Differences in fixation strength among constructs of atlantoaxial fixation

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To avoid jeopardizing an aberrant vertebral artery, there are three common options in placing a C2 screw, including pedicle, pars, and translaminar screws. Although biomechanical studies have demonstrated similar strength among these C2 screws in vitro, there are limited clinical data to address their differences in vivo. When different screws were placed in each side, few reports have compared the outcomes. The present study aimed to evaluate these multiple combinations of C2 screws.


Consecutive adult patients who underwent posterior atlantoaxial (AA) fixation were retrospectively reviewed. Every patient uniformly had bilateral C1 lateral mass screws in conjunction with 2 C2 screws (1 C2 screw on each side chosen among the three options: pedicle, pars, or translaminar screws, based on individualized anatomical consideration). These patients were then grouped according to the different combinations of C2 screws for comparison of the outcomes.


A total of 63 patients were analyzed, with a mean follow-up of 34.3 months. There were five kinds of construct combinations of the C2 screws: 2 pedicle screws (the Ped-Ped group, n = 24), 2 translaminar screws (the La-La group, n = 7), 2 pars screws (the Pars-Pars group, n = 6), 1 pedicle and 1 pars screw (the Ped-Pars group, n = 7), and 1 pedicle and 1 translaminar screw (the Ped-La group, n = 19). The rate of successful fixation in each of the groups was 100%, 57.1%, 100%, 100%, and 78.9% (Ped-Ped, La-La, Par-Par, Ped-Par, and Ped-La, respectively). The patients who had no translaminar screw had a higher rate of success than those who had 1 or 2 translaminar screws (100% vs 73.1%, p = 0.0009). Among the 5 kinds of construct combinations, 2 C2 pedicle screws (the Ped-Ped group) had higher rates of success than 1 C2 pedicle and 1 C2 translaminar screw (the Ped-La group, p = 0.018). Overall, the rate of successful fixation was 87.3% (55/63). There were 7 patients (4 in the Ped-La group and 3 in the La-La group) who lost fixation/reduction, and they all had at least 1 translaminar screw.


In AA fixation, C2 pedicle or pars screws or a combination of both provided very high success rates. Involvement of 1 or 2 C2 translaminar screws in the construct significantly lowered success rates. Therefore, a C2 pars screw is recommended over a translaminar screw.

ABBREVIATIONS AA = atlantoaxial; ADI = atlantodental interval; HRVA = high-riding VA; TAS = transarticular screw; VA = vertebral artery.

Article Information

Correspondence Jau-Ching Wu: Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan. jauching@gmail.com.

INCLUDE WHEN CITING Published online October 19, 2018; DOI: 10.3171/2018.6.SPINE171390.

C.C.C. and W.C.H. contributed equally to this work.

Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

© AANS, except where prohibited by US copyright law.



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    Preoperative lateral dynamic radiographs (flexion and extension, A and B), CT scan (C), and MR image (D) of a patient with chronic traumatic odontoid fracture. The patient underwent AA fixation with a combination of pedicle and translaminar screws in the C2 vertebra. The postoperative lateral radiographs and CT (E and F) demonstrated complete reduction, wiring, and autologous bone grafting. However, resubluxation was demonstrated at 1.5 months postoperatively on a lateral radiograph (G) and CT scan (H). The patient had few symptoms and was managed conservatively and maintained follow-up to date.

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    Preoperative lateral dynamic radiographs (flexion and extension, A and B) and MR image (C) of a patient with AA subluxation who underwent fixation with bilateral C1 lateral mass screws and C2 translaminar screws. Reduction of the AA subluxation was achieved by surgery as shown on a lateral radiograph (D) and CT scan (E) 3 days postoperatively. However, there was gradual loss of reduction (F, 2-month postoperative lateral radiograph) and fracture of the C1 screw (G, 6-month postoperative lateral radiograph).

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    Comparison of the symmetry between constructs: Ped-Ped (A) and Ped-La (B). Copyright Shao-Yen Huang. Interactive 3D version: https://sketchfab.com/Taroyen. Published with permission. Figure is available in color online only.



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