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Traumatic Spondylolisthesis of Axis (Hangman's Fracture)

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Introduction pagebreak
  • Traumatic anterior spondylolithesis of the axis due to bilateral fracture of pars interarticularis
    • MVA is most common cause
  • Mechanism is
    • hyperextension
      • leads to fracture of pars
    • secondary flexion
      • tears PLL and disc allowing subluxation
  • Associated injuries
    • 30% have concomitant c-spine fx
Presentation
  • Symptoms
    • neck pain
  • Physical exam
    • patients are usually neurologically intact
Imaging
  • Radiographs
    • flexion and extension radiographs show subluxation  
  • CT
    • study of choice to delineate fracture pattern
  • MRA
    • consider if suspicious of a vascular injury to the vertebral artery
Classification & Treatment

Levine and Edwards Classification (based on mechanism of injury)  
Type I   Axial compression and hyperextension
  • < 3mm horizontal displacement C2/3 
  • No angulation
  • C2/3 disc remains intact
  • stable fx pattern 
  • Rigid collar x 4-6 weeks
Type II   Hyperextension and axial load followed by rebound flexion
  • > 3mm of horizontal displacement
  • Significant angulation
  • Vertical fracture line
  • C2/3 disc and PLL are disrupted
  • unstable fracture pattern
  • If < 5mm displacement, reduction with traction then halo immobilization x 6-12 weeks
  • If > 5mm displacement, surgery or prolonged traction
  • Usually heal despite displacement (autofuse C2 on C3)
Type IIA   Flexion-distraction
  • No horizontal displacement
  • Horizontal fracture line
  • Significant angulation
  • Avoid Traction in Type IIA.
  • Reduction with gentle axial load + hyperextension, then compression halo immobilization for 6-12 weeks.
Type III   Flexion-distraction followed by hyperextension
  • Type I fracture with associated bilateral C2-3 facet dislocation
  • Rare injury pattern
  • Surgical reduction of facet dislocation followed by stabilization required.

 
Treatment
  • Nonoperative
    • rigid cervical collar x 4-6 weeks  
      • indications
        • Type I fractures (< 3mm horizontal displacement)
    • closed reduction followed by halo immobilization for 8-12 weeks
      • indications
        • Type II with 3-5 mm displacement
        • Type IIA
      • reduction technique
        • Type II use axial traction combined + extension
        • Type IIA use hyperextension (avoid axial traction in Type IIA)
  • Operative
    • reduction with surgical stabilization
      • indications
        • Type II with > 5 mm displacement and severe angulation
        • Type III (facet dislocations)
      • technique
        • anterior C2-3 interbody fusion
        • posterior C1-3 fusion
        • bilateral C2 pars screw osteosynthesis
 

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