Traumatic Spondylolisthesis of the Axis (aka Hangman s Fracture):

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Phyllis Lamb
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1 Traumatic Spndyllisthesis f the Axis (aka Hangman s Fracture): Carl Bellabarba, MD Prfessr Department f Orthpaedics & Sprts Medicine Department f Neurlgical Surgery University f Washingtn Schl f Medicine Acting Chief f Orthpaedics Harbrview Medical Center Seattle, WA Demgraphics: 5% f all C-spine fractures Bimdal distributin High energy injuries in yunger patients Lw energy injuries in elderly patients Classificatin Effendi Classificatin, mdified by Levine & Edwards 5 types described 3 primary types 2 subtypes Primary Type I: Minimally displaced (<3mm) Cnfirm with upright xrays t distinguish frm Type II Type II: Hyperextensin mechanism causes pincer effect & vertical pars fracture Disruptin f PLL resulting in >3mm f subluxatin Mst cmmn type Type III: Assciated C2-3 facet dislcatin Either unilateral r bilateral Behaves mre like subaxial jumped facet injury Risk f neurlgical injury C2 pars fracture cmpnent usually nn- r minimally displaced (Type I) Subtypes: Type IA (Atypical) Catch-all categry with range f fracture patterns Typically blique transverse plane fracture thrugh C2 pars & bdy n ppsite sides

2 Risk f neurlgical Injury May behave unpredictably with nnperative treatment Type IIA Flexin-distractin injury pattern Kyphtic angulatin ut f prprtin with degree f translatin Extent has never been specifically defined Fracture cmpnent generally mre transverse than Type II Evaluatin: Radigraphic: Plain radigraphs False negative rate as high as 40% Upright radigraphs may help distinguish stability (eg Type I vs Type II) CT scan mst reliable Assciated injuries Vertebral artery framen invlvement MRI rle uncertain C2-3 disc disruptin Assciated ligamentus injury CTA/MRA Cntrversial VAI reprted in up t ~25% f patients Distractive injuries & fxs invlving vertebral framina Significance? Clinical: Neurlgical injuries uncmmn with Hangman s fractures Injury patterns that cause canal cmprmise represent highest risk: Type III injuries (assciated facet dislcatin) Type 1A (atypical) fractures - asymmetric bdy/pars fracture Type II injuries with severe anterlisthesis Cmpressin caused by psterir C1 arch Treatment: Cntingent n: Fracture type Neurlgical exam Assciated spine injuries Assciated nn-spine injuries ~3/4 f all Hangman s fractures treated nnperatively Types I & II usually treated nnperatively Types IIA & III usually treated peratively Type IA (atypical) mre difficult t categrize as p vs nnp

3 Nnperative treatment generally with rigid cervical cllar vs hal-vest Operative treatment generally C2-3 ACDF vs C2-3 PSIF vs C1-3 PSIF C1-3 PSIF less favrable due t lss f C1-2 mtin Direct pars repair cntrversial Type I: Cnfirm with upright radigraphs in rigid cllar Rle f flexin-extensin radigraphs cntrversial Treat with rigid cervical cllar fr 6-12 weeks Type II: Vast majrity can be treated nnperatively Hal-vest vs rigid cervical cllar Mre displaced injuries may require initial reductin with skeletal tractin Bny healing may ccur at pars fracture r acrss C2-3 disc Indicatins fr perative interventin: Plytrauma Neurlgical Injury Assciated ligamentus injury Multifcal spine injuries Failure f cnservative treatment Inability t tlerate external immbilizatin Surgical Optins: C1-3 PSIF Type III: Requires perative interventin Usually pen psterir reductin and C2-3 PSIF May require C1-3 PSIF if C2 fixatin unacceptable C2-3 ACDF may be useful in unusual situatins Type 1A (atypical): Behaves unpredictably Can usually be treated nnperatively Rigid cervical cllar vs hal-vest Higher likelihd f failure f nnperative treatment than fr Type I r II injuries Indicatins fr perative interventin: Plytrauma Neurlgical Injury Assciated ligamentus injury Multifcal spine injuries

4 Failure f cnservative treatment Inability t tlerate external immbilizatin Surgical Optins: C1-3 PSIF Type IIA: Avid tractin - will wrsen defrmity Require perative interventin C1-C3 PSIF Cmplicatins: Missed injuries Elderly patients Lw energy injuries Fracture displacement/failure f nnperative treatment Nnunin Malunin Arthritis (C2 lateral mass r inferir facet invlvement) Lss f mtin Pain Hal-related cmplicatins Pin tract infectins Scarring Decubiti *age-related Periperative Psterir Infectin Neurvascular injury Vertebral artery Nnunin Malalignment Failure f fixatin Anterir Malalignment Orpharyngeal injury Neurvascular injury Hypglssal nerve Dysphagia

5 Dysphnia Airway cmprmise Higher risk with upper cervical expsures Outcmes: Generally cnsidered favrable, particularly in absence f neur deficits Paucity f literature ~3/4 anticipated t be pain free withut restricted mtin at ne year. References: Cric D, Wilsn JA, Kelly DL Jr. Treatment f traumatic spndyllisthesis f the axis with nnrigid immbilizatin: a review f 64 cases. J Neursurg. 1996;85(4): Chittibina P, Wylen E, Ogden A, Mukherjee DP, Vannemreddy P, Nanda A. Traumatic spndyllisthesis f the axis: a bimechanical cmparisn f clinically relevant anterir and psterir fusin techniques. J Neursurg Spine. 2009;11(4): Duggal N, Chamberlain RH, Perez-Garza LE, Espinza-Laris A, Snntag VK, Crawfrd NR. Hangman's fracture: a bimechanical cmparisn f stabilizatin techniques. Spine (Phila Pa 1976) 2007;32(2): De Zuche Marshall JJ. Judicial executins. BMJ. 1888;2(1449): Ding T, Maltenfrt M, Yang H. et al. Crrelatin f C2 fractures and vertebral artery injury. Spine (Phila Pa 1976) 2010;35(12):E520 E524. Effendi B, Ry D, Crnish B, Dussault RG, Laurin CA. Fractures f the ring f the axis. A classificatin based n analysis f 131 cases. J Bne Jint Surg Br. 1981;63-B(3): Greene KA, Dickman C A, Marcian F F, Drabier J B, Hadley M N, Snntag V K. Acute axis fractures. Analysis f management and utcme in 340 cnsecutive cases. Spine. 1997;22(16): James R, Nasmyth-Jnes R. The ccurrence f cervical fractures in victims f judicial hanging. Frensic Sci Int. 1992;54(1): Levine AM, Edwards C C. The management f traumatic spndyllisthesis f the axis. J Bne Jint Surg Am. 1985;67(2): Li X-F, Dai L-Y, Lu H, Chen X-D. A systematic review f the management f hangman's fractures. Eur Spine J. 2006;15(3): Lin JT, Lee JL, Lee ST. Evaluatin f ccult cervical spine fractures n radigraphs and CT. Emerg Radil. 2003;10(3): Schleicher P, Schlz M, Pingel A, Kandzira F. Traumatic Spndyllisthesis f the Axis Vertebra in Adults. Glbal Spine J Aug; 5(4): Schneider RC, Livingstn KE, Cave AJ, Hamiltn G. Hangman's fracture f the cervical spine. J Neursurg. 1965;22: Watanabe M, Nmura T, Th E, Sat M, Mchida J. Residual neck pain after traumatic spndyllisthesis f the axis. J Spinal Disrd Tech. 2005;18(2): Wd-Jnes F. The ideal lesin prduced by judicial hanging. Lancet. 1913;181(4662):53.

Neurological outcome from conservative or surgical treatment of cervical spinal cord injured patients

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