{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,1,19]],"date-time":"2026-01-19T10:42:01Z","timestamp":1768819321387,"version":"3.49.0"},"reference-count":27,"publisher":"Journal of Neurosurgery Publishing Group (JNSPG)","issue":"5","content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["SPI"],"published-print":{"date-parts":[[2013,11]]},"abstract":"<jats:sec>\n<jats:title>Object<\/jats:title>\n<jats:p>Several controversial issues arise in the management of unstable hangman's fractures. Some surgeons perform external reduction and immobilize the patient's neck in a halo vest, while others perform surgical reduction and internal fixation. The nonsurgical treatments with rigid collar or halo vest immobilization present problems, including nonunion, pseudarthrosis, skull fracture, and scalp laceration and may also fail to achieve anatomical realignment of the local C2\u20133 kyphosis. With recent advances in surgical technique and technology, surgical intervention is increasingly performed as the primary treatment in high cervical fractures. The outcomes of such surgeries are often superior to those of conservative treatment. The authors propose that surgical intervention as a primary management for hangman's fracture may avoid risks inherent in conservative management when severe circumferential discoligamentous instability is present and may reduce the risk of catastrophic results at the fracture site.<\/jats:p>\n<jats:p>The purposes of this study were to assess fracture healing following expedient reduction and surgical fixation and to propose a guideline for treatment of unstable hangman's fractures.<\/jats:p><\/jats:sec>\n<jats:sec>\n<jats:title>Methods<\/jats:title>\n<jats:p>From April 2006 to December 2011, the authors treated 105 patients with high cervical fractures. This study included 23 (21.9%) of these patients (15 men and 8 women; mean age 46.4 years) with Type II, IIa, and III hangman's fractures according to the Levine and Edwards classification. The patient's age, sex, mechanism of injury, associated injuries, neurological status, and complications were ascertained. The authors retrospectively assessed the clinical outcome (Neck Disability Index), radiological findings (disc height, translation, and angulation), and bony healing.<\/jats:p><\/jats:sec>\n<jats:sec>\n<jats:title>Results<\/jats:title>\n<jats:p>The average follow-up period was 28.9 months (range 12\u201363.2 months). The overall average Neck Disability Index score at the time of this study was 6.6 \u00b1 2.3. The average duration of hospitalization was 20.3 days, and fusion was achieved in all cases by 14.8 \u00b1 1.6 weeks after surgery, as demonstrated on dynamic radiographs and cervical 3D CT scans.<\/jats:p>\n<jats:p>The mean pretreatment translation was 6.9 \u00b1 3.2 mm, and the mean postoperative translation was 1.6 \u00b1 1.8 mm (mean reduction 5.2 \u00b1 3.1 mm). The initial angulation was 4.7\u00b0 \u00b1 5.3\u00b0 and the postoperative angulation was 2.5\u00b0 \u00b1 1.8\u00b0 (mean reduction 6.1\u00b0 \u00b1 5.3\u00b0). The preoperative and postoperative values for translation and angulation differed significantly (p &lt; 0.05). The overall C2\u20133 disc height was 6.7 \u00b1 1.2 mm preoperatively, whereas 3 months after surgery it was 6.4 \u00b1 1.1 mm. These values did not differ significantly (p = 0.0963).<\/jats:p><\/jats:sec>\n<jats:sec>\n<jats:title>Conclusions<\/jats:title>\n<jats:p>The authors observed effective reduction and bony healing in cases of unstable hangman's fractures after fixation, and all patients experienced favorable clinical outcomes with neck pain improvement. The protocols allowed for physiological reconstruction of the fractured deformities and avoided external fixation. The authors suggest that posterior reduction and screw fixation should be used as a primary treatment to promote stability of hangman's fracture in the presence of discoligamentous instability or combined fractures.<\/jats:p><\/jats:sec>","DOI":"10.3171\/2013.8.spine12948","type":"journal-article","created":{"date-parts":[[2013,9,13]],"date-time":"2013-09-13T13:58:23Z","timestamp":1379080703000},"page":"569-575","source":"Crossref","is-referenced-by-count":21,"title":["Primary surgical management by reduction and fixation of unstable hangman's fractures with discoligamentous instability or combined fractures"],"prefix":"10.3171","volume":"19","author":[{"given":"Jun Jae","family":"Shin","sequence":"first","affiliation":[{"name":"Department of Neurosurgery, Sanggye Paik Hospital, Inje University College of Medicine, Seoul;"},{"name":"Department of Neurosurgery, Stanford University School of Medicine, Stanford, California"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Sang Hyun","family":"Kim","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, Ajou University School of Medicine, Suwon;"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Yong Eun","family":"Cho","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, Spine Hospital, Kangnam Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea; and"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Samuel H.","family":"Cheshier","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, Stanford University School of Medicine, Stanford, California"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Jon","family":"Park","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, Stanford University School of Medicine, Stanford, California"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1754","reference":[{"key":"b1-spine12948","series-title":"J Neurosurg Spine","doi-asserted-by":"publisher","first-page":"379","DOI":"10.3171\/2009.4.SPINE08516","article-title":"Traumatic spondylolisthesis of the axis: a biomechanical comparison of clinically relevant anterior and posterior fusion techniques. Laboratory investigation","volume":"11","author":"Chittiboina","year":"2009"},{"key":"b2-spine12948","series-title":"J Neurosurg","doi-asserted-by":"publisher","first-page":"550","DOI":"10.3171\/jns.1996.85.4.0550","article-title":"Treatment of traumatic spondylolisthesis of the axis with nonrigid immobilization: a review of 64 cases","volume":"85","author":"Coric","year":"1996"},{"key":"b3-spine12948","series-title":"Spine (Phila Pa 1976)","doi-asserted-by":"publisher","first-page":"182","DOI":"10.1097\/01.brs.0000251917.83529.0b","article-title":"Hangman's fracture: a biomechanical comparison of stabilization techniques","volume":"32","author":"Duggal","year":"2007"},{"key":"b4-spine12948","series-title":"J Bone Joint Surg Br","doi-asserted-by":"publisher","first-page":"319","DOI":"10.1302\/0301-620X.63B3.7263741","article-title":"Fractures of the ring of the axis. A classification based on the analysis of 131 cases","volume":"63-B","author":"Effendi","year":"1981"},{"key":"b5-spine12948","series-title":"Eur Spine J","doi-asserted-by":"publisher","first-page":"1299","DOI":"10.1007\/s00586-010-1401-2","article-title":"Transpedicular screw fixation for type II Hangman's fracture: a motion preserving procedure","volume":"19","author":"ElMiligui","year":"2010"},{"key":"b6-spine12948","series-title":"Neurosurgery","doi-asserted-by":"publisher","first-page":"281","DOI":"10.1227\/00006123-198508000-00006","article-title":"Axis fractures: a comprehensive review of management and treatment in 107 cases","volume":"17","author":"Hadley","year":"1985"},{"issue":"3 Suppl","key":"b7-spine12948","series-title":"Neurosurgery","first-page":"S125","article-title":"Isolated fractures of the axis in adults","volume":"50","year":"2002"},{"key":"b8-spine12948","series-title":"Luxation Congen\u00e9nitale de la Hanche: Fractures du Cou-de-pied Rachis Cervical. Actualit\u00e9s de Chirurgie Orthop\u00e9dique de l'H\u00f4pital Raymond-Poincar\u00e9","first-page":"147","article-title":"Fracture et luxation des deux premi\u00e8res vert\u00e8bres cervicales","author":"Leconte","year":"1964"},{"key":"b9-spine12948","series-title":"J Bone Joint Surg Am","doi-asserted-by":"publisher","first-page":"217","DOI":"10.2106\/00004623-198567020-00007","article-title":"The management of traumatic spondylolisthesis of the axis","volume":"67","author":"Levine","year":"1985"},{"key":"b10-spine12948","series-title":"Eur Spine J","doi-asserted-by":"publisher","first-page":"257","DOI":"10.1007\/s00586-005-0918-2","article-title":"A systematic review of the management of hangman's fractures","volume":"15","author":"Li","year":"2006"},{"key":"b11-spine12948","series-title":"Exp Ther Med","doi-asserted-by":"publisher","first-page":"667","DOI":"10.3892\/etm.2013.898","article-title":"One-stage posterior C2 and C3 pedicle screw fixation or combined anterior C2-C3 fusion for the treatment of unstable hangman's fracture","volume":"5","author":"Liu","year":"2013"},{"key":"b12-spine12948","series-title":"Spine (Phila Pa 1976)","doi-asserted-by":"publisher","first-page":"2675","DOI":"10.1097\/00007632-200010150-00022","article-title":"Cervical pedicle screws: comparative accuracy of two insertion techniques","volume":"25","author":"Ludwig","year":"2000"},{"key":"b13-spine12948","series-title":"Spine (Phila Pa 1976)","doi-asserted-by":"publisher","first-page":"529","DOI":"10.1097\/BRS.0b013e3181d60067","article-title":"Posterior short-segment fixation and fusion in unstable Hangman's fractures","volume":"36","author":"Ma","year":"2011"},{"key":"b14-spine12948","series-title":"Eur Spine J","doi-asserted-by":"publisher","first-page":"123","DOI":"10.1007\/s005860050222","article-title":"Traumatic spondylolisthesis of the axis: treatment rationale based on the stability of the different fracture types","volume":"9","author":"M\u00fcller","year":"2000"},{"key":"b15-spine12948","series-title":"Neurosurgery","doi-asserted-by":"publisher","first-page":"76","DOI":"10.1227\/00006123-198007000-00014","article-title":"Basic biomechanics of the spine","volume":"7","author":"Panjabi","year":"1980"},{"key":"b16-spine12948","series-title":"J Spinal Disord Tech","doi-asserted-by":"publisher","first-page":"616","DOI":"10.1097\/BSD.0b013e318074f978","article-title":"Iso-C3D fluoroscopy-based navigation in direct pedicle screw fixation of Hangman fracture: a case report","volume":"20","author":"Rajasekaran","year":"2007"},{"key":"b17-spine12948","series-title":"J Neurosurg","doi-asserted-by":"publisher","first-page":"633","DOI":"10.3171\/jns.1984.60.3.0633","article-title":"Hangman's fracture with complete dislocation of C-2 on C-3. Case report","volume":"60","author":"Roda","year":"1984"},{"key":"b18-spine12948","series-title":"J Bone Joint Surg Br","doi-asserted-by":"publisher","first-page":"1046","DOI":"10.1302\/0301-620X.82B7.0821046","article-title":"Hangman's fracture: the relationship between asymmetry and instability","volume":"82","author":"Samaha","year":"2000"},{"key":"b19-spine12948","series-title":"J Neurosurg","doi-asserted-by":"publisher","first-page":"141","DOI":"10.3171\/jns.1965.22.2.0141","article-title":"\u201cHangman's fracture\u201d of the cervical spine","volume":"22","author":"Schneider","year":"1965"},{"key":"b20-spine12948","series-title":"Yonsei Med J","doi-asserted-by":"publisher","first-page":"648","DOI":"10.3349\/ymj.2010.51.5.648","article-title":"Optimal use of the halo-vest orthosis for upper cervical spine injuries","volume":"51","author":"Shin","year":"2010"},{"key":"b21-spine12948","series-title":"Eur Spine J","doi-asserted-by":"publisher","first-page":"863","DOI":"10.1007\/s00586-011-2085-y","article-title":"Posterior fixation and fusion of unstable Hangman's fracture by using intraoperative three-dimensional fluoroscopy-based navigation","volume":"21","author":"Tian","year":"2012"},{"key":"b22-spine12948","series-title":"Neurosurgery","first-page":"761","article-title":"Caspar plate fixation for the treatment of complex hangman's fractures","volume":"30","author":"Tuite","year":"1992"},{"key":"b23-spine12948","series-title":"Spine (Phila Pa 1976)","doi-asserted-by":"publisher","first-page":"2229","DOI":"10.1097\/00007632-200210150-00009","article-title":"Early halo immobilization of displaced traumatic spondylolisthesis of the axis","volume":"27","author":"Vaccaro","year":"2002"},{"key":"b24-spine12948","series-title":"Surg Neurol","doi-asserted-by":"publisher","first-page":"253","DOI":"10.1016\/S0090-3019(97)00300-5","article-title":"Hangman's fracture: arguments in favor of surgical therapy for type II and III according to Edwards and Levine","volume":"49","author":"Verheggen","year":"1998"},{"key":"b25-spine12948","series-title":"J Spinal Disord Tech","doi-asserted-by":"publisher","first-page":"148","DOI":"10.1097\/01.bsd.0000154459.47467.d6","article-title":"Residual neck pain after traumatic spondylolisthesis of the axis","volume":"18","author":"Watanabe","year":"2005"},{"key":"b26-spine12948","series-title":"Spine (Phila Pa 1976)","doi-asserted-by":"publisher","first-page":"295","DOI":"10.1097\/00007632-199902010-00022","article-title":"Transoral fusion with internal fixation in a displaced hangman's fracture","volume":"24","author":"Wilson","year":"1999"},{"key":"b27-spine12948","series-title":"Int Orthop","doi-asserted-by":"publisher","first-page":"85","DOI":"10.1007\/s00264-008-0658-0","article-title":"Anterior discectomy and fusion with internal fixation for unstable hangman's fracture","volume":"34","author":"Xu","year":"2010"}],"container-title":["Journal of Neurosurgery: Spine"],"original-title":[],"link":[{"URL":"https:\/\/thejns.org\/view\/journals\/j-neurosurg-spine\/19\/5\/article-p569.xml","content-type":"text\/html","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/thejns.org\/downloadpdf\/journals\/j-neurosurg-spine\/19\/5\/article-p569.xml","content-type":"text\/html","content-version":"vor","intended-application":"syndication"},{"URL":"https:\/\/thejns.org\/downloadpdf\/journals\/j-neurosurg-spine\/19\/5\/article-p569.xml","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2023,4,15]],"date-time":"2023-04-15T23:09:56Z","timestamp":1681600196000},"score":1,"resource":{"primary":{"URL":"https:\/\/thejns.org\/view\/journals\/j-neurosurg-spine\/19\/5\/article-p569.xml"}},"subtitle":["Clinical article"],"short-title":[],"issued":{"date-parts":[[2013,11]]},"references-count":27,"journal-issue":{"issue":"5"},"URL":"https:\/\/doi.org\/10.3171\/2013.8.spine12948","relation":{},"ISSN":["1547-5654"],"issn-type":[{"value":"1547-5654","type":"print"}],"subject":[],"published":{"date-parts":[[2013,11]]}}}