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Minimally Invasive Unilateral Percutaneous Transfracture Fixation of a Hangman’S Fracture Using Neuronavigation and Intraoperative Fluoroscopy Mohamed A.R

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Minimally Invasive Unilateral Percutaneous Transfracture Fixation of a Hangman’S Fracture Using Neuronavigation and Intraoperative Fluoroscopy Mohamed A.R 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 Neurosurgery, 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 axis 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 neck 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-arms. 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
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