Atlantoaxial stabilization with the use of C1–3 lateral mass screw fixation

Technical note

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✓ Atlantoaxial stabilization has evolved from simple posterior wiring to transarticular screw fixation. In some patients, however, the course of the vertebral artery (VA) through the axis varies, and therefore transarticular screw placement is not always feasible. For these patients, the authors have developed a novel method of atlantoaxial stabilization that does not require axial screws. In this paper, they describe the use of this technique in the first 10 cases.

Ten consecutive patients underwent the combined C1–3 lateral mass–sublaminar axis cable fixation technique. The mean age of the patients was 62.6 years (range 23–84 years). There were six men and four women. Eight patients were treated after traumatic atlantoaxial instability developed (four had remote trauma and previous nonunion), whereas in the other two atlantoaxial instability was caused by arthritic degeneration. All had VA anatomy unsuitable to traditional transarticular screw fixation.

There were no intraoperative complications in any of the patients. Postoperative computed tomography studies demonstrated excellent screw positioning in each patient. Nine patients were treated postoperatively with the aid of a rigid cervical orthosis. The remaining patient was treated using a halo fixation device. One patient died of respiratory failure 2 months after surgery. Follow-up data (mean follow-up duration 13.1 months) were available for seven of the remaining nine patients and demonstrated a stable construct with fusion in each patient.

The authors present an effective alternative method in which C1–3 lateral mass screw fixation is used to treat patients with unfavorable anatomy for atlantoaxial transarticular screw fixation. In this series of 10 patients, the method was a safe and effective way to provide stabilization in these anatomically difficult patients.

Abbreviation used in this paper:VA = vertebral artery.

Article Information

Address reprint requests to: Volker K. H. Sonntag, M.D., c/o Neuroscience Publications, Barrow Neurological Institute, 350 West Thomas Road, Phoenix, Arizona 85013. email:

© AANS, except where prohibited by US copyright law.



  • View in gallery

    Schematic illustrations showing the technique of C1–3 lateral mass fixation with C-2 sublaminar wiring and graft placement. Posterior view (A) of the final construct. Axial views of the lateral mass screws in C-1 (B) and C-3 (C). Reprinted with permission from Barrow Neurological Institute.

  • View in gallery

    Axial (A) and sagittal (B and C) reconstructed computed tomography scans obtained in a patient with an atlantoaxial distraction injury treated using the C1–3 fixation technique. Note the high-riding and medially oriented transverse foramina bilaterally in the axis (black arrows).

  • View in gallery

    Intraoperative photograph showing the final construct.

  • View in gallery

    Postoperative lateral radiograph confirming excellent screw and graft placement.



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