C-2 neurectomy during atlantoaxial instrumented fusion in the elderly: patient satisfaction and surgical outcome

Clinical article

D. Kojo Hamilton Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland; and

Search for other papers by D. Kojo Hamilton in
jns
Google Scholar
PubMed
Close
 M.D.
,
Justin S. Smith Department of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia

Search for other papers by Justin S. Smith in
jns
Google Scholar
PubMed
Close
 M.D., Ph.D.
,
Charles A. Sansur Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland; and

Search for other papers by Charles A. Sansur in
jns
Google Scholar
PubMed
Close
 M.D.
,
Aaron S. Dumont Department of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia

Search for other papers by Aaron S. Dumont in
jns
Google Scholar
PubMed
Close
 M.D.
, and
Christopher I. Shaffrey Department of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia

Search for other papers by Christopher I. Shaffrey in
jns
Google Scholar
PubMed
Close
 M.D.
Restricted access

Purchase Now

USD  $45.00

Spine - 1 year subscription bundle (Individuals Only)

USD  $392.00

JNS + Pediatrics + Spine - 1 year subscription bundle (Individuals Only)

USD  $636.00
USD  $45.00
USD  $392.00
USD  $636.00
Print or Print + Online Sign in

Object

The originally described technique of atlantoaxial stabilization using C-1 lateral mass and C-2 pars screws includes a C-2 neurectomy to provide adequate hemostasis and visualization for screw placement, enable adequate joint decortication and arthrodesis, and prevent new-onset postoperative C-2 neuralgia. However, inclusion of a C-2 neurectomy for this procedure remains controversial, likely due in part to a lack of studies that have specifically addressed whether it affects patient outcome. The authors' objective was to assess the surgical and clinical impact of routine C-2 neurectomy performed with C1–2 segmental instrumented arthrodesis in a consecutive series of elderly patients with C1–2 instability.

Methods

Forty-four consecutive patients (mean age 71 years) underwent C1–2 instrumented fusion, including C-1 lateral mass screw insertion. Bilateral C-2 neurectomies were performed. Standardized clinical assessments were performed both pre- and postoperatively. Numbness or discomfort in a C-2 distribution was documented at follow-up. Fusion was assessed using the Lenke fusion grade.

Results

Among all 44 patients, mean blood loss was 200 ml (range 100–350 ml) and mean operative time was 129 minutes (range 87–240 minutes). There were no intraoperative complications, and no patients reported new postoperative onset or worsening of C-2 neuralgia postoperatively. Outcomes for the 30 patients with a minimum 13-month follow-up (range 13–72 months) were assessed. At a mean follow-up of 36 months, Nurick grade and pain numeric rating scale scores improved from 3.7 to 1.0 (p < 0.001) and 9.4 to 0.6 (p < 0.001), respectively. The mean postoperative Neck Disability Index score was 7.3%. The fusion rate was 97%, and the patient satisfaction rate was 93%. All 24 patients with preoperative occipital neuralgia reported relief. Seventeen patients noticed C-2 distribution numbness only during examination in the clinic, and 2 patients reported C-2 numbness, but it did not affect their daily function.

Conclusions

In this series of C1–2 instrumented arthrodesis in elderly patients, excellent fusion rates were achieved, and patient satisfaction was not negatively affected by C-2 neurectomy. In the authors' experience, C-2 neurectomy enhanced surgical exposure of the C1–2 joint, thereby facilitating hemostasis, placement of instrumentation, and decortication of the joint space for arthrodesis. Importantly, with C-2 neurectomy in the present series, no cases of new onset postoperative C-2 neuralgia occurred, in contrast to a growing number of reports in the literature documenting new-onset C-2 neuralgia without C-2 neurectomy. On the contrary, 80% of patients in the present series had preoperative occipital neuralgia and in all of these patients this neuralgia was relieved following C1–2 instrumented arthrodesis with C-2 neurectomy.

Abbreviations used in this paper:

EBL = estimated blood loss; NDI = Neck Disability Index.
  • Collapse
  • Expand
  • 1

    Aryan HE, , Newman CB, , Nottmeier EW, , Acosta FL Jr, , Wang VY, & Ames CP: Stabilization of the atlantoaxial complex via C-1 lateral mass and C-2 pedicle screw fixation in a multicenter clinical experience in 102 patients: modification of the Harms and Goel techniques. J Neurosurg Spine 8:222229, 2008

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 2

    Brooks AL, & Jenkins EB: Atlanto-axial arthrodesis by the wedge compression method. J Bone Joint Surg Am 60:279284, 1978

  • 3

    Clavel M, & Clavel P: Occipital neuralgia secondary to exuberant callus formation. Case report. J Neurosurg 85:11701171, 1996

  • 4

    Conroy E, , Laing A, , Kenneally R, & Poynton AR: C1 lateral mass screw-induced occipital neuralgia: a report of two cases. Eur Spine J 19:474476, 2010

  • 5

    Coric D, , Branch CL Jr, , Wilson JA, & Robinson JC: Arteriovenous fistula as a complication of C1-2 transarticular screw fixation. Case report and review of the literature. J Neurosurg 85:340343, 1996

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 6

    Crisco JJ III, , Panjabi MM, , Oda T, , Grob D, & Dvorak J: Bone graft translation of four upper cervical spine fixation techniques in a cadaveric model. J Orthop Res 9:835846, 1991

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 7

    De Iure F, , Donthineni R, & Boriani S: Outcomes of C1 and C2 posterior screw fixation for upper cervical spine fusion. Eur Spine J 18:Suppl 1 26, 2009

  • 8

    Ehni G, & Benner B: Occipital neuralgia and the C1–2 arthrosis syndrome. J Neurosurg 61:961965, 1984

  • 9

    Gallie W: Fractures and dislocations of the cervical spine. Am J Surg 46:495499, 1939

  • 10

    Gille O, , Lavignolle B, & Vital JM: Surgical treatment of greater occipital neuralgia by neurolysis of the greater occipital nerve and sectioning of the inferior oblique muscle. Spine 29:828832, 2004

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 11

    Gluf WM, , Schmidt MH, & Apfelbaum RI: Atlantoaxial transarticular screw fixation: a review of surgical indications, fusion rate, complications, and lessons learned in 191 adult patients. J Neurosurg Spine 2:155163, 2005

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 12

    Goel A: Atlantoaxial instability. J Neurosurg Spine 1:347, 2004. (Letter)

  • 13

    Goel A, , Desai KI, & Muzumdar DP: Atlantoaxial fixation using plate and screw method: a report of 160 treated patients. Neurosurgery 51:13511357, 2002

  • 14

    Goel A, & Laheri V: Plate and screw fixation for atlanto-axial subluxation. Acta Neurochir (Wien) 129:4753, 1994

  • 15

    Grob D, , Crisco JJ III, , Panjabi MM, , Wang P, & Dvorak J: Biomechanical evaluation of four different posterior atlantoaxial fixation techniques. Spine 17:480490, 1992

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 16

    Grob D, , Dvorák J, , Panjabi MM, & Hayek J: Dorsal atlanto-axial screw fixation. A stability test in vitro and in vivo. Orthopade 20:154162, 1991

  • 17

    Grob D, , Jeanneret B, , Aebi M, & Markwalder TM: Atlanto-axial fusion with transarticular screw fixation. J Bone Joint Surg Br 73:972976, 1991

  • 18

    Harms J, & Melcher RP: Posterior C1–C2 fusion with polyaxial screw and rod fixation. Spine 26:24672471, 2001

  • 19

    Henriques T, , Cunningham BW, , Olerud C, , Shimamoto N, , Lee GA, & Larsson S, et al.: Biomechanical comparison of five different atlantoaxial posterior fixation techniques. Spine 25:28772883, 2000

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 20

    Kerr RW: A mechanism to account for frontal headache in cases of posterior-fossa tumors. J Neurosurg 18:605609, 1961

  • 21

    Lee SH, , Kim ES, , Sung JK, , Park YM, & Eoh W: Clinical and radiological comparison of treatment of atlantoaxial instability by posterior C1-C2 transarticular screw fixation or C1 lateral mass-C2 pedicle screw fixation. J Clin Neurosci 17:886892, 2010

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 22

    Lenke LG, , Bridwell KH, , Bullis D, , Betz RR, , Baldus C, & Schoenecker PL: Results of in situ fusion for isthmic spondylolisthesis. J Spinal Disord 5:433442, 1992

  • 23

    Liu G, , Buchowski JM, , Shen H, , Yeom JS, & Riew KD: The feasibility of microscope-assisted “free-hand” C1 lateral mass screw insertion without fluoroscopy. Spine 33:10421049, 2008

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 24

    Madawi AA, , Casey AT, , Solanki GA, , Tuite G, , Veres R, & Crockard HA: Radiological and anatomical evaluation of the atlantoaxial transarticular screw fixation technique. J Neurosurg 86:961968, 1997

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 25

    Magerl F, & Seemann PS, Stable posterior fusion of the atlas and axis by transarticular screw fixation. Kehr P, & Weidner A: Cervical Spine I New York, Springer, 1986. 322327

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 26

    McDowell I, & Newell C: Measuring Health: A Guide to Rating Scales and Questionnaires New York, Oxford University Press, 1996

  • 27

    Naderi S, , Crawford NR, , Song GS, , Sonntag VK, & Dickman CA: Biomechanical comparison of C1–C2 posterior fixations. Cable, graft, and screw combinations. Spine 23:19461956, 1998

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 28

    Nurick S: The natural history and the results of surgical treatment of the spinal cord disorder associated with cervical spondylosis. Brain 95:101108, 1972

  • 29

    Payer M, , Luzi M, & Tessitore E: Posterior atlanto-axial fixation with polyaxial C1 lateral mass screws and C2 pars screws. Acta Neurochir (Wien) 151:223229, 2009

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 30

    Rhee WT, , You SH, , Kim SK, & Lee SY: Troublesome occipital neuralgia developed by c1–c2 harms construct. J Korean Neurosurg Soc 43:111113, 2008

  • 31

    Sciubba DM, , Noggle JC, , Vellimana AK, , Alosh H, , McGirt MJ, & Gokaslan ZL, et al.: Radiographic and clinical evaluation of free-hand placement of C-2 pedicle screws. Clinical article. J Neurosurg Spine 11:1522, 2009

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 32

    Scott M: Occipital neuralgia. Pa Med 71:8588, 1968

  • 33

    Seal C, , Zarro C, , Gelb D, & Ludwig S: C1 lateral mass anatomy: proper placement of lateral mass screws. J Spinal Disord Tech 22:516523, 2009

  • 34

    Star MJ, , Curd JG, & Thorne RP: Atlantoaxial lateral mass osteoarthritis. A frequently overlooked cause of severe occipitocervical pain. Spine 17:6 Suppl S71S76, 1992

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 35

    Stulik J, , Vyskocil T, , Sebesta P, & Kryl J: Atlantoaxial fixation using the polyaxial screw-rod system. Eur Spine J 16:479484, 2007

  • 36

    Vernon H, & Mior S: The Neck Disability Index: a study of reliability and validity. J Manipulative Physiol Ther 14:409415, 1991

  • 37

    Wright NM, & Lauryssen C: 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 88:634640, 1998

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 38

    Xie Y, , Li Z, , Tang H, , Li M, & Guan Z: Posterior C1 lateral mass and C2 pedicle screw internal fixation for atlantoaxial instability. J Clin Neurosci 16:15921594, 2009

    • PubMed
    • Search Google Scholar
    • Export Citation

Metrics

All Time Past Year Past 30 Days
Abstract Views 1263 172 32
Full Text Views 235 33 0
PDF Downloads 265 31 0
EPUB Downloads 0 0 0