Unilateral posterior atlantoaxial transarticular screw fixation

✓ 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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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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Atlantoaxial instability in Dyggve-Melchior-Clausen syndrome

Journal of Neurosurgery Spine ◽

10.3171/spi.2002.96.1.0112 ◽

2002 ◽

Vol 96 (1) ◽

pp. 112-117 ◽

Cited By ~ 2

Author(s):

Frank Kandziora ◽

Luitgard Neumann ◽

Klaus John Schnake ◽

Cyrus Khodadadyan-Klostermann ◽

Stefan Rehart ◽

...

Keyword(s):

Screw Fixation ◽

Cord Compression ◽

Atlantoaxial Instability ◽

Posterior Fixation ◽

Content Type ◽

First Case ◽

Solid Fusion ◽

Specific Care ◽

Preventable Complication

✓ Dyggve-Melchior-Clausen (DMC) syndrome is a very rare disease. Only 58 cases have been reported in the literature. The syndrome is probably an autosomal recessive inherited disorder, one that is characterized by mental retardation, the short-spine type of dwarfism, and skeletal abnormalities, especially of the spine, hands, and pelvis. Atlantoaxial instability— induced spinal cord compression is a serious and preventable complication. The purpose of this report is to describe the first case of DMC syndrome in which anterior transarticular atlantoaxial screw fixation was used to treat atlantoaxial instability. The authors report on a 17-year-old man with DMC syndrome and concomitant severe atlantoaxial instability. Computerized tomography scanning and magnetic resonance angiography demonstrated an irregular course of the vertebral artery (VA) at C-2, which made a posterior fixation procedure impossible. Additionally, transoral fusion was impossible because the patient was unable to open his mouth sufficiently. Therefore, the patient underwent anterior transarticular screw fixation. Follow-up examination 36 weeks after surgery showed solid fusion without implant failure. In conclusion, treatment of atlantoaxial instability in DMC syndrome must be considered. Specific care must be taken to determine the course of the VA. If posterior and transoral fusion are impossible, anterior transarticular atlantoaxial screw fixation might be the only alternative.

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

Journal of Neurosurgery ◽

10.3171/jns.1996.85.2.0221 ◽

1996 ◽

Vol 85 (2) ◽

pp. 221-224 ◽

Cited By ~ 286

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.

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The anatomical suitability of C1-2 transarticular screw placement in pediatric patients

Neurosurgical FOCUS ◽

10.3171/foc.1999.6.6.9 ◽

1999 ◽

Vol 6 (6) ◽

pp. E8

Author(s):

Douglas L. Brockmeyer ◽

Julie E. York ◽

Ronald I. Apfelbaum

Keyword(s):

Pediatric Patients ◽

Screw Fixation ◽

Pediatric Population ◽

Vascular Complications ◽

Joint Space ◽

Screw Placement ◽

Atlantoaxial Instability ◽

Os Odontoideum ◽

Transarticular Screw ◽

Transarticular Screw Fixation

Craniovertebral instability is a challenging problem in pediatric spinal surgery. Recently, C1-2 transarticular screw fixation in pediatric patients has been used to assist in the stabilization of the craniovertebral joint. Currently there are no data that define the anatomical suitability of this technique in the pediatric population. The authors report their experience in 32 pediatric patients in whom craniovertebral instability was treated by placement of C1-2 transarticular screws. From March 1991 to October 1998, 32 patients 16 years of age or younger with atlantooccipital, or atlantoaxial instability, or both were evaluated at our institution. There were 22 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 (nine patients). Six patients had undergone a total of nine previous attempts at posterior fusion at outside institutions. All patients underwent extensive preoperative radiological evaluation including thin cut (1-mm) computerized tomography scanning with multiplanar reconstruction to evaluate the C1-2 joint space anatomy. Of the 64 possible C1-2 joint spaces in 32 patients, 55 sides (86%) were considered suitable for transarticular screw placement preoperatively. In three patients the C1-2 joint space anatomy was considered unsuitable for screw placement bilaterally. In three patients the anatomy was considered inadequate on one side. Fifty-five C1-2 transarticular screws were subsequently placed, with no resulting neurological or vascular complications. We 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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Arteriovenous fistula as a complication of C1–2 transarticular screw fixation

Journal of Neurosurgery ◽

10.3171/jns.1996.85.2.0340 ◽

1996 ◽

Vol 85 (2) ◽

pp. 340-343 ◽

Cited By ~ 99

Author(s):

Domagoj Coric ◽

Charles L. Branch ◽

John A. Wilson ◽

James C. Robinson

Keyword(s):

Vertebral Artery ◽

Arteriovenous Fistula ◽

Screw Fixation ◽

Atlantoaxial Instability ◽

Unusual Complication ◽

Venous Plexus ◽

Fixation Technique ◽

Transarticular Screw ◽

Content Type ◽

Transarticular 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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Radiological and anatomical evaluation of the atlantoaxial transarticular screw fixation technique

Journal of Neurosurgery ◽

10.3171/jns.1997.86.6.0961 ◽

1997 ◽

Vol 86 (6) ◽

pp. 961-968 ◽

Cited By ~ 374

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.

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