Atlantoaxial Fusion Using C1 Sublaminar Cables and C2 Translaminar Screws

2017 ◽  
Vol 14 (6) ◽  
pp. 647-653 ◽  
Author(s):  
Alexandra M Giantini Larsen ◽  
Benjamin L Grannan ◽  
Robert M Koffie ◽  
Jean-Valéry Coumans
Keyword(s):  
Vertebral Artery ◽  
Nerve Root ◽  
Limited Range ◽  
Atlantoaxial Instability ◽  
Posterior Arch ◽  
Hardware Failure ◽  
Risk Of Injury ◽  
Limited Range Of Motion ◽  
C2 Nerve Root ◽  
Translaminar Screws

Abstract BACKGROUND Atlantoaxial instability, which can arise in the setting of trauma, degenerative diseases, and neoplasm, is often managed surgically with C1–C2 arthrodesis. Classical C1–C2 fusion techniques require placement of instrumentation in close proximity to the vertebral artery and C2 nerve root. OBJECTIVE To report a novel C1–C2 fusion technique that utilizes C2 translaminar screws and C1 sublaminar cables to decrease the risk of injury to the vertebral artery and C2 nerve root. METHODS To facilitate fixation to the atlas, while minimizing the risk of injury to the vertebral artery and to the C2 nerve root, we sought to determine the feasibility of using a soft cable around the C1 arch and affixing it to a rod connected to C2 laminar screws. We reviewed our experience in 3 patients. RESULTS We used this technique in patients in whom we anticipated difficult C1 screw placement. Three patients were identified through a review of the senior author's cases. Atlantoaxial instability was associated with trauma in 2 patients and chronic degenerative changes in 1 patient. Common symptoms on presentation included pain and limited range of motion. All patients underwent C1–C2 fusion with C2 translaminar screws with sublaminar cable harnessing of the posterior arch of C1. There were no reports of postoperative complications or hardware failure. CONCLUSION We demonstrate a novel, technically straightforward approach for C1–C2 fusion that minimizes risk to the vertebral artery and to the C2 nerve root, while still allowing for semirigid fixation in instances of both traumatic and chronic degenerative atlantoaxial instability.

Bow Hunter's Syndrome: Complete Microsurgical Decompression of Vertebral Artery by Far Lateral Retrocondylar Approach: 3-Dimensional Operative Video

2019 ◽  
Author(s):  
Qazi Zeeshan ◽  
Juan P Carrasco Hernandez ◽  
Laligam N Sekhar
Keyword(s):  
Vertebral Artery ◽  
Nerve Root ◽  
Dynamic Compression ◽  
Skin Incision ◽  
Left Vertebral Artery ◽  
Occipital Condyle ◽  
Cerebral Angiogram ◽  
Microsurgical Decompression ◽  
C2 Nerve Root ◽  
The Right

Abstract This 50-yr-old man had a 15-yr history of presyncopal episodes that were precipitated by turning his head to the right, and had worsened recently. Cerebral angiogram demonstrated complete cessation of anterograde flow in left vertebral artery (VA) at the level of the C1 sulcus arteriosus while turning head to right, indicating dynamic compression at the C1 level.  Patient underwent left extreme lateral retrocondylar approach, partial C1 laminectomy and opening of the C1 foramen with complete microsurgical decompression of the VA. After skin incision, meticulous muscle dissection was performed and superior and inferior oblique muscles were disconnected from the tubercle of C1. The VA was exposed, and three areas of constriction were visible, first at the atlanto-occipital membrane laterally; second, located more medially as the artery curved around the occipital condyle to enter the posterior fossa; and third, located anterior to C2 nerve root. The artery was dissected from all the surrounding tissues, preserving the C2 nerve root, and the Cl foramen was opened completely. The Cl lamina was also partially resected and grooved to allow free placement of the VA. The VA was also decompressed near the C2 foramen. Postoperative computed tomography angiogram of the head and neck showed complete decompression of VA. The patient had no episodes of presyncope or dizziness while turning head to right and his mRs was 0 at 8 mo follow up.  This 3D video shows the technical nuances of decompression of V3 segment of VA in bow hunters's syndrome.  Informed consent was obtained from the patient prior to the surgery that included videotaping of the procedure and its distribution for educational purposes. All relevant patient identifiers have also been removed from the video and accompanying radiology slides.

Translaminar rigid screw fixation of the axis

2005 ◽  
Vol 3 (5) ◽  
pp. 409-414 ◽  
Author(s):  
Neill M. Wright
Keyword(s):  
At Risk ◽  
Vertebral Artery ◽  
Screw Fixation ◽  
Vascular Complications ◽  
Pedicle Screws ◽  
Rigid Fixation ◽  
Content Type ◽  
Risk Of Injury ◽  
Translaminar Screws ◽  
Fine Print

✓ Rigid fixation of the axis with C1–2 transarticular screws or C-2 pedicle screws results in high fusion rates but remains technically demanding because of the risk of injury to the vertebral artery (VA) and the limitations imposed by anatomical variability. Translaminar fixation of the axis with crossing bilateral screws provides rigid fixation and is technically simple, is not affected by variations in individual anatomy, and does not place the VA at risk. The longterm results in 20 patients treated with translaminar fixation for craniocervical, atlantoaxial, and axial—subaxial instability are presented, with 100% fusion rates and no neurological or vascular complications. Translaminar screws may be a good option for rigid fixation of the axis for surgeons not proficient in the more technically demanding methods of stabilization.

Supplementation of Screw-Rod C1-C2 Fixation With Posterior Arch Femoral Head Allograft Strut

2020 ◽  
Author(s):  
David D Liu ◽  
Kendall Rivera-Lane ◽  
Owen P Leary ◽  
Nathan J Pertsch ◽  
Tianyi Niu ◽  
...  
Keyword(s):  
Femoral Head ◽  
Intraoperative Complications ◽  
Spinous Process ◽  
Atlantoaxial Instability ◽  
Posterior Arch ◽  
Sublaminar Wiring ◽  
Fixation Techniques ◽  
C2 Nerve Root ◽  
Dural Tears ◽  
C2 Fixation

Abstract BACKGROUND Numerous C1-C2 fixation techniques exist for the treatment of atlantoaxial instability. Limitations of screw-rod and sublaminar wiring techniques include C2 nerve root sacrifice and dural injury, respectively. We present a novel technique that utilizes a femoral head allograft cut with a keyhole that rests posteriorly on the arches of C1 and C2 and straddles the C2 spinous process, secured by sutures. OBJECTIVE To offer increased fusion across C1-C2 without the passage of sublaminar wiring or interarticular arthrodesis. METHODS A total of 6 patients with atlantoaxial instability underwent C1-C2 fixation using our method from 2015 to 2016. After placement of a C1-C2 screw/rod construct, a cadaveric frozen femoral head allograft was cut into a half-dome with a keyhole and placed over the already decorticated dorsal C1 arch and C2 spinous process. Notches were created in the graft and sutures were placed in the notches and around the rods to secure it firmly in place. RESULTS The femoral head's shape allowed for creation of a graft that provides excellent surface area for fusion across C1-C2. There were no intraoperative complications, including dural tears. Postoperatively, no patients had sensorimotor deficits, pain, or occipital neuralgia. 5 patients demonstrated clinical resolution of symptoms by 3 mo and radiographic (computed tomography) evidence of fusion at 1 yr. One patient had good follow-up at 1 mo but died due to complications of Alzheimer disease. CONCLUSION The posterior arch femoral head allograft strut technique with securing sutures is a viable option for supplementing screw-rod fixation in the treatment of complex atlantoaxial instability.

Morphometric Anatomy of the Posterior Aspect of the Atlas and the Vertebral Artery Groove in Relation to Lateral Mass Screw Placement

2021 ◽  
Author(s):  
Selda Aksoy ◽  
Bulent Yalcin
Keyword(s):  
Vertebral Artery ◽  
Screw Placement ◽  
Atlantoaxial Instability ◽  
Posterior Arch ◽  
Lateral Mass ◽  
Lateral Mass Screw ◽  
Entry Zone ◽  
Mean Width ◽  
The Mean ◽  
The Right

Abstract Background Atlantoaxial instability is an important disorder that causes serious symptoms such as difficulties in walking, limited neck mobility, sensory deficits, etc. Atlantal lateral mass screw fixation is a surgical technique that has gained important recognition and popularity. Because accurate drilling area for screw placement is of utmost importance for a successful surgery, we aimed to investigate morphometry of especially the posterior part of C1. Methods One hundred and fifty-eight human adult C1 dried vertebrae were obtained. Measurements were performed directly on dry atlas vertebrae, and all parameters were measured by using a digital caliper accurate to 0.01 mm for linear measurements. Results The mean distance between the tip of the posterior arch and the medial inner edge of the groove was found to be 10.59 ± 2.26 and 10.49 ± 2.20 mm on the right and left, respectively. The mean distance between the tip of the posterior arch and the anterolateral outer edge of the groove was 21.27 ± 2.28 mm (right: 20.96 ± 2.22 mm; left: 21.32 ± 2.27 mm). The mean height of the screw entry zone on the right and left sides, respectively, were 3.86 ± 0.81 and 3.84 ± 0.77 mm. The mean width of the screw entry zone on both sides was 13.15 ± 1.17 and 13.25 ± 1.3 mm. Conclusion Our result provided the literature with a detailed database for the morphometry of C1, especially in relation to the vertebral artery groove. We believe that the data in the present study can help surgeons to adopt a more accurate approach in terms of accurate lateral mass screw placement in atlantoaxial instability.

scholarly journals Posterior arch C-1 screw technique: a cadaveric comparison study

2017 ◽  
Vol 26 (6) ◽  
pp. 679-683 ◽  
Author(s):  
Marc Moisi ◽  
Christian Fisahn ◽  
Lara Tkachenko ◽  
Shiveindra Jeyamohan ◽  
Stephen Reintjes ◽  
...  
Keyword(s):  
Vertebral Artery ◽  
Nerve Root ◽  
Access Point ◽  
Screw Placement ◽  
Posterior Arch ◽  
Lateral Mass ◽  
Entry Site ◽  
Starting Point ◽  
The Right

OBJECTIVEPosterior atlantoaxial stabilization and fusion using C-1 lateral mass screw fixation has become commonly used in the treatment of instability and for reconstructive indications since its introduction by Goel and Laheri in 1994 and modification by Harms in 2001. Placement of such lateral mass screws can be challenging because of the proximity to the spinal cord, vertebral artery, an extensive venous plexus, and the C-2 nerve root, which overlies the designated starting point on the posterior center of the lateral mass. An alternative posterior access point starting on the posterior arch of C-1 could provide a C-2 nerve root–sparing starting point for screw placement, with the potential benefit of greater directional control and simpler trajectory. The authors present a cadaveric study comparing an alternative strategy (i.e., a C-1 screw with a posterior arch starting point) to the conventional strategy (i.e., using the lower lateral mass entry site), specifically assessing the safety of screw placement to preserve the C-2 nerve root.METHODSFive US-trained spine fellows instrumented 17 fresh human cadaveric heads using the Goel/Harms C-1 lateral mass (GHLM) technique on the left and the posterior arch lateral mass (PALM) technique on the right, under fluoroscopic guidance. After screw placement, a CT scan was obtained on each specimen to assess for radiographic screw placement accuracy. Four faculty spine surgeons, blinded to the surgeon who instrumented the cadaver, independently graded the quality of screw placement using a modified Upendra classification.RESULTSOf the 17 specimens, the C-2 nerve root was anatomically impinged in 13 (76.5%) of the specimens. The GHLM technique was graded Type 1 or 2, which is considered “acceptable,” in 12 specimens (70.6%), and graded Type 3 or 4 (“unacceptable”) in 5 specimens (29.4%). In contrast, the PALM technique had 17 (100%) of 17 graded Type 1 or 2 (p = 0.015). There were no vertebral artery injuries found in either technique. All screw violations occurred in the medial direction.CONCLUSIONSThe PALM technique showed statistically fewer medial penetrations than the GHLM technique in this study. The reason for this is not clear, but may stem from a more angulated ”up-and-in” screw direction necessary with a lower starting point.

Rotational vertebral artery occlusion from occipital bone anomaly: a rare cause of embolic stroke

2002 ◽  
Vol 97 (6) ◽  
pp. 1456-1459 ◽  
Author(s):  
Teiji Tominaga ◽  
Toshiyuki Takahashi ◽  
Hiroaki Shimizu ◽  
Takashi Yoshimoto
Keyword(s):  
Vertebral Artery ◽  
Three Dimensional ◽  
Craniovertebral Junction ◽  
Artery Occlusion ◽  
Occipital Bone ◽  
Atlantoaxial Instability ◽  
Posterior Arch ◽  
Content Type ◽  
The Right ◽  
Fine Print

✓ Vertebral artery (VA) occlusion by rotation of the head is uncommon, but can result from mechanical compression of the artery, trauma, or atlantoaxial instability. Occipital bone anomalies rarely cause rotational VA occlusion, and patients with nontraumatic intermittent occlusion of the VA usually present with compromised vertebrobasilar flow. A 34-year-old man suffered three embolic strokes in the vertebrobasilar system within 2 months. Magnetic resonance imaging demonstrated multiple infarcts in the vertebrobasilar territory. Angiography performed immediately after the third attack displayed an embolus in the right posterior cerebral artery. Radiographic and three-dimensional computerized tomography bone images exhibited an anomalous osseous process of the occipital bone projecting to the posterior arch of the atlas. Dynamic angiography indicated complete occlusion of the left VA between the osseous process and the posterior arch while the patient's head was turned to the right. Surgical decompression of the VA resulted in complete resolution of rotational occlusion of the artery. An occipital bone anomaly can cause rotational VA occlusion at the craniovertebral junction in patients who present with repeated embolic strokes resulting from injury to the arterial wall.

Biomechanical Comparison of Two Atlantoaxial Arthrodeses in a Cadaveric Spine Model: Transarticular Screw Fixation Versus Screw and Rod Fixation

2002 ◽  
Author(s):  
V. K. Goel ◽  
H. Kuroki ◽  
S. Holekamp ◽  
V. Pitka¨nen ◽  
S. Rengachary ◽  
...  
Keyword(s):  
Vertebral Artery ◽  
Screw Fixation ◽  
Atlantoaxial Instability ◽  
Transarticular Screw ◽  
Transarticular Screw Fixation ◽  
Risk Of Injury ◽  
Spine Model ◽  
Fixation Techniques ◽  
A New Technique ◽  
Biomechanical Comparison

The causes of atlantoaxial instability include trauma, tumor, congenital malformation, or rheumatoid arthritis. Commonly available fixation techniques to stabilize the atlantoaxial complex are several posterior wiring procedures (Brooks fusion, Gallie fusion), transarticular screw procedure (Magerl technique), either alone or in combination. Wiring procedures are obviously easier to accomplish however these do not provide sufficient immobilization across the atlantoaxial complex1,3,4. On the other hand, although transarticular screw fixation (TSF) affords a much stiffer atlantoaxial arthrodesis than posterior wiring procedures. However, TSF has some drawbacks; for example the injury of vertebral artery. Furthermore, body habitus (obesity or thoracic kyphosis) may prevent from achieving the low angle needed for correct placement of screws between C1 and C2. Recently, a new technique of screw and rod fixation (SRF) that minimizes the risk of injury to the vertebral artery and allows intraoperative reduction has been reported2,6. The purpose of this study was to compare the biomechanical stability imparted to the C1 and C2 vertebrae by either TSF or SRF technique in a cadaver model.

scholarly journals Sectioning of C2 nerve roots during C1–2 fusion: report of aberrant vertebral artery during C2 nerve root sectioning. Illustrative case

2021 ◽  
Vol 2 (18) ◽  
Author(s):  
Max Kahn ◽  
Paul MacMahon ◽  
Thomas Russell ◽  
Jeffrey D. Klopfenstein ◽  
Daniel R. Fassett
Keyword(s):  
Vertebral Artery ◽  
Nerve Root ◽  
Vascular Anatomy ◽  
Preoperative Assessment ◽  
Illustrative Case ◽  
Vascular Control ◽  
Instrumented Fusion ◽  
Arterial Bleeding ◽  
C2 Nerve Root ◽  
The Right

BACKGROUND Sectioning the C2 nerve root is increasingly utilized during posterior C1–2 fusion, as the nerve overlies the entry point for C1 lateral mass screws and the C1–2 joint. Nerve sectioning improves visualization for screw placement and enables joint decortication for arthrodesis. While rare, vascular injury is a devastating complication of atlantoaxial fusion. Anomalous vascular anatomy at C1–2 greatly increases risk of iatrogenic injury. OBSERVATIONS A 78-year-old female with rheumatoid arthritis and prior C2–7 fusion presented with myelopathy from a compressive pannus at C1–2. She underwent C1 laminectomy and C1–2 posterior instrumented fusion. Intraoperatively, arterial bleeding occurred as the right C2 nerve root was sectioned. Vertebral artery injury was suspected, and tamponade was performed while vascular control was established. The artery passed aberrantly beneath the nerve root in the C1–2 foramen. It was repaired microsurgically, and patency was confirmed using indocyanine green. The remainder of the fusion was aborted. The patient wore a cervical collar and was treated with aspirin for 6 weeks before undergoing instrumented fusion. The patient suffered no deficits. LESSONS Although rare, anomalous vertebral artery anatomy increases risk of injury at time of C2 nerve root sectioning. Preoperative assessment of the vasculature is vital.

Impairment Tutorial: Rating Tears of the Acetabular Labrum

2006 ◽  
Vol 11 (6) ◽  
pp. 4-7
Author(s):  
Charles N. Brooks ◽  
Richard E. Strain ◽  
James B. Talmage
Keyword(s):  
Magnetic Resonance ◽  
Hip Arthroscopy ◽  
Age Groups ◽  
Limited Range ◽  
Labral Repair ◽  
X Rays ◽  
Joint Stability ◽  
Acetabular Labrum ◽  
Complete Excision ◽  
Limited Range Of Motion

Abstract The primary function of the acetabular labrum, like that of the glenoid, is to deepen the socket and improve joint stability. Tears of the acetabular labrum are common in older adults but occur in all age groups and with equal frequency in males and females. The AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fifth Edition, is silent about rating tears, partial or complete excision, or repair of the acetabular labrum. Provocative tests to detect acetabular labrum tears involve hip flexion and rotation; all rely on production of pain in the groin (typically), clicking, and/or locking with passive or active hip motions. Diagnostic tests or procedures rely on x-rays, conventional arthrography, computerized tomography, magnetic resonance imaging (MRI), magnetic resonance arthrography (MRA), and hip arthroscopy. Hip arthroscopy is the gold standard for diagnosis but is the most invasive and most likely to result in complications, and MRA is about three times more sensitive and accurate in detecting acetabular labral tears than MRI alone. Surgical treatment for acetabular labrum tears usually consists of arthroscopic debridement; results tend to be better in younger patients. In general, an acetabular labral tear, partial labrectomy, or labral repair warrants a rating of 2% lower extremity impairment. Evaluators should avoid double dipping (eg, using both a Diagnosis-related estimates and limited range-of-motion tests).

The Correlation of the Limitations of Movement of the Shoulder Joint with the Functional Ability of Frozen Shoulder Patients at the Medical Rehabilitation Institute Dr. Mohammad Hoesin Palembang

2020 ◽  
Vol 3 (3) ◽  
pp. 88-96
Author(s):  
Ine Sintia ◽  
Nyimas Fatimah
Keyword(s):  
Functional Ability ◽  
Shoulder Joint ◽  
Frozen Shoulder ◽  
Limited Range ◽  
Medical Rehabilitation ◽  
Cross Sectional ◽  
Shoulder Joints ◽  
Limited Range Of Motion ◽  
Active Flexion ◽  
Cross Sectional Design

Background: Frozen shoulder is a condition of the shoulder joint that experiences inflammation, pain, adhesions, atrophyand shortening of the joint capsule resulting in limited motion. In frozen shoulder patients, the limited range of motion ofthe shoulder joint can affect and reduce functional ability. This study aims to analyze the correlation between the limitedarea of motion of the shoulder joint with the functional ability of frozen shoulder patients at the Medical RehabilitationInstallation Dr. Mohammad Hoesin Palembang. Methods: This study was an observational analytic study, correlationtest, with a cross sectional design. There were 29 frozen shoulder patients who met the inclusion criteria in the MedicalRehabilitation Installation Dr. Mohammad Hoesin Palembang in November 2018 was taken as a sample using consecutivesampling techniques. Functional ability was assessed using the quickDASH questionnaire and the area of motion wasmeasured using a goniometer, then analyzed. Results: The results of the correlation test showed significant resultsbetween functional abilities and the area of motion of the shoulder joints. Active flexion (p = 0.000; r = -0.669), activeextension (p = 0.004; r = -0.520), active abduction (p = 0.000; r = -0.663), active adduction (p = 0.022; r = -0.423 ), passiveflexion (p = 0.001; r = -0.589), passive extension (p = 0.002; r = -0.543), passive abduction (p = 0.000; r = -0.676), passiveadduction (p = 0.038; r = -0.388). Conclusion: There is a significant correlation between limited joint motion andfunctional ability in frozen shoulder patients at the Medical Rehabilitation Installation of Dr. Mohammad HoesinPalembang

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