You will be presented with the full text of a biomedical research paper. Please write an abstract for this paper. Your response should include the abstract and no additional text.

Paper text:
it includes nonoperative management with traction followed by immobilization in halo vest or somi brace or operative management in the form of posterior fixation with c2 pedicle screw only or c2-c3 fusion with c2 pedicle and c3 lateral mass screw and c2-c3 anterior fusion .
however , when untreated it poses a complicated problem . the surgical management of untreated hangman fracture in not reported in literature .
we report the surgical management of untreated hangman 's fracture in a 30-year - old male who reported to us 12 weeks following injury .
a 30-year - old man , manual laborer by occupation had fallen from 20 feet height .
he had acute pain in the neck and took treatment in the form of over the counter medication .
on presentation to the opd , he was having tenderness on the upper cervical spine and severe limitation of cervical spine movements in all directions .
he had spasticity and exaggerated deep tendon reflexes in all 4 extremities , however the muscle power and sensation were normal .
radiograph revealed a type iia hangman fracture ( levine and edward modification of effendi classification ) with localized c2-c3 kyphosis of 33 [ figure 1 ] .
computed tomography ( ct ) scan revealed fracture of pars interarticularis of c2 with spondylolisthesis of c2 over c3 .
magnetic resonance imaging revealed the compression of epidural space posterior to c3 with intensity changes in the odontoid process [ figure 3 ] .
after the application of gardner - wells tongs , gentle reduction maneuver was attempted ; however the reduction could not be achieved .
. grade iii spondylolisthesis of c2 over c3 with localized kyphosis of 33 dynamic x rays showing absence of any significant c2-c3 mobility magnetic resonance imaging showing edema of odontoid process with compression of epidural sac posterior to c3 
 stage 1 : with patient in supine position , anterior exposure was done using smith - robinson approach .
wound was closed in layers.stage 2 : following anterior release and c2-c3 discectomy , gradual extension resulted in improved c2-c3 alignment .
patient was then carefully turned to prone position and posterior midline exposure was carried out .
further reduction was carried out by using a well - contoured rod pulling the c2 posteriorly .
autologous posterior iliac crest bone grafting was done and wound closed in layers over a drain.stage 3 : patient was again placed in supine position and c2 and c3 bodies were exposed via the previous incision .
c2-c3 anterior fusion was done using tri - cortical iliac crest bone graft and stabilization was carried out with the anterior cervical plate .
stage 1 : with patient in supine position , anterior exposure was done using smith - robinson approach .
stage 2 : following anterior release and c2-c3 discectomy , gradual extension resulted in improved c2-c3 alignment .
patient was then carefully turned to prone position and posterior midline exposure was carried out .
further reduction was carried out by using a well - contoured rod pulling the c2 posteriorly .
autologous posterior iliac crest bone grafting was done and wound closed in layers over a drain .
stage 3 : patient was again placed in supine position and c2 and c3 bodies were exposed via the previous incision .
c2-c3 anterior fusion was done using tri - cortical iliac crest bone graft and stabilization was carried out with the anterior cervical plate .
anterior c2-c3 union was noted at 5 months postoperative and confirmed with x - ray [ figure 4 ] and ct scan [ figure 5 ] , following which brace was discontinued . at 18 months postoperative , the patient had normal neurological examination and had resumed his pretrauma occupation .
x - ray at 5 months showing acceptable c2-c3 alignment with c2-c3 anterior fusion computed tomography scan at 18 months showing solid c2-c3 interbody fusion
neglected spinal injuries , either secondary to overlooked diagnosis or due to the circumstantial and socioeconomic factors , are not uncommon but discussed infrequently in the literature .
management of cervical dislocations is challenging when it is delayed by more than 3 weeks .
formation of fibro cartilaginous tissue around facet joints and contracture of anterior supporting ligament , muscles , and disc make closed reduction extremely difficult and sometimes hazardous .
the management of neglected subaxial cervical spine dislocation has been discussed in literature and varying approaches have been suggested .
these are posterior release followed by anterior fusion , anterior release followed by posterior fixation and posterior release followed by anterior discectomy , and fusion followed by posterior fixation .
the management of neglected type 2a hangman 's fracture poses unique problems and guideline for the treatment of neglected subaxial cervical spine dislocation can not be applied .
preoperative traction was contraindicated in our case as being a type iia hangman fracture which is a flexion distraction injury , damage to annulus and posterior longitudinal ligament is expected and traction can lead to injury to the spinal cord or nerve roots .
moreover , traction on the newly formed fibro cartilaginous tissue within the canal between fractured pars and remaining posterior elements , may lead to kinking and worsening of neurological deficit . due to these reasons , preoperative traction was avoided .
liu et al . , srivastava et al . and jain et al . reported satisfactory results by a two - staged procedure consisting of posterior release and partial facetectomy followed by for anterior discectomy and fusion , for neglected subaxial dislocations . in our case , since the c2-c3 facet was already aligned , release of contracted anterior structures and c2-c3 discectomy is to be the logical first step .
this ensures feasibility of reduction and neural protection by preventing retropulsion of c2-c3 disc during reduction . in stage
ii , posterior fixation is to be done as putting implant on the tensile ( posterior ) surface provides a biomechanically sound construct . following reduction and posterior instrumentation , anterior void in c2-c3 disc space
the satisfactory outcome in our patient leads us to believe that anterior - posterior - anterior is the appropriate surgical approach for the treatment of such patients .
acute management of hangman fracture is well described ; however the surgical management of neglected hangman fracture has not been described in literature . 
 we report the surgical management of an untreated hangman 's fracture . 
 a 30-year - old male had fallen from a tree 12 weeks back . 
 patient presented with cervical myelopathy and restricted neck movements . 
 radiographs and computed tomography ( ct ) scan revealed fracture of pars interarticularis of axis with grade iii c2-c3 spondylolisthesis with localized kyphosis of 33. gentle reduction under general anesthesia ( ga ) failed to improve the alignment . 
 patient was operated in three stages in a single setting . in stage 
 i , release of contracted anterior structures and c2-c3 discectomy was done in supine position followed by c2-c3 posterior fixation and fusion in stage ii . 
 c2-c3 
 interbody bone grafting and anterior plating completed the third stage . 
 c2-c3 interbody fusion was seen at 5 months and a ct scan at 18 months postoperative confirmed fusion and maintenance of alignment . 
 the satisfactory outcome in our patient leads us to believe that anterior - posterior - anterior is the appropriate surgical approach for treatment of such patients .