Hangman's fracture: Management strategy and healing rate in a prospective multi-centre observational study of 34 patients - 19/04/19

Doi : 10.1016/j.otsr.2019.03.009

Solène Prost ^a, Cédric Barrey ^b, Benjamin Blondel ^a,^⁎ , Stéphane Fuentes ^a, Laurent Barresi ^c, Benjamin Nicot ^d, Vincent Challier ^e, Maxime Lleu ^f, Joël Godard ^g, Pascal Kouyoumdjian ^h, Nicolas Lonjon ⁱ, Paulo Marinho ^j, Eurico Freitas ^b, Sébastien Schuller ^k, Jérémy Allia ^c, Julien Berthiller ^l, Yann Philippe Charles ^k
French Society for Spine Surgery (SFCR)^m
^a ISM, CNRS, unité de chirurgie rachidienne, Aix-Marseille université, CHU de Timone, AP–HM, 264, rue Saint-Pierre, 13005 Marseille, France
^b Service de neurochirurgie C et chirurgie du rachis, université Claude-Bernard Lyon 1, hôpital P. Wertheimer, 59, boulevard Pinel, 69003 Lyon, France
^c Unité de chirurgie rachidienne, CHU de Nice, Institut universitaire de l’appareil Locomoteur et du sport, hôpital Pasteur 2, 30, voie Romaine, 06001 Nice, France
^d Département de neurochirurgie, CHU de Grenoble, avenue Maquis-du-Grésivaudan, 38700 La Tronche, France
^e Unité d’orthopédie-traumatologie rachis I, CHU de Bordeaux, hôpital Tripode, place Amélie-Raba-Léon, 33076 Bordeaux cedex, France
^f Service de neurochirurgie, CHU de Dijon, 14, rue Paul-Gaffarel, 21000 Dijon cedex, France
^g Service de neurochirurgie, hôpital Jean-Minjoz, 3, boulevard A. Fleming, 25030 Besançon cedex, France
^h Service d’orthopédie-traumatologie, CHU de Nîmes, avenue du Pr. Debré, 30000 Nîmes, France
ⁱ Service de neurochirurgie, hôpital Gui de Chauliac, 80, avenue Augustin-Fliche, 34090 Montpellier, France
^j Service de neurochirurgie, CHRU de Lille, hôpital Roger-Salengro, rue Emile-Laine, 59037 Lille, France
^k Service de chirurgie du rachis, hôpitaux universitaires de Strasbourg, 1, place de l’Hôpital, BP 426, 67091 Strasbourg cedex, France
^l Pôle IMER, hospices civils de Lyon, 162, avenue Lacassagne, 69424 Lyon cedex 03, France
^m Société Française de Chirurgie Rachidienne, 56, rue Boisonnade, 75014 Paris, France

^⁎Corresponding author. Spine Unit, CHU de Timone, 264, rue Saint-Pierre, 13005 Marseille, France.France

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Abstract

Background

Hangman's fractures account for 15% to 20% of all cervical spine fractures. The grading system developed by Effendi and modified by Levine and Edwards is generally used as the basis for management decisions. Nonetheless, the optimal management remains controversial. The objective of this study was to describe the treatments used in France in patients with hangman's fractures. The complications and healing rates were analysed according to the fracture type and treatment used.

Hypothesis

Among patients with hangman's fracture, those with disc damage must be treated surgically.

Material and methods

A prospective, multi-centre, observational study was conducted under the aegis of the French Society for Spine Surgery (Société Française de Chirurgie Rachidienne, SFCR). Patients were included if they had computed tomography (CT) evidence of hangman's fracture. Follow-up data were collected prospectively. Fracture healing was assessed on CT scans obtained 3 and 12 months after the injury. The type of treatment and complications were recorded routinely.

Results

We included 34 patients. The fracture type according to Effendi modified by Levine and Edwards was I in 68% of patients, II in 29% of patients, and III in a single patient (3%). The treatment was non-operative in 21 (62%) patients and surgical in 11 (32%). All 28 patients re-evaluated after 1 year had evidence of fracture healing. The remaining 6 patients were lost to follow-up.

Conclusion

Hangman's fracture is associated with low rates of mortality and neurological complications. Non-operative treatment is appropriate in Type I hangman's fracture, with a 100% healing rate in our study. Types II and III are characterised by damage to the ligaments and discs requiring either anterior C2-C3 fusion or posterior C1-C3 screw fixation.