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

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 | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report 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Review Qingfeng Shen, Hua Wei, Xiaoming Tian, Junwei Gao, Shibo Ma, Haifeng Song, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7621483/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background This report navigated transoral anterior pedicle screw technique achieved secure fixation for unstable hangman's fracture. It circumvented posterior approach risks and anterior contamination concerns. This offers a paradigm for complex cases where posterior fixation is unsuitable. Case presentation We report a 58-year-old male presenting with a C2 vertebral body fracture, right C2 pedicle fracture, and concurrent C2/3 disc injury, which manifested as a chronic fracture (4 weeks post-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 hours 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 (VAS) score decreased from 4 (preoperatively) to 0 (1 week postoperatively), the Japanese Orthopaedic Association (JOA) score improved from 11 to 16, and the Neck Disability Index (NDI) decreased from 28% to 6%. Following-up CT imaging demonstrated satisfactory fusion. Conclusion The minimally invasive transoral approach combined with reverse pedicle screw fixation is an effective surgical option for treating Levine-Edwards Type III chronic Hangman’s fracture. This study provides a reference for optimizing surgical strategies in the management of upper cervical trauma. Transoral Pedicle screw Hangman’s fracture C2 vertebra Axis Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Background Hangman’s fracture (HF), or traumatic spondylolisthesis of the axis (TSA), was first described and termed by Schneider in 1965 [ 1 ]. It involves fractures of the superior and inferior articular processes of the C2 vertebra, resulting from hyperextension, hyperflexion, and axial loading forces. These injuries are often accompanied by ligamentous and disc damage, leading to C2–C3 instability. HF accounts for 23–27% of all axis fractures. The management of HF is primarily guided by fracture classification, with the Levine-Edwards system being the most widely adopted [ 2 ].Unstable HF generally requires surgical intervention, though the optimal surgical approach remains controversial. Historically, posterior C2 pedicle screw fixation was considered the gold standard, as it enables direct fracture compression, anatomical reduction, and preservation of cervical motion [3]. However, this technique has notable limitations: open posterior dissection carries a risk of C2 nerve root irritation and venous plexus disruption, leading to high rates of persistent postoperative occipital neuralgia [4]. While navigation-assisted percutaneous screw placement may mitigate some risks, its accuracy is compromised in highly unstable fractures and may even exacerbate fracture displacement during screw insertion (Fig. 1) [5]. For patients with traumatic disc herniation causing spinal cord compression, Verheggen and Jansen advocated for C2–3 anterior cervical discectomy and fusion (ACDF) [6]. ACDF allows direct disc excision and fusion via a natural anatomical plane, minimizing intraoperative blood loss [7]. However, it is associated with risks such as dysphagia and donor-site morbidity from autogenous iliac bone grafting [8]. Additionally, ACDF is ineffective for unstable axis fractures with pedicle displacement. To address these limitations—while achieving anatomical fixation, avoiding posterior neurovascular complications, preserving C1–3 motion, and reducing ACDF-related morbidity—we employed a transoral reverse pedicle screw technique with cortical compression screws for a chronic Levine-Edwards Type III HF in April 2025. This report details the case and provides a review of relevant literature. Case presentation 1. General Information A 58-year-old male presented with neck pain and restricted range of motion 1 month after falling down a flight of stairs (from the second to the first floor) and landing on his right head. Immediately after the trauma, he developed severe neck pain and marked motion restriction. No loss of consciousness, limb sensory/motor deficits, perianal sensory loss, or bowel/bladder dysfunction was reported. Initial cervical CT at a local hospital revealed a C2 fracture (Fig 2A–B). He was referred to an orthopedic specialist, who initiated conservative management with a cervical collar. One month later, cervical radiographs showed progressive fracture displacement (Fig 2C–D). Persistent pain prompted further evaluation, leading to admission to our spine surgery department. The patient’s general health was good, with a history of chronic snoring. Physical examination revealed a mild antalgic gait while wearing the cervical collar. No obvious cervical deformity was noted; tenderness was present at the C2 spinous process and paraspinal regions (+). Upper limb sensation and tone were normal, with bilateral muscle strength graded 5/5. Upper limb reflexes were +++ on the left and ++ on the right, with a positive bilateral Hoffmann’s sign. Cervical CT with sagittal bone window reconstruction confirmed a fracture involving the posterior left C2 vertebral body and right C2 pedicle, accompanied by anterior C2 displacement and angulation. MRI demonstrated C2 fracture-dislocation and diffuse edema in the C2–7 interspinous ligaments. The final diagnosis was Chronic Levine-Edwards Type III Hangman’s Fracture (Figs 2–3). 2. Surgical Technique General anesthesia was administered, and the patient was placed in a supine position with the neck maintained in a fixed extended posture. The surgeon, positioned cephalad, prepared the oral cavity using povidone-iodine. A Codman retractor was used to achieve adequate exposure of the operative field. After confirming the C1–2 anatomical location via C-arm fluoroscopy, a 20 mm midline longitudinal incision was made in the posterior pharyngeal wall. Prevertebral muscles were dissected using bipolar electrocautery to expose the anterior C2 vertebral body. A nerve dissector was used to expose a 7-mm segment of the odontoid base. The screw entry point was marked 6 mm caudal and 6 mm lateral to the medial border of the C2 lateral mass articulation. A 2.00-mm drill was used to create a cortical entry hole, angled 20° caudally and laterally. An awl was advanced 2.7 mm into the vertebral bone in a controlled manner. A guidewire was inserted, and its position was confirmed via C-arm fluoroscopy. The awl was then advanced further until a loss of resistance was appreciated. Two 40×3.5 mm cortical bone compression screws were inserted sequentially. Clear tactile feedback confirmed fracture compression during screw tightening. C-arm fluoroscopy verified satisfactory fracture reduction and implant position. The naso-oropharynx was irrigated repeatedly with povidone-iodine. The muscular and mucosal layers were closed with absorbable sutures. The total duration of exposure and fixation was 1 hour, with intraoperative blood loss of 20 mL (Fig 4). 3. Postoperative Management The patient was intubated and monitored in the intensive care unit (ICU) for 24 hours, followed by successful extubation. Enteral nutrition was administered via a nasogastric tube for 7 days. Prophylactic anticoagulation, broad-spectrum antibiotics, and analgesics were prescribed. Cervical collar-assisted rehabilitation was initiated on postoperative day 2, and ambulation was started on day 3. The patient wore the cervical collar for 3 months, with instructions to avoid strenuous neck activities. Imaging obtained at 1 week postoperatively is shown in Fig 5. 4. Follow-up Follow-up radiographs and CT scans at 1 and 3 months postoperatively showed progressive fracture healing (Figs 6–7). The patient remained asymptomatic, with excellent functional outcomes. Discussion Schneider first described and termed “Hangman’s fracture” in 1965; this injury is also referred to as “axis ring fracture” or traumatic spondylolisthesis of the axis (TSA) [9]. It accounts for 4–7% of all spinal fractures and 20–22% of cervical fractures [10]. Effendi et al. proposed a classification system for HF in 1981 [11], which was later modified by Levine in 1985 into the widely used 4-type system based on injury mechanism [2]. Type I fractures are stable and managed non-operatively with a rigid cervical collar [12], while Types II, IIA, and III involve significant flexion forces leading to C2–C3 disc injury and require surgical stabilization [13]. Surgical options for unstable HF include posterior and anterior approaches. Posterior C2 pedicle screw fixation was once considered ideal for achieving anatomical reduction via screw thread compression while preserving motion. However, the inability to achieve bicortical fixation often limits effective compression and may exacerbate displacement (Fig 1). Type III fractures with C2–3 instability—particularly those involving the posterior inferior corner of C2 often require C2–3 fusion [2]. Open posterior surgery carries a risk of C2 nerve root irritation and venous plexus injury, which contribute to persistent postoperative neck pain [14–17]. While navigation can facilitate percutaneous screw placement, its accuracy is unreliable in highly unstable fractures [5]. Anteriorly, Verheggen and Jansen advocated for ACDF in HF patients with traumatic disc herniation causing spinal cord compression [6]. ACDF allows direct disc excision and fusion via an anatomical plane, with reduced intraoperative blood loss [18]. However, high cervical ACDF is associated with a risk of dysphagia, and autologous iliac bone grafting may cause donor-site morbidity [7]. Studies have shown that patients with HF treated with ACDF have significantly higher postoperative VAS scores compared to those undergoing posterior fixation [3]. Standalone C2 fracture fixation stabilizes the injury while preserving segmental motion. The transoral approach has been reported for the treatment of atlas fractures using screw-wire or plate systems [19, 20]. Posterior lag screws have been used for minimally displaced anterior C1 ring fractures and coronally split lateral mass fractures to prevent degenerative changes and displacement [21–25]. Kandziora et al. defined safe zones for C1/C2 screw insertion [26]. With advances in surgical techniques and instrumentation, the complication rate of transoral procedures has decreased [27–31]. However, a comprehensive literature search (CNKI, CMA, PubMed, Web of Science) revealed no prior reports of the transoral reverse pedicle screw technique for Levine-Edwards Type III chronic HF. We present a novel transoral reverse pedicle screw technique for this fracture type, with key advantages including minimal invasiveness (2-cm pharyngeal incision) and bicortical compression fixation via reverse pedicle screws——facilitating healing, preventing long-term sequelae, and preserving cervical motion. While conceptually promising, the clinical application of transoral reverse pedicle screws is in its early stages; only one report has described its use for unilateral atlas fracture fixation [32]. The present case represents the first successful application of this technique for an unstable axis fracture. Given the chronic nature of the fracture and the significant fracture gap, full-length bicortical compression screws (40 mm) were essential for achieving complete reduction (Fig 4A). Postoperative CT imaging clearly showed that the screw tips protruded 3 mm beyond the posterior margin of the C2 articular processes, confirming successful bicortical compression fixation. The posterior aspect of the C2 pedicle is covered by thick soft tissues, including the semispinalis cervicis muscle, inferior obliquus capitis muscle, and nuchal ligament. Imaging analysis revealed a soft tissue thickness of approximately 5 mm posterior to the pedicle in this patient, confirming that the 3-mm screw protrusion remained within safe limits. This innovative technique overcomes the limitations of isolated posterior or anterior approaches, establishing it as a promising solution for unstable axis fractures. Key advantages of the transoral approach include minimal tissue disruption (facilitating faster exposure and reduced swelling), shorter postoperative intubation times, and a potentially lower infection risk compared to traditional transoral procedures. Compared to posterior transpedicular compression screw fixation, the anterior approach minimizes the risk of fracture fragment displacement during screw insertion—since the dense posterior musculoligamentous complex may act as a fulcrum. Furthermore, the relatively thin soft tissue envelope anterior to the C1–C2 complex poses a risk: excessively long bicortical screws placed posteriorly may breach the anterior pharyngeal wall, causing oropharyngeal contamination. Critically, the transoral anterior approach eliminates this concern, allowing surgeons to confidently select screws of sufficient length to achieve secure bicortical compression fixation without risking visceral injury. Specific perioperative risks must be considered. Studies indicate that approximately 4.2% of patients develop acute airway obstruction due to retropharyngeal edema, requiring delayed extubation [33]. More severe complications include retropharyngeal infection with tissue loss, which may necessitate complex reconstruction. Postoperative infection rates (4–7%) are comparable to those of other spinal surgeries when performed by experienced surgeons [34]. Notably, transoral procedures performed by experienced surgeons do not carry higher mortality or morbidity rates than other established spinal surgical approaches [33]. In the present case, manual placement of the right pedicle screw adjacent to the laminar fracture failed to perfectly traverse the fracture line. While bilateral fixation controlled rotational instability and facilitated early (4-week) healing, this highlights the complexity of transoral upper cervical anatomy and the limitations of C-arm fluoroscopy. It underscores the need for enhanced intraoperative guidance——such as intraoperative CT and real-time navigation—to ensure precise screw placement. Conclusion The innovative transoral reverse pedicle screw fixation technique is an effective surgical option for chronic unstable axis fractures. In this case of Levine-Edwards Type III chronic Hangman’s fracture, the technique achieved anatomical reduction, bony fusion, and preservation of cervical motion. Abbreviations VAS Visual analog scale JOA Japanese orthopaedic association NDI Neck disability index HF Hangman’s fracture TSA Traumatic spondylolisthesis of the axis ACDF Anterior cervical discectomy and fusion ICU Intensive care unit Declarations Ethics approval and consent to participate This case report did not undergo formal ethics committee review. The patient identifiers have been removed from imaging and clinical data to ensure anonymity. Written informed consent for publication was obtained from the patient. Consent for publication The patient gave informed written consent to the publication of personal or clinical data and images in this study. Availability of data and materials The materials used during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare no competing interests. Funding This study was supported by Tianjin Medical Key Disciplines (Specialist) Construction Project (TJYXZDXK-064B). Clinical Trial Number: not applicable. Author Contribution Qingfeng Shen and Yingpeng Xia conceptualized the surgical design; Hua Wei drafted the manuscript; Xiaoming Tian processed and annotated the imaging data; Junwei Gao, Shibo Ma and Haifeng Song contributed to clinical data acquisition and analysis. All authors critically reviewed and approved the final manuscript for submission. References Schneider RC, Livingston KE, Cave AJ, et al. “HANGMAN’S FRACTURE” OF THE CERVICAL SPINE. J Neurosurg 1965;22:141–154; doi: 10.3171/jns.1965.22.2.0141. Levine AM, Edwards CC. The management of traumatic spondylolisthesis of the axis. J Bone Joint Surg Am 1985;67(2):217–226. Mahmoud A, Shanmuganathan K, Montgomery A. Surgical Management of Hangman’s Fracture: A Systematic Review. Int J Spine Surg 2023;17(3):454–467; doi: 10.14444/8445. Li G, Zhong D, Wang Q. A novel classification for atypical Hangman fractures and its application. Medicine (Baltimore) 2017;96(28):e7492; doi: 10.1097/MD.0000000000007492. Wang J, Miao J, Zhan Y, et al. Spine Surgical Robotics: Current Status and Recent Clinical Applications. Neurospine 2023;20(4):1256; doi: 10.14245/ns.2346610.305. Verheggen R, Jansen J. Hangman’s fracture: arguments in favor of surgical therapy for type II and III according to Edwards and Levine. Surg Neurol 1998;49(3):253–261; discussion 261-262; doi: 10.1016/s0090-3019(97)00300-5. Li Z, Li F, Hou S, et al. Anterior discectomy/corpectomy and fusion with internal fixation for the treatment of unstable hangman’s fractures: a retrospective study of 38 cases. J Neurosurg Spine 2015;22(4):387–393; doi: 10.3171/2014.11.SPINE13959. Jain V, Thakur MK, Thakur A, et al. Functional outcome in unstable Hangman’s fracture managed with anterior approach: A prospective study. J Craniovertebr Junction Spine 2017;8(4):350–353; doi: 10.4103/jcvjs.JCVJS_113_17. Prost S, Barrey C, Blondel B, et al. Hangman’s fracture: Management strategy and healing rate in a prospective multi-centre observational study of 34 patients. Orthop Traumatol Surg Res 2019;105(4):703–707; doi: 10.1016/j.otsr.2019.03.009. Scholz M, Kandziora F, Kobbe P, et al. Treatment of Axis Ring Fractures: Recommendations of the Spine Section of the German Society for Orthopaedics and Trauma (DGOU). Global Spine J 2018;8(2 Suppl):18S-24S; doi: 10.1177/2192568217745061. Effendi B, Roy D, Cornish B, et al. Fractures of the ring of the axis. A classification based on the analysis of 131 cases. J Bone Joint Surg Br 1981;63-B(3):319–327; doi: 10.1302/0301-620X.63B3.7263741. Termansen NB. Hangman’s fracture. Acta Orthop Scand 1974;45(4):529–539; doi: 10.3109/17453677408989176. Li X-F, Dai L-Y, Lu H, et al. A systematic review of the management of hangman’s fractures. Eur Spine J 2006;15(3):257–269; doi: 10.1007/s00586-005-0918-2. Harms J, Melcher RP. Posterior C1-C2 fusion with polyaxial screw and rod fixation. Spine (Phila Pa 1976) 2001;26(22):2467–2471; doi: 10.1097/00007632-200111150-00014. Blagg SE, Don AS, Robertson PA. Anatomic Determination of Optimal Entry Point and Direction For C1 Lateral Mass Screw Placement. Clinical Spine Surgery 2009;22(4):233; doi: 10.1097/BSD.0b013e31817ff95a. Gunnarsson T, Massicotte EM, Govender PV, et al. The Use of C1 Lateral Mass Screws in Complex Cervical Spine Surgery: Indications, Techniques, and Outcome in a Prospective Consecutive Series of 25 Cases. Clinical Spine Surgery 2007;20(4):308; doi: 10.1097/01.bsd.0000211291.21766.4d. Rhee W-T, You S-H, Kim S-K, et al. Troublesome Occipital Neuralgia Developed by C1-C2 Harms Construct. J Korean Neurosurg Soc 2008;43(2):111–113; doi: 10.3340/jkns.2008.43.2.111. Ge C, Hao D, He B, et al. Anterior cervical discectomy and fusion versus posterior fixation and fusion of C2-3 for unstable hangman’s fracture. J Spinal Disord Tech 2015;28(2):E61-66; doi: 10.1097/BSD.0000000000000150. Ruf M, Melcher R, Harms J. Transoral reduction and osteosynthesis C1 as a function-preserving option in the treatment of unstable Jefferson fractures. Spine (Phila Pa 1976) 2004;29(7):823–827; doi: 10.1097/01.brs.0000116984.42466.7e. Keskil S, Göksel M, Yüksel U. Transoral screw and wire fixation for unstable anterior ½ atlas fracture. J Craniovertebr Junction Spine 2017;8(4):364–368; doi: 10.4103/jcvjs.JCVJS_94_17. Keskil S, Göksel M, Yüksel U. Unilateral lag-screw technique for an isolated anterior 1/4 atlas fracture. J Craniovertebr Junction Spine 2016;7(1):50–54; doi: 10.4103/0974-8237.176625. Felbaum DR, Stewart JJ, Suskin ZD, et al. Unilateral C1 Sagittal Split Fractures: An Unusual Entity Revisited. World Neurosurg 2018;109:263–270; doi: 10.1016/j.wneu.2017.09.206. Minardi M, Narducci A, Vercelli GG, et al. Lag screws for reduction of bilateral lateral mass fractures due to spinal trauma. Brain Spine 2022;2:100877; doi: 10.1016/j.bas.2022.100877. Tabbosha M, Dowdy J, Pait TG. Placement of unilateral lag screw through the lateral mass of C-1: description of a novel technique. J Neurosurg Spine 2013;19(1):128–132; doi: 10.3171/2013.4.SPINE12826. Lakshmanan P, Jones A, Howes J, et al. CT evaluation of the pattern of odontoid fractures in the elderly--relationship to upper cervical spine osteoarthritis. Eur Spine J 2005;14(1):78–83; doi: 10.1007/s00586-004-0743-z. Kandziora F, Schulze-Stahl N, Khodadadyan-Klostermann C, et al. Screw placement in transoral atlantoaxial plate systems: an anatomical study. J Neurosurg 2001;95(1 Suppl):80–87; doi: 10.3171/spi.2001.95.1.0080. Apuzzo ML, Weiss MH, Heiden JS. Transoral exposure of the atlantoaxial region. Neurosurgery 1978;3(2):201–207; doi: 10.1227/00006123-197809000-00012. Crockard HA. The transoral approach to the base of the brain and upper cervical cord. Ann R Coll Surg Engl 1985;67(5):321–325. Dickman CA, Locantro J, Fessler RG. The influence of transoral odontoid resection on stability of the craniovertebral junction. J Neurosurg 1992;77(4):525–530; doi: 10.3171/jns.1992.77.4.0525. Menezes AH, VanGilder JC. Transoral-transpharyngeal approach to the anterior craniocervical junction. Ten-year experience with 72 patients. J Neurosurg 1988;69(6):895–903; doi: 10.3171/jns.1988.69.6.0895. Tuite GF, Veres R, Crockard HA, et al. Pediatric transoral surgery: indications, complications, and long-term outcome. J Neurosurg 1996;84(4):573–583; doi: 10.3171/jns.1996.84.4.0573. Tinner C, Aregger FC, Deml MC. Transoral unilateral lag screw osteosynthesis for coronal split fracture of the lateral mass of the atlas – case report, operative technique and review of the literature. Brain Spine 2023;3:101761; doi: 10.1016/j.bas.2023.101761. Amelot A, Terrier L-M, Lot G. Craniovertebral Junction Transoral Approach: Predictive Factors of Complications. World Neurosurg 2018;110:568–574; doi: 10.1016/j.wneu.2017.09.135. Balabaud L, Pitel S, Caux I, et al. Lumbar spine surgery in patients 80 years of age or older: morbidity and mortality. Eur J Orthop Surg Traumatol 2015;25 Suppl 1:S205-212; doi: 10.1007/s00590-014-1556-3. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7621483","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":522324150,"identity":"50d96375-610b-4f06-96d7-0d7677099074","order_by":0,"name":"Qingfeng Shen","email":"","orcid":"","institution":"Tianjin Union Medical Center, The First Affiliated Hospital of Nankai University","correspondingAuthor":false,"prefix":"","firstName":"Qingfeng","middleName":"","lastName":"Shen","suffix":""},{"id":522324152,"identity":"e6838e4a-fda4-41c4-a757-220e92f2cbfa","order_by":1,"name":"Hua Wei","email":"","orcid":"","institution":"The First Hospital of Hebei Medical University","correspondingAuthor":false,"prefix":"","firstName":"Hua","middleName":"","lastName":"Wei","suffix":""},{"id":522324154,"identity":"3a1917fa-4e4c-4130-affd-bc42a81b1373","order_by":2,"name":"Xiaoming Tian","email":"","orcid":"","institution":"Tianjin Union Medical Center, The First Affiliated Hospital of Nankai University","correspondingAuthor":false,"prefix":"","firstName":"Xiaoming","middleName":"","lastName":"Tian","suffix":""},{"id":522324156,"identity":"4a027713-75ad-406d-95e9-f82e128dabf3","order_by":3,"name":"Junwei Gao","email":"","orcid":"","institution":"Tianjin Union Medical Center, The First Affiliated Hospital of Nankai University","correspondingAuthor":false,"prefix":"","firstName":"Junwei","middleName":"","lastName":"Gao","suffix":""},{"id":522324158,"identity":"1ca56c66-952d-4aa8-bc20-4dea3e530743","order_by":4,"name":"Shibo Ma","email":"","orcid":"","institution":"Tianjin Union Medical Center, The First Affiliated Hospital of Nankai University","correspondingAuthor":false,"prefix":"","firstName":"Shibo","middleName":"","lastName":"Ma","suffix":""},{"id":522324160,"identity":"64828099-ad73-4992-b8b2-17a444cd2c42","order_by":5,"name":"Haifeng Song","email":"","orcid":"","institution":"Tianjin Union Medical Center, The First Affiliated Hospital of Nankai University","correspondingAuthor":false,"prefix":"","firstName":"Haifeng","middleName":"","lastName":"Song","suffix":""},{"id":522324162,"identity":"3aae08e7-b85d-4830-bfb3-10c575bb60b0","order_by":6,"name":"Yingpeng Xia","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABEElEQVRIiWNgGAWjYDACZiBOgDIf//1TI8fG3n6AaC1sBrwNx4z5eM4kEG+jBG8Dc+I8CQcDvKoMjjM/k3i4ozaPX7r9goHkDrb0NgmgrT8qtuHUItnMZiaReOZ4seScMwUPDM/I5LZJNx5g7DlzG6cWfmYGoJa2Y4kbbuQkGCSwseW2yRxIYGZsw62FjZn9G1jLfqAWiQNszOlsEgkGeLXwM/OAbKlJ3CCRfkCysY05gaAWyWaeYovEtgPFEjdy2IwZzhwzbAMG8kF8fjE4f3zjzZ9tdXn8M9IfP2aoqJGXb28/+OBHBW4tQMAiwcBwOIGBgQcRHQfwqQcC5g8MDHVALewPCCgcBaNgFIyCkQoAFfxZziPuq9EAAAAASUVORK5CYII=","orcid":"","institution":"Tianjin Union Medical Center, The First Affiliated Hospital of Nankai University","correspondingAuthor":true,"prefix":"","firstName":"Yingpeng","middleName":"","lastName":"Xia","suffix":""}],"badges":[],"createdAt":"2025-09-15 14:08:33","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7621483/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7621483/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":92573888,"identity":"eb3d17f6-4ad5-495e-aff5-c67c08206c06","added_by":"auto","created_at":"2025-10-01 08:09:37","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":7021747,"visible":true,"origin":"","legend":"","description":"","filename":"TransoralApproachwithReversePedicleScrew.docx","url":"https://assets-eu.researchsquare.com/files/rs-7621483/v1/a5c38dc7b93f4e7fba01d836.docx"},{"id":92573876,"identity":"c96b1cd2-a29a-43e5-a286-e1996d8ba418","added_by":"auto","created_at":"2025-10-01 08:09:37","extension":"json","order_by":1,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":8493,"visible":true,"origin":"","legend":"","description":"","filename":"caec64e003314578b3d927986ba4a553.json","url":"https://assets-eu.researchsquare.com/files/rs-7621483/v1/bc226b75e318b67ca209d834.json"},{"id":92573883,"identity":"d769d71d-8f82-4120-8ff6-69f7ade644a6","added_by":"auto","created_at":"2025-10-01 08:09:37","extension":"xml","order_by":2,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":68504,"visible":true,"origin":"","legend":"","description":"","filename":"caec64e003314578b3d927986ba4a5531enriched.xml","url":"https://assets-eu.researchsquare.com/files/rs-7621483/v1/b34c480bfcd74619e648f467.xml"},{"id":92573886,"identity":"58055576-e005-4b47-bebe-30f417ef8e92","added_by":"auto","created_at":"2025-10-01 08:09:37","extension":"jpeg","order_by":3,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":1917518,"visible":true,"origin":"","legend":"","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7621483/v1/25040aa1c7b7e6edd55ca27d.jpeg"},{"id":92575034,"identity":"7e4d9a98-140d-4ebc-900f-5d42dc8bd1ae","added_by":"auto","created_at":"2025-10-01 08:17:37","extension":"jpeg","order_by":4,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":4609762,"visible":true,"origin":"","legend":"","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7621483/v1/32ee255266a4b8896bbe35ac.jpeg"},{"id":92576151,"identity":"4988d515-673e-4623-be9d-b95753dac9e4","added_by":"auto","created_at":"2025-10-01 08:25:37","extension":"jpeg","order_by":5,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":784694,"visible":true,"origin":"","legend":"","description":"","filename":"floatimage3.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7621483/v1/9679b23109ac120e843d365b.jpeg"},{"id":92573881,"identity":"75fd38e9-e275-43f2-a61c-f297162b45ef","added_by":"auto","created_at":"2025-10-01 08:09:37","extension":"jpeg","order_by":6,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":1214879,"visible":true,"origin":"","legend":"","description":"","filename":"floatimage4.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7621483/v1/b6d0356aec7c869cfbbab625.jpeg"},{"id":92573894,"identity":"a5c92ce1-115e-4227-b651-648716831020","added_by":"auto","created_at":"2025-10-01 08:09:37","extension":"jpeg","order_by":7,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":2040261,"visible":true,"origin":"","legend":"","description":"","filename":"floatimage5.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7621483/v1/5a45c08d0ccf1526216b593d.jpeg"},{"id":92573891,"identity":"e8879a2b-c8cb-4e2c-be17-9aa2dbba488d","added_by":"auto","created_at":"2025-10-01 08:09:37","extension":"jpeg","order_by":8,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":319747,"visible":true,"origin":"","legend":"","description":"","filename":"floatimage6.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7621483/v1/9dbfcff1b83622fa64bc9d18.jpeg"},{"id":92573899,"identity":"54d396dd-f658-4f6a-90c9-cf1fa2ac6191","added_by":"auto","created_at":"2025-10-01 08:09:37","extension":"jpeg","order_by":9,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":965720,"visible":true,"origin":"","legend":"","description":"","filename":"floatimage7.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7621483/v1/2b971ef5aa4b57d9c85b4c5a.jpeg"},{"id":92573889,"identity":"f8249dcd-37a1-427c-aa8e-34a18126f6d8","added_by":"auto","created_at":"2025-10-01 08:09:37","extension":"jpeg","order_by":10,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":611104,"visible":true,"origin":"","legend":"","description":"","filename":"floatimage8.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7621483/v1/a59abe4ecaf57c0325b0265a.jpeg"},{"id":92575037,"identity":"a6336819-7fa6-4c72-968e-f89251ddfc26","added_by":"auto","created_at":"2025-10-01 08:17:37","extension":"png","order_by":11,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":40535,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-7621483/v1/d82bed508c5013d0f65dc4ca.png"},{"id":92573900,"identity":"6263ada0-3182-478b-b4cc-0c594724da52","added_by":"auto","created_at":"2025-10-01 08:09:37","extension":"png","order_by":12,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":299595,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-7621483/v1/c55ec1b8ce3dc58f0a3c89ce.png"},{"id":92576152,"identity":"e02978ed-88bd-4749-abc8-a37f4a704ed1","added_by":"auto","created_at":"2025-10-01 08:25:37","extension":"png","order_by":13,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":166481,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-7621483/v1/3fd65a8af6b849b2ebaa6439.png"},{"id":92573897,"identity":"528d5534-35da-40ff-87a1-fd04b8788fcf","added_by":"auto","created_at":"2025-10-01 08:09:37","extension":"png","order_by":14,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":237283,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage4.png","url":"https://assets-eu.researchsquare.com/files/rs-7621483/v1/b5ad7b1f77cfaaab7c145d13.png"},{"id":92575040,"identity":"9118e94e-5b8a-4b50-806f-321af8dc87b4","added_by":"auto","created_at":"2025-10-01 08:17:37","extension":"png","order_by":15,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":569982,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage5.png","url":"https://assets-eu.researchsquare.com/files/rs-7621483/v1/dbc9fe7a3ddfa911fc6406ca.png"},{"id":92575039,"identity":"feeea02e-98b8-412d-b3f6-a095f2243026","added_by":"auto","created_at":"2025-10-01 08:17:37","extension":"png","order_by":16,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":71399,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage6.png","url":"https://assets-eu.researchsquare.com/files/rs-7621483/v1/1f8f1a370bcc0e75558a31c4.png"},{"id":92573901,"identity":"15475bea-8d63-4f0a-9cae-559ea124e54a","added_by":"auto","created_at":"2025-10-01 08:09:37","extension":"png","order_by":17,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":264072,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage7.png","url":"https://assets-eu.researchsquare.com/files/rs-7621483/v1/0a45bffa95d6c2d5fbbd9c3b.png"},{"id":92573898,"identity":"f6f6fbb1-adce-4240-a213-bb818ea6debc","added_by":"auto","created_at":"2025-10-01 08:09:37","extension":"png","order_by":18,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":119136,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage8.png","url":"https://assets-eu.researchsquare.com/files/rs-7621483/v1/c5eaf9d6bf30dcdc64858551.png"},{"id":92575035,"identity":"0c06b880-01c6-4a2b-837e-43b91c5980d7","added_by":"auto","created_at":"2025-10-01 08:17:37","extension":"xml","order_by":19,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":66815,"visible":true,"origin":"","legend":"","description":"","filename":"caec64e003314578b3d927986ba4a5531structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-7621483/v1/572b36a5d5d05568b1c934cc.xml"},{"id":92573903,"identity":"b7a29f95-276b-43bd-b8c4-1fc4ffa2761a","added_by":"auto","created_at":"2025-10-01 08:09:37","extension":"html","order_by":20,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":74304,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7621483/v1/f6fd1f3c78433b91133017c3.html"},{"id":92573878,"identity":"39e5d58c-24ef-443a-ae1d-0d85b553cc78","added_by":"auto","created_at":"2025-10-01 08:09:37","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":71213,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eImaging of a Prior Case Treated with a Standard Posterior Approach\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003ePostoperative imaging demonstrates exacerbated fracture displacement secondary to screw insertion (Fig 1C).\u003c/em\u003e\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7621483/v1/3148db8209e40d843df6bbda.jpg"},{"id":92573879,"identity":"1785bfb4-8e7f-477a-a92d-4330c584e8d2","added_by":"auto","created_at":"2025-10-01 08:09:37","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":180963,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003ePreoperative Imaging Demonstrating Anteriorly Displaced C2 Fracture\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eA–B: Initial CT scans at the time of injury; C–D: Cervical radiographs obtained 1 month post-injury; E–P: Imaging studies acquired during the current admission; E–F: Anteroposterior (AP) and lateral cervical radiographs; G–H: Flexion and extension cervical radiographs; I: Sagittal CT reconstruction revealing significant C2 anterior displacement and C2–C3 dislocation. J–L: Axial CT slices showing increased fracture displacement compared with initial imaging, with no evidence of fracture healing; M–P: Sagittal and axial MRI sequences demonstrating no spinal cord compression.\u003c/em\u003e\u003c/p\u003e","description":"","filename":"2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7621483/v1/f5d61db6d39231980381573d.jpg"},{"id":92575030,"identity":"951d614c-e195-4e4d-a7e1-743a835e8b59","added_by":"auto","created_at":"2025-10-01 08:17:37","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":130781,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003ePreoperative Computed Tomography Angiography (CTA) for Evaluating Transoral Approach-Related Risks.The course of the internal carotid artery (ICA) was unremarkable, confirming a relatively safe surgical corridor for the transoral approach.\u003c/em\u003e\u003c/p\u003e","description":"","filename":"3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7621483/v1/bd54d3aeebcb274547ec9dfd.jpg"},{"id":92575032,"identity":"1ed02a3d-cf1d-4ed0-95bb-643ed32d8ea6","added_by":"auto","created_at":"2025-10-01 08:17:37","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":172605,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eIntraoperative Details. A: Cortical bone compression screws utilized in the procedure; B: Intraoperative patient positioning; C: Preoperative three-dimensional (3D) anatomical model for surgical planning of screw trajectory; D–E: Intraoperative anteroposterior (AP) and lateral fluoroscopic images; F: Intraoperative photograph demonstrating satisfactory screw fixation.\u003c/em\u003e\u003c/p\u003e","description":"","filename":"4.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7621483/v1/8392a4b4b246b8a9016d07df.jpg"},{"id":92575031,"identity":"2bee695e-658c-4e99-9343-e05a5f0b5502","added_by":"auto","created_at":"2025-10-01 08:17:37","extension":"jpg","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":87183,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003ePostoperative Imaging at 1 Week. A–B: Axial CT views demonstrating optimal screw positioning; C–D: Sagittal CT reconstructions showing satisfactory fracture reduction and compression1-week postoperative imaging.\u003c/em\u003e\u003c/p\u003e","description":"","filename":"5.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7621483/v1/8e606e518c2894b937b76717.jpg"},{"id":92573885,"identity":"543aa71d-e842-454d-9a36-f95a26b4aba5","added_by":"auto","created_at":"2025-10-01 08:09:37","extension":"jpg","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":220456,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003e1-Month Postoperative Follow-Up Imaging. A–D: Anteroposterior (AP), lateral, flexion, and extension cervical radiographs; E–H: Sagittal CT views; I: Axial CT view demonstrating fracture line blurring.\u003c/em\u003e\u003c/p\u003e","description":"","filename":"6.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7621483/v1/913572ab41c6cbfb825f9257.jpg"},{"id":92575033,"identity":"b1dae5c9-2a42-40cc-a569-ed1247ce5f02","added_by":"auto","created_at":"2025-10-01 08:17:37","extension":"jpg","order_by":7,"title":"Figure 7","display":"","copyAsset":false,"role":"figure","size":209910,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003e3-Month Postoperative Follow-Up Imaging. A: Anteroposterior (AP) cervical radiograph; B–C: Flexion and extension cervical radiographs; D–H: CT scans demonstrating: Bony union of the right C2 pedicle fracture and blurring of the fracture line involving the left posterior C2 vertebral body\u003c/em\u003e\u003c/p\u003e","description":"","filename":"7.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7621483/v1/bb56f7091298b4d0da03dbb1.jpg"},{"id":93482103,"identity":"5fa0d95d-c278-4df2-9d2e-20e4878a2661","added_by":"auto","created_at":"2025-10-14 10:17:18","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1542724,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7621483/v1/1108318b-a32b-41bc-90c1-372a46adc302.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"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","fulltext":[{"header":"Background","content":"\u003cp\u003eHangman\u0026rsquo;s fracture (HF), or traumatic spondylolisthesis of the axis (TSA), was first described and termed by Schneider in 1965 [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. It involves fractures of the superior and inferior articular processes of the C2 vertebra, resulting from hyperextension, hyperflexion, and axial loading forces. These injuries are often accompanied by ligamentous and disc damage, leading to C2\u0026ndash;C3 instability. HF accounts for 23\u0026ndash;27% of all axis fractures. The management of HF is primarily guided by fracture classification, with the Levine-Edwards system being the most widely adopted [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].Unstable HF generally requires surgical intervention, though the optimal surgical approach remains controversial. Historically, posterior C2 pedicle screw fixation was considered the gold standard, as it enables direct fracture compression, anatomical reduction, and preservation of cervical motion [3]. However, this technique has notable limitations: open posterior dissection carries a risk of C2 nerve root irritation and venous plexus disruption, leading to high rates of persistent postoperative occipital neuralgia [4]. While navigation-assisted percutaneous screw placement may mitigate some risks, its accuracy is compromised in highly unstable fractures and may even exacerbate fracture displacement during screw insertion (Fig.\u0026nbsp;1) [5]. For patients with traumatic disc herniation causing spinal cord compression, Verheggen and Jansen advocated for C2\u0026ndash;3 anterior cervical discectomy and fusion (ACDF) [6]. ACDF allows direct disc excision and fusion via a natural anatomical plane, minimizing intraoperative blood loss [7]. However, it is associated with risks such as dysphagia and donor-site morbidity from autogenous iliac bone grafting [8]. Additionally, ACDF is ineffective for unstable axis fractures with pedicle displacement. To address these limitations\u0026mdash;while achieving anatomical fixation, avoiding posterior neurovascular complications, preserving C1\u0026ndash;3 motion, and reducing ACDF-related morbidity\u0026mdash;we employed a transoral reverse pedicle screw technique with cortical compression screws for a chronic Levine-Edwards Type III HF in April 2025. This report details the case and provides a review of relevant literature.\u003c/p\u003e"},{"header":"Case presentation","content":"\u003cp\u003e\u003cstrong\u003e1. General Information\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA 58-year-old male presented with neck pain and restricted range of motion 1 month after falling down a flight of stairs (from the second to the first floor) and landing on his right head. Immediately after the trauma, he developed severe neck pain and marked motion restriction. No loss of consciousness, limb sensory/motor deficits, perianal sensory loss, or bowel/bladder dysfunction was reported. Initial cervical CT at a local hospital revealed a C2 fracture (Fig 2A\u0026ndash;B). He was referred to an orthopedic specialist, who initiated conservative management with a cervical collar. One month later, cervical radiographs showed progressive fracture displacement (Fig 2C\u0026ndash;D). Persistent pain prompted further evaluation, leading to admission to our spine surgery department. The patient\u0026rsquo;s general health was good, with a history of chronic snoring. Physical examination revealed a mild antalgic gait while wearing the cervical collar. No obvious cervical deformity was noted; tenderness was present at the C2 spinous process and paraspinal regions (+). Upper limb sensation and tone were normal, with bilateral muscle strength graded 5/5. Upper limb reflexes were +++ on the left and ++ on the right, with a positive bilateral Hoffmann\u0026rsquo;s sign. Cervical CT with sagittal bone window reconstruction confirmed a fracture involving the posterior left C2 vertebral body and right C2 pedicle, accompanied by anterior C2 displacement and angulation. MRI demonstrated C2 fracture-dislocation and diffuse edema in the C2\u0026ndash;7 interspinous ligaments. The final diagnosis was Chronic Levine-Edwards Type III Hangman\u0026rsquo;s Fracture (Figs 2\u0026ndash;3).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2. Surgical Technique\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eGeneral anesthesia was administered, and the patient was placed in a supine position with the neck maintained in a fixed extended posture. The surgeon, positioned cephalad, prepared the oral cavity using povidone-iodine. A Codman retractor was used to achieve adequate exposure of the operative field. After confirming the C1\u0026ndash;2 anatomical location via C-arm fluoroscopy, a 20 mm midline longitudinal incision was made in the posterior pharyngeal wall. Prevertebral muscles were dissected using bipolar electrocautery to expose the anterior C2 vertebral body. A nerve dissector was used to expose a 7-mm segment of the odontoid base. The screw entry point was marked 6 mm caudal and 6 mm lateral to the medial border of the C2 lateral mass articulation. A 2.00-mm drill was used to create a cortical entry hole, angled 20\u0026deg; caudally and laterally. An awl was advanced 2.7 mm into the vertebral bone in a controlled manner. A guidewire was inserted, and its position was confirmed via C-arm fluoroscopy. The awl was then advanced further until a loss of resistance was appreciated. Two 40\u0026times;3.5 mm cortical bone compression screws were inserted sequentially. Clear tactile feedback confirmed fracture compression during screw tightening. C-arm fluoroscopy verified satisfactory fracture reduction and implant position. The naso-oropharynx was irrigated repeatedly with povidone-iodine. The muscular and mucosal layers were closed with absorbable sutures. The total duration of exposure and fixation was 1 hour, with intraoperative blood loss of 20 mL (Fig 4).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3. Postoperative Management\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe patient was intubated and monitored in the intensive care unit (ICU) for 24 hours, followed by successful extubation. Enteral nutrition was administered via a nasogastric tube for 7 days. Prophylactic anticoagulation, broad-spectrum antibiotics, and analgesics were prescribed. Cervical collar-assisted rehabilitation was initiated on postoperative day 2, and ambulation was started on day 3. The patient wore the cervical collar for 3 months, with instructions to avoid strenuous neck activities. Imaging obtained at 1 week postoperatively is shown in Fig 5.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e4. Follow-up\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFollow-up radiographs and CT scans at 1 and 3 months postoperatively showed progressive fracture healing (Figs 6\u0026ndash;7). The patient remained asymptomatic, with excellent functional outcomes.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eSchneider first described and termed “Hangman’s fracture” in 1965; this injury is also referred to as “axis ring fracture” or traumatic spondylolisthesis of the axis (TSA) [9]. It accounts for 4–7% of all spinal fractures and 20–22% of cervical fractures [10]. Effendi et al. proposed a classification system for HF in 1981 [11], which was later modified by Levine in 1985 into the widely used 4-type system based on injury mechanism [2]. Type I fractures are stable and managed non-operatively with a rigid cervical collar [12], while Types II, IIA, and III involve significant flexion forces leading to C2–C3 disc injury and require surgical stabilization [13]. Surgical options for unstable HF include posterior and anterior approaches. Posterior C2 pedicle screw fixation was once considered ideal for achieving anatomical reduction via screw thread compression while preserving motion. However, the inability to achieve bicortical fixation often limits effective compression and may exacerbate displacement (Fig 1). Type III fractures with C2–3 instability—particularly those involving the posterior inferior corner of C2 often require C2–3 fusion [2]. Open posterior surgery carries a risk of C2 nerve root irritation and venous plexus injury, which contribute to persistent postoperative neck pain [14–17]. While navigation can facilitate percutaneous screw placement, its accuracy is unreliable in highly unstable fractures [5]. Anteriorly, Verheggen and Jansen advocated for ACDF in HF patients with traumatic disc herniation causing spinal cord compression [6]. ACDF allows direct disc excision and fusion via an anatomical plane, with reduced intraoperative blood loss [18]. However, high cervical ACDF is associated with a risk of dysphagia, and autologous iliac bone grafting may cause donor-site morbidity [7]. Studies have shown that patients with HF treated with ACDF have significantly higher postoperative VAS scores compared to those undergoing posterior fixation [3]. Standalone C2 fracture fixation stabilizes the injury while preserving segmental motion. The transoral approach has been reported for the treatment of atlas fractures using screw-wire or plate systems [19, 20]. Posterior lag screws have been used for minimally displaced anterior C1 ring fractures and coronally split lateral mass fractures to prevent degenerative changes and displacement [21–25]. Kandziora et al. defined safe zones for C1/C2 screw insertion [26]. With advances in surgical techniques and instrumentation, the complication rate of transoral procedures has decreased [27–31]. However, a comprehensive literature search (CNKI, CMA, PubMed, Web of Science) revealed no prior reports of the transoral reverse pedicle screw technique for Levine-Edwards Type III chronic HF.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWe present a novel transoral reverse pedicle screw technique for this fracture type, with key advantages including minimal invasiveness (2-cm pharyngeal incision) and bicortical compression fixation via reverse pedicle screws——facilitating healing, preventing long-term sequelae, and preserving cervical motion. While conceptually promising, the clinical application of transoral reverse pedicle screws is in its early stages; only one report has described its use for unilateral atlas fracture fixation [32]. The present case represents the first successful application of this technique for an unstable axis fracture. Given the chronic nature of the fracture and the significant fracture gap, full-length bicortical compression screws (40 mm) were essential for achieving complete reduction (Fig 4A). Postoperative CT imaging clearly showed that the screw tips protruded 3 mm beyond the posterior margin of the C2 articular processes, confirming successful bicortical compression fixation. The posterior aspect of the C2 pedicle is covered by thick soft tissues, including the semispinalis cervicis muscle, inferior obliquus capitis muscle, and nuchal ligament. Imaging analysis revealed a soft tissue thickness of approximately 5 mm posterior to the pedicle in this patient, confirming that the 3-mm screw protrusion remained within safe limits. This innovative technique overcomes the limitations of isolated posterior or anterior approaches, establishing it as a promising solution for unstable axis fractures.\u003c/p\u003e\n\u003cp\u003eKey advantages of the transoral approach include minimal tissue disruption (facilitating faster exposure and reduced swelling), shorter postoperative intubation times, and a potentially lower infection risk compared to traditional transoral procedures. Compared to posterior transpedicular compression screw fixation, the anterior approach minimizes the risk of fracture fragment displacement during screw insertion—since the dense posterior musculoligamentous complex may act as a fulcrum. Furthermore, the relatively thin soft tissue envelope anterior to the C1–C2 complex poses a risk: excessively long bicortical screws placed posteriorly may breach the anterior pharyngeal wall, causing oropharyngeal contamination. Critically, the transoral anterior approach eliminates this concern, allowing surgeons to confidently select screws of sufficient length to achieve secure bicortical compression fixation without risking visceral injury.\u003c/p\u003e\n\u003cp\u003eSpecific perioperative risks must be considered. Studies indicate that approximately 4.2% of patients develop acute airway obstruction due to retropharyngeal edema, requiring delayed extubation [33]. More severe complications include retropharyngeal infection with tissue loss, which may necessitate complex reconstruction. Postoperative infection rates (4–7%) are comparable to those of other spinal surgeries when performed by experienced surgeons [34]. Notably, transoral procedures performed by experienced surgeons do not carry higher mortality or morbidity rates than other established spinal surgical approaches [33].\u003c/p\u003e\n\u003cp\u003eIn the present case, manual placement of the right pedicle screw adjacent to the laminar fracture failed to perfectly traverse the fracture line. While bilateral fixation controlled rotational instability and facilitated early (4-week) healing, this highlights the complexity of transoral upper cervical anatomy and the limitations of C-arm fluoroscopy. It underscores the need for enhanced intraoperative guidance——such as intraoperative CT and real-time navigation—to ensure precise screw placement.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe innovative transoral reverse pedicle screw fixation technique is an effective surgical option for chronic unstable axis fractures. In this case of Levine-Edwards Type III chronic Hangman\u0026rsquo;s fracture, the technique achieved anatomical reduction, bony fusion, and preservation of cervical motion.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eVAS \u0026nbsp; Visual analog scale\u003c/p\u003e\n\u003cp\u003eJOA \u0026nbsp; Japanese orthopaedic association\u003c/p\u003e\n\u003cp\u003eNDI \u0026nbsp; Neck disability index\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eHF \u0026nbsp; \u0026nbsp;Hangman\u0026rsquo;s fracture\u003c/p\u003e\n\u003cp\u003eTSA \u0026nbsp; Traumatic spondylolisthesis of the axis\u003c/p\u003e\n\u003cp\u003eACDF \u0026nbsp; Anterior cervical discectomy and fusion\u003c/p\u003e\n\u003cp\u003eICU \u0026nbsp; Intensive care unit\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis case report did not undergo formal ethics committee review. The patient identifiers have been removed from imaging and clinical data to ensure anonymity. Written informed consent for publication was obtained from the patient.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe patient gave informed written consent to the publication of personal or\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eclinical data and images in this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe materials used during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was supported by Tianjin Medical Key Disciplines (Specialist) Construction Project (TJYXZDXK-064B).\u003c/p\u003e\n\u003cp\u003eClinical Trial Number: not applicable.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eQingfeng Shen and Yingpeng Xia conceptualized the surgical design; Hua Wei drafted the manuscript; Xiaoming Tian processed and annotated the imaging data; Junwei Gao, Shibo Ma and Haifeng Song contributed to clinical data acquisition and analysis. All authors critically reviewed and approved the final manuscript for submission.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eSchneider RC, Livingston KE, Cave AJ, et al. \u0026ldquo;HANGMAN\u0026rsquo;S FRACTURE\u0026rdquo; OF THE CERVICAL SPINE. J Neurosurg 1965;22:141\u0026ndash;154; doi: 10.3171/jns.1965.22.2.0141.\u003c/li\u003e\n\u003cli\u003eLevine AM, Edwards CC. The management of traumatic spondylolisthesis of the axis. J Bone Joint Surg Am 1985;67(2):217\u0026ndash;226.\u003c/li\u003e\n\u003cli\u003eMahmoud A, Shanmuganathan K, Montgomery A. Surgical Management of Hangman\u0026rsquo;s Fracture: A Systematic Review. Int J Spine Surg 2023;17(3):454\u0026ndash;467; doi: 10.14444/8445.\u003c/li\u003e\n\u003cli\u003eLi G, Zhong D, Wang Q. A novel classification for atypical Hangman fractures and its application. Medicine (Baltimore) 2017;96(28):e7492; doi: 10.1097/MD.0000000000007492.\u003c/li\u003e\n\u003cli\u003eWang J, Miao J, Zhan Y, et al. Spine Surgical Robotics: Current Status and Recent Clinical Applications. Neurospine 2023;20(4):1256; doi: 10.14245/ns.2346610.305.\u003c/li\u003e\n\u003cli\u003eVerheggen R, Jansen J. Hangman\u0026rsquo;s fracture: arguments in favor of surgical therapy for type II and III according to Edwards and Levine. Surg Neurol 1998;49(3):253\u0026ndash;261; discussion 261-262; doi: 10.1016/s0090-3019(97)00300-5.\u003c/li\u003e\n\u003cli\u003eLi Z, Li F, Hou S, et al. Anterior discectomy/corpectomy and fusion with internal fixation for the treatment of unstable hangman\u0026rsquo;s fractures: a retrospective study of 38 cases. J Neurosurg Spine 2015;22(4):387\u0026ndash;393; doi: 10.3171/2014.11.SPINE13959.\u003c/li\u003e\n\u003cli\u003eJain V, Thakur MK, Thakur A, et al. Functional outcome in unstable Hangman\u0026rsquo;s fracture managed with anterior approach: A prospective study. J Craniovertebr Junction Spine 2017;8(4):350\u0026ndash;353; doi: 10.4103/jcvjs.JCVJS_113_17.\u003c/li\u003e\n\u003cli\u003eProst S, Barrey C, Blondel B, et al. Hangman\u0026rsquo;s fracture: Management strategy and healing rate in a prospective multi-centre observational study of 34 patients. Orthop Traumatol Surg Res 2019;105(4):703\u0026ndash;707; doi: 10.1016/j.otsr.2019.03.009.\u003c/li\u003e\n\u003cli\u003eScholz M, Kandziora F, Kobbe P, et al. Treatment of Axis Ring Fractures: Recommendations of the Spine Section of the German Society for Orthopaedics and Trauma (DGOU). Global Spine J 2018;8(2 Suppl):18S-24S; doi: 10.1177/2192568217745061.\u003c/li\u003e\n\u003cli\u003eEffendi B, Roy D, Cornish B, et al. Fractures of the ring of the axis. A classification based on the analysis of 131 cases. J Bone Joint Surg Br 1981;63-B(3):319\u0026ndash;327; doi: 10.1302/0301-620X.63B3.7263741.\u003c/li\u003e\n\u003cli\u003eTermansen NB. Hangman\u0026rsquo;s fracture. Acta Orthop Scand 1974;45(4):529\u0026ndash;539; doi: 10.3109/17453677408989176.\u003c/li\u003e\n\u003cli\u003eLi X-F, Dai L-Y, Lu H, et al. A systematic review of the management of hangman\u0026rsquo;s fractures. Eur Spine J 2006;15(3):257\u0026ndash;269; doi: 10.1007/s00586-005-0918-2.\u003c/li\u003e\n\u003cli\u003eHarms J, Melcher RP. Posterior C1-C2 fusion with polyaxial screw and rod fixation. Spine (Phila Pa 1976) 2001;26(22):2467\u0026ndash;2471; doi: 10.1097/00007632-200111150-00014.\u003c/li\u003e\n\u003cli\u003eBlagg SE, Don AS, Robertson PA. Anatomic Determination of Optimal Entry Point and Direction For C1 Lateral Mass Screw Placement. Clinical Spine Surgery 2009;22(4):233; doi: 10.1097/BSD.0b013e31817ff95a.\u003c/li\u003e\n\u003cli\u003eGunnarsson T, Massicotte EM, Govender PV, et al. The Use of C1 Lateral Mass Screws in Complex Cervical Spine Surgery: Indications, Techniques, and Outcome in a Prospective Consecutive Series of 25 Cases. Clinical Spine Surgery 2007;20(4):308; doi: 10.1097/01.bsd.0000211291.21766.4d.\u003c/li\u003e\n\u003cli\u003eRhee W-T, You S-H, Kim S-K, et al. Troublesome Occipital Neuralgia Developed by C1-C2 Harms Construct. J Korean Neurosurg Soc 2008;43(2):111\u0026ndash;113; doi: 10.3340/jkns.2008.43.2.111.\u003c/li\u003e\n\u003cli\u003eGe C, Hao D, He B, et al. Anterior cervical discectomy and fusion versus posterior fixation and fusion of C2-3 for unstable hangman\u0026rsquo;s fracture. J Spinal Disord Tech 2015;28(2):E61-66; doi: 10.1097/BSD.0000000000000150.\u003c/li\u003e\n\u003cli\u003eRuf M, Melcher R, Harms J. Transoral reduction and osteosynthesis C1 as a function-preserving option in the treatment of unstable Jefferson fractures. Spine (Phila Pa 1976) 2004;29(7):823\u0026ndash;827; doi: 10.1097/01.brs.0000116984.42466.7e.\u003c/li\u003e\n\u003cli\u003eKeskil S, G\u0026ouml;ksel M, Y\u0026uuml;ksel U. Transoral screw and wire fixation for unstable anterior \u0026frac12; atlas fracture. J Craniovertebr Junction Spine 2017;8(4):364\u0026ndash;368; doi: 10.4103/jcvjs.JCVJS_94_17.\u003c/li\u003e\n\u003cli\u003eKeskil S, G\u0026ouml;ksel M, Y\u0026uuml;ksel U. Unilateral lag-screw technique for an isolated anterior 1/4 atlas fracture. J Craniovertebr Junction Spine 2016;7(1):50\u0026ndash;54; doi: 10.4103/0974-8237.176625.\u003c/li\u003e\n\u003cli\u003eFelbaum DR, Stewart JJ, Suskin ZD, et al. Unilateral C1 Sagittal Split Fractures: An Unusual Entity Revisited. World Neurosurg 2018;109:263\u0026ndash;270; doi: 10.1016/j.wneu.2017.09.206.\u003c/li\u003e\n\u003cli\u003eMinardi M, Narducci A, Vercelli GG, et al. Lag screws for reduction of bilateral lateral mass fractures due to spinal trauma. Brain Spine 2022;2:100877; doi: 10.1016/j.bas.2022.100877.\u003c/li\u003e\n\u003cli\u003eTabbosha M, Dowdy J, Pait TG. Placement of unilateral lag screw through the lateral mass of C-1: description of a novel technique. J Neurosurg Spine 2013;19(1):128\u0026ndash;132; doi: 10.3171/2013.4.SPINE12826.\u003c/li\u003e\n\u003cli\u003eLakshmanan P, Jones A, Howes J, et al. CT evaluation of the pattern of odontoid fractures in the elderly--relationship to upper cervical spine osteoarthritis. Eur Spine J 2005;14(1):78\u0026ndash;83; doi: 10.1007/s00586-004-0743-z.\u003c/li\u003e\n\u003cli\u003eKandziora F, Schulze-Stahl N, Khodadadyan-Klostermann C, et al. Screw placement in transoral atlantoaxial plate systems: an anatomical study. J Neurosurg 2001;95(1 Suppl):80\u0026ndash;87; doi: 10.3171/spi.2001.95.1.0080.\u003c/li\u003e\n\u003cli\u003eApuzzo ML, Weiss MH, Heiden JS. Transoral exposure of the atlantoaxial region. Neurosurgery 1978;3(2):201\u0026ndash;207; doi: 10.1227/00006123-197809000-00012.\u003c/li\u003e\n\u003cli\u003eCrockard HA. The transoral approach to the base of the brain and upper cervical cord. Ann R Coll Surg Engl 1985;67(5):321\u0026ndash;325.\u003c/li\u003e\n\u003cli\u003eDickman CA, Locantro J, Fessler RG. The influence of transoral odontoid resection on stability of the craniovertebral junction. J Neurosurg 1992;77(4):525\u0026ndash;530; doi: 10.3171/jns.1992.77.4.0525.\u003c/li\u003e\n\u003cli\u003eMenezes AH, VanGilder JC. Transoral-transpharyngeal approach to the anterior craniocervical junction. Ten-year experience with 72 patients. J Neurosurg 1988;69(6):895\u0026ndash;903; doi: 10.3171/jns.1988.69.6.0895.\u003c/li\u003e\n\u003cli\u003eTuite GF, Veres R, Crockard HA, et al. Pediatric transoral surgery: indications, complications, and long-term outcome. J Neurosurg 1996;84(4):573\u0026ndash;583; doi: 10.3171/jns.1996.84.4.0573.\u003c/li\u003e\n\u003cli\u003eTinner C, Aregger FC, Deml MC. Transoral unilateral lag screw osteosynthesis for coronal split fracture of the lateral mass of the atlas \u0026ndash; case report, operative technique and review of the literature. Brain Spine 2023;3:101761; doi: 10.1016/j.bas.2023.101761.\u003c/li\u003e\n\u003cli\u003eAmelot A, Terrier L-M, Lot G. Craniovertebral Junction Transoral Approach: Predictive Factors of Complications. World Neurosurg 2018;110:568\u0026ndash;574; doi: 10.1016/j.wneu.2017.09.135.\u003c/li\u003e\n\u003cli\u003eBalabaud L, Pitel S, Caux I, et al. Lumbar spine surgery in patients 80 years of age or older: morbidity and mortality. Eur J Orthop Surg Traumatol 2015;25 Suppl 1:S205-212; doi: 10.1007/s00590-014-1556-3.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Transoral, Pedicle screw, Hangman’s fracture, C2 vertebra, Axis","lastPublishedDoi":"10.21203/rs.3.rs-7621483/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7621483/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis report navigated transoral anterior pedicle screw technique achieved secure fixation for unstable hangman's fracture. It circumvented posterior approach risks and anterior contamination concerns. This offers a paradigm for complex cases where posterior fixation is unsuitable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCase presentation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe report a 58-year-old male presenting with a C2 vertebral body fracture, right C2 pedicle fracture, and concurrent C2/3 disc injury, which manifested as a chronic fracture (4 weeks post-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 hours 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 (VAS) score decreased from 4 (preoperatively) to 0 (1 week postoperatively), the Japanese Orthopaedic Association (JOA) score improved from 11 to 16, and the Neck Disability Index (NDI) decreased from 28% to 6%. Following-up CT imaging demonstrated satisfactory fusion.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe minimally invasive transoral approach combined with reverse pedicle screw fixation is an effective surgical option for treating Levine-Edwards Type III chronic Hangman’s fracture. This study provides a reference for optimizing surgical strategies in the management of upper cervical trauma.\u003c/p\u003e","manuscriptTitle":"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","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-01 08:09:32","doi":"10.21203/rs.3.rs-7621483/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"563a3c58-2201-4fb4-ad39-d9b19ca21a5c","owner":[],"postedDate":"October 1st, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-10-14T10:09:09+00:00","versionOfRecord":[],"versionCreatedAt":"2025-10-01 08:09:32","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7621483","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7621483","identity":"rs-7621483","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}