==== Front Surg Neurol IntSurg Neurol IntSNISurgical Neurology International2229-50972152-7806Medknow Publications & Media Pvt Ltd India SNI-9-14710.4103/sni.sni_172_18Spine: Case ReportHangman's fracture surgical management with posterior C2-4 fusion: Case description and literature review Ceja-Espinosa A. alexcjae@hotmail.com*Huato-Reyes R. raul.huato@yahoo.comOrtega-Valencia R. drricardoortegavalencia@gmail.comDepartment of Neurosurgery, Centro Médico “Lic. Adolfo Lòpez Mateos”, Instituto de Salud del Estado de México, Av. Nicolás San Juan s/n Ex Hacienda La Magdalena, Estado de México, México* Corresponding author 2018 26 7 2018 9 14720 6 2018 26 6 2018 Copyright: © 2018 Surgical Neurology International2018This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms.Background: Hangman's fractures of the C2 verebrae represent approximately 20% of all cervical fractures. They are challenging cases and there is still no consensus regarding the optimal surgical vs nonoperative treatment. Case Description: A 40-year-old female presented with a C2 bilateral pars articularis fracture. She exhibited a partial spastic quadriparesis. Computed tomography and magnetic resonance imaging showed a C2 “hangman's” fracture with compromise of the C2-3 intervertebral disk. Adequate reduction of the fracture and subaxial stabilization were achieved utilizing C2 transarticular and C3-4 transfacet screws. Conclusions: The optimal management of unstable hangman's fractures remains controversial. They represent challenging cases, and new treatment options are available. Here, we successfully utilized a C2 transarticular and C3-4 transfacet screw fusion without neurological sequelae. C2 transpedicular screwsHangman's fractureposterior fusion ==== Body INTRODUCTION In 1964 Garber introduced the term “traumatic spondylolisthesis of the axis.”.[3] A year later Schneider noted the similarity with judicial hangings, and introduced the term “hangman's fracture.”[8] These fractures are defined by bilateral laminae, articular facets, pedicles, and/or pars articularis fractures of the axis, and are typically attributed to trauma (e.g., motor vehicle accidents, falls, or diving). Nevertheless, there are different management and surgical options for treating hangman's fractures, and, particularly for types II, IIa, and III (e.g., according to Effendi, Levine, and Edwards).[25] CASE DESCRIPTION A 40-year-old female, following a motor vehicle accident, presented with severe neck pain and decreased motor function (e.g. 4/5 in the right arm, left arm 2/5 proximally, 1/5 distally, but 5/5 in both lower extremities). Reflexes were diminished in both arms, and she had no sensory deficit. Magnetic resonance imaging (MRI) and computed tomography (MRI) documented a C2 Hangman's fracture type IIa [Figures 1 and 2]. MRI also showed rupture of the C2-3 intervertebral disk and ligaments at the C1-2 junction, resulting in angulation of 13.3 degrees [Figure 3]. Figure 1 CT sagital scan showing C2 Fracture Figure 2 CT axial scan showing bilateral facet C2 fracture Figure 3 Sagital MRI that shows the angulation greater than 11 grades and comprise of the C2-3 intervertebral disc Cervical surgery The patient underwent a posterior instrumented fusion performed under fluoroscopy. First, C3 and C4 facet screws were placed followed by bilateral C2 transpedicular screw application. Prior to the placement of 2 titanium bars, the C2-3 subluxation was reduced with active manipulation of the craniocervical joint under direct fluoroscopy. Next, 2 titanium bars/six locks, cross link, and 10 ml of bone matrix were applied [Figures 4–8]. Figure 4 Axial CT scan that shows adequate reduction of C2 fracture with transpedicular screws Figure 5 Sagital CT scan that shows reduction of fractured elements Figure 6 3D reconstruction showing posterior C2-4 fusion Figure 7 Transoperative view of the cervical screws in place Figure 8 Transoperative fluoroscopic control showing adequate placement of cervical C2-4 screws Postoperatively, the patient regained motor function as follows: right arm 4/5, left arm 3/5 proximal and distal, and both legs remained at 5/5 (Daniels scale). Reflexes in both her arms also improved +/++. DISCUSSION Hangman's fractures (bilateral fracture of pars interarticularis) constitue approximately 20% of all C2 injuries, and the optimal management of unstable hangman's fractures remains controversial.[679] The optimal management of unstable hangman's fractures (Effendi, Levine, and Edwards types II, IIa and III) remains controversial, and different approaches have been recommended. Available surgical options include anterior C2-3 discectomy with fusion, posterior C2-3 fusion, r C2 pars pedicle screw fusion alone, and combined anterior and posterior fixation.[9] Here, a patient with a hangman's Fracture underwent a posterior instrumented fusion with C2 transarticular and C3-4 transfacet screws without neurological sequelae. Nonoperative management Management guidelines in the literature are based on level III evidence. External immobilization is recommended for the initial management of traumatic spondylolisthesis. Most authors suggest nonoperative treatments for stable fracture types.[1] Surgical management Surgical stabilization and fusion are reserved for severe angulation of C2 over C3, disruption of C2-3 disk, and/or inability to achieve/maintain fracture alignment with external immobilization. In 2006, Li et al. reviewed the management of hangman's fractures and concluced that patients with Effendi, Levine, and Edwards IIa and III might be candidates for surgical stabilization and fusion.[6] In 2017 Kovari et al. described a mini open approach for a posterior C2 fracture fixation and fusion with transpedicular and transmuscular screws.[4] Here, we concluded that surgical reduction with posterior cervical fusion was the best operative choice, and included the placement of bilateral C2 transpedicular screws and bilateral C3-4 transfacet screws. CONCLUSION Here, the patient presented an unstable C2 Hangman's fracture successfully managed with the placement of bilateral C2 transpedicular screws and bilateral C3-4 transfacet screws. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest. http://surgicalneurologyint.com/Hangman's-fracture-surgical-management-with-posterior-C2-4-fusion:-Case-description-and-literature-review/ ==== Refs REFERENCES 1 Al-Mahfoudh Beagrie C Woolley E Zakaria R Radon M Clark S Management of typical and atypical Hangman's fractures Global Spine J 2016 6 248 56 27099816 2 Effendi B Roy D Cornish B Dussault RG Laurin CA Fractures of the ring of the axis: A classification based on the Analysis of 131 cases J Bone Joint Surg 1981 63B 319 27 3 Garber JN Abnormalities of the Atlas and Axis Vertebrae—Congenital and Traumatic J Bone Joint Surg Am 1964 46 1782 91 14239870 4 Kovari VZ Josvai A Csokay A Transpedicular direct osteosynthesis of hangman's fracture from a mini-open exposure as a less invasive procedure: A technical note Trauma Case Rep 2017 12 66 71 29644289 5 Levine AM Edwards CC The management of traumatic spondylolisthesis of the axis J Bone Joint Surg Am 1985 67 217 26 3968113 6 Li XF Dai LY Lu H Chen XD A systematic review of the management of hangman's fractures Eur Spine J 2006 15 257 69 16235100 7 Schleicher P Scholz M Pingel A Kandziora F Traumatic Spondylolisthesis of the Axis vertebra in Adults Global Spine J 2015 5 346 58 26225285 8 Schneider RC Livingston KE Cave AJE Hamilton G “Hangman's Fracture” of the cervical spine J Neurosurg 1965 22 141 54 14288425 9 Xie N Khoo LT Yuan W Ye XJ Chen DY Xiao JR Combined Anterior C2-C3 Fusion and C2 Pedicle Screw Fixation for the Treatment of Unstable Hangman's Fracture. A contrast to Anterior Approach Only Spine 2010 35 613 9 20150833