Saradhi's single stage, anterior sequential reduction utilizing C3 for type III hangman's fracture: A novel technique

Abstract

Background: Levine Edward's Type III Hangman's fractures are highly unstable and in absence of level 1 evidence, the treatment is individualized. A longer cantilever beam can achieve not just reduction of highly displaced fragments but can also provide a stable construct without the need of global instrumentation.

Objective: We extrapolated the surgical techniques of the long cantilever beam to this rare group of cohorts for anterior alone, sequential reduction utilizing C3 rather than sacrificing in a single sitting and single approach.

Materials and methods: This is a prospective observational study from 2015 to 2019, of all consecutive 10 patients diagnosed and treated as Type III Hangman's fracture in the Department of Neurosurgery. Clinical evaluation and pain scores were recorded in the preoperative assessment. Radiological investigations included plain roentgenograms in anterior-posterior and lateral views, magnetic resonance imaging, and computed tomography scan of the cervical spine. Preoperative cervical traction was placed in all cases for the achievement of facetal reduction. The high cervical extra-pharyngeal approach was utilized for discectomy, bone grafting, reduction, and sequential plating.

Results: Complete reduction was achieved in all the cases and none required additional posterior surgery. There was a significant decrease in axial neck pain with complete fusion of the graft, and healing of fracture site.

Conclusion: The anterior alone approach with a longer cantilever for primary internal stabilization is a technically safe and suitable option for unstable Type III Hangman's fracture.

Keywords: Fixation; Hangman's fracture; Sequential reduction; fusion; longer cantilever.

Figure 1

Pictorial diagram of the Sequential reduction technique showing steps 6, 7 and 8

Figure 2

The typical Hangman's fracture Type III. X ray showing Fracture with anterior subluxation C2 over C3with locked facets. Magnetic resonance imaging and computed tomography showing gross translation, angulation and axial rotation. Note the posterior and superior part of C3 impinging on theca sac; (arrow yellow- showing the disrupted anterior longitudinal ligament with collection)

Figure 3

Sequential tightening of screws on the plate. Upper holes A and B middle holes C and D lower holes E and F The sequence of inserting screws is as follows A F C B E and D. This final D will pull up the fragment totally to the plate with resulting fixation

Figure 4

X-Ray cervical spine a patient immediately after surgery (postoperative) (left) and after 6 months (right) in the same patient showing solid fusion