Radiological and anatomical evaluation of the atlantoaxial transarticular screw fixation technique

1997 ◽  
Vol 86 (6) ◽  
pp. 961-968 ◽  
Author(s):  
Ali Abou Madawi ◽  
Adrian T. H. Casey ◽  
Guirish A. Solanki ◽  
Gerald Tuite ◽  
Robert Veres ◽  
...  
Keyword(s):  
Screw Fixation ◽  
Screw Placement ◽  
Transoral Surgery ◽  
Spinal Instability ◽  
Lateral Mass ◽  
Transarticular Screw ◽  
Content Type ◽  
Posterior Surgery ◽  
Transarticular Screw Fixation ◽  
Fine Print

✓ Sixty-one patients treated with C1–2 transarticular screw fixation for spinal instability participated in a detailed clinical and radiological study to determine outcome and clarify potential hazards. The most common condition was rheumatoid arthritis (37 patients) followed by traumatic instability (15 patients). Twenty-one of these patients (onethird) underwent either surgical revision for a previously failed posterior fusion technique or a combined anteroposterior procedure. Eleven patients underwent transoral odontoidectomy and excision of the arch of C-1 prior to posterior surgery. No patient died, but there were five vertebral artery (VA) injuries and one temporary cranial nerve palsy. Screw malposition (14% of placements) was comparable to another large series reported by Grob, et al. There were five broken screws, and all were associated with incorrect placement. Anatomical measurements were made on 25 axis bones. In 20% the VA groove on one side was large enough to reduce the width of the C-2 pedicle, thus preventing the safe passage of a 3.5-mm diameter screw. In addition to the obvious dangers in patients with damaged or deficient atlantoaxial lateral mass, the following risk factors were identified in this series: 1) incomplete reduction prior to screw placement, accounting for two-thirds of screw complications and all five VA injuries; 2) previous transoral surgery with removal of the anterior tubercle or the arch of the atlas, thus obliterating an important fluoroscopic landmark; and 3) failure to appreciate the size of the VA in the axis pedicle and lateral mass. A low trajectory with screw placement below the atlas tubercle was found in patients with VA laceration. The technique that was associated with an 87% fusion rate requires detailed computerized tomography scanning prior to surgery, very careful attention to local anatomy, and nearly complete atlantoaxial reduction during surgery.

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

2000 ◽  
Vol 92 (1) ◽  
pp. 7-11 ◽  
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.

The anatomical suitability of the C1–2 complex for transarticular screw fixation

1996 ◽  
Vol 85 (2) ◽  
pp. 221-224 ◽  
Author(s):  
Christopher G. Paramore ◽  
Curtis A. Dickman ◽  
Volker K. H. Sonntag
Keyword(s):  
Screw Fixation ◽  
Ct Scans ◽  
Screw Placement ◽  
Consecutive Series ◽  
Transarticular Screw ◽  
Transverse Foramen ◽  
Content Type ◽  
Transarticular Screw Fixation ◽  
The Right ◽  
Fine Print

✓ Posterior transarticular screw fixation of the C1–2 complex has become an accepted method of rigid internal fixation for patients requiring posterior C1–2 fusion. The principal limitation of this procedure is the location of the vertebral artery, because an anomalous position may prohibit screw placement. In this study, a consecutive series of computerized tomography (CT) scans was reviewed, and the suitability of each patient for transarticular screw fixation was evaluated. All of the fine-slice axial C1–2 CT scans and reconstructions performed on a spiral scanner over 2 years were reviewed. A novel screw trajectory reconstruction was designed to visualize the potential path of a transarticular screw in the plane of the reconstruction. Scans were reviewed for bone anatomy and the position of the transverse foramen. Seventeen (18%) of 94 patients had a high-riding transverse foramen on at least one side of the C-2 vertebra that would prohibit the placement of transarticular screws. The left side was involved in nine patients and the right in five. Three patients had bilateral anomalies. The mean age of the group with anomalies (35.9 years, range 10–76) was not significantly different from the overall mean age (35.7 years, range 6–94). An additional five patients (5%) were considered to have anatomy in which screw placement was feasible but risky. On the basis of these data, it is postulated that 18% to 23% of patients may not be suitable candidates for posterior C1–2 transarticular screw fixation on at least one side.

Biomechanical comparison of C1–2 posterior fixation techniques

2005 ◽  
Vol 2 (2) ◽  
pp. 175-181 ◽  
Author(s):  
Jonathan S. Hott ◽  
James J. Lynch ◽  
Robert H. Chamberlain ◽  
Volker K. H. Sonntag ◽  
Neil R. Crawford
Keyword(s):  
Screw Fixation ◽  
Graft Fixation ◽  
Lateral Mass ◽  
Transarticular Screw ◽  
Content Type ◽  
Transarticular Screw Fixation ◽  
Significant Difference ◽  
Pars Interarticularis ◽  
Flexion And Extension ◽  
Fine Print

Object. In a nondestructive, repeated-measures in vitro flexibility experiment, the authors compared the acute stability of C1–2 after placement of C-1 lateral mass and C-2 pars interarticularis (LC1—PC2) instrumentation with that of C1–2 transarticular screw fixation. Methods. The effect of C-1 laminectomy and C1–2 interspinous cable/graft fixation on LC1—PC2 stability was studied. Screw pullout strengths were also compared. Seven human cadaveric occiput—C3 specimens were loaded nondestructively with pure moments while measuring nonconstrained atlantoaxial motion. Specimens were tested with graft alone, LC1—PC2 alone, LC1—PC2 combined with C-1 laminectomy, and graft-augmented LC1—PC2. Interspinous cable/graft fixation significantly enhanced LC1—PC2 stability during extension. After C-1 laminectomy, the LC1—PC2 construct allowed increased motion during flexion and extension. There was no significant difference in lax zone or range of motion between LC1—PC2 fixation and transarticular screw fixation, but graft-assisted transarticular screws yielded a significantly smaller stiff zone during extension. The difference in pullout resistance between C-1 lateral mass screws and C-2 pars interarticularis screws was insignificant. The LC1—PC2 region restricted motion to within the normal range during all loading modes. Atlantal laminectomy reduced LC1—PC2 stability during flexion and extension. Conclusions. The instrumentation-augmented LC1—PC2 construct performed biomechanically similarly to the C1–2 transarticular screw fixation. The LC1—PC2 construct resisted flexion, lateral bending, and axial rotation well. The weakness of the LC1—PC2 fixation in resisting extension can be overcome by adding an interspinous graft to the construct.

Atlantoaxial transarticular screw fixation: a review of surgical indications, fusion rate, complications, and lessons learned in 67 pediatric patients

2005 ◽  
Vol 2 (2) ◽  
pp. 164-169 ◽  
Author(s):  
Wayne M. Gluf ◽  
Douglas L. Brockmeyer
Keyword(s):  
Pediatric Patients ◽  
Screw Fixation ◽  
Fusion Rate ◽  
Lessons Learned ◽  
Os Odontoideum ◽  
Consecutive Series ◽  
Transarticular Screw ◽  
Content Type ◽  
Transarticular Screw Fixation ◽  
Fine Print

Object. In this, the second of two articles regarding C1–2 transarticular screw fixation, the authors discuss their surgical experience in treating patients 16 years of age and younger, detailing the rate of fusion, complication avoidance, and lessons learned in the pediatric population. Methods. The authors retrospectively reviewed 67 consecutive patients (23 girls and 44 boys) younger than 16 years of age in whom at least one C1–2 transarticular screw fixation procedure was performed. A total of 127 transarticular screws were placed in these 67 patients whose mean age at time of surgery was 9 years (range 1.7–16 years). The indications for surgery were trauma in 24 patients, os odontoideum in 22 patients, and congenital anomaly in 17 patients. Forty-four patients underwent atlantoaxial fusion and 23 patients underwent occipitocervical fusion. Two of the 67 patients underwent halo therapy postoperatively. All patients were followed for a minimum of 3 months. In all 67 patients successful fusion was achieved.Complications occurred in seven patients (10.4%), including two vertebral artery injuries. Conclusions. The use of C1–2 transarticular screw fixation, combined with appropriate atlantoaxial and craniovertebral bone/graft constructs, resulted in a 100% fusion rate in a large consecutive series of pediatric patients. The risks of C1–2 transarticular screw fixation can be minimized in this population by undertaking careful patient selection and meticulous preoperative planning.

Posterior atlantoaxial dislocation without fracture

2003 ◽  
Vol 98 (1) ◽  
pp. 73-76 ◽  
Author(s):  
Do Heum Yoon ◽  
Kook Hee Yang ◽  
Keung Nyun Kim ◽  
Sung Han Oh
Keyword(s):  
Successful Treatment ◽  
Open Reduction ◽  
Screw Fixation ◽  
Odontoid Process ◽  
Atlantoaxial Dislocation ◽  
Posterior Dislocation ◽  
Transarticular Screw ◽  
Content Type ◽  
Transarticular Screw Fixation ◽  
Fine Print

✓ Posterior dislocation of the atlas onto the axis without related fracture of the odontoid process is a very rare traumatic condition of which five cases have been previously reported. The authors present a sixth case in which management was different from the others. The patient was successfully treated by open reduction of the dislocation and C1–2 transarticular screw fixation. The rarity of the lesion, the differences in diagnostic studies, and the successful treatment by safe intraoperative reduction and fixation are factors of interest in this case.

Use of an aiming device in posterior atlantoaxial transarticular screw fixation

2002 ◽  
Vol 97 (1) ◽  
pp. 123-127 ◽  
Author(s):  
Masashi Neo ◽  
Mutsumi Matsushita ◽  
Tadashi Yasuda ◽  
Takeshi Sakamoto ◽  
Takashi Nakamura
Keyword(s):  
Posterior Approach ◽  
Screw Fixation ◽  
Guide Wire ◽  
Posterior Part ◽  
Cannulated Screw ◽  
Atlantoaxial Joint ◽  
Transarticular Screw ◽  
Content Type ◽  
Transarticular Screw Fixation ◽  
Fine Print

✓ Posterior atlantoaxial transarticular screw fixation is an excellent procedure associated with high fusion rates. There is, however, the potential risk of vertebral artery (VA) injury. The authors designed a special aiming device that allows a cannulated screw to be inserted accurately in the most posterior part of the C1–2 joint via the most posterior and medial part of the isthmus of C-2; this screw pathway most safely avoids VA injury. The instruments include an aiming device and a flexible screw-inserting system. The tip of the aiming device is placed on the ridge of the C-2 isthmus just posterior to the atlantoaxial joint. The guide wire should then pass 1 mm below the device tip. The system consists of flexible guide wires, a drill, a tap, and a screwdriver, and the screw is inserted easily via a posterior approach in which the patient's back is not obstructive. Ten patients with atlantoaxial subluxation or osteoarthritis underwent surgery in which the device was used. In all cases, the screws were inserted safely without causing VA injury, although preoperative computerized tomography (CT) reconstructions revealed a high-risk high-riding unilateral VA in three patients. Postoperative CT reconstructions demonstrated that all screws but one were inserted as planned, and successfully cleared the vertebral groove. In conclusion, this newly designed device is practical and useful for the accurate insertion of screws, thus avoiding VA injury during atlantoaxial transarticular screw fixation.

A bone and cable girth-hitch technique for atlantoaxial fusion in pediatric patients

2002 ◽  
Vol 97 (3) ◽  
pp. 400-402 ◽  
Author(s):  
Douglas L. Brockmeyer
Keyword(s):  
Pediatric Patients ◽  
Screw Fixation ◽  
New Technique ◽  
Transarticular Screw ◽  
Content Type ◽  
Transarticular Screw Fixation ◽  
Atlantoaxial Fusion ◽  
A New Technique ◽  
Halo Orthosis ◽  
Fine Print

✓ A new technique for performing a posterior rib and multistranded cable atlantoaxial fusion in children is described. The technique has been used successfully, in two patients 22 and 18 months of age, respectively. In both cases, fusion was used to augment C1–2 transarticular screw fixation, and solid arthrodesis was achieved without a halo orthosis.

Posterior atlantoaxial facet screw fixation in rheumatoid arthritis

1998 ◽  
Vol 89 (1) ◽  
pp. 8-12 ◽  
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.

Atlantoaxial Screw Fixation

2005 ◽  
Vol 3 (6) ◽  
pp. 509-510
Author(s):  
Masashi Neo
Keyword(s):  
Screw Fixation ◽  
Patient Positioning ◽  
Lessons Learned ◽  
Os Odontoideum ◽  
Patient Death ◽  
Transarticular Screw ◽  
Content Type ◽  
Transarticular Screw Fixation ◽  
The Mean ◽  
Fine Print

Object. In this, the first of two articles regarding C1–2 transarticular screw fixation, the authors assessed the rate of fusion, surgery-related complications, and lessons learned after C1–2 transarticular screw fixation in an adult patient series.Methods. The authors retrospectively reviewed 191 consecutive patients (107 women and 84 men; mean age 49.7 years, range 17–90 years) in whom at least one C1–2 transarticular screw was placed. Overall 353 transarticular screws were placed for trauma (85 patients), rheumatoid arthritis (63 patients), congenital anomaly (26 patients), os odontoideum (four patients), neoplasm (eight patients), and chronic cervical instability (five patients). Among these, 67 transarticular screws were placed in 36 patients as part of an occipitocervical construct. Seventeen patients had undergone 24 posterior C1–2 fusion attempts prior to referral. The mean follow-up period was 15.2 months (range 0.1–106.3 months).Fusion was achieved in 98% of cases followed to commencement of fusion or for at least 24 months. The mean duration until fusion was 9.5 months (range 3–48 months). Complications occurred in 32 patients. Most were minor; however, five patients suffered vertebral artery (VA) injury. One bilateral VA injury resulted in patient death. The others did not result in any permanent neurological sequelae.Conclusions. Based on this series, the authors have learned important lessons that can improve outcomes and safety. These include techniques to improve screw-related patient positioning, development of optimal instrumentation, improved screw materials and design, and defining the role for stereotactic navigation. Atlantoaxial transarticular screw fixation is highly effective in achieving fusion, and the complication rate is low when performed by properly trained surgeons.

Impact of interlaminar graft materials on the fusion status in atlantoaxial transarticular screw fixation

2005 ◽  
Vol 2 (1) ◽  
pp. 23-26 ◽  
Author(s):  
Morio Matsumoto ◽  
Kazuhiro Chiba ◽  
Masaya Nakamura ◽  
Yuto Ogawa ◽  
Yoshiaki Toyama ◽  
...  
Keyword(s):  
Screw Fixation ◽  
Statistical Significance ◽  
Fusion Rate ◽  
Os Odontoideum ◽  
Transarticular Screw ◽  
Content Type ◽  
Transarticular Screw Fixation ◽  
Group A ◽  
Group B ◽  
Fine Print

Object. Structural interlaminar graft materials were used for atlantoaxial transarticular screw fixation (TSF), and its impact on the fusion status was investigated. Methods. Forty-two patients (10 men, 32 women, mean age 51 years, mean follow-up period 45 months; 30 with rheumatoid arthritis, and 12 with os odontoideum) underwent TSF and modified Brooks posterior wiring involving titanium cables. As interlaminar graft materials, autologous bone from posterior iliac crest alone was used in 20 patients (Group A), and a structural spacer (13 ceramic spacers, nine titanium mesh cages) in 22 (Group B). Lateral radiographs were evaluated to determine bone fusion, alignment of the cervical spine, and wire loosening. Solid osseous fusion was obtained in 95% of Group A and 96% of Group B patients. The mean atlantoaxial angle was 19.1 ± 9.7° and 16.7 ± 10.4° before surgery (p = 0.45), and 27.4± 7.8° and 22.1 ± 5.5° after surgery (p = 0.02) in Groups A and B, respectively. Atlantoaxial hyperlordosis (atlantoaxial angle ≥ 30°) was observed in 32% of Group A and 18% of Group B patients (p = 0.26). Postoperative kyphosis occurred in 40% of Group A and 23% of Group B patients (p = 0.28). Loosening of the cable was demonstrated in 50% of Group A and 36% of Group B patients (p = 0.37). In Group B patients maintenance of cervical lordosis was more likely than in those in Group A, although the differences did not reach statistical significance. Conclusions. These results indicate that structural interlaminar spacers can maintain proper cervical alignment without a decease in the fusion rate; the authors recommend their use in conjunction with TSF.

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