Treatment of Axis Ring Fractures: Recommendations of the Spine Section of the German Society for Orthopaedics and Trauma (DGOU)

Study Design: Narrative literature review and expert recommendation. Objective: To establish treatment recommendations for axis ring fractures based on the knowledge of the experts of the Spine Section of the German Society for Orthopaedics and Trauma. Methods: This recommendation summarizes the knowledge of the experts of the Spine Section of the German Society for Orthopaedics and Trauma with regard to the treatment of axis ring fractures based on a narrative literature review. Results: Typical "hangman's fractures" with bilateral separation of the neural arch from C2 and atypical "hangman's fractures" with irregular fracture morphology are described. Computed tomography is the "gold" standard used to detect and analyse these fractures adequately. Furthermore, the detection of vertebral artery integrity is necessary. To classify axis ring fractures, the Levine-Edwards or Josten classification is recommended. In particular, the integrity of the C2/3 disc and the integrity of the anterior longitudinal ligament are used to determine the treatment strategy. While Levine-Edwards type I and type IIA (Josten type 1 and 2) fractures should be treated conservatively, Levine type II and type III (Josten type 3 and 4) fractures should be treated operatively. Levine-Edwards type II fractures will be predominately treated by anterior C2/3 fusion. Levine-Edwards type III fractures have to be primary reduced, if an anterior fusion is planned (anterior cervical discectomy and fusion [ACDF] C2/3). If a closed reduction of a type III fracture is impossible, an open reduction and posterior fixation/fusion is the treatment of choice. Conclusion: Conservative treatment is predominantly reserved for Levine-Edwards I and IIA fractures. Operative treatment should be performed in case of Levine-Edwards II and III fractures.