Transoral Approach With Reverse Pedicle Screw Technique for the Treatment of Chronic Levine-Edwards Type III Hangman's Fracture: A Case Report, Surgical Technique, and Literature Review.

backgroundThe optimal surgical strategy for unstable hangman's fractures remains controversial, particularly in cases where posterior fixation is unsuitable and evidence for alternative approaches is lacking. CASE PRESENTATION: A 58-year-old man presented with a C2 vertebral body fracture, right C2 pedicle fracture, and concurrent C2/C3 disc injury, which manifested as a chronic fracture (4 weeks after trauma). Despite multiple courses of conservative treatment and use of a cervicothoracic orthosis, fracture displacement progressed. No significant neurological deficits were noted. The fracture was reduced and stabilized via a transoral approach using a bilateral reverse pedicle screw technique with cortical bone compression screws. A 2-cm incision was made, with a total surgical duration of 1 hour and intraoperative blood loss of 20 mL; no neurovascular injuries occurred. Immediate intraoperative fracture reduction and fixation were achieved, and no postoperative infections were observed. Postoperatively, the patient wore a cervical collar, initiated neck rehabilitation at 48 hours, and resumed daily activities within 1 week. The visual analog scale score decreased from 4 (preoperatively) to 0 (1 week postoperatively), the Japanese Orthopedic Association score improved from 11 to 16, and the Neck Disability Index score decreased from 28% to 6%. Follow-up computed tomographic imaging demonstrated satisfactory fusion.

conclusionThe minimally invasive transoral approach combined with reverse pedicle screw fixation is an effective surgical option for treating Levine and Edwards type III chronic hangman's fracture. This study provides a reference for optimizing surgical strategies in the management of upper cervical trauma. CLINICAL RELEVANCE: This case report demonstrates that the minimally invasive transoral reverse pedicle screw technique is a safe and effective alternative for treating chronic, unstable hangman's fractures, particularly in patients for whom posterior fixation is unsuitable or motion preservation is desired. The findings may help expand the surgical armamentarium for upper cervical trauma. LEVEL OF EVIDENCE: 4: