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Hangman’s fracture
Introduction
Traumatic fractures of the second cervical vertebra account for nearly 20% of all acute cervical spinal fractures with approximately 8.5% of surviving patients having neurological deficits after the injury. The low rate of neurological deficits with these injuries has been attributed to the relatively wide canal at the level of the axis. C2 fractures can be classified as odontoid fractures, hangman’s fractures, or fractures of the body of C2. Bilateral fractures of the par interarticularis are termed hangman’s fractures . They were first described in 1866 by Samuel Haughton after noting this fracture pattern in people who had been subjected to execution by hanging. This was termed traumatic spondylolisthesis of the axis when it was noted that this same fracture pattern was seen in many individuals after motor vehicle collisions. The mechanism of injury that was originally described for hangman’s fractures was hyperextension and distraction, but modern-day hangman’s fractures seen after motor vehicle collisions are typically caused by hyperextension and compression. The most commonly used classification scheme for axis fracture is a modification of the Effendi classification, which classifies fractures based on their morphology ( Table 23.1 ). Most patients with stable traumatic spondylolisthesis of the axis can be managed with traction and external orthosis. Surgery is generally preferred for type III fractures and those who fail to achieve proper alignment with traction and immobilization. In this chapter, we will review the case of a patient with a C2 hangman fracture and review the pertinent anatomy, treatment options, and final treatment strategy for this specific case.
Example case
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Chief complaint: neck pain after motor vehicle collision
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History of present illness: This is a 52-year-old female who presented to the emergency room with neck pain after a motor vehicle collision. She has midline neck tenderness to palpation. She does not have any neurological symptoms in her extremities. Computed tomography scans of the cervical spine were obtained, which revealed evidence of a fracture through bilateral pars interarticularis ( Fig. 23.1 ).
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Medications: antidepressants
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Allergies: no known drug allergies
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Past medical history: depression, anxiety
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Past surgical history: noncontributory
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Family history: none
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Social history: none
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Physical examination: awake, alert, and oriented to person, place, and time; cranial nerves II–XII intact; bilateral deltoids/triceps/biceps 5/5; interossei 5/5; iliopsoas/knee flexion/knee extension/dorsi, and plantar flexion 5/5
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Reflexes: 2+ in bilateral biceps/triceps/brachioradialis with negative Hoffman; 2+ in bilateral patella/ankle; no clonus or Babinski; sensation intact to light touch
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Laboratories: all within normal limits
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| Preoperative | ||||
| Additional tests requested |
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MRA or CTA to evaluate vertebral arteries |
| Surgical approach selected | Posterior C1-C3 fusion | Conservative management | Hard collar initially, if there is nonunion or displacement then posterior C1-3 fusion | Hard collar for 6 weeks |
| If young patient | Potential collar | Same approach | Same approach | Same approach |
| If older adult patient | Fusion | Same approach | Fusion | Same approach |
| Goal of surgery | Prevent subluxation and spinal cord injury | Achieve fusion, long-term stability, maintain neurological status | ||
| Perioperative | ||||
| Positioning | Prone with Mayfield pins | Prone with Mayfield pins | ||
| Surgical equipment |
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| Medications | +/- Steroids, maintain MAPs | None | ||
| Anatomical considerations | Vertebral artery, avoid spinal manipulation | Vertebral artery, C2 pedicle anatomy, spinal cord, dura, C2 nerve roots | ||
| Complications feared with approach chosen | Pseudoarthrosis, spinal cord injury | Pseudoarthrosis, spinal cord injury, vertebral artery injury, C2 neuralgia, epidural bleeding, malpositioned instrumentation | ||
| Intraoperative | ||||
| Anesthesia | General | General | ||
| Exposure | C1-3 | C1-3 | ||
| Levels decompressed | None | None | ||
| Levels fusion | C1-3 | C1-3 | ||
| Surgical narrative | Head is pinned, placed prone with care, fluoroscopy to confirm cervical alignment, subperiosteal dissection from C1-3, bilateral lateral mass screws at C1 and C3, secure with rods, decortication of joins and auto/allograft used for fusion | Asleep fiberoptic intubation, head is pinned, sandwich flip using Allen table, position prone with pins, posterior midline incision, expose C1-3, attach reference frame, O-arm spin, expose C1 lateral mass with control of epidural venous plexus, section C2 nerve roots in preganglionic fashion if needed, drill and tap C1 lateral masses/left C2 pedicle/C3 lateral masses, place polyaxial screws and connect with rods, remove C2-3 spinous process, combine autograft with small unit of BMP for bone grafting, decorticate posterior elements of C1-3, place local bone graft and BMP, layered closure with subfascial drain, local wound anesthetic and vancomycin powder | ||
| Complication avoidance | Surgical navigation, limit to C1-3 | Fiberoptic intubation, sandwich flip, surgical navigation, limit to C1-3, preganglionic section C2 if needed to assess C1 lateral mass, avoid right C2 pedicle, BMP | ||
| Postoperative | ||||
| Admission | Stepdown unit | Floor | Stepdown unit | Floor |
| Postoperative complications feared | Infection, vertebral artery injury | Infection, non/union, hardware failure, epidural hematoma, C2 neuralgia | ||
| Anticipated length of stay | 2-3 days | 1 day | 3 days | 1 day |
| Follow-up testing | CT C-spine or x-rays |
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Cervical x-rays 6 weeks, 3 months, 6 months after discharge |
| Bracing | Cervical collar when out of bed | Aspen collar for 8 weeks | Hard collar for 6 weeks | Hard collar for 6 weeks |
| Follow-up visits | 2 weeks for wound check; 3, 12, and 24 months with x-rays | 2 weeks | 6 weeks, 3 months, 6 months, 12 months, 24 months after surgery | 6 weeks, 3 months, 6 months after discharge |
AP , Anteroposterior; CT , computed tomography; CTA , computed tomography angiography; BMP , bone morphogenic protein; IOM , intraoperative monitoring; MAP , mean arterial pressure; MEP , motor evoked potentials; MRA , magnetic resonance angiography; MRI , magnetic resonance imaging; SSEP , somatosensory evoked potentials.
Table 23.1
Effendi and Levine Classification for Traumatic Spondylolisthesis of C2
| Description | Stability | Management | |
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| Type I | Fracture lines vertical and posterior to vertebral body | Stable | Cervical collar or halo |
| Type II | >3 mm of subluxation, disruption of C2–3 disk | May lead to early instability | Halo traction and then immobilization in a halo vest; may require stabilization for instability |
| Type IIA | Oblique fracture with >11 degrees angulation | Unstable | No traction with increased angulation; may need stabilization |
| Type III | Disruption of the bilateral C2–3 joint | Unstable | Surgical stabilization |
Differential diagnosis
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Axis fracture
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Atlas fracture
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Cervical muscle strain
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Spinal cord injury
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