Arteriovenous fistula as a complication of C1–2 transarticular screw fixation

✓ A case is reported of a vertebral artery-to-epidural venous plexus fistula as a complication of posterior atlantoaxial facet screw fixation. The use of transarticular screws to stabilize the C1–2 joint has become an increasingly popular fixation technique, most notably for atlantoaxial instability due to trauma or rheumatoid disease. Despite the fact that this approach is technically challenging, there have been few reports of complications associated with C1–2 transarticular fixation. Although damage to the vertebral artery is a documented hazard of transarticular fixation at this level, a symptomatic arteriovenous fistula resulting from the procedure has not been described previously. The etiology, presentation, and treatment of this unusual complication are discussed.

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Anatomical suitability of C1–2 transarticular screw placement in pediatric patients

Journal of Neurosurgery Spine ◽

10.3171/spi.2000.92.1.0007 ◽

2000 ◽

Vol 92 (1) ◽

pp. 7-11 ◽

Cited By ~ 20

Author(s):

Douglas L. Brockmeyer ◽

Julie E. York ◽

Ronald I. Apfelbaum

Keyword(s):

Pediatric Patients ◽

Screw Fixation ◽

Vascular Complications ◽

Screw Placement ◽

Atlantoaxial Instability ◽

Os Odontoideum ◽

Transarticular Screw ◽

Content Type ◽

Transarticular Screw Fixation ◽

Fine Print

Object. Craniovertebral instability is a challenging problem in pediatric spinal surgery. Recently, C1–2 transarticular screw fixation has been used to assist in craniovertebral joint stabilization in pediatric patients. Currently there are no available data that define the anatomical suitability of this technique in the pediatric population. The authors report their experience in treating 31 pediatric patients with craniovertebral instability by using C1–2 transarticular screws. Methods. From March 1992 to October 1998, 31 patients who were 16 years of age or younger with atlantooccipital or atlantoaxial instability, or both, were evaluated at our institution. There were 21 boys and 10 girls. Their ages ranged from 4 to 16 years (mean age 10.2 years). The most common causes of instability were os odontoideum (12 patients) and ligamentous laxity (eight patients). Six patients had undergone a total of nine previous attempts at posterior fusion while at outside institutions. All patients underwent extensive preoperative radiological evaluation including fine-slice (1-mm) computerized tomography scanning with multiplanar reconstruction to evaluate the anatomy of the C1–2 joint space. Preoperatively, of the 62 possible C1–2 joint spaces in 31 patients, 55 sides (89%) were considered suitable for transarticular screw placement. In three patients the anatomy was considered unsuitable for bilateral screw placement. In three patients the anatomy was considered inadequate on one side. Fifty-five C1–2 transarticular screws were subsequently placed, and there were no neurological or vascular complications. Conclusions. The authors conclude that C1–2 transarticular screw fixation is technically possible in a large proportion of pediatric patients with craniovertebral instability.

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Posterior atlantoaxial facet screw fixation in rheumatoid arthritis

Journal of Neurosurgery ◽

10.3171/jns.1998.89.1.0008 ◽

1998 ◽

Vol 89 (1) ◽

pp. 8-12 ◽

Cited By ~ 55

Author(s):

Mohammed Aly Eleraky ◽

Roberto Masferrer ◽

Volker K. H. Sonntag

Keyword(s):

Screw Fixation ◽

Class Ii ◽

Atlantoaxial Instability ◽

Rigid Fixation ◽

Class Iii ◽

Transarticular Screw ◽

Content Type ◽

Transarticular Screw Fixation ◽

Fine Print

Object. This retrospective review was conducted to determine the efficacy of transarticular screw fixation in a group of patients who were treated for rheumatoid atlantoaxial instability. Methods. Thirty-six patients (mean age 63 years) with rheumatoid atlantoaxial instability were treated with posterior atlantoaxial transarticular screw fixation supplemented with an interspinous C1–2 strut graft—cable construct to provide immediate three-point fixation to facilitate bone fusion. Previous attempts at fusions by using bone grafting with wire fixation at other institutions had failed in six of these patients. Six patients underwent transoral odontoid resections for removal of large irreducible pannus as a first-stage procedure, which was followed within 2 to 3 days by the posterior procedure. Postoperatively, 33 patients were placed in hard cervical collars and three required halo vests because of severe osteoporosis. Of eight patients categorized as Ranawat Class II preoperatively, all eight returned to normal after surgery; of eight patients in Ranawat Class III-A preoperatively, four improved to Class II and four remained unchanged. All 20 patients classified as Ranawat Class I preoperatively recovered completely. Pain decreased or resolved in all patients, and there were no complications related to instrumentation. At follow-up review (mean 2 years), 33 patients (92%) had solid bone fusions, and three (8%) had stable fibrous unions. Conclusions. Posterior atlantoaxial transarticular screw fixation provides a good surgical alternative for the management of patients with rheumatoid atlantoaxial instability. This technique provides immediate three-point rigid fixation of the C1–2 region, thus obviating the need for halo vest immobilization in most cases.

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Anatomical evaluation of the groove for the vertebral artery in the axis vertebrae for atlanto-axial transarticular screw fixation technique

Clinical Anatomy ◽

10.1002/1098-2353(2000)13:4<237::aid-ca2>3.0.co;2-k ◽

2000 ◽

Vol 13 (4) ◽

pp. 237-243 ◽

Cited By ~ 23

Author(s):

Saim Kazan ◽

Fato? Yildirim ◽

Muzaffer Sindel ◽

Recai? Tuncer

Keyword(s):

Vertebral Artery ◽

Screw Fixation ◽

Fixation Technique ◽

Transarticular Screw ◽

Transarticular Screw Fixation

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

Advances in Bioengineering ◽

10.1115/imece2002-32631 ◽

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.

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Reducible Nonunited Type II Odontoid Fracture with Atlantoaxial Instability: Outcomes of Two Different Fixation Techniques

International Journal of Environmental Research and Public Health ◽

10.3390/ijerph18157990 ◽

2021 ◽

Vol 18 (15) ◽

pp. 7990

Author(s):

Torphong Bunmaprasert ◽

Vorapop Trirattanapikul ◽

Nantawit Sugandhavesa ◽

Areerak Phanphaisarn ◽

Wongthawat Liawrungrueang ◽

...

Keyword(s):

Screw Fixation ◽

Fusion Rate ◽

Odontoid Fracture ◽

Atlantoaxial Instability ◽

Type Ii ◽

Fixation Technique ◽

Transarticular Screw ◽

Transarticular Screw Fixation ◽

Fixation Techniques ◽

Surgical Fixation

Displaced nonunited type II odontoid fracture can result in atlantoaxial instability, causing delayed cervical myelopathy. Both Magerl’s C1-C2 transarticular screw fixation technique and Harms-Goel C1-C2 screw-rod segmental fixation technique are effective techniques to provide stability. This study aimed to demonstrate the results of two surgical fixation techniques for the treatment of reducible nonunited type II odontoid fracture with atlantoaxial instability. Medical records of patients with reducible nonunited type II odontoid fracture hospitalized for spinal fusion between April 2007 and April 2018 were reviewed. For each patient, specific surgical fixation, either Magerl’s C1-C2 transarticular screw fixation technique augmented with supplemental wiring or Harms-Goel C1-C2 screw-rod fixation technique, was performed according to our management protocol. We reported the fusion rate, fusion period, and complications for each technique. Of 21 patients, 10 patients were treated with Magerl’s C1-C2 transarticular screw fixation technique augmented with supplemental wiring, and 11 were treated with Harms-Goel C1-C2 screw-rod fixation technique. The bony fusion rate was 100% in both groups. The median time to fusion was 69.7 (95%CI 53.1, 86.3) days in Magerl’s C1-C2 transarticular screw fixation technique and 75.2 (95%CI 51.8, 98.6) days in Harms-Goel C1-C2 screw-rod fixation technique. No severe complications were observed in either group. Displaced reducible, nonunited type II odontoid fracture with cervical myelopathy should be treated by surgery. Both fixation techniques promote bony fusion and provide substantial construct stability.

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Transarticular Fixation Following Mobilization of “High-Riding” Vertebral Artery

Operative Neurosurgery ◽

10.1093/ons/opaa456 ◽

2021 ◽

Author(s):

Atul Goel ◽

Apurva Prasad ◽

Abhidha Shah ◽

Sumeet Sasane ◽

Akshay Hawaldar ◽

...

Keyword(s):

Vertebral Artery ◽

Screw Fixation ◽

Basilar Invagination ◽

Transarticular Screw ◽

Posterior Aspect ◽

Screw Insertion ◽

Transarticular Screw Fixation ◽

History Of ◽

C2 Vertebra ◽

Transarticular Fixation

Abstract BACKGROUND AND IMPORTANCE: The article identifies the feasibility of transarticular screw fixation after mobilizing the vertebral artery in cases where it is in a “high-riding” location. CLINICAL PRESENTATION: A 42-yr-old male patient had a 4-yr history of progressive quadriparesis. Investigations revealed severe basilar invagination. There was assimilation of atlas and C2-3 fusion. The vertebral artery was “high-riding” into the pedicle-facet of C2 vertebra on both sides. Vertebral artery loop was exposed and mobilized inferiorly on both sides after careful drilling of pedicular bone on the posterior aspect of the dome of the artery. C2 facetal bone on the anterior face of the vertebral artery dome was now available for screw insertion. The C1-2 facets and the articulation were directly in line, making transarticular screw fixation relatively straightforward. The wide bone space available permitted insertion of 2 screws in a transarticular fashion on both sides. The patient had satisfactory clinical improvement. Imaging after 22 mo showed bone fusion across the facets. CONCLUSION: Mobilization of the high-riding vertebral artery loop can help salvage the surgical procedure of lateral mass stabilization.

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Unilateral posterior atlantoaxial transarticular screw fixation

Journal of Neurosurgery ◽

10.3171/jns.1997.87.6.0851 ◽

1997 ◽

Vol 87 (6) ◽

pp. 851-855 ◽

Cited By ~ 76

Author(s):

Geun Sung Song ◽

Nicholas Theodore ◽

Curtis A. Dickman ◽

Volker K. H. Sonntag

Keyword(s):

Bone Graft ◽

Screw Fixation ◽

Vascular Complications ◽

Atlantoaxial Instability ◽

Spinal Instability ◽

Transarticular Screw ◽

Transverse Foramen ◽

Content Type ◽

Screw Breakage ◽

Solid Fusion

✓ Bilateral posterior C1–2 transfacet screw placement with associated posterior bone graft wiring is the accepted treatment for patients with atlantoaxial instability. This technique was modified to treat 19 patients with atlantoaxial instability and unilateral anomalies that prevented placement of a screw across the C1–2 facet. In these cases, a single contralateral transarticular screw was placed in conjunction with interspinous bone graft wiring to avoid neural or vertebral artery injury and to provide C1–2 stability. Postoperatively, all 19 patients were placed in Philadelphia collars (mean immobilization 8 weeks, range 6–12 weeks). Unilateral C1–2 facet screw fixation was needed for the following reasons: a high-riding transverse foramen of the C-2 vertebra present in 13 patients (left side in eight, right side in five), poor screw purchase in two (left side in both), screw malposition in one (left side), severe degenerative arthritis in one (right side), neurofibroma in one (right side), and fracture of the C-1 lateral mass in one (left side). Six weeks postsurgery, one patient presented with a broken screw and required occipitocervical fusion with a Steinmann pin and wire cable from the occiput to C-3 to achieve solid fusion. Solid fusions were achieved in the other 18 patients (mean follow-up period 31 months, range 14–54 months); there was no delayed screw breakage, wire breakage, or spinal instability. There were no operative or postoperative neurological or vascular complications. The authors' experience demonstrates that unilateral C1–2 facet screw fixation with interspinous bone graft wiring is an excellent alternative in the treatment of atlantoaxial instability when bilateral screw fixation is contraindicated.

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Traumatic arteriovenous fistula of the vertebral artery with spinal cord symptoms

Journal of Neurosurgery ◽

10.3171/jns.1977.46.5.0681 ◽

1977 ◽

Vol 46 (5) ◽

pp. 681-687 ◽

Cited By ~ 36

Author(s):

Chikao Nagashima ◽

Takashi Iwasaki ◽

Seiichi Kawanuma ◽

Arata Sakaguchi ◽

Akira Kamisasa ◽

...

Keyword(s):

Spinal Cord ◽

Vertebral Artery ◽

Arteriovenous Fistula ◽

Rapid Improvement ◽

Direct Closure ◽

Content Type ◽

Vertebral Arteriovenous Fistula ◽

Fine Print

✓ The authors report a case of a traumatic vertebral arteriovenous fistula with spinal cord symptoms. Direct closure of the fistula was followed by rapid improvement.

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