MAZOR-X robotic-navigated percutaneous C2 screw placement for hangman’s fracture: a case report

Case Reports


doi: 10.21037/jss-20-676.

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Case Reports

David T Asuzu et al.


J Spine Surg.


2021 Sep.

Abstract

Robotic-navigated screw placement has potential for higher precision and accuracy. Robotic assistance is well-described in the lumbar spine, however only few studies have evaluated its use in the cervical spine. Surgical treatment for hangman’s fractures after nonunion typically involves C2-3 anterior fusion or posterior occipito-cervical fusion. However, occipito-cervical fusion involves loss of mobility in the cervical spine with associated morbidity. We have previously described a minimally invasive approach using percutaneous screw fixation with X-ray navigation. Robotic assistance is ideally suited for cervical fusion given smaller bony anatomy and adjacent critical structures. We describe a young healthy patient who presented with a hangman’s fracture initially managed conservatively with immobilization. She presented with nonunion and persistent symptoms. Surgical options considered included anterior cervical discectomy and fusion, or posterior cervical fusion with or without extension to the occiput. These options would have involved some loss of flexion/extension and rotational motion with associated morbidity. We performed percutaneous screw fixation of the hangman’s fracture using MAZOR-X robotic navigation and achieved good radiographic fracture reduction with accurate screw placement. To our knowledge this is the first case of a robotic-assisted percutaneous screw fixation for a hangman’s fracture. Robotic-navigated screw placement can be used safely and accurately for cervical spine fractures.


Keywords:

Hangman’s fracture; case report; percutaneous screws; robotic assistance.

Conflict of interest statement

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://dx.doi.org/10.21037/jss-20-676). The authors have no conflicts of interest to declare.

Figures


Figure 1



Figure 1

CT imaging of a patient with Levine-Edwards Type II hangman’s fracture of C2. (A) Axial CT showing bilateral pars defects; (B) sagittal CT through the left pars; (C) 3D reconstruction of the occiput and upper cervical spine showing partially displaced bone fragment; (D-F) axial, coronal and sagittal reconstructions using the MAZOR-X software to specify C2 lag screws including screw size and trajectory.


Figure 2



Figure 2

Intraoperative and postoperative images. (A) Insertion of operating cylinder after drilling using the MAZOR-X robotic arm. (B) K-wires were inserted through the operating cylinder. The first screw was tapped, and the lag screw is shown being placed over the K-wire. (C) With the first lag screw in place, the second is shown being tapped over the K-wire. (D) Operating room setup with C-arm in place and robotic arm being used to place K wires at the lag screw sites. (E,F) Post-operative lateral and open-mouth X-rays confirming adequate screw placement and fracture reduction.

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