Atlantoaxial transarticular screw fixation: a review of surgical indications, fusion rate, complications, and lessons learned in 191 adult patients

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Object. In this, the first of two articles regarding C1–2 transarticular screw fixation, the authors assessed the rate of fusion, surgery-related complications, and lessons learned after C1–2 transarticular screw fixation in an adult patient series.

Methods. The authors retrospectively reviewed 191 consecutive patients (107 women and 84 men; mean age 49.7 years, range 17–90 years) in whom at least one C1–2 transarticular screw was placed. Overall 353 transarticular screws were placed for trauma (85 patients), rheumatoid arthritis (63 patients), congenital anomaly (26 patients), os odontoideum (four patients), neoplasm (eight patients), and chronic cervical instability (five patients). Among these, 67 transarticular screws were placed in 36 patients as part of an occipitocervical construct. Seventeen patients had undergone 24 posterior C1–2 fusion attempts prior to referral. The mean follow-up period was 15.2 months (range 0.1–106.3 months).

Fusion was achieved in 98% of cases followed to commencement of fusion or for at least 24 months. The mean duration until fusion was 9.5 months (range 3–48 months). Complications occurred in 32 patients. Most were minor; however, five patients suffered vertebral artery (VA) injury. One bilateral VA injury resulted in patient death. The others did not result in any permanent neurological sequelae.

Conclusions. Based on this series, the authors have learned important lessons that can improve outcomes and safety. These include techniques to improve screw-related patient positioning, development of optimal instrumentation, improved screw materials and design, and defining the role for stereotactic navigation. Atlantoaxial transarticular screw fixation is highly effective in achieving fusion, and the complication rate is low when performed by properly trained surgeons.

Article Information

Address reprint requests to: Ronald I. Apfelbaum, M.D., Department of Neurosurgery, University of Utah, 30 N. 1900 East, Suite 3B409, Salt Lake City, Utah 84132-2303. email: ronald.apfelbaum@hsc.utah.edu.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Reformatted CT scans in the multiple planes of the proposed screw placement are used to ensure that a safe pathway exists. A: A safe trajectory is demonstrated for placement of a 4-mm transarticular screw. B: Stereotactic workstation images of the contralateral side in same patient demonstrated a very large VA foramen, which prevented safe screw trajectory.

  • View in gallery

    Photographs showing patient positioning. A: The back and legs of the surgical table are elevated, and slight Trendelenburg is used to optimize trajectory. B: The patient is in a military tuck position with the lower cervical spine in slight extension, the upper cervical spine and occiput in neutral or slight flexion, and the head translated posteriorly.

  • View in gallery

    Illustration. The C-2 pars interarticularis is the key landmark for safe passage of C1–2 transarticular screws. Note the relationship to the adjacent structures. The desired screw pathway is indicated by the dashed line.

  • View in gallery

    Artist's illustration. A: The drill bit is placed through the drill guide tube and a pilot hole is drilled under fluoroscopic visualization through the C-2 pars, across the C1–2 lateral mass articulation, and into the anterior cortex of the lateral mass of C-1 (white arrows in B). B: Fluoroscopic image showing a Penfield No. 4 dissector on the dorsal surface of the C-2 pars, where it serves as a landmark as the drill is advanced. The drill should pass immediately below this instrument and is usually aimed at the upper half of the C-1 anterior arch (black arrowhead). It ideally crosses the C1–2 joint (white arrowhead) near its midsection.

  • View in gallery

    Illustrations. Lateral (A) and posterior (B) views of the bone graft and cable construct. The superior edge of the bone is notched to fit snugly against both the posterior surface (arrow) and inferior surface (arrowhead) of the C-1 posterior ring as seen in A. A V-shaped notch is also cut in the inferior edge of the bone graft to fit over the spinous process of C-2 (arrows in B).

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