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C1–C2 posterior screw fixation in atlantoaxial fractures revisited: technical update based on 127 cases

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Abstract

Introduction

Posterior fusion of traumatic odontoid fractures by C1 lateral mass and C2 isthmic screws (modified Harms–Goel technique) is a viable alternative to transarticular screw fixation due to its universal applicability. This retrospective study reports on a series of 127 patients.

Material and methods

Our clinical database was screened for patients with fractures of the upper cervical spine incorporating a C2 fracture, operated on between 2007 and 2015. Patients were included if fused by internal fixation via C1 lateral mass screws, C2 isthmic screws in freehand technique under lateral fluoroscopy. Screw placement was controlled postoperatively by computed tomography and rated using the Gertzbein & Robbins classification. Surgery-related complications, consecutive treatment, revision surgeries and duration of surgeries were registered.

Results

In total, 127 patients were identified with altogether 572 screws. Correct screw positions of grade A and B according to Gertzbein & Robbins were achieved in a total of 539 (94.2%) screws (grade A: 453 (79.2%); grade B: 86 (15%)), grade C screw malpositions noted in 21 (3.7%), grade D in 10 (1.7%) and grade E in 2 (0.3%) screws. Vertebral artery canal breaches occurred in 29 screws (5.1%), with vertebral artery occlusion in 4 patients. Coiling of injured vertebral artery had to be performed in one patient. None of these patients suffered clinically apparent cerebrovascular complications. Revision surgery was performed in 8 patients (6%).

Conclusion

Posterior fixation of atlantoaxial fractures by C1 lateral mass and C2 isthmic screws with fluoroscopy without navigation is a safe and feasible method but not free of risk of vertebral artery injuries.

Graphic abstract

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References

  1. Denaro V, Papalia R, Di Martino A, Denaro L, Maffulli N (2011) The best surgical treatment for type II fractures of the dens is still controversial. Clin Orthop Relat Res 469(3):742–750. https://doi.org/10.1007/s11999-010-1677-x

    Article  PubMed  Google Scholar 

  2. Harrop JS (2013) Type II odontoid fractures: what to do? World Neurosurg 80(3–4):313–314. https://doi.org/10.1016/j.wneu.2012.04.011

    Article  PubMed  Google Scholar 

  3. Chapman J, Smith JS, Kopjar B, Vaccaro AR, Arnold P, Shaffrey CI, Fehlings MG (2013) The AOSpine North America geriatric odontoid fracture mortality study: a retrospective review of mortality outcomes for operative versus nonoperative treatment of 322 patients with long-term follow-up. Spine 38(13):1098–1104. https://doi.org/10.1097/BRS.0b013e318286f0cf

    Article  PubMed  PubMed Central  Google Scholar 

  4. Vaccaro AR, Kepler CK, Kopjar B, Chapman J, Shaffrey C, Arnold P, Gokaslan Z, Brodke D, France J, Dekutoski M, Sasso R, Yoon ST, Bono C, Harrop J, Fehlings MG (2013) Functional and quality-of-life outcomes in geriatric patients with type-II dens fracture. J Bone Joint Surg Am 95(8):729–735. https://doi.org/10.2106/JBJS.K.01636

    Article  PubMed  Google Scholar 

  5. Ryang YM, Torok E, Janssen I, Reinke A, Buchmann N, Gempt J, Ringel F, Meyer B (2016) Early morbidity and mortality in 50 very elderly patients after posterior atlantoaxial fusion for traumatic odontoid fractures. World Neurosurg 87:381–391. https://doi.org/10.1016/j.wneu.2015.12.026

    Article  PubMed  Google Scholar 

  6. Kaesmacher J, Schweizer C, Valentinitsch A, Baum T, Rienmuller A, Meyer B, Kirschke JS, Ryang YM (2017) Osteoporosis Is the most important risk factor for odontoid fractures in the elderly. J Bone Miner Res 32(7):1582–1588. https://doi.org/10.1002/jbmr.3120

    Article  PubMed  Google Scholar 

  7. Jeanneret B, Magerl F (1992) Primary posterior fusion C1/2 in odontoid fractures: indications, technique, and results of transarticular screw fixation. J Spinal Disord 5(4):464–475

    Article  CAS  PubMed  Google Scholar 

  8. Magerl F, Seemann P-S (1987) Stable posterior fusion of the atlas and axis by transarticular screw fixation. In: Cervical spine I. Springer, pp 322–327

  9. Huang DG, Hao DJ, He BR, Wu QN, Liu TJ, Wang XD, Guo H, Fang XY (2015) Posterior atlantoaxial fixation: a review of all techniques. Spine J 15(10):2271–2281. https://doi.org/10.1016/j.spinee.2015.07.008

    Article  PubMed  Google Scholar 

  10. Steltzlen C, Lazennec JY, Catonne Y, Rousseau MA (2013) Unstable odontoid fracture: surgical strategy in a 22-case series, and literature review. Orthop Traumatol Surg Res 99(5):615–623. https://doi.org/10.1016/j.otsr.2013.02.007

    Article  CAS  PubMed  Google Scholar 

  11. Goel A, Laheri V (1994) Plate and screw fixation for atlanto-axial subluxation. Acta Neurochir (Wien) 129(1–2):47–53

    Article  CAS  Google Scholar 

  12. Goel A, Desai KI, Muzumdar DP (2002) Atlantoaxial fixation using plate and screw method: a report of 160 treated patients. Neurosurgery 51(6):1351–1356

    Article  PubMed  Google Scholar 

  13. Harms J, Melcher RP (2001) Posterior C1–C2 fusion with polyaxial screw and rod fixation. Spine 26(22):2467–2471

    Article  CAS  PubMed  Google Scholar 

  14. Madawi A, Solanki G, Casey AT, Crockard HA (1997) Variation of the groove in the axis vertebra for the vertebral artery. Implications for instrumentation. J Bone Joint Surg Br 79(5):820–823

    Article  PubMed  Google Scholar 

  15. Madawi AA, Casey AT, Solanki GA, Tuite G, Veres R, Crockard HA (1997) Radiological and anatomical evaluation of the atlantoaxial transarticular screw fixation technique. J Neurosurg 86(6):961–968. https://doi.org/10.3171/jns.1997.86.6.0961

    Article  CAS  PubMed  Google Scholar 

  16. Wright NM, Lauryssen C (1998) Vertebral artery injury in C1–2 transarticular screw fixation: results of a survey of the AANS/CNS section on disorders of the spine and peripheral nerves. J Neurosurg 88(4):634–640

    Article  CAS  PubMed  Google Scholar 

  17. Gautschi OP, Payer M, Corniola MV, Smoll NR, Schaller K, Tessitore E (2014) Clinically relevant complications related to posterior atlanto-axial fixation in atlanto-axial instability and their management. Clin Neurol Neurosurg 123:131–135. https://doi.org/10.1016/j.clineuro.2014.05.020

    Article  CAS  PubMed  Google Scholar 

  18. Akinduro OO, Baum GR, Howard BM, Pradilla G, Grossberg JA, Rodts GE Jr, Ahmad FU (2016) Neurological outcomes following iatrogenic vascular injury during posterior atlanto-axial instrumentation. Clin Neurol Neurosurg 150:110–116. https://doi.org/10.1016/j.clineuro.2016.08.012

    Article  PubMed  Google Scholar 

  19. Kraus M, dem Berge S, Perl M, Krischak G, Weckbach S (2014) Accuracy of screw placement and radiation dose in navigated dorsal instrumentation of the cervical spine: a prospective cohort study. Int J Med Robot 10(2):223–229. https://doi.org/10.1002/rcs.1555

    Article  PubMed  Google Scholar 

  20. Scheufler KM, Franke J, Eckardt A, Dohmen H (2011) Accuracy of image-guided pedicle screw placement using intraoperative computed tomography-based navigation with automated referencing, part I: cervicothoracic spine. Neurosurgery 69(4):782–795. https://doi.org/10.1227/NEU.0b013e318222ae16

    Article  PubMed  Google Scholar 

  21. Hecht N, Kamphuis M, Czabanka M, Hamm B, Konig S, Woitzik J, Synowitz M, Vajkoczy P (2016) Accuracy and workflow of navigated spinal instrumentation with the mobile AIRO((R)) CT scanner. Eur Spine J 25(3):716–723. https://doi.org/10.1007/s00586-015-3814-4

    Article  PubMed  Google Scholar 

  22. Kantelhardt SR, Keric N, Giese A (2012) Management of C2 fractures using Iso-C(3D) guidance: a single institution's experience. Acta Neurochir (Wien) 154(10):1781–1787. https://doi.org/10.1007/s00701-012-1443-9

    Article  Google Scholar 

  23. Smith JD, Jack MM, Harn NR, Bertsch JR, Arnold PM (2016) Screw placement accuracy and outcomes following O-Arm-Navigated atlantoaxial fusion: a feasibility study. Global Spine J 6(4):344–349. https://doi.org/10.1055/s-0035-1563723

    Article  PubMed  Google Scholar 

  24. Ringel F, Reinke A, Stuer C, Meyer B, Stoffel M (2012) Posterior C1–2 fusion with C1 lateral mass and C2 isthmic screws: accuracy of screw position, alignment and patient outcome. Acta Neurochir (Wien) 154(2):305–312. https://doi.org/10.1007/s00701-011-1224-x

    Article  Google Scholar 

  25. Payer M, Luzi M, Tessitore E (2009) Posterior atlanto-axial fixation with polyaxial C1 lateral mass screws and C2 pars screws. Acta Neurochir (Wien) 151(3):223–229. https://doi.org/10.1007/s00701-009-0198-4

    Article  CAS  Google Scholar 

  26. Tessitore E, Bartoli A, Schaller K, Payer M (2011) Accuracy of freehand fluoroscopy-guided placement of C1 lateral mass and C2 isthmic screws in atlanto-axial instability. Acta Neurochir (Wien) 153(7):1417–1425. https://doi.org/10.1007/s00701-011-1039-9

    Article  Google Scholar 

  27. Nitising A, Jetjumnong C, Tisavipat N, Nantaaree S (2011) Posterior C1–C2 fusion using C1 lateral mass and C2 pars screw with rod fixation: techniques and outcomes. J Med Assoc Thai 94(7):794–800

    PubMed  Google Scholar 

  28. Bourdillon P, Perrin G, Lucas F, Debarge R, Barrey C (2014) C1–C2 stabilization by Harms arthrodesis: indications, technique, complications and outcomes in a prospective 26-case series. Orthop Traumatol Surg Res 100(2):221–227. https://doi.org/10.1016/j.otsr.2013.09.019

    Article  CAS  PubMed  Google Scholar 

  29. Elliott RE, Tanweer O, Boah A, Morsi A, Ma T, Smith ML, Frempong-Boadu A (2014) Atlantoaxial fusion with screw-rod constructs: meta-analysis and review of literature. World Neurosurg 81(2):411–421. https://doi.org/10.1016/j.wneu.2012.03.013

    Article  PubMed  Google Scholar 

  30. Elliott RE, Tanweer O, Boah A, Morsi A, Ma T, Frempong-Boadu A, Smith ML (2014) Outcome comparison of atlantoaxial fusion with transarticular screws and screw-rod constructs: meta-analysis and review of literature. J Spinal Disord Tech 27(1):11–28. https://doi.org/10.1097/BSD.0b013e318277da19

    Article  PubMed  Google Scholar 

  31. Costa F, Ortolina A, Attuati L, Cardia A, Tomei M, Riva M, Balzarini L, Fornari M (2015) Management of C1–2 traumatic fractures using an intraoperative 3D imaging-based navigation system. Journal of neurosurgery Spine 22(2):128–133. https://doi.org/10.3171/2014.10.SPINE14122

    Article  PubMed  Google Scholar 

  32. Jeon SW, Jeong JH, Choi GH, Moon SM, Hwang HS, Choi SK (2012) Clinical outcome of posterior fixation of the C1 lateral mass and C2 pedicle by polyaxial screw and rod. Clin Neurol Neurosurg 114(6):539–544. https://doi.org/10.1016/j.clineuro.2011.11.001

    Article  PubMed  Google Scholar 

  33. Yang YL, Zhou DS, He JL (2013) Comparison of isocentric C-arm 3-dimensional navigation and conventional fluoroscopy for C1 lateral mass and C2 pedicle screw placement for atlantoaxial instability. J Spinal Disord Tech 26(3):127–134. https://doi.org/10.1097/BSD.0b013e31823d36b6

    Article  PubMed  Google Scholar 

  34. Bredow J, Oppermann J, Kraus B, Schiller P, Schiffer G, Sobottke R, Eysel P, Koy T (2015) The accuracy of 3D fluoroscopy-navigated screw insertion in the upper and subaxial cervical spine. Eur Spine J 24(12):2967–2976. https://doi.org/10.1007/s00586-015-3974-2

    Article  CAS  PubMed  Google Scholar 

  35. Czabanka M, Haemmerli J, Hecht N, Foehre B, Arden K, Liebig T, Woitzik J, Vajkoczy P (2017) Spinal navigation for posterior instrumentation of C1–2 instability using a mobile intraoperative CT scanner. J Neurosurg Spine 27(3):268–275. https://doi.org/10.3171/2017.1.SPINE16859

    Article  PubMed  Google Scholar 

  36. Akins PT, Harris J, Alvarez JL, Chen Y, Paxton EW, Bernbeck J, Guppy KH (2015) Risk factors associated with 30-day readmissions after instrumented spine surgery in 14,939 patients: 30-day readmissions after instrumented spine surgery. Spine (Phila Pa 1976) 40(13):1022–1032. https://doi.org/10.1097/BRS.0000000000000916

    Article  Google Scholar 

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Buchmann, N., Schweizer, C., Kirschke, J.S. et al. C1–C2 posterior screw fixation in atlantoaxial fractures revisited: technical update based on 127 cases. Eur Spine J 29, 1036–1042 (2020). https://doi.org/10.1007/s00586-019-06244-2

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