C1-C3 lateral mass fusion for type IIa and type III Hangman's fracture
A 36-year-old female who was the unrestrained passenger in a vehicle, which was involved in a collision and roll over and she lost consciousness briefly and on regaining consciousness, she complained of neck pain. She was transferred to a nearby medical facility where radiographs revealed Hangman's fracture and the patient was subsequently transferred to our department for surgical management. On admission, she was noted to have no neurological deficits, but had tenderness over the cervical spine. Her cranial computed tomography (CT) examination was normal. Her radiographs of the cervical spine revealed Levine and Edwards type IIa Hangman's fracture []. Magnetic resonance imaging (MRI) of the spine revealed evidence of hematoma extending from clivus to C4 anteriorly and from occiput to C7 posteriorly []. There was also evidence of anterior translation and mild angulation at C2-C3 suggestive of type IIa Levine and Edwards Hangman's fracture. In view of the unstable nature of the fracture and the presence of angulation, it was believed immobilization with external orthosis will not be effective and hence, surgical fixation was opted for. Pre-operative traction was not attempted as the patient was not willing for the same. CT studies of the spine showed that the fracture fragments were displaced [] and hence, direct fixation of the pars fracture with pars screws as suggested by Bristol et al. and Dalbayrak et al. was not considered safe or feasible.[] Hence, C1-C3 lateral mass fusion was planned. With the patient kept under skeletal traction in the prone position, proper alignment was achieved under fluoroscopic control and then the region from C1 to C3 was exposed. The C2 root and ganglion were sectioned on either side and the C1 lateral mass was exposed. The C3 lateral masses were exposed on either side or 3.5 mm × 28 mm polyaxial titanium screws were inserted into the C1 lateral masses on either side followed by insertion of 3.5 mm × 14 mm polyaxial screws into the lateral masses of C3. For insertion of C1 lateral mass screw, the entry point was the middle of the lateral mass with 10* medial angulation aiming for the anterior tubercle of atlas and for C 3 lateral mass screw, the entry point was 1mm medial to the center of the lateral mass with 30* lateral and 15* rostral angulation. The exposed posterior surfaces of C1, C2, and C3 were decorticated and autologous grafts obtained from posterior iliac crest was applied as onlay graft and the wound was closed in layers. Post-operative radiographs showed good alignment with proper placement of screws []. Post-operatively, when examined 3 months later, there was no change in the patient's clinical condition except for numbness in the occipital region due to sectioning of C2 root.