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

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Object

Stabilization of the atlantoaxial complex has proven to be very challenging. Because of the high mobility of the C1–2 motion segment, fusion rates at this level have been substantially lower than those at the subaxial spine. The set of potential surgical interventions is limited by the anatomy of this region. In 2001 Jürgen Harms described a novel technique for individual fixation of the C-1 lateral mass and the C-2 pedicle by using polyaxial screws and rods. This method has been shown to confer excellent stability in biomechanical studies. Cadaveric and radiographic analyses have indicated that it is safe with respect to osseous and vascular anatomy. Clinical outcome studies and fusion rates have been limited to small case series thus far. The authors reviewed the multicenter experience with 102 patients undergoing C1–2 fusion via the polyaxial screw/rod technique. They also describe a modification to the Harms technique.

Methods

One hundred two patients (60 female and 42 male) with an average age of 62 years were included in this analysis. The average follow-up was 16.4 months. Indications for surgery were instability at the C1–2 level, and a chronic Type II odontoid fracture was the most frequent underlying cause. All patients had evidence of instability on flexion and extension studies. All underwent posterior C-1 lateral mass to C-2 pedicle or pars screw fixation, according to the method of Harms. Thirty-nine patients also underwent distraction and placement of an allograft spacer into the C1–2 joint, the authors' modification of the Harms technique. None of the patients had supplemental sublaminar wiring.

Results

All but 2 patients with at least a 12-month follow-up had radiographic evidence of fusion or lack of motion on flexion and extension films. All patients with an allograft spacer demonstrated bridging bone across the joint space on plain x-ray films and computed tomography. The C-2 root was sacrificed bilaterally in all patients. A postoperative wound infection developed in 4 patients and was treated conservatively with antibiotics and local wound care. One patient required surgical debridement of the wound. No patient suffered a neurological injury. Unfavorable anatomy precluded the use of C-2 pedicle screws in 23 patients, and thus, they underwent placement of pars screws instead.

Conclusions

Fusion of C1–2 according to the Harms technique is a safe and effective treatment modality. It is suitable for a wide variety of fracture patterns, congenital abnormalities, or other causes of atlantoaxial instability. Modification of the Harms technique with distraction and placement of an allograft spacer in the joint space may restore C1–2 height and enhance radiographic detection of fusion by demonstrating a graft–bone interface on plain x-ray films, which is easier to visualize than the C1–2 joint.

Abbreviations used in this paper: CT = computed tomography; rhBMP = recombinant human bone morphogenetic protein; VA = vertebral artery.

Article Information

Address correspondence to: Christopher P. Ames, M.D., Department of Neurosurgery, University of California, San Francisco Medical Center, 400 Parnassus Avenue, A808, San Francisco, California 94143. email: amesc@neurosurg.ucsf.edu.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Intraoperative photograph showing an allograft spacer placed into the C1–2 joint.

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    Preoperative sagittal (left) and coronal (right) reconstruction CT scans revealing os odontoideum.

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    Postoperative lateral plain radiograph demonstrating proper appearance of instrumentation.

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    Sagittal (left) and coronal (right) reconstruction CT scans obtained 1-year postoperatively, demonstrating the bridging trabecular bone.

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    Extension (upper) and flexion (lower) radiographs demonstrating subtle motion indicative of pseudarthrosis and screw fracture. The patient was asymptomatic.

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    Drawings depicting bicortical C-1 lateral mass screws (A) and their ability to reduce a C-1 fracture (B and C).

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