eurospine 2013 p84 motion preserving procedure for the

EUROSPINE 2013

P84

Motion Preserving Procedure for the Treatment of Hangman’s Fracture

Gohsuke Hattori1, Takahiro Miyahara1, Hisaaki Uchikado2, Motohiro Morioka1

1Department of Neurosurgery, Kurume University School of Medicine, Fukuoka, Japan 2Uchikado Neuro-Spine Clinic, Fukuoka, Japan

Background

Traumatic spondylolisthesis of axis (hangman’s fracture) is often caused by cervical hyper-extension injury such as falling, diving or traffic accidents. However the mortality rate is very high in the cases, some patients complain just neck pain without neurological deficit.

The popular treatments for these injuries are the rigid immobilization like the halo vest or the internal fixation surgery. Halo vest is the most strong external immobilization technique for the cervical spine, but there are some problems; long hospitalization, complication of head pins, risk of nonunion.

On the other hand, internal fixation surgery has become popular today. There are varied fixation procedures for treatment of hangman’s fracture. The occipitocervical fixation or the C1-C3 fixation is sometimes performed to immobilize the fractured regions of axis, but they cause a restriction of the physiological cervical motion.

Recently, we perform the C2 pedicle screw as the fracture line screw for the treatment of hangman’s fracture. That screw instrumentation is a biomechanically strong fixation witch although done through a simple posterior approach. The purpose of this study is to determine the effectiveness of C2 pedicle screw fixation on Hangman’s fracture management.

Department of Neurosurgery, Kurume University School of Medicine

Methods

Patients

From 2003 to 2011, twelve patients with hangman’s fracture admitted to our institute. Conventional X-rays and CT scans revealed type I fracture in four patients, type II fractures in five patients, type IIA fracture in two patients, and type III fracture in other one patient. All patients with type I fracture and one patient with type II fracture who couldn’t receive surgical procedure because of his bad general condition underwent nonsurgical treatment.

Six patients with type II or IIA fracture underwent posterior fixation procedure with C2 pedicle screw and were included this study. We performed anterior fixation procedure of one patient with type III fracture. (Table 1)

This prospective study included six patients with displaced type II or IIA traumatic spondylolisthesis of the axis. There were three females and three males with mean age of 58 years at surgery. The cause of injury was a road traffic accident in three patients and a falling from height in three patients. (Table 2)

Age / Gender

Cause Fracture

type Extra-spinal injury Procedure

68 / M Traffic I DBI, mandibular -

80 / M Traffic II DBI -

53 / M Falling III - Anterior

20 / M Traffic I DBI -

78 / M Traffic IIA Skull, AEDH, clavicle Posterior

59 / F Falling II - Posterior

38 / M Falling I - -

60 / M Falling I Skull base, DBI -

67 / F Falling IIA - Posterior

50 / F Traffic II Skull, ASDH, DBI,

clavicle, thigh Posterior

60 / M Traffic II R. VA occlusion Posterior

33 / M Falling II - Posterior

Mean 56 y F:M = 3:9

F = 6 T = 6

I = 4 (33) II = 5 (42)

IIA = 2 (17) III =1 (8)

Head injury = 6/12 (50) A = 1 (8) P = 6 (50)

(%)

Table 1. hangman’s fracture cases (2003-2011)


Methods

Surgical Procedure

All six patients had a single stage surgery with reduction and fixation. Under the intravenous general anesthesia, we performed direct transpedicular screw fixation through the C2 pedicles. C-arm fluoroscopy, Doppler study of vertebral arteries, motor evoked potentials and somatosensory evoked potentials were monitored intraoperatively. Two patients with type IIA fracture required additional fixation with the C3 lateral mass screws. (Figure 1)

Follow-up

During follow-up, clinical evaluation and plain X-rays were performed at each visit; at 3, 6, and 12-month follow-up, additional dynamic lateral flexion/extension views and a CT scan were performed.

Effendi

Levine & Edwards

Type I Type II Type III

Type II Type II A

external immobilization (or C2 PS) C2 PS C2 PS + C3 LMS C2 PS + C3 LMS (or AF)

PS; pedicle screw, LMS; lateral mass screw, AF; anterior fixation

Treatment Strategy

Figure 1. classification and treatment strategy of hangman’s fracture


Results

This study included six consecutive patients with displaced type II or IIA traumatic spondylolisthesis of the axis. Three patients with type II fracture underwent bilateral transpedicular screw fixation through the C2 pedicles. One patient with unilateral hangman’s fracture and C2 laminar fracture underwent unilateral C2 pedicle screw and C2 laminar screw. We performed C2 pedicle screw and additional C2-C3 fixation with C3 lateral mass screw or C3 laminar screw for two patients with type IIA fracture.

Follow-up CT scans at postoperative three or six months showed bony fusion of fracture and adequate screw position in all patients. Every patients got good functional recovery without restriction of cervical motion.

Age / Gender

Cause Fracture

type Procedure

(date) F/U

(months) Bony fusion

(months)

59 / F Fall II C2 PS

(day 15) 50 6

50 / F Traffic II C2 PS

(day 33) 44 6

60 / M Traffic II C2 PS

(day 11) 15 6

33 / M Fall II C2 PS / LS (day 11)

15 3

78 / M Traffic IIA C2 PS + C3 LMS (day 20)

52 3

67 / F Fall IIA C2 PS +

C3 LMS/LS (day 12)

45 6

Mean 58 y F:M = 3:3

F = 3 T = 3

II = 4 IIA = 2

C2 PS = 4 C2-C3 = 2

Mean 37

5

PS; pedicle screw, LMS; lateral mass screw, LS; laminar screw

Table 2. cases of posterior fixation with C2 pedicle screw


Illustrative case #1; type II fracture 59-year-old Woman, Falling

L R

Bil. C2 pedicle screw

C2

L R

C2

2 months 6 months

The patient fell from hight, and hit her head against the ground. She complained just neck pain. The X-ray and CT revealed type II hangman’s fracture, CTA and MRI demonstrated no injury of the vertebral artery or the spinal cord.

At day 15, we performed the C2 pedicle screw fixation under the total intravenous anesthesia, with monitoring of motor evoked potentials and somatosensory evoked potentials.

At Six months after surgery, follow-up CT demonstrated good bony fusion of the fractured regions.

Preop.

Postop.

Anesth: TIVA Monitoring: -MEP -SEP -VA Doppler -Fluoroscope (radiolucent head frame)


Illustrative case #2; type IIA fracture 78-year-old Man, Traffic Accident

L R

C2

L R

C3

bone graft

3 months

Preop.

Postop.

The patient struck his head at a traffic accident. Head CT and X-ray revealed the epidural hematoma with skull fracture. Open evacuation of the hematoma was performed immediately.

X-ray of the cervical spine revealed type IIA hangman’s fracture, CTA demonstrated reduced gaps of the fracture and no injury of the vertebral artery.

At day 20, we performed the C2 pedicle screw fixation and additional C2-C3 fixation with C3 lateral mass screw and iliac bone graft.

At three months after surgery, follow-up CT demonstrated good bony fusion of the fractured regions.

Bil. C2 pedicle screw Bil. C3 lateral mass screw


Discussion

Although there are many studies about the treatment of hangman’s fracture, a few studies about the operative treatment were reported.

In the conservative treatment series, the success rate was under 50% in the cases with type IIA or III fractures.

About the surgical approach, the posterior approach was commonly chosen in the case with Type I, II, or IIA. But the anterior and posterior approaches were almost equal in type III fractures.

Non-operative

Rigid alone

Nonrigid alone

Both

Effendi Type I 46% 50% 37.5% 12.5%

Effendi Type II 26% 67% - 33%

Levine & Edwards Type II 23% 50% 25% 25%

Levine & Edwards Type IIa 3% 100% - -

Effendi Type III 2% 100% - -

surgical approach conservative treatment

number of publication


Type I Effendi Type II

Levine- Edwards Type II

Levine- Edwards Type IIA

Type III

Discussion

Boullosa et al. reported the C2 pedicle screw fixation technique for the treatment of hangman’s fracture. They performed C2 pedicle screw fixation for type I or type II fracture, and additional fixation of C2-C3 for type II fracture with great dislocation.

The surgical indication of our study is similar to the study of Boullosa et al. However there is a difference in treatment for type I fracture. They performed the surgical fixation for type I fracture with the severe head injury and pseudoarthrosis in the chronic stage.

However we did not perform surgery for type I fracture with good outcome. We considered that surgical treatment is needed only for the case with pseudoarthrosis.

Indication Effendi C2 PS C2 PS – C3 LMS

Pseudoarthrosis, chronic stage; 4 Type I: 1 1 -

Type II: 3 3 -

Severe head injury, early stage; 3 Type I: 1 1 -

Type II: 2 2 -

Great dislocation, early stage; 3 Type I: - - -

Type II: 3 1 2

Age; 21-52 y.o. (35.7) M:F = 8:2


Conclusions

We reported consecutive series of six patients with type II or type IIA traumatic spondylolisthesis of axis (hangman’s fracture).

Transpedicular screw fixation through the C2 pedicles is a safe and effective method in the treating of type II or type IIA traumatic spondylolisthesis of the axis, resulting in good clinical and radiological outcomes. Adequate reduction was achieved and motion segments were preserved with its use.

Address correspondence to:

Gohsuke Hattori, M.D., Ph.D.,

Department of Neurosurgery, Kurume University School of Medicine,

67 Asahi-machi, Kurume, Fukuoka 830-0011, Japan.

email: [email protected]

eurospine 2013 p84 motion preserving procedure for the

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