OBJECTIVETo determine the outcome of combined anterior C2,3 reduction and fusion with posterior compressive C2 pedicle screw fixation for the management of unstable Hangman's fractures.

METHODSSixteen cases of unstable Hangman's fractures were retrospectively reviewed through X-ray, MRI and three dimensional CT scans. Pre- and postoperative radiographs were measured for translation and angulation of C2,3. Skull traction under extension poison was conducted in all the patients right after their admission. Then anterior C2,3 discectomy followed by interbody fusion, either with iliac autograft or with box cage, and locking plate fixation were performed in each case. Because dissatisfied reduction, mainly residual large fracture gap or kyphosis, was found by the C-arm fluoroscopy during operations, posterior compressive C2 pedicle screw fixation was performed in one stage. According to the Levine-Edwards classification, there were 12 cases of type II, 2 of type I a and 2 of type III in this group.

RESULTSFollow-up ranged 6-38 months, averaged 26 months. Fracture union and bone graft fusion were completed in an average of 4 months after operation. Complaints of neck pain and numbness of limbs disappeared in all patients after surgery, but range of neck motion decreased compared with normal people. Translation of C2 decreased from (4.2 +/- 1.4) mm preoperatively to (2.3 +/- 1.1) mm postoperatively, while angulation of C2,3 decreased from 8.6 degrees +/- 2.1 degrees preoperatively to 2.6 degrees +/- 1.0 degrees postoperatively. Both have statistical significance (P < 0.05). No implant failure or infection was observed.

CONCLUSIONSThe classification of Hangman's fracture should be modified in combination with MRI and CT scans to determine the stability of the fracture. Combined anterior C2,3 reduction and fusion with posterior compressive C2 pedicle screw fixation is the treatment of choice for patients with unstable Hangman's fractures.