Case Report

Minimally Invasive Unilateral Percutaneous Transfracture Fixation of a Hangman’s Fracture Using Neuronavigation and Intraoperative Fluoroscopy Mohamed A.R. Soliman1, Benjamin Y.M. Kwan2, Balraj S. Jhawar2

Key words - BACKGROUND: Traumatic spondylolisthesis or hangman’s fracture is a - Cervical fracture common cervical spine fracture. Most cases of traumatic spondylolisthesis are - Hangman’s fracture - Image guidance treated nonoperatively with external immobilization. The indications for surgery - Minimally invasive have generally included fracture instability or failed nonoperative management. - Neuronavigation Operative stabilization can be performed through either anterior or posterior - Unilateral approaches and has generally required instrumentation using open methods. We Abbreviations and Acronyms propose a technique for surgical repair of hangman’s fracture that is minimally 3D: 3-Dimensional invasive and motion preserving using recent advances in 3-dimensional image- CT: Computed tomography guidance technology. We believe this method represents another option in the K-wire: Kirschner wire treatment of hangman’s fractures, because it allows for immediate stabilization, From the 1Department of , Cairo University, prompt recovery, and quick mobilization. Cairo, Egypt; and 2Department of Neurosurgery, Windsor - Regional Hospital, Western University, Windsor, Ontario, CASE DESCRIPTION: We present the case of 2 patients with hangman’s Canada fractures who had undergone surgical unilateral transfixation with minimally To whom correspondence should be addressed: invasive percutaneous screw placement. In both cases, we used 3-dimensional Mohamed A.R. Soliman, M.Sc. neuronavigation and bidirectional intraoperative fluoroscopy. The operative time [E-mail: [email protected]] from incision to closure was <30 minutes. Preparation and positioning after Citation: World Neurosurg. (2019) 122:90-95. https://doi.org/10.1016/j.wneu.2018.10.140 intubation varied from 40 to 150 minutes. No intraoperative complications Journal homepage: www.journals.elsevier.com/world- occurred. Both patients were discharged within 48 hours postoperatively. The neurosurgery follow-up examinations at 3 months, 12 months, and 5 years revealed healthy Available online: www.sciencedirect.com bony fusion on computed tomography imaging and an excellent clinical 1878-8750/$ - see front matter ª 2018 Elsevier Inc. All recovery. rights reserved. - CONCLUSION: We have provided 2 examples in which minimally invasive INTRODUCTION unilateral fixation of hangman’s fractures proved to be safe and effective. In both Traumatic spondylolisthesis of the or cases, the patients were immediately relieved of their pain, quickly mobilized, hangman’s fracture represents w4% of all and promptly discharged. The achievement of successful fusion confirmed at the cervical spine traumas.1 Numerous follow-up examinations. treatments have been proposed; however, for most cases external immobilization has remained the mainstay of treatment.1-3 Rigid halo immobilization has been conditions.8,9 Certain unstable fractures, and lengthy procedural times. The reported to achieve high fusion rates such as Effendi type III, which involve locked complications have included possible blood >90%.2,4-6 Cervical collars have also been and dislocated C2-C3 facets, or Levine- loss requiring transfusion, infection, used to successfully treat hangman’s Edwards type IIa/III, which involve fracture lengthy recovery, and nontrivial medical fractures.1,3 Surgery could potentially displacement and angulation, have also been risksforelderlyindividualswith improve the fusion rate1,4,5,7 but the patient recognized to be insufficiently treated by comorbidities.12 Minimally invasive surgery, must accept the additional risk. external fixation, and experts have generally however, avoids many of these issues by Consequently, most clinicians have recommended surgery.1-3,5,10 Halo fixation exposing patients to less tissue invasion.13 resorted to surgery as a secondary option, canalsofailandhasitsownseriesofcom- These techniques have been increasingly when traditional management has failed.1,3 plications, including infection, nerve injury, used in spinal surgerytoachieveimproved In some circumstances, surgery could be scalp laceration, pain, and visible scarring.1,11 outcomes by exploiting careful preoperative indicated as a primary treatment. Halo vests Although, in general, the surgical fusion planning and recent innovations in are known to compromise pulmonary vol- rates have tended to be greater than nonop- neuronavigation technology.14-16 umes and can compromise respiratory erative procedures, they can be associated With these advantages, minimally capacity, which can be dangerous and lead to with significant morbidity and/or mortality.1 invasive internal fixation of a hangman’s respiratory failure in patients with Traditional surgical techniques have tended fracture using pedicle screw insertion with pre-existing or acquired pulmonary to be open, requiring extensive dissection neuronavigation could be another option

90 www.SCIENCEDIRECT.com WORLD NEUROSURGERY, https://doi.org/10.1016/j.wneu.2018.10.140 CASE REPORT MOHAMED A.R. SOLIMAN ET AL. UNILATERAL BEFORE MINIMALLY

Figure 1. (AeC) Sagittal computed tomography (CT) scans of the cervical showing the fixated fracture immediately postoperatively. (G,H) Sagittal CT spine showing hangman’s fracture with angulation of C2-C3 over C3. (D) scans of the cervical spine showing the fixated fracture at the 3-month Sagittal T2-weighted magnetic resonance imaging scan of the cervical spine follow-up visit. Sagittal CT scans of the cervical spine showing the (I) right showing the ligamentous injury. (E,F) Sagittal CT scans of the cervical spine and (J) left sides of the fixated fracture at the 5-year follow-up visit. in the management of nonangulated Patient 1 a hangman’s fracture, type IIa (Levine hangman’s fractures in stable patients. A 35-year-old man experienced a traumatic classification; Figure 1AeC). A magnetic hyperextension injury from a fall down 4 resonance imaging scan of the cervical stairs. He presented with pain and no spine showed edema in the area of the CASE DESCRIPTION neurological deficits. Computed tomogra- C2-C3 interspinous ligaments, suggesting We present the cases of 2 patients with phy (CT) imaging revealed fractures additional ligamentous injury (Figure 1D). hangman’s fractures. through both parts of C2, consistent with The patient was offered the option of

WORLD NEUROSURGERY 122: 90-95, FEBRUARY 2019 www.journals.elsevier.com/world-neurosurgery 91 CASE REPORT MOHAMED A.R. SOLIMAN ET AL. UNILATERAL BEFORE MINIMALLY

92 www.SCIENCEDIRECT.com WORLD NEUROSURGERY, https://doi.org/10.1016/j.wneu.2018.10.140 CASE REPORT MOHAMED A.R. SOLIMAN ET AL. UNILATERAL BEFORE MINIMALLY minimally invasive surgery, including occurred, which could be avoided in future screw was inserted showed further union. transfracture fixation with the intention patients by performing 3D imaging studies At the 12 month follow-up study, CT im- to stabilize the fractured segment. The after screw insertion. The patient had aging showed partial union of the fracture patient elected for surgery. experienced immediate resolution of his and good apposition of the bony struc- The patient was brought to the oper- pain on examination in the recovery room tures (Figure 2I). No evidence of instability ating room 4 days after injury. After and was discharged 2 days later. was seen. fiberoptic intubation, he was placed in Follow-up CT imaging at 3 months Mayfield head fixation and turned to postoperatively confirmed early fusion on the prone position. During the next 47 the fixated right side of C2 and evidence of DISCUSSION fi minutes, the patient was positioned to fusion on the non xated left side We have reported 2 patients who had achieve perfect orthogonal views with (Figure 1G,H). At the 12-month and 5-year developed hangman’s fractures that were perpendicularly placed C-. The ante- follow-up imaging studies (Figure 1I,J), successfully managed with minimally roposterior and lateral images of the axis fusion had occurred on both sides, with invasive neuronavigation-assisted instru- were then used to calibrate our neuro- no evidence of instability. mented fixation. The technique allowed navigation system (BrainLAB, Munich, for anatomical joint preservation, minimal fl Germany) using CT uoroscopic guidance Patient 2 tissue disruption, and relatively short (Figure 1C). After calibration, the potential After an all-terrain vehicle injury, a 76- operative times. We believe that with the trajectories were then determined on each year-old man (a farmer) experienced recent advances in accuracy and reliability side through each fracture. The entry fractures of C1, C2, and C3. The C2 frac- in neuronavigation technology,16-18 it is point was through the posterolateral ture was a hangman’s fracture type I now safer than previously to be able to portion of each facet, directed (Levine classification) and was through percutaneously fixate fractures throughout anteromedially through the pedicle and both pars. The C1 fracture was a bilateral the entire spine, without the need to then the fracture. For patient 1, the right posterior laminar fracture, and at C3, the perform extensive and potentially side was thought to be the ideal fracture was through the spinous process. dangerous dissection. Under certain cir- trajectory, and the distance from the skin He also had coexisting pulmonary in- cumstances, in appropriate patients, and to the facet was 15 cm. juries but had no neurological deficits. with adequate training, we believe that the A 1.5-cm skin incision was made in the The patient was offered the option of indications for surgical management of posterolateral neck. A precalibrated trocar minimally invasive surgery, including hangman’s fractures can be widened. e was passed down to the facet laminar transfracture fixation, with the intention Hangman’s fractures are frequently fl junction with repeated uoroscopic to stabilize the fractured segment. The managed with conservative treatment us- imaging for guidance. Trajectories for the patient elected for surgery. ing a rigid or halo immo- Kirschner wire (K-wire) were then esti- The same operative method for our first bilization device for 12 weeks, because it fi mated again and con rmed. The K-wire patient was used for patient 2. The prep- results in high fusion rates and, in gen- was inserted through the facet, pedicle, aration time before surgery, but after eral, has a low rate of complications.1-3,11 and fracture and placed as close as intubation, was 150 minutes. The trajec- However, external immobilization will possible to the anterior cortical border tory from the skin to the facet was 50 mm. not be appropriate for all cases, in without breaching this . A cannulated The threaded screw length was 34 mm and particular, those with unstable C2 frac- drill was used to widen this trajectory with the diameter was 4 mm. The total surgical tures, halo intolerance, and/or coexisting careful attention aimed toward preventing cut time was 25 minutes. Postoperative CT trauma and many elderly in- K-wire advancement. For patient 1, a imaging of the cervical spine showed dividuals.1,2,8,11,19 Complications resulting 30-mm-long, 4-mm-diameter threaded excellent screw positioning (Figure 2C). from external immobilization have been screw successfully captured the fractured The patient had experienced almost reported in previous studies and have segment and reduced the fracture complete relief of pain postoperatively. described cases of pin site infection, (Figure 1E). The wound was closed within The patient was quickly mobilized and pressure sores, and aspiration pneu- 20 minutes of the incision. discharged home 2 days later. Follow-up monia.8,11 Hangman’s fractures are also fi Postoperative CT imaging con rmed CT imaging of the cervical spine scan at painful, with many patients requiring excellent screw positioning and trans- 3 months postoperatively showed sub- opioids to manage their pain. Such fi xation of the fractured segment. How- stantial healing (Figure 2E). The right side treatment can be necessary for many ever, a breach of the C1-C2 joint had of the C2 where the transarticular weeks when patients are managed

Figure 2. (A) Axial computed tomography (CT) scan of the cervical spine showing the hangman’s fracture. (B) Axial CT scan of the cervical spine showing the fixated fracture immediately postoperatively. Sagittal CT scans of the cervical spine showing the (C) fixated fracture (right side) and (D) fixated fracture (left side) immediately postoperatively. (E) Axial CT scan of the cervical spine showing the fixated fracture at the 3-month follow-up visit. Sagittal CT scans of the cervical spine showing the (F) right and (G) left sides of the fixated fracture at the 3-month follow-up visit. (H) Axial CT scan of the cervical spine showing the fixated fracture at the 12-month follow-up visit. Sagittal CT scans of the cervical spine showing the (I) right and (J) left sides of the fixated fracture at the 12-month follow-up visit. (K) Axial CT scan of the cervical spine showing the fixated fracture at the 5-year follow-up visit. (L) Sagittal CT scan of the cervical spine of the fixated fracture (left side) at the 5-year follow-up visit.

WORLD NEUROSURGERY 122: 90-95, FEBRUARY 2019 www.journals.elsevier.com/world-neurosurgery 93 CASE REPORT MOHAMED A.R. SOLIMAN ET AL. UNILATERAL BEFORE MINIMALLY nonoperatively. Our 2 patients were able to Tjardes et al.27 on neuronavigation for fractures in stable patients and reducible be weaned off opioids rapidly. They spinal surgery highlighted the use of angulated fractures in the absence of experienced immediate pain control CT-guided, 2-dimensional and 3D fluo- C2-C3 disc herniation. The use of preop- within hours after surgery. Cervical collars roscopy usage during surgery throughout erative CT angiography or magnetic reso- were not necessary. the cervical spine, including odontoid nance angiography in future cases to select Traditional open surgical techniques in fractures, atlantoaxial instability, C6-C7 the nondominant vertebral artery could the management of hangman’s fractures subluxation, and hangman’s fractures. further decrease the risk of vertebral artery can be fairly invasive and associated with Image-guided variants of the approach injury. small, but significant, risks of injury to the reported by Judet et al.22 are becoming vertebral artery, spinal cord, and nearby more common and have been described neural structures.1,12 Commonly used using both intraoperative CT guidance by CONCLUSION surgical methods have included anterior Taller et al.14 and isocentric mobile C- Although external immobilization remains fusion of C2 and C3 with interpositional 3D navigation navigation by an important treatment modality, it is not bone grafts and cervical plating, which has Rajasekaran et al.15,20 without complications or impair- risks such as injury to the facial nerve or We have proposed the use of 2 C-arms ment.1-3,8,9 We have proposed a novel external carotid artery branches and loss to take both anteroposterior and lateral method of fixation of nonangulated of range of motion.10,15,20 Posterior radiographs with neuronavigation for hangman’s fracture in stable patients and segmental fusion has also been proposed unilateral minimally invasive percutaneous in patients with reducible unstable frac- as a treatment of hangman’s fracture with transarticular screw fixation of a hang- tures in the absence of C2-C3 disc herni- almost perfect fusion rates.15,21 However, man’s fracture.15 This surgical operation ation. Our method is minimally invasive, posterior segmental fusion results in sig- does have important risks, including with a short operative time, allows for nificant reduction in rotational move- vertebral artery injury, cervical nerve quick mobilization, preserves the range of ment.15 Furthermore, the extensive injury, , and pedicle motion, and offers a short recovery dissection results in a more difficult compromise during insertion. Excessive time.14,15,20,28 We believe that with recovery than with anterior procedures.16 advancement of K-wires and adequate training and experience, this Judet et al.22 in 1970 proposed misadvancement of K-wires must be method can be safely used to improve transpedicular osteosynthesis, which is a monitored constantly.18 Although in our outcomes and achieve high rates of fusion. “physiological” operation, because it 2 patients, the position of the vertebral As advancements in intraoperative imag- leads to direct fixation of the fracture artery was inferred by the location of the ing and navigation continue, these and preservation of the range of motion, foramen transversarium, angiographic methods will be increasingly used to treat does not lead to segmental fusion, and studies such as CT angiography or spinal injuries.16,29 However, our study allows for anatomic healing.14 However, magnetic resonance angiography could was small. We encourage further evalua- their method of pedicle screw fixation aid surgical planning and decrease the tion with larger patient series and does have important risks such as risk by choosing to fixate the side with thoughtful analysis before general recom- trauma to the vertebral artery and/or the nondominant vertebral artery. mendations are made. spinal cord.23 Minimally invasive versions Complications will be minimized, of their method have since been however, using the percutaneous REFERENCES proposed to help limit the risks of approach, which helps to limit blood 1. Pryputniewicz D, Hadley M. Axis fractures. trauma to neurovascular structures by loss and injuries to the vertebral artery. Neurosurgery. 2010;66:A68-A82. allowing for preoperative assessment of This technique might also be more cost the fracture path using neuronavigation. effective than nonoperative care because 2. Li X, Dai L, Lu H, Chen X. A systematic review of the management of hangman’s fractures. 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