2023, Number 4
Transpedicular screw fixation at C2 in the treatment of Levine-Edwards type III Hangman's fracture: an option to preserve motion
Full text
10.35366/113727
Language: English
References: 13
Page: 252-255
PDF size: 196.13 Kb.
ABSTRACT
Introduction: bilateral pars interarticularis fracture of C2 due to traumatic spondylolisthesis accounts for 4 to 7% of cervical fractures and 20 to 22% of C2 fractures. The choice of surgical approach remains controversial; available options include C2-C3 ACDF, C2-C3 posterior fusion, C2 transpedicular screw alone, and 360° approach. Case presentation: male, 60 years old, after a rollover car accident, presents with neck pain VAS 10/10, radiculopathy in right C2-C5, strength 3/5 on the MRC Scale in right C4-C5, right bicipital reflex 1/+. CT with Hangman Type III fracture. We performed external cervical reduction with Mayfield head support, posterior cervical approach and transpedicular fixation of C2, polyaxial trans facet screws in C3 and lateral titanium bars. Conclusiones: Hangman type III fractures must be diagnosed promptly due to the risk of neurological injury. These should be treated with fixation, if possible, with a transpedicular screw at C2, which is an excellent option for reduction and stabilization of the fracture, maintenance of cervical alignment and preservation of ranges of motion.INTRODUCTION
The Hangman fracture is a bilateral fracture of the pars interarticularis of C2 due to traumatic spondylolisthesis. First described in 1965 by Schneider1 in an avulsion fracture of the C2 lamina with dislocation and listhesis of the axis on C3, which was correlated with the fracture pattern described in judicial hangings that used a submental knot. These injuries account for 4% to 7% of all cervical spine fractures2 and 20 to 22% of C2 fractures.3 65% of C2 fractures are caused by motor vehicle accidents, 15% by falls from high impact and 6% from diving injuries.4 Due to unstable Hangman fractures, great caution is required when treating them and proper diagnosis of these injuries allows us to distinguish between stable and unstable fracture patterns and non-surgical vs surgical treatments.4 The choice of surgical approach remains controversial; available options include C2-C3 anterior cervical discectomy and fusion (ACDF), C2-C3 posterior fusion, C2 transpedicular screw alone, and 360° fixation and fusion.3,5,6
PRESENTATION OF CASE
A 60-year-old male, who had a rollover-type car accident, while being the co-pilot and without safety measures, reported sudden right cervicobrachialgia of intensity 10/10, disabling, and loss of strength in the right thoracic limb. The neurological examination showed neck pain 10/10 on the VAS, as well as radiculopathy in C2, C3 right (pain and dysesthesia VAS 10/10 in the occipital, temporal and right auricular region), C4 and C5 right (pain and dysesthesia in the clavicular and right shoulder), strength 3/5 on the MRC Scale in right C4-C5, right bicipital reflex 1/+.
We performed a simple CT of the cervical spine, in which we showed bilateral fracture of the pars interarticularis of C2, with C2 spondylolisthesis of 7.1 mm, C2-C3 angulation of 12.4° and dislocation of the bilateral articular facets (Figure 1). Simple MRI of the cervical spine with C2 spondylolisthesis and early data of spinal cord edema at the C2-C3 level (Figure 2). Angiography without evidence of injury to both vertebral arteries.
With the patient under balanced general anesthesia, in the prone position we carried out cervical reduction with Mayfield head support, we continued through a posterior cervical approach to perform transpedicular fixation of C2 and trans facet screws in C3 and lateral titanium bars (Figure 3). In the immediate postoperative period with total improvement of the right C2-C4 radiculopathy and recovery of MTD strength 5/5 on the MRC scale. At 3 months of follow-up, the patient is showing excellent neurological evolution, with preserved and complete ranges of motion in flexion, extension, lateral inclination and rotation.
DISCUSSION
The first Hangman's fracture classification was proposed in 1981 by Effendi.7 This classification system is based on the degree and type of displacement of the anterior and posterior fragments of the C2 fracture. The classification scheme proposed by Effendi was modified by Levine and Edwards8 in 1985, and is the most widely used classification system for typical Hangman's fractures. Type I injuries are non-angulated fractures with a displacement of < 3 mm, resulting from an axial loading force in hyperextension. Type II injuries present angulation < 11° and a displacement > 3 mm, resulting from an axial load force in hyperextension combined with flexion and anterior compression. Type IIa lesions present angulation > 11° and a displacement > 3 mm. Type III injuries present angulation > 11° and a displacement > 3 mm with dislocation of the bilateral facet joints, due to a flexion-compression mechanism.8 It is widely accepted that type II, IIa and III fractures are unstable and must be treated surgically.9
Hangman's type III fractures should be diagnosed and treated promptly due to the risk of neurological injury. In 1964, Leconte10 described direct C2 transpedicular fixation for the Hangman's fracture, demonstrating its effectiveness. This C2 fixation is an excellent option for reduction and stabilization of the fracture and is considered a "physiological operation", preserving the movement of the normal segments.2 The surgical objectives, in addition to the reduction, stabilization and maintenance of the alignment of the cervical spine, should be the preservation of the range of motion.9,11
Different surgical approaches, both anterior and posterior, have been described for the treatment of Hangman's type III fracture.2,5,9,11 An anterior approach has the advantage of a technically simple and relatively short fusion involving a C2-C3 discectomy with interbody fusion and plating.12 However, the anterior approach cannot address the detached posterior arch of C2 and may have approach-related problems. The high risks of the anterior approach are mainly injuries to vital structures, especially to the facial and hypoglossal nerves, branches of the external carotid artery, contents of the carotid sheath, and the superior laryngeal nerve.2 The posterior approach is associated with a relatively simple exposure. without important vascular or visceral structures, as well as a lower rate of complications. However, both discectomy and ACDF and posterior fixation with C1-C2 screws will lose mobility of the fused segment.2,9 Direct repair of the pars interarticularis fracture with a transpedicular screw across the fracture line has the advantage of preserve segment motion.2,13 However, traditional transpedicular screw fixation for Hangman fracture has several disadvantages. First, reduction cannot be easily achieved with a traditional transpedicular screw because the direction of the screw hole is usually not perpendicular to the fracture line, which can lead to loss of reduction during compression. Secondly, it could not offer enough stability (which is why in our case we decided to place trans facet screws in C3). Third, this method easily causes excessive compression, and the extent of compression depends on the experience of the surgeon. The healing rate of Hangman type III fractures treated by C2 transpedicular fixation is high (89.29%).9,13
CONCLUSION
In the treatment of unstable traumatic spondylolisthesis of the axis, posterior fixation of C2-C3 is preferred, with a transpedicular screw in C2, obtaining open reduction of dislocations, as well as favorable clinical and radiological results. This procedure is technically demanding and must be performed with great care to avoid possible complications. Hopefully, with the availability of modern innovations in our developing countries, these dangers will be reduced to a minimum.
REFERENCES
AFFILIATIONS
1 Department of Neurosurgery and Spine Surgery, Regional Hospital Monterrey ISSSTE, Institute of Security and Social Services for State Workers, Monterrey, Nuevo León, Mexico.
2 ORCID: 0000-0001-8874-372X
Funding: none.
Conflict of interests: there are no conflict of interest.
CORRESPONDENCE
Abrahan Alfonso Tafur-Grandett. E-mail: atafur.grandett@hotmail.comReceived: September 28, 2023. Accepted: September 30, 2023.