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Amory J. Fiore, Regis W. Haid, Gerald E. Rodts, Brian R. Subach, Praveen V. Mummaneni, Charles J. Riedel and Barry D. Birch

Object

A variety of techniques may be used to achieve fixation of the upper cervical spine. Transarticular atlantoaxial screws, posterior interspinous cable and graft constructs, and interlaminar clamps have been used effectively to achieve atlantoaxial fixation. Various anatomical factors, however, may preclude the successful application of these techniques. These factors include aberrant vertebral artery anatomy, irreducible atlantoaxial subluxation, exaggerated cervicothoracic kyphosis, and the absence of the osseous substrate for fixation. In these cases, an alternative method of fixation must be performed. The authors present an alternative method to achieve fixation of the atlas in which lateral mass screws can be applied to atlantoaxial and occipitocervical fixation.

Methods

Between February 1998 and November 2001, eight patients who ranged in age from 16 to 74 years underwent posterior fixation for upper cervical instability. Diagnoses included C-2 metastastic disease in two patients, irreducible odontoid fractures in two patients, atlantoaxial subluxation in two patients, and transverse ligament synovial cyst in two patients. Various anatomical factors precluded transarticular atlantoaxial screw fixation in seven patients. One patient with a highly unstable spine due to a C-2 metastasis and pathological fracture underwent occipitocervical fusion.

Atlantocervical fixation was achieved in seven patients by using varying constructs incorporating C-1 lateral mass screws. Occipitocervical fixation was achieved in one patient by incorporating C-1 lateral mass screws as an additional fixation point. A total of 14 C-1 lateral mass screws were placed in eight patients. There were no intraoperative complications. In all patients rigid fixation was achieved as demonstrated on postoperative radiographs. One patient died on postoperative Day 9 of aspiration pneumonia. At a mean follow-up time of 7.4 months, rigid fixation was maintained in all patients.

Conclusions

Atlantal lateral mass screws can be used to provide a safe and efficacious means of achieving atlantoaxial fixation when anatomical constraints preclude the use of a more traditional procedure. Atlantal lateral mass screws may also be incorporated in occipitocervical constructs to provide additional fixation points which may prevent construct failure.

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querying the Cochrane Collaboration, Educus journal search, PubMed, and Google Scholar databases using the following phrases: “spine injury return to play,” “cervical spine injury athletes,” and “return to play thoracolumbar.” Additionally relevant references from these articles were reviewed. Results: All recommendations represent level III evidence. Absolute contraindications for return to play include atlantoaxial fusions, occipitalcervical fusions, atlantodental interval >3mm adult (> 4mm child),acute herniated discs, discs with pain and neurologic deficits

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Andrew K. Chan, Arnau Benet, Junichi Ohya, Xin Zhang, Todd D. Vogel, Daniel W. Flis, Ivan H. El-Sayed and Praveen V. Mummaneni

and morbidity associated with a palate-splitting technique (velopharyngeal insufficiency) and an expanded endonasal approach (mucus crusting, sinusitis, and potential lacerum or cavernous-paraclival internal carotid artery injury). For appropriately selected lesions near the palatal line, the endoscopic transoral approach appears to be the preferred approach. References 1 Apuzzo ML , Weiss MH , Heiden JS : Transoral exposure of the atlantoaxial region . Neurosurgery 3 : 201 – 207 , 1978 2 Benet A , Rincon-Torroella J , Lawton MT

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orthosis, 2 with a Minerva brace, and 1 with a halo. Two patients required cervical surgery; an occipital cervical fusion for a type 2 odontoid fracture and one atlantoaxial fusion for atlantoaxial instability was performed. At the follow up appointments, none of the patients were found to have delayed instability based on clinical examination, upright x-rays or flexion-extension x-rays. Conclusion: All isolated OCF are likely stable injuries. Our data suggests all isolated OCF may be treated conservatively with any type of cervical orthosis and minimal follow up