Evolution in the Management of Combined Atlas—Hangman's Fracture

Introduction: Combined C1-Hangman fractures are uncommon and management usually compromises C1-C2 mobility.

Objective: To evaluate treatment and outcome of combined C1-Hangman's fracture with and without intraoperative O-arm-based navigation system

Methods: Out of 11 patients (18.33%) of combined C1 and Hangman's fracture, we included 10 patients in our study who had at least 6 months follow-up. Neurological deficit was present in 4 patients (ASIA B in 1 patient, ASIA C in 2 patients, and ASIA D in 1 patient). Operative intervention was performed in nine patients. Specific treatment was determined by the combination of fractures. O-arm was used in five patients and its use allowed more anatomical and more motion preserving procedure in these five patients. In one patient, C2 pedicle screws and C3 lateral mass screw and rod fixation was done, and in four patients C2 pedicle screw and C3 to C4 lateral mass screw and rod fixation was done.

Results: Mean follow-up period was 28.7 ± 9.2 months. Neurological recovery occurred in all four patients with preoperative neurological deficits. Radiological fusion occurred in all cases. Rotation at C1 to 2 was preserved in all cases.

Conclusions: The goals in treating these complex fractures are to achieve early maximum stability and preserving maximum range of motion. These are often competing phenomena. Treatment in these combination fractures is based on the type of Hangman's fracture. Good healing can be achieved in elderly patients also and we should be aggressive in managing these patients with new intraoperative computed tomography scans and navigation system.