Unilateral posterior atlantoaxial transarticular screw fixation

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✓ 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.

Article Information

Address reprint requests to: Volker K. H. Sonntag, M.D., c/o Neuroscience Publications, Barrow Neurological Institute, 350 West Thomas Road, Phoenix, Arizona 85013.

© AANS, except where prohibited by US copyright law.

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Figures

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    Upper Left: Dynamic lateral cervical radiograph obtained in a patient with os odontoideum demonstrating a 12-mm atlantodental interval during flexion that is completely reduced on extension. Upper Right: Dynamic sagittal CT scans of the C1–2 area demonstrating marked anterior subluxation of C-1 onto C-2 and a severely narrowed spinal canal during flexion. The subluxation is completely reduced on extension. Lower Left: Axial CT scan of C-2 showing an anomalous medial location of the left transverse foramen of C-2 (arrow). A screw should not be placed on the left side to avoid vascular injury, but on the right side there is adequate bone for safe screw passage. Lower Right: Anteroposterior MR angiogram of the neck illustrating a high-riding VA on the left side (arrow) as compared with the right side.

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    Illustration depicting a unilateral posterior C1–2 transfacet screw fixation and interspinous bone graft wiring construct. When a high-riding VA at C-2 prevents placement of a screw across the C1–2 facet, a single contralateral transarticular screw is placed.

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    Lateral (left) and anteroposterior (right) cervical radiographs obtained 3 years postoperatively demonstrating a solid osseous union that developed after a unilateral posterior C1–2 transarticular screw, cable, and bone graft were placed in a patient with os odontoideum. Both screw and cable are well positioned and intact.

References

  • 1.

    Apfelbaum RI: Screw fixation of the upper cervical spine: indications and techniques. Contemp Neurosurg 16:181994Apfelbaum RI: Screw fixation of the upper cervical spine: indications and techniques. Contemp Neurosurg 16:1–8 1994

  • 2.

    Brooks ALJenkins EB: Atlanto-axial arthrodesis by the wedge compression method. J Bone Joint Surg (Am) 60:2792841978Brooks AL Jenkins EB: Atlanto-axial arthrodesis by the wedge compression method. J Bone Joint Surg (Am) 60:279–284 1978

  • 3.

    Cooper PR: Posterior stabilization of the cervical spine. Clin Neurosurg 40:2863201993Cooper PR: Posterior stabilization of the cervical spine. Clin Neurosurg 40:286–320 1993

  • 4.

    Coric DBranch CL JrWilson JAet al: Arteriovenous fistula as a complication of C1–2 transarticular screw fixation. Case report and review of the literature. J Neurosurg 85:3403431996Coric D Branch CL Jr Wilson JA et al: Arteriovenous fistula as a complication of C1–2 transarticular screw fixation. Case report and review of the literature. J Neurosurg 85:340–343 1996

  • 5.

    Dickman CAFoley KTSonntag VKHet al: Cannulated screws for odontoid screw fixation and atlantoaxial transarticular screw fixation. Technical note. J Neurosurg 83:109511001995Dickman CA Foley KT Sonntag VKH et al: Cannulated screws for odontoid screw fixation and atlantoaxial transarticular screw fixation. Technical note. J Neurosurg 83:1095–1100 1995

  • 6.

    Dickman CASonntag VKH: Surgical techniques for the stabilization of the cervical spine in Schmidek HHSweet WH (eds): Operative Neurosurgical Techniques. Indications Methods and Results. Philadelphia: WB Saunders1995 pp 18491873Dickman CA Sonntag VKH: Surgical techniques for the stabilization of the cervical spine in Schmidek HH Sweet WH (eds): Operative Neurosurgical Techniques. Indications Methods and Results. Philadelphia: WB Saunders 1995 pp 1849–1873

  • 7.

    Dickman CASonntag VKHMarcotte PJ: Techniques of screw fixation of the cervical spine. BNI Q 8:9261992Dickman CA Sonntag VKH Marcotte PJ: Techniques of screw fixation of the cervical spine. BNI Q 8:9–26 1992

  • 8.

    Dickman CASonntag VKHPapadopoulos SMet al: The interspinous method of posterior atlantoaxial arthrodesis. J Neurosurg 74:1901981991Dickman CA Sonntag VKH Papadopoulos SM et al: The interspinous method of posterior atlantoaxial arthrodesis. J Neurosurg 74:190–198 1991

  • 9.

    Dull STToselli RM: Preoperative oblique axial computed tomographic imaging for C1–2 transarticular screw fixation: technical note. Neurosurgery 37:1501521995Dull ST Toselli RM: Preoperative oblique axial computed tomographic imaging for C1–2 transarticular screw fixation: technical note. Neurosurgery 37:150–152 1995

  • 10.

    Fielding JWHawkins RJRatzan SA: Spine fusion for atlantoaxial instability. J Bone Joint Surg (Am) 58:4004071976Fielding JW Hawkins RJ Ratzan SA: Spine fusion for atlantoaxial instability. J Bone Joint Surg (Am) 58:400–407 1976

  • 11.

    Gallie WE: Fractures and dislocations of the cervical spine. Am J Surg 46:4954991939Gallie WE: Fractures and dislocations of the cervical spine. Am J Surg 46:495–499 1939

  • 12.

    Griswold DMAlbright JASchiffman Eet al: Atlanto-axial fusion for instability. J Bone Joint Surg (Am) 60:2852921978Griswold DM Albright JA Schiffman E et al: Atlanto-axial fusion for instability. J Bone Joint Surg (Am) 60:285–292 1978

  • 13.

    Grob DCrisco JJ IIIPanjabi MMet al: Biomechanical evaluation of four different posterior atlantoaxial fixation techniques. Spine 17:4804901992Grob D Crisco JJ III Panjabi MM et al: Biomechanical evaluation of four different posterior atlantoaxial fixation techniques. Spine 17:480–490 1992

  • 14.

    Grob DJeanneret BAebi Met al: Atlanto-axial fusion with transarticular screw fixation. J Bone Joint Surg (Br) 73:9729761991Grob D Jeanneret B Aebi M et al: Atlanto-axial fusion with transarticular screw fixation. J Bone Joint Surg (Br) 73:972–976 1991

  • 15.

    Hanson PBMontesano PXSharkey NAet al: Anatomic and biomechanical assessment of transarticular screw fixation for atlantoaxial instability. Spine 16:114111451991Hanson PB Montesano PX Sharkey NA et al: Anatomic and biomechanical assessment of transarticular screw fixation for atlantoaxial instability. Spine 16:1141–1145 1991

  • 16.

    Jeanneret BMagerl F: Primary posterior fusion C1/2 in odontoid fractures: indications, technique, and results of transarticular screw fixation. J Spinal Disord 5:4644751992Jeanneret B Magerl F: Primary posterior fusion C1/2 in odontoid fractures: indications technique and results of transarticular screw fixation. J Spinal Disord 5:464–475 1992

  • 17.

    Magerl FSeemann PS: Stable posterior fusion of the atlas and axis by transarticular screw fixation in Kehr PWeidner A (eds): Cervical Spine I. New York: Springer-Verlag1987 pp 322327Magerl F Seemann PS: Stable posterior fusion of the atlas and axis by transarticular screw fixation in Kehr P Weidner A (eds): Cervical Spine I. New York: Springer-Verlag 1987 pp 322–327

  • 18.

    Marcotte PDickman CASonntag VKHet al: Posterior atlantoaxial facet screw fixation. J Neurosurg 79:2342371993Marcotte P Dickman CA Sonntag VKH et al: Posterior atlantoaxial facet screw fixation. J Neurosurg 79:234–237 1993

  • 19.

    Montesano PXJuach ECAnderson PAet al: Biomechanics of cervical spine internal fixation. Spine 16 (Suppl 3):S10S161991Montesano PX Juach EC Anderson PA et al: Biomechanics of cervical spine internal fixation. Spine 16 (Suppl 3):S10–S16 1991

  • 20.

    Paramore CGDickman CASonntag VKH: The anatomical suitability of the C1–2 complex for transarticular screw fixation. J Neurosurg 85:2212241996Paramore CG Dickman CA Sonntag VKH: The anatomical suitability of the C1–2 complex for transarticular screw fixation. J Neurosurg 85:221–224 1996

  • 21.

    Roy LGibson DA: Cervical spine fusions in children. Clin Orthop 73:1461511970Roy L Gibson DA: Cervical spine fusions in children. Clin Orthop 73:146–151 1970

  • 22.

    Sasso RCJeanneret BFischer Ket al: Occipitocervical fusion with posterior plate and screw instrumentation. A long-term follow-up study. Spine 19:236423681994Sasso RC Jeanneret B Fischer K et al: Occipitocervical fusion with posterior plate and screw instrumentation. A long-term follow-up study. Spine 19:2364–2368 1994

  • 23.

    Sharma RRParekh HCPrabhu Set al: Compression of the C-2 root by a rare anomalous ectatic vertebral artery. Case report. J Neurosurg 78:6696721993Sharma RR Parekh HC Prabhu S et al: Compression of the C-2 root by a rare anomalous ectatic vertebral artery. Case report. J Neurosurg 78:669–672 1993

  • 24.

    Sherk HHSnyder B: Posterior fusions of the upper spine: indications, techniques and prognosis. Orthop Clin North Am 9:109110991978Sherk HH Snyder B: Posterior fusions of the upper spine: indications techniques and prognosis. Orthop Clin North Am 9:1091–1099 1978

  • 25.

    Smith MDKotzar GYoo Jet al: A biomechanical analysis of atlantoaxial stabilization methods using a bovine model. C1/C2 fixation analysis. Clin Orthop 290:2852951993Smith MD Kotzar G Yoo J et al: A biomechanical analysis of atlantoaxial stabilization methods using a bovine model. C1/C2 fixation analysis. Clin Orthop 290:285–295 1993

  • 26.

    Smith MDPhillips WAHensinger RN: Complications of fusion to the upper cervical spine. Spine 16:7027051991Smith MD Phillips WA Hensinger RN: Complications of fusion to the upper cervical spine. Spine 16:702–705 1991

  • 27.

    Sonntag VKHDickman CA: Craniocervical stabilization. Clin Neurosurg 40:2432721996Sonntag VKH Dickman CA: Craniocervical stabilization. Clin Neurosurg 40:243–272 1996

  • 28.

    Sonntag VKHDickman CA: Occipitocervical and high cervical stabilization in Rengachary SSWilkins RH (eds): Neurosurgical Operative Atlas. Baltimore: Williams & Wilkins1991 pp 327337Sonntag VKH Dickman CA: Occipitocervical and high cervical stabilization in Rengachary SS Wilkins RH (eds): Neurosurgical Operative Atlas. Baltimore: Williams & Wilkins 1991 pp 327–337

  • 29.

    Stillerman CBWilson JA: Atlanto-axial stabilization with posterior transarticular screw fixation: technical description and report of 22 cases. Neurosurgery 2:9489551993Stillerman CB Wilson JA: Atlanto-axial stabilization with posterior transarticular screw fixation: technical description and report of 22 cases. Neurosurgery 2:948–955 1993

  • 30.

    Tokuda KMiyasaka KAbe Het al: Anomalous atlantoaxial portions of vertebral and posterior inferior cerebellar arteries. Neuroradiology 27:4104131985Tokuda K Miyasaka K Abe H et al: Anomalous atlantoaxial portions of vertebral and posterior inferior cerebellar arteries. Neuroradiology 27:410–413 1985

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