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Computed Tomography-Guided C2 Pedicle Screw Placement for Treatment of Unstable Hangman Fractures

Singh, Pankaj Kumar MCh; Garg, Kanwaljeet MCh; Sawarkar, Duttaraj MS; Agarwal, Deepak MCh; Satyarthee, Guru Dutta MCh; Gupta, Deepak MCh; Sinha, Sumit MCh; Kale, Shashank Sarad MCh; Sharma, Bhawani Shankar MCh

doi: 10.1097/BRS.0000000000000451
Cervical Spine

Study Design. Case series and description of technique.

Objective. The purpose of this study was to evaluate the feasibility and accuracy of inserting pedicle screws in unstable Hangman fracture cases by using intraoperative CT (O-arm) based navigation.

Summary of Background Data. Hangman fracture, also known as traumatic spondylolisthesis of the C2, is defined as a fracture involving the lamina, articular facets, pedicles, or pars of the axis vertebra. Opinions vary regarding the optimal treatment of unstable Hangman fractures. Some authors have recommended the use of rigid orthosis, whereas others have recommended surgical stabilization. The peculiar anatomy of the upper cervical spine is highly variable, and the presence of surrounding neurovascular structures makes pedicle screw fixation even more technically challenging. The advent of intraoperative 3-dimensional navigation systems permits safe and accurate instrumentation of the cervical spine.

Methods. Ten patients with unstable Hangman fracture, with age ranging from 17 years to 81 years, were operated under O-arm–based navigation, and screw position was confirmed with intraoperative computed tomographic scan.

Results. A total of 52 screws were inserted under O-arm guidance: 20 in C2 pedicle, 20 in C3 lateral mass, and rest in C4 lateral mass. Screw misplacement was seen in only 1 C2 pedicle screw (1 of 20, 5%). No new-onset neurological deficit developed in any of the patients. Follow-up ranged from 3 months to 21 months. Bony fusion was achieved in all. Full rotation was preserved at C1–C2 joint. All the patients (50%) with neurological deficits before surgery improved after surgery.

Conclusion. This series demonstrates that C2 pedicle screws can be put with precision under O-arm–guided navigation, and intraoperative computed tomographic scan can confirm position of screws. Patients can be operated and mobilized early with negligible risk of screw misplacement, with preservation of motion at the C1–C2 joint.

Level of Evidence: 4

In Brief

Hangman fracture is also known as traumatic spondylolisthesis of the C2. There can be variable displacement of C2 on C3. High rates of C2 pedicle screw misplacement have been reported, when done using conventional techniques. The advent of intraoperative 3-dimensional navigation systems permits safe and accurate instrumentation of the cervical spine. We demonstrate management of 10 patients with Hangman fractures with C 2 pedicle screw and C3 or C3 C4 lateral mass screw fixation, under O-arm–based navigation.

Author Information

From the Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India.

Address correspondence and reprint requests to Pankaj Kumar Singh, Mch, Department of Neurosurgery, Room No 717, CN Centre, AIIMS, New Delhi 110029; E-mail:

Acknowledgment date: October 18, 2013. First revision date: February 2, 2014. Second revision date: March 21, 2014. Third revision date: May 14, 2014. Acceptance date: May 22, 2014.

The device(s)/drug(s) is/are FDA approved or approved by corresponding national agency for this indication.

No funds were received in support of this work.

No relevant financial activities outside the submitted work.

© 2014 by Lippincott Williams & Wilkins