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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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Maxwell Boakye, Praveen V. Mummaneni, Mark Garrett, Gerald Rodts and Regis Haid

with profound quadriparesis following an MVA. Single-level discectomy was performed in 12 patients, two-level ACDF in nine, and three-level ACDF in three. Three patients presented with acute disc herniations, 16 with cervical spondylosis, two with ossification of the posterior longitudinal ligament, one with pseudarthrosis after a prior ACDF, one with an MVA-induced spinal cord contusion and disc herniation, and one patient with a fall-related C7—T1 subluxation. Anterior cervical discectomy was performed using previously described techniques. 15 Following

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Adam S. Kanter, Michael Y. Wang and Praveen V. Mummaneni

occur at or below C-7, at least partial upper extremity function would be preserved. Simmons 39 , 40 initially described the cervical posterior wedge osteotomy technique that he performed with the patient in the awake sitting position without posterior instrumentation. Mehdian and colleagues 25 were among the first to expand on Simmons' technique with the incorporation of posterior instrumentation to avoid sudden spinal subluxation during the correction maneuver and to avoid the use of postoperative halo immobilization. McMaster 24 reported on his experience in

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Fred C. Lam, Adam S. Kanter, David O. Okonkwo, James W. Ogilvie and Praveen V. Mummaneni

Modifiers Modifiers Modifiers Lumbar CSVL to Lumbar Apex Lumbar Lordosis Sagittal Deformity A btwn pedicles A marked (>40°) proximal thoracic (T2–5)≥ +20° B touches lat apex B mod (0–40°) main thoracic (T5–12)≥+50° C CSVL completely medial C none thoracolumbar (T10–L2)≥+20° lumbar (T12 S1) ≥−40° Thoracic Curve Subluxation Amount Lumbar Degenerative – hypo (<10°) 0 no subluxation degenerative disc disease N normal (10–40°) + max 1–6 mm listhesis + hyper (>40°) ++ max >7 mm

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, reduced ROM, >2 level ACDF, ligamentous injuries >3.5mm subluxation or >11° of angulation, burst fractures with retropulsion, lateral mass fractures with incongruity, delayed cervical instability, junction spanning instrumentation. Patients who are pain free, without neurologic deficit, have full ROM, radiologic evidence of a healed axis lateral mass fractures, odontoid fractures, non-displaced Jefferson fractures, <2 level ACDF, single level corpectomies, compression fractures, fractures without retropulsion, chronic discs, fully fused, asymptomatic, non

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Yoon Ha, Keishi Maruo, Linda Racine, William W. Schairer, Serena S. Hu, Vedat Deviren, Shane Burch, Bobby Tay, Dean Chou, Praveen V. Mummaneni, Christopher P. Ames and Sigurd H. Berven

DT group and 9.1% (2 patients) in the PT group (p = 1.000). However, the types of PJK were different between the groups, comparing the incidence of compression fracture and subluxation (p = 0.014). In the DT group, compression fracture of the UIV (9 patients) or UIV-1/UIV-2 (7 patients) was the most common type of PJK. In the PT group, subluxation with anterolisthesis of the proximal vertebra on the UIV was the most common mechanism of PJK. History of prior surgery was not different in the 2 groups. However, within each group, history of prior surgery was more

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Praveen V. Mummaneni, Christopher I. Shaffrey, Lawrence G. Lenke, Paul Park, Michael Y. Wang, Frank La Marca, Justin S. Smith, Gregory M. Mundis Jr., David O. Okonkwo, Bertrand Moal, Richard G. Fessler, Neel Anand, Juan S. Uribe, Adam S. Kanter, Behrooz Akbarnia and Kai-Ming G. Fu

radiographs. Patients in this treatment class should have at most an anterior or lateral Meyerding Grade 1 subluxation. The treatment goal in this group of patients is central canal, lateral recess, and/or foraminal nerve root decompression as needed and not correction of their overall mild spinal deformity. Minimally invasive techniques are well suited for this type of decompression. Typically, a fixed port tubular retractor or a small expandable tubular retractor is placed via a muscle-sparing approach and is used to perform an ipsilateral hemilaminotomy and foraminotomy

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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

Engl 67 : 321 – 325 , 1985 8 Crockard HA , Pozo JL , Ransford AO , Stevens JM , Kendall BE , Essigman WK : Transoral decompression and posterior fusion for rheumatoid atlantoaxial subluxation . J Bone Joint Surg Br 68 : 350 – 356 , 1986 9 Dasenbrock HH , Clarke MJ , Bydon A , Sciubba DM , Witham TF , Gokaslan ZL , : Endoscopic image-guided transcervical odontoidectomy: outcomes of 15 patients with basilar invagination . Neurosurgery 70 : 351 – 360 , 2012 10 de Almeida JR , Snyderman CH , Gardner PA

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Junichi Ohya, David P. Bray, Stephen T. Magill, Todd D. Vogel, Sigurd Berven and Praveen V. Mummaneni

of cervical spine fractures and subluxations using plates and screws . Neurosurgery 23 : 300 – 306 , 1988 10.1227/00006123-198809000-00003 3226509 8 Cornefjord M , Alemany M , Olerud C : Posterior fixation of subaxial cervical spine fractures in patients with ankylosing spondylitis . Eur Spine J 14 : 401 – 408 , 2005 15148595 10.1007/s00586-004-0733-1 9 Daneshvar P , Roffey DM , Brikeet YA , Tsai EC , Bailey CS , Wai EK : Spinal cord injuries related to cervical spine fractures in elderly patients: factors affecting mortality