Halo, Collar, Anterior, or Posterior Fusion? Comparative Outcomes in Typical and Atypical Hangman's Fractures: A Systematic Review of Fusion Rate and Complication Profile

STUDY DESIGN: Systematic review. OBJECTIVE: Hangman's fracture, a traumatic spondylolisthesis of the C2 vertebra, represents a significant challenge in cervical spine management because of its complex anatomy and biomechanical considerations. Management strategies range from nonsurgical immobilization (rigid collar, halo vest) to surgical stabilization (anterior cervical discectomy and fusion [ACDF], posterior fusion, or combination of both anterior and posterior approaches). This systematic review evaluates fusion rates and complication profiles associated with collar, halo, ACDF, and posterior fusion in typical and atypical Hangman's fractures. METHODS: We systematically searched PubMed, Ovid Medline, Scopus, and Google Scholar for peer-reviewed studies up to June 2025. Eligible studies included patients with typical or atypical Hangman's fractures managed surgically or conservatively. Quality was assessed using National Institutes of Health and Joanna Briggs Institute tools. RESULTS: Fifty-two studies (1101 patients, mean age 41.6 years, range 7-94 years) were included. Nonsurgical treatments (collar, halo) achieved high union rates, although the use of halo required prolonged immobilization and was associated with pin-site infections. ACDF (primarily C2-C3 with plating) and posterior fusion demonstrated comparable fusion success. ACDF was associated with dysphagia, aspiration pneumonia, and hoarseness, whereas posterior fusion carried greater risks of hardware loosening, screw-related complications, infection, and greater intraoperative blood loss. In atypical fractures (123 patients), all approaches achieved fusion, though recovery duration varied. CONCLUSIONS: Although fusion is achievable with all approaches, failure rates exist particularly in posterior fusion for atypical Hangman's fractures. Complication patterns also vary between anterior and posterior techniques. No single method is universally superior; treatment should be tailored to fracture type, patient factors, and surgeon expertise. Prospective multicenter trials are needed to refine surgical indications and long-term outcomes.