Unstable Hangman's fracture: Anterior or posterior surgery?

Context: Literature evaluating the efficacy and long-term clinico-radiological outcomes of anterior cervical discectomy and fusion (ACDF) and posterior fixation at C2-C3 for the treatment of unstable hangman's fractures is scanty. Aims: The aim of this study is to compare the efficacy, clinical-radiological outcomes, and complications of ACDF and posterior fixation techniques performed for unstable hangman's fractures. Settings and Design: The study design involves retrospective comparative study. Subjects and Methods: This study conducted from 2012 to 2018 included 21 patients with unstable hangman's fracture (Levine and Edwards Type II, Ila and III). All patients were divided into two groups based on the approach taken for fracture fixation (Group A-anterior approach and Group B-posterior approach). Peri-operative clinical, radiological parameters, postoperative complications, and outcomes were evaluated and compared in both the groups. Statistical Analysis Used: Chi-square test and Student's t-test were used. Results: The mean age was 39.8 +/- 4.5 years in-group A and 41.3 +/- 6.7 years in-group B.The male patients outnumbered the female patients and road traffic accident was the most common cause of unstable fractures.There were statistical significant differences in surgical time (P= 0.15), operative blood loss, pain-free status postsurgery, and hospital stay (P = 0.15) between two groups. No statistically significant differences noted in clinic-radiological outcomes in the form of visual analog scale and fusion rate at final follow-up between two groups at final follow-up. Conclusions: The unstable hangman's fractures can be effectively managed with both anterior and posterior approaches with comparable clinico-radiological outcome. A minimally invasive nature, earlier pain-free status, early mobilization with reduced hospitalization make the ACDF efficacious, particularly in cases with no medullary canal in C2 pedicles and traumatic C2-3 disc herniation with listhesis compressing the spinal cord.