Levine and Edwards Classification

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Synonyms
Modified Effendi classification

The Levine and Edwards classification was published in 19851 and modifies Effendi's original classification of Hangman fractures2; it is therefore also referred to as the modified Effendi classification3:

Type Description Fracture Morphology Comment
Type I Vertical fracture through the pars directly posterior to the C2 vertebral body ≤ 3mm subluxation of C2 on C3. <br /> No angulation Stable <br /> Neurological deficits are rare
Type II Type I + disruption of the C2/C3 disco-ligamentous complex > 3 mm subluxation of C2 on C3 <br /> ± angulation Reduction by traction <br /> Can often be treated with rigid immobilization if closed reduction can be achieved.
Type IIa Oblique fracture through the pars with disruption of the disco-ligamentous complex but an intact anterior longitudinal ligament Minimal subluxation < 3 mm <br /> Significant angulation (often > 15°) Unstable <br /> Traction should not be attempted if widening of the disc space is present
Type III Type II + bilateral C2/C3 facet joint disruption Subluxation or locking of the C2/C3 facet joints <br /> ± subluxation of C2 on C3 <br /> ± angulation <br /> Mechanism associated with flexion and compression Unstable <br /> Neurological deficits are more common <br /> Traction should not be attempted <br /> Requires posterior surgical stabilization

References

    1. Levine AM, Edwards CC. The Management of Traumatic Spondylolisthesis of the Axis. J Bone Joint Surg. 1985;67A:217-226. ↩ ↩

    2. 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. 1981;63B:319-327. ↩ ↩

    3. Neurosurgery Case Review: Questions and Answers. Remi Nader, Abdulrahman J Sabbagh. 2020 Thieme Verlage. ISBN 9781626231986 ↩ ↩

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    • Text changed: “The Levine and Edwards classification was published in 1985[^1] and modifies Effendi’s original classification of Hangman fractures[^2]; it is therefore also referred to as the modified Effendi classification[^3]:”“The Levine and Edwards classification was published in 1985[^1] and modifies Effendi's original classification of Hangman fractures[^2]; it is therefore also referred to as the modified Effendi classification[^3]:”
    • Text changed: “| Type | Description | Fracture morphology | Comment | | --- | ------------ | --------------------- | --------- | | Type I | Vertical fracture through the pars directly posterior to the C2 vertebral body | ≤ 3 mm subluxation of C2 on C3. <br \/> No angulation | Stable <br \/> Neurological deficits are rare | | Type II | Type I + disruption of the C2\/C3 discoligamentous complex | > 3 mm subluxation of C2 on C3 <br \/> ± angulation | Reduction by traction <br \/> Can often be treated with rigid immobilization if closed reduction can be achieved. | | Type IIa | Oblique fracture through the pars with disruption of the discoligamentous complex but an intact anterior longitudinal ligament | Minimal subluxation < 3 mm <br \/> Significant angulation (often > 15°) | Unstable <br \/> Traction should not be attempted if widening of the disc space is present | | Type III | Type II + bilateral C2\/C3 facet disruption | Subluxation or locking of the C2\/C3 facet joints <br \/> ± subluxation of C2 on C3 <br \/> ± angulation <br \/> Mechanism associated with flexion and compression | Unstable <br \/> Neurological deficits are more common <br \/> Traction should not be attempted <br \/> Requires posterior surgical stabilization |”“| Type | Description | Fracture Morphology | Comment | | --- | ------------ | --------------------- | --------- | | Type I | Vertical fracture through the pars directly posterior to the C2 vertebral body | ≤ 3mm subluxation of C2 on C3. <br \/> No angulation | Stable <br \/> Neurological deficits are rare | | Type II | Type I + disruption of the C2\/C3 disco-ligamentous complex | > 3 mm subluxation of C2 on C3 <br \/> ± angulation | Reduction by traction <br \/> Can often be treated with rigid immobilization if closed reduction can be achieved. | | Type IIa | Oblique fracture through the pars with disruption of the disco-ligamentous complex but an intact anterior longitudinal ligament | Minimal subluxation < 3 mm <br \/> Significant angulation (often > 15°) | Unstable <br \/> Traction should not be attempted if widening of the disc space is present | | Type III | Type II + bilateral C2\/C3 facet joint disruption | Subluxation or locking of the C2\/C3 facet joints <br \/> ± subluxation of C2 on C3 <br \/> ± angulation <br \/> Mechanism associated with flexion and compression | Unstable <br \/> Neurological deficits are more common <br \/> Traction should not be attempted <br \/> Requires posterior surgical stabilization |”
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