Advantages of Posterior Harms-Goel C1C3 Fixation over Anterior C2C3 Discectomy and Fusion with Plate and Screws for Highly Unstable Hangman's Fracture: Time to Close the Debate?

We read with interest Sonawane et al.'s 1) study on the surgical management of Hangman fracture of the upper cervical spine using the anterior approach.The authors address the issue of patients suffering from Levine-Edwards type 2 or 2a subacute Hangman fractures of C2, left untreated for at least 3 weeks before referral.They report their experience treating five such cases using solely C2C3 anterior discectomy and fusion with iliac crest bone graft, plate, and screws.Although we congratulate the authors for their fortunate results with this patient series, we have a few concerns regarding surgical considerations, postoperative management, and the generalization of this technique to all unstable cases of Hangman's fracture.