo, E.C., Paul, J.P., Evans, J.H., et al.: Experimental investigation of failure load and fracture patterns of C2 (axis). J
Biomech 34, 1005–1010 (2001)
91. Tuite, G.F., Papadopoulos, S.M., Sonntag, V.K.: Caspar plate
fixation for the treatment of complex hangman’s fractures.
Neurosurgery 30, 761–764 (1992). discussion 764–765
92. Umebese, P.F., Orhewere, F.A.: Hangman’s fracture in head
injury. East Afr Med J 66, 611–614 (1989)
93. Vaccaro, A.R., Madigan, L., Bauerle, W.B., et al.: Early halo
immobilization of displaced traumatic spondylolisthesis of
the axis. Spine (Phila Pa 1976) 27, 2229–2233 (2002)
94. Verheggen, R., Jansen, J.: Hangman’s fracture: arguments in
favor of surgical therapy for type II and III according to
Edwards and Levine. Surg Neurol 49, 253–261 (1998). discussion 261–252
95. Vichard, P., Mirbey, J., Pinon, P.: Value of anterior arthrodesis in the treatment of fractures of the pedicles of the axis
(author’s transl). J Chir (Paris) 118, 565–572 (1981)
96. Vieweg, U., Schultheiss, R.: A review of halo vest treatment
of upper cervical spine injuries. Arch Orthop Trauma Surg
121, 50–55 (2001)
97. Vlach, O., Leznar, M., Bayer, M.: Diagnosis, classification
and treatment of so-called hangman’s fractures. Acta Chir
Orthop Traumatol Cech 55, 456–466 (1988)
98. White 3rd, A.A., Johnson, R.M., Panjabi, M.M., et al.:
Biomechanical analysis of clinical stability in the cervical
spine. Clin Orthop Relat Res 109, 85–96 (1975)
99. White 3rd, A.A., Moss, H.L.: Hangman’s fracture with nonunion and late cord compression. A case report. J Bone Joint
Surg Am 60, 839–840 (1978)
100. Wilson, A.J., Marshall, R.W., Ewart, M.: Transoral fusion
with internal fixation in a displaced hangman’s fracture.
Spine (Phila Pa 1976) 24, 295–298 (1999)
101. Wood-Jones, F.: The ideal lesion produced by judicial
hanging. Lancet 181, 53 (1913)
102. Yarbrough, B.E., Hendey, G.W.: Hangman’s fracture result-
ing from improper seat belt use. South Med J 83, 843–845
(1990)
103. Zapletal, J., de Valois, J.C.: Radiologic prevalence of
advanced lateral C1-C2 osteoarthritis. Spine (Phila Pa
1976) 22, 2511–2513 (1997)
104. Zavanone, M., Guerra, P., Rampini, P., et al.: Traumatic
fractures of the craniovertebral junction. Management of
23 cases. J Neurosurg Sci 35, 17–22 (1991)
Miscellaneous C2 Fractures
P. Suchomel and J. Hradil
13
The category of miscellaneous axis fractures was introduced by Hadley [6] to cover all non-odontoid and nonhangman like fractures. These “non-classifiable C2
injuries” represent about one quarter of all C2 fractures.
Apart from this “broad” definition, there are narrower
alternatives as well. Some authors distinguish certain
groups of fractures as separate categories (namely, axis
body fractures and tear-drop fractures), excluding them
from “miscellaneous” category. However, any detailed
categorization faces problems with terminology, classification and, of course, certain uniqueness of this class
of axis injuries. The literature on miscellaneous fractures is scarce and terminology is not consistent. There
is no firm evidence to guide the treatment strategies.
13.1 Incidence and Classification
For the purpose of this text, we use Hadley’s “broad
definition”. Further groups can be identified within
this category. These include (a) coronal, (b) sagittal, (c)
transverse, and (d) burst fractures of the axis body, (e)
tear drop fractures, (f) non-hangman injuries to lamina
and spinous process, (g) fractures of the superior facet
area, and (h) fractures through the vertebral foramen
(transverse process). The borders between the groups
cannot be precisely defined and this categorization
serves only as a general guide. In reality, every “atypical” axis injury needs a strictly individual approach.
It is very difficult to estimate the incidence of miscella-
neous axis fractures within the population. The literature
P. Suchomel and J. Hradil
Department of Neurosurgery,
Neurocenter, Regional Hospital Liberec,
Husova St.10, 46063 Liberec, Czech Republic
is very limited and certain fracture patterns are clearly
underreported, for example severe fractures/dislocations
in polytrauma patients with early death of the patient.
While mild cases are treated in local hospitals (fracture
of spinous process), certain patterns are generally underdiagnosed (impression through the superior facet joint).
The reported incidence depends on types of fractures considered as “miscellaneous” and therefore, varies between 19 and 32% of axis fractures. Non-odontiod/
non-hangman fractures represent about 20% of axis
trauma referred to tertiary spine center, according to
the largest series of Greene. This number does not
change in time, according to single institution data
covering different periods of time [5–7].
Hadley et al. [6] described characteristics and management of 23 miscellaneous fractures: 8 body fractures, 7 lateral mass fractures, 3 lamina fractures, 2
pedicle fractures, 2 spinous process fractures, and 1
pars interarticularis fracture. The authors applied halovest or SOMI brace for 8–12 weeks. Rigid/soft collar or
varying “descendent” combinations of external immobilization were applied in more stable injuries. Further
reports from the same institution from 1989 [7] and 1997
[5] with a total of 67 non-odontiod and non-hangman
fractures out of 340 axis fractures brought no change
in diagnostic or treatment rationale. The reported rate
of nonunion leading to delayed surgery was 1.6%, no
further outcome measures were provided.
Fujimura [3] suggested a classification of axis
body fractures based on 31 cases including 17 cases
of sagittal fractures. Authors distinguish four categories: avulsion, transverse, burst, and sagittal. The
results of conservative treatment were mostly
satisfactory with the exception of sagittal fractures,
where 8 of 17 cases treated by external immobilization required C1-C2 fusion due to neck pain based
on early C1/C2 joint degeneration. The authors
P. Suchomel and O. Choutka, Reconstruction of Upper Cervical Spine and Craniovertebral Junction,
DOI: 10.1007/978-3-642-13158-5_13, © Springer-Verlag Berlin Heidelberg 2011
197