Yue-Qi Du, Yi-Heng Yin, Guang-Yu Qiao and Xin-Guang Yu
The authors describe a novel “in-out-in” technique as an alternative option for posterior C2 screw fixation in cases that involve narrow C2 isthmus. Here, they report the preliminary radiological and clinical outcomes in 12 patients who had a minimum 12-month follow-up period.
Twelve patients with basilar invagination and atlantoaxial dislocation underwent atlantoaxial reduction and fixation. All patients had unilateral hypoplasia of the C2 isthmus that prohibited insertion of pedicle screws. A new method, the C2 medial pedicle screw (C2MPS) fixation, was used as an alternative. In this technique, the inner cortex of the narrow C2 isthmus was drilled to obtain space for screw insertion, such that the lateral cortex could be well preserved and the risk of vertebral artery injury could be largely reduced. The C2MPS traveled along the drilled inner cortex into the anterior vertebral body, achieving a 3-column fixation of the axis with multicortical purchase.
Satisfactory C2MPS placement and reduction were achieved in all 12 patients. No instance of C2MPS related vertebral artery injury or dural laceration was observed. There were no cases of implant failure, and solid fusion was demonstrated in all patients.
This novel in-out-in technique can provide 3-column rigid fixation of the axis with multicortical purchase. Excellent clinical outcomes with low complication rates were achieved with this technique. When placement of a C2 pedicle screw is not possible due to anatomical constraints, the C2MPS can be considered as an efficient alternative.
Yue-Qi Du, Teng Li, Chao Ma, Guang-Yu Qiao, Yi-Heng Yin and Xin-Guang Yu
The authors conducted a study to investigate the biomechanical feasibility and stability of C1 lateral mass–C2 bicortical translaminar screw (C1LM-C2TL) fixation, C1 lateral mass–C2/3 transarticular screw (C1LM-C2/3TA) fixation, and C1LM-C2/3TA fixation with transverse cross-links (C1LM-C2/3TACL) as alternative techniques to the Goel-Harms technique (C1 lateral mass–C2 pedicle screw [C1LM-C2PS] fixation) for atlantoaxial fixation.
Eight human cadaveric cervical spines (occiput–C7) were tested using an industrial robot. Pure moments that were a maximum of 1.5 Nm were applied in flexion-extension (FE), lateral bending (LB), and axial rotation (AR). The specimens were first tested in the intact state and followed by destabilization (a type II odontoid fracture) and fixation as follows: C1LM-C2PS, C1LM-C2TL, C1LM-C2/3TA, and C1LM-C2/3TACL. For each condition, the authors evaluated the range of motion and neutral zone across C1 and C2 in all directions.
Compared with the intact spine, each instrumented spine significantly increased in stability at the C1–2 segment. C1LM-C2TL fixation demonstrated similar stability in FE and LB and greater stability in AR than C1LM-C2PS fixation. C1LM-C2/3TA fixation was equivalent in LB and superior in FE to those of C1LM-C2PS and C1LM-C2TL fixation. During AR, the C1LM-C2/3TA–instrumented spine failed to maintain segmental stability. After adding a cross-link, the rotational stability was significantly increased in the C1LM-C2/3TACL–instrumented spine compared with the C1LM-C2/3TA–instrumented spine. Although inferior to C1LM-C2TL fixation, the C1LM-C2/3TACL–instrumented spine showed equivalent rotational stability to the C1LM-C2PS–instrumented spine.
On the basis of our biomechanical study, C1LM-C2TL and C1LM-C2/3TACL fixation resulted in satisfactory atlantoaxial stabilization compared with C1LM-C2PS. Therefore, the authors believe that the C1LM-C2TL and C1LM-C2/3TACL fixation may serve as alternative procedures when the Goel-Harms technique (C1LM-C2PS) is not feasible due to anatomical constraints.