{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,5,23]],"date-time":"2026-05-23T10:04:40Z","timestamp":1779530680082,"version":"3.53.1"},"reference-count":46,"publisher":"Journal of Neurosurgery Publishing Group (JNSPG)","issue":"2","content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"published-print":{"date-parts":[[2017,8]]},"abstract":"\n OBJECTIVE<\/jats:title>\n In traumatic spondylolistheses of the axis, there is a marked heterogeneity of the observed injury patterns, with a wide range of the severity\u2014from stable fractures, which can be treated conservatively with very good success, to highly unstable fractures, which should be treated surgically. A number of classification systems have been devised to assess the instability of the injuries and to derive a corresponding therapy recommendation. In particular, the results and recommendations regarding medium-severity cases are still inconclusive. Minimally invasive percutaneous procedures performed using modern techniques such as 3D fluoroscopy and neuronavigation have the potential for improvements in the therapeutic outcome and procedural morbidity against open surgical procedures and conservative therapy.<\/jats:p>\n <\/jats:sec>\n \n METHODS<\/jats:title>\n A minimally invasive method using 3D fluoroscopy and neuronavigation for percutaneous lag screw osteosynthesis of the pars interarticularis was performed in 12 patients with a Levine-Edwards Type II fracture. Ten patients had an isolated hangman\u2019s fracture and 2 patients had an additional odontoid fracture of the axis (Type II according to the Anderson and D\u2019Alonzo classification system). Complications, operating parameters, screw positions, and bony fusion were evaluated for the description and evaluation of the technique.<\/jats:p>\n <\/jats:sec>\n \n RESULTS<\/jats:title>\n In 6 men and 6 women, percutaneous lag screw osteosynthesis was performed successfully. Correct placement could be verified postoperatively for all inserted screws. In the case series, nonunion was not observed. In all patients with a complete follow-up, a bony fusion, an intact vertebral alignment, and no deformity could be detected on CT scans obtained after 3 months.<\/jats:p>\n <\/jats:sec>\n \n CONCLUSIONS<\/jats:title>\n The percutaneous pars interarticularis lag screw osteosynthesis is a minimally invasive and mobility-preserving surgical technique. Its advantages over alternative methods are its minimal invasiveness, a shortened treatment time, and high fusion rates. The benefits are offset by the risk of injury to the vertebral arteries. The lag screw osteosynthesis is only possible with Levine-Edwards Type II fractures, because the intervertebral joints to C-3 are functionally preserved. A further development and evaluation of the operative technique as well as comparison with conservative and alternative surgical treatment options are deemed necessary.<\/jats:p>\n <\/jats:sec>","DOI":"10.3171\/2017.5.focus17201","type":"journal-article","created":{"date-parts":[[2017,8,1]],"date-time":"2017-08-01T03:36:48Z","timestamp":1501558608000},"page":"E2","source":"Crossref","is-referenced-by-count":2,"title":["Neuronavigation and 3D fluoroscopy\u2013guided lag screw reduction and osteosynthesis for traumatic spondylolistheses of the axis: a path worth exploring?"],"prefix":"10.3171","volume":"43","author":[{"given":"Jan-Philip","family":"Zeden","sequence":"first","affiliation":[{"name":"Department of Neurosurgery, University Medicine Greifswald, Germany; and"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jan-Uwe","family":"M\u00fcller","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, University Medicine Greifswald, Germany; and"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ehab Ahmed","family":"Mohamed El Refaee","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, University Medicine Greifswald, Germany; and"},{"name":"Department of Neurosurgery, Cairo University, Cairo, Egypt"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Henry W. S.","family":"Schroeder","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, University Medicine Greifswald, Germany; and"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Dirk T.","family":"Pillich","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, University Medicine Greifswald, Germany; and"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1754","reference":[{"key":"b1","series-title":"Global Spine J","first-page":"248","article-title":"Management of typical and atypical hangman\u2019s fractures","volume":"6","author":"Al-Mahfoudh R","year":"2016","unstructured":"Al-Mahfoudh R, Beagrie C, Woolley E, Zakaria R, Radon M, Clark S, : Management of typical and atypical hangman\u2019s fractures. Global Spine J 6:248\u2013256, 2016"},{"issue":"3B","key":"b2","series-title":"Arq Neuropsiquiatr","first-page":"821","article-title":"Surgical management of axis\u2019 traumatic spondylolisthesis (Hangman\u2019s fracture)","volume":"62","author":"Boullosa JLR","year":"2004","unstructured":"Boullosa JLR, Colli BO, Carlotti CG Jr, Tanaka K, dos Santos MB: Surgical management of axis\u2019 traumatic spondylolisthesis (Hangman\u2019s fracture). Arq Neuropsiquiatr 62 (3B):821\u2013826, 2004"},{"key":"b3","series-title":"J Neurosurg Spine","first-page":"459","article-title":"Minimally invasive percutaneous screw fixation of traumatic spondylolisthesis of the axis","volume":"22","author":"Buchholz AL","year":"2015","unstructured":"Buchholz AL, Morgan SL, Robinson LC, Frankel BM: Minimally invasive percutaneous screw fixation of traumatic spondylolisthesis of the axis. J Neurosurg Spine 22:459\u2013465, 2015"},{"key":"b4","series-title":"Turk Neurosurg","first-page":"163","article-title":"Traumatic spondylolisthesis of the axis treated with direct C2 pars screw","volume":"19","author":"Dalbayrak S","year":"2009","unstructured":"Dalbayrak S, Yilmaz M, Firidin M, Naderi S: Traumatic spondylolisthesis of the axis treated with direct C2 pars screw. Turk Neurosurg 19:163\u2013167, 2009"},{"key":"b5","series-title":"J Bone Joint Surg Br","first-page":"319","article-title":"Fractures of the ring of the axis. A classification based on the analysis of 131 cases","volume":"63-B","author":"Effendi B","year":"1981","unstructured":"Effendi B, Roy D, Cornish B, Dussault RG, Laurin CA: Fractures of the ring of the axis. A classification based on the analysis of 131 cases. 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J Bone Joint Surg Br 63-B:313\u2013318, 1981"},{"key":"b8","series-title":"AJNR Am J Neuroradiol","first-page":"209","article-title":"Correlation of MR imaging findings with intraoperative findings after cervical spine trauma","volume":"28","author":"Goradia D","year":"2007","unstructured":"Goradia D, Linnau KF, Cohen WA, Mirza S, Hallam DK, Blackmore CC: Correlation of MR imaging findings with intraoperative findings after cervical spine trauma. AJNR Am J Neuroradiol 28:209\u2013215, 2007"},{"key":"b9","series-title":"Spine (Phila Pa 1976)","first-page":"1843","article-title":"Acute axis fractures. Analysis of management and outcome in 340 consecutive cases","volume":"22","author":"Greene KA","year":"1997","unstructured":"Greene KA, Dickman CA, Marciano FF, Drabier JB, Hadley MN, Sonntag VK: Acute axis fractures. Analysis of management and outcome in 340 consecutive cases. 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Eur Spine J 9:123\u2013128, 2000"},{"issue":"Suppl 2","key":"b18","series-title":"Neurosurgery","first-page":"132","article-title":"Management of isolated fractures of the axis in adults","volume":"72","author":"Ryken TC","year":"2013","unstructured":"Ryken TC, Hadley MN, Aarabi B, Dhall SS, Gelb DE, Hurlbert RJ, : Management of isolated fractures of the axis in adults. Neurosurgery 72 (Suppl 2):132\u2013150, 2013"},{"key":"b19","series-title":"Spine (Phila Pa 1976)","first-page":"569","article-title":"Primary surgical management by reduction and fixation of unstable hangman\u2019s fractures with discoligamentous instability or combined fractures","volume":"19","author":"Shin JJ","year":"2013","unstructured":"Shin JJ, Kim SH, Cho YE, Cheshier SH, Park J: Primary surgical management by reduction and fixation of unstable hangman\u2019s fractures with discoligamentous instability or combined fractures. Spine (Phila Pa 1976) 19:569\u2013575, 2013"},{"key":"b20","series-title":"Eur Spine J","first-page":"863","article-title":"Posterior fixation and fusion of unstable Hangman\u2019s fracture by using intraoperative three-dimensional fluoroscopy-based navigation","volume":"21","author":"Tian W","year":"2012","unstructured":"Tian W, Weng C, Liu B, Li Q, Hu L, Li ZY, : Posterior fixation and fusion of unstable Hangman\u2019s fracture by using intraoperative three-dimensional fluoroscopy-based navigation. Eur Spine J 21:863\u2013871, 2012"},{"key":"b21","series-title":"Surg Neurol","first-page":"253","article-title":"Hangman\u2019s fracture: arguments in favor of surgical therapy for type II and III according to Edwards and Levine","volume":"49","author":"Verheggen R","year":"1998","unstructured":"Verheggen R, Verheggen R, Jansen J, Jansen J: Hangman\u2019s fracture: arguments in favor of surgical therapy for type II and III according to Edwards and Levine. Surg Neurol 49:253\u2013262, 1998"},{"key":"b22","series-title":"Int Orthop","first-page":"85","article-title":"Anterior discectomy and fusion with internal fixation for unstable hangman\u2019s fracture","volume":"34","author":"Xu H","year":"2010","unstructured":"Xu H, Zhao J, Yuan J, Wang C: Anterior discectomy and fusion with internal fixation for unstable hangman\u2019s fracture. Int Orthop 34:85\u201388, 2010"},{"key":"b23","series-title":"Spine (Phila Pa 1976)","first-page":"255","article-title":"Anterior cervical discectomy and fusion for unstable traumatic spondylolisthesis of the axis","volume":"33","author":"Ying Z","year":"2008","unstructured":"Ying Z, Wen Y, Xinwei W, Yong T, Hongyu L, Zhu H, : Anterior cervical discectomy and fusion for unstable traumatic spondylolisthesis of the axis. Spine (Phila Pa 1976) 33:255\u2013258, 2008"},{"key":"b1","series-title":"Global Spine J","first-page":"248","article-title":"Management of typical and atypical hangman\u2019s fractures","volume":"6","author":"Al-Mahfoudh R","year":"2016","unstructured":"Al-Mahfoudh R, Beagrie C, Woolley E, Zakaria R, Radon M, Clark S, : Management of typical and atypical hangman\u2019s fractures. Global Spine J 6:248\u2013256, 2016"},{"issue":"3B","key":"b2","series-title":"Arq Neuropsiquiatr","first-page":"821","article-title":"Surgical management of axis\u2019 traumatic spondylolisthesis (Hangman\u2019s fracture)","volume":"62","author":"Boullosa JLR","year":"2004","unstructured":"Boullosa JLR, Colli BO, Carlotti CG Jr, Tanaka K, dos Santos MB: Surgical management of axis\u2019 traumatic spondylolisthesis (Hangman\u2019s fracture). Arq Neuropsiquiatr 62 (3B):821\u2013826, 2004"},{"key":"b3","series-title":"J Neurosurg Spine","first-page":"459","article-title":"Minimally invasive percutaneous screw fixation of traumatic spondylolisthesis of the axis","volume":"22","author":"Buchholz AL","year":"2015","unstructured":"Buchholz AL, Morgan SL, Robinson LC, Frankel BM: Minimally invasive percutaneous screw fixation of traumatic spondylolisthesis of the axis. J Neurosurg Spine 22:459\u2013465, 2015"},{"key":"b4","series-title":"Turk Neurosurg","first-page":"163","article-title":"Traumatic spondylolisthesis of the axis treated with direct C2 pars screw","volume":"19","author":"Dalbayrak S","year":"2009","unstructured":"Dalbayrak S, Yilmaz M, Firidin M, Naderi S: Traumatic spondylolisthesis of the axis treated with direct C2 pars screw. Turk Neurosurg 19:163\u2013167, 2009"},{"key":"b5","series-title":"J Bone Joint Surg Br","first-page":"319","article-title":"Fractures of the ring of the axis. A classification based on the analysis of 131 cases","volume":"63-B","author":"Effendi B","year":"1981","unstructured":"Effendi B, Roy D, Cornish B, Dussault RG, Laurin CA: Fractures of the ring of the axis. A classification based on the analysis of 131 cases. J Bone Joint Surg Br 63-B:319\u2013327, 1981"},{"key":"b6","series-title":"Eur Spine J","first-page":"1299","article-title":"Transpedicular screw fixation for type II Hangman\u2019s fracture: a motion preserving procedure","volume":"19","author":"ElMiligui Y","year":"2010","unstructured":"ElMiligui Y, Koptan W, Emran I: Transpedicular screw fixation for type II Hangman\u2019s fracture: a motion preserving procedure. Eur Spine J 19:1299\u20131305, 2010"},{"key":"b7","series-title":"J Bone Joint Surg Br","first-page":"313","article-title":"Traumatic spondylolisthesis of the axis","volume":"63-B","author":"Francis WR","year":"1981","unstructured":"Francis WR, Fielding JW, Hawkins RJ, Pepin J, Hensinger R: Traumatic spondylolisthesis of the axis. J Bone Joint Surg Br 63-B:313\u2013318, 1981"},{"key":"b8","series-title":"AJNR Am J Neuroradiol","first-page":"209","article-title":"Correlation of MR imaging findings with intraoperative findings after cervical spine trauma","volume":"28","author":"Goradia D","year":"2007","unstructured":"Goradia D, Linnau KF, Cohen WA, Mirza S, Hallam DK, Blackmore CC: Correlation of MR imaging findings with intraoperative findings after cervical spine trauma. AJNR Am J Neuroradiol 28:209\u2013215, 2007"},{"key":"b9","series-title":"Spine (Phila Pa 1976)","first-page":"1843","article-title":"Acute axis fractures. Analysis of management and outcome in 340 consecutive cases","volume":"22","author":"Greene KA","year":"1997","unstructured":"Greene KA, Dickman CA, Marciano FF, Drabier JB, Hadley MN, Sonntag VK: Acute axis fractures. Analysis of management and outcome in 340 consecutive cases. Spine (Phila Pa 1976) 22:1843\u20131852, 1997"},{"key":"b10","series-title":"J Trauma","first-page":"426","article-title":"Utility of flexion and extension radiographs of the cervical spine in the acute evaluation of blunt trauma","volume":"53","author":"Insko EK","year":"2002","unstructured":"Insko EK, Gracias VH, Gupta R, Goettler CE, Gaieski DF, Dalinka MK: Utility of flexion and extension radiographs of the cervical spine in the acute evaluation of blunt trauma. J Trauma 53:426\u2013429, 2002"},{"key":"b11","series-title":"Orthopade","first-page":"394","article-title":"Die traumatische Spondylolisthese des Axis","volume":"28","author":"Josten C","year":"1999","unstructured":"Josten C: Die traumatische Spondylolisthese des Axis. Orthopade 28:394\u2013400, 1999"},{"key":"b12","series-title":"J Chir (Paris)","first-page":"249","article-title":"[Tetraplegia caused by fracture-dislocations of the cervical spine treated by emergency reduction and osteosynthesis.]","volume":"101","author":"Judet J","year":"1971","unstructured":"Judet J, Roy-Camille R, Rose B, Feghali G, Bedoiseau M, Saillant G: [Tetraplegia caused by fracture-dislocations of the cervical spine treated by emergency reduction and osteosynthesis.] J Chir (Paris) 101:249\u2013258, 1971 (Fr)"},{"key":"b13","series-title":"J Orthop Trauma","first-page":"51","article-title":"Use of flexion and extension radiographs of the cervical spine to rule out acute instability in patients with negative computed tomography scans","volume":"25","author":"Khan SN","year":"2011","unstructured":"Khan SN, Erickson G, Sena MJ, Gupta MC: Use of flexion and extension radiographs of the cervical spine to rule out acute instability in patients with negative computed tomography scans. J Orthop Trauma 25:51\u201356, 2011"},{"key":"b14","series-title":"J Bone Joint Surg Am","first-page":"217","article-title":"The management of traumatic spondylolisthesis of the axis","volume":"67","author":"Levine AM","year":"1985","unstructured":"Levine AM, Edwards CC: The management of traumatic spondylolisthesis of the axis. J Bone Joint Surg Am 67:217\u2013226, 1985"},{"key":"b15","series-title":"Eur Spine J","first-page":"257","article-title":"A systematic review of the management of hangman\u2019s fractures","volume":"15","author":"Li XF","year":"2006","unstructured":"Li XF, Dai LY, Lu H, Chen XD: A systematic review of the management of hangman\u2019s fractures. Eur Spine J 15:257\u2013269, 2006"},{"key":"b16","series-title":"Spine (Phila Pa 1976)","first-page":"2754","article-title":"Traumatic cervical discoligamentous injuries: correlation of magnetic resonance imaging and operative findings","volume":"34","author":"Malham GM","year":"2009","unstructured":"Malham GM, Ackland HM, Varma DK, Williamson OD: Traumatic cervical discoligamentous injuries: correlation of magnetic resonance imaging and operative findings. Spine (Phila Pa 1976) 34:2754\u20132759, 2009"},{"key":"b17","series-title":"Eur Spine J","first-page":"123","article-title":"Traumatic spondylolisthesis of the axis: treatment rationale based on the stability of the different fracture types","volume":"9","author":"M\u00fcller EJ","year":"2000","unstructured":"M\u00fcller EJ, Wick M, Muhr G: Traumatic spondylolisthesis of the axis: treatment rationale based on the stability of the different fracture types. Eur Spine J 9:123\u2013128, 2000"},{"issue":"Suppl 2","key":"b18","series-title":"Neurosurgery","first-page":"132","article-title":"Management of isolated fractures of the axis in adults","volume":"72","author":"Ryken TC","year":"2013","unstructured":"Ryken TC, Hadley MN, Aarabi B, Dhall SS, Gelb DE, Hurlbert RJ, : Management of isolated fractures of the axis in adults. Neurosurgery 72 (Suppl 2):132\u2013150, 2013"},{"key":"b19","series-title":"Spine (Phila Pa 1976)","first-page":"569","article-title":"Primary surgical management by reduction and fixation of unstable hangman\u2019s fractures with discoligamentous instability or combined fractures","volume":"19","author":"Shin JJ","year":"2013","unstructured":"Shin JJ, Kim SH, Cho YE, Cheshier SH, Park J: Primary surgical management by reduction and fixation of unstable hangman\u2019s fractures with discoligamentous instability or combined fractures. Spine (Phila Pa 1976) 19:569\u2013575, 2013"},{"key":"b20","series-title":"Eur Spine J","first-page":"863","article-title":"Posterior fixation and fusion of unstable Hangman\u2019s fracture by using intraoperative three-dimensional fluoroscopy-based navigation","volume":"21","author":"Tian W","year":"2012","unstructured":"Tian W, Weng C, Liu B, Li Q, Hu L, Li ZY, : Posterior fixation and fusion of unstable Hangman\u2019s fracture by using intraoperative three-dimensional fluoroscopy-based navigation. Eur Spine J 21:863\u2013871, 2012"},{"key":"b21","series-title":"Surg Neurol","first-page":"253","article-title":"Hangman\u2019s fracture: arguments in favor of surgical therapy for type II and III according to Edwards and Levine","volume":"49","author":"Verheggen R","year":"1998","unstructured":"Verheggen R, Verheggen R, Jansen J, Jansen J: Hangman\u2019s fracture: arguments in favor of surgical therapy for type II and III according to Edwards and Levine. Surg Neurol 49:253\u2013262, 1998"},{"key":"b22","series-title":"Int Orthop","first-page":"85","article-title":"Anterior discectomy and fusion with internal fixation for unstable hangman\u2019s fracture","volume":"34","author":"Xu H","year":"2010","unstructured":"Xu H, Zhao J, Yuan J, Wang C: Anterior discectomy and fusion with internal fixation for unstable hangman\u2019s fracture. Int Orthop 34:85\u201388, 2010"},{"key":"b23","series-title":"Spine (Phila Pa 1976)","first-page":"255","article-title":"Anterior cervical discectomy and fusion for unstable traumatic spondylolisthesis of the axis","volume":"33","author":"Ying Z","year":"2008","unstructured":"Ying Z, Wen Y, Xinwei W, Yong T, Hongyu L, Zhu H, : Anterior cervical discectomy and fusion for unstable traumatic spondylolisthesis of the axis. 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