Clinical Study
Clinical and radiological Comparison of treatment of atlantoaxial instability by posterior C1–C2 transarticular screw fixation or C1 lateral mass-C2 pedicle screw fixation

https://doi.org/10.1016/j.jocn.2009.10.008Get rights and content

Abstract

We compared the clinical and radiological results of posterior atlantoaxial fixation surgery using transarticular screws to those using a polyaxial screw–rod system in 55 patients with symptomatic atlantoaxial instability. Patients underwent posterior C1–C2 fixation: 28 patients (group 1) underwent C1–C2 transarticular screw fixation and 27 patients (group 2) underwent C1 lateral mass–C2 pedicle screw fixation. Patients were followed-up for at least 24 months. The clinical and radiological results were evaluated in the early postoperative period and at 3, 6, 12 and 24 months after surgery. Long-term postoperative stability and bone fusion were examined. After surgery, 93% of patients in group 1 and 96% of patients in group 2 were free of neck pain. The solid fusion rates were 82% for group 1 patients and 96% for group 2 patients at 12 months (p < 0.092). In group 1, three patients showed fibrous union. Four patients had hardware failure due to a screw malposition (one in group 1) and pseudoarthrodesis (two in group 1 and one in group 2). One patient in group 1 had cerebrospinal fluid leakage. One patient in group 2 had occipital neuralgia. One vertebral artery injury occurred during the screw placement in group 1 and another in group 2 during the muscle dissection. C1–C2 transarticular screw fixation and C1 lateral mass–C2 pedicle screw fixation both produced excellent results for stabilization of the atlantoaxial complex, but the radiological outcome tended to be superior in C1 lateral mass–C2 pedicle screw fixation.

Introduction

Since the introduction of C1–C2 transarticular screw fixation by Magerl and Seemann, posterior atlantoaxial screw fixation has been a highly effective way to fuse the atlas and axis in treating atlantoaxial instability resulting from trauma, inflammatory disease, tumor, and congenital abnormalities, with a low complication rate.[1], [2], [3], [4], [5], [6] However, widespread acceptance of the technique has been hindered by the risk of complications, such as hardware failure and errant screw placement, coupled with major morbidity such as hypoglossal nerve paresis and vertebral artery (VA) injuries.[4], [7], [8] This method is also contraindicated in patients with damage to the posterior column and a fixed severe anterior dislocation of the atlas.[9], [10] Atlantoaxial screw/rod fixation is proposed to be safer and applicable to more patients than transarticular screw fixation.8 Although there have been many clinical analyses of each technique, these two approaches have not been compared in the management of atlantoaxial instability except for several biomechanical studies.[11], [12], [13], [14], [15], [16], [17], [18], [19], [20] The aim of this study was to compare the clinical and radiographic results and complications in patients who underwent a C1 lateral mass–C2 pedicle screw fixation for atlantoaxial instability to a matched group of patients treated using C1–C2 transarticular screw fixation at the same institution.

Section snippets

Patient population

From July 2001 to June 2007, the authors surgically treated 63 patients with symptomatic atlantoaxial instability. Fifty-five of these patients, either adult or child, were selected for this retrospective study according to the following criteria: (i) atlantoaxial fusion was performed for C1–C2 instability; and (ii) follow-up duration was a minimum of 24 months. Patients were excluded from the study if they had instability that required extended posterior fixation or if the instability had been

Results

There were 22 females and 33 males. The patients’ ages ranged from 7 years to 79 years (mean, 47.9 years). The mean follow-up period was 46.7 months with a minimum period of 2 years (range, 24–99 months). The etiology of atlantoaxial instability was pseudoarthrosis of the anterior odontoid fixation in eight patients, acute fracture of the odontoid in 12 patients, C1–C2 complex ligamentous injury in 10 patients, os odontoideum in nine patients, rheumatoid arthritis in eight patients, traumatic

Discussion

The placement of transarticular C1–C2 screws, as described by Magerl and Seeman,5 provides an excellent three-point fixation technique for atlantoaxial instability and a biomechanically sound construct with the incorporation of four cortical surfaces.[1], [2], [5], [6], [21], [22] However, the insertion procedure is technically demanding due to the danger of VA injury, particularly in patients where atlantoaxial subluxation remains irreducible preoperatively.[1], [23] Moreover, there is an

Conclusion

C1–C2 transarticular screw fixation and C1 lateral mass–C2 pedicle screw fixation are effective for stabilizing the atlantoaxial complex. We found that the clinical results were excellent in both techniques, but the radiological outcome was slightly better in C1 lateral mass–C2 pedicle screw fixation. In addition, this fixation enabled us to provide temporary fixation without damaging the atlantoaxial joints.

References (28)

  • C.A. Dickman et al.

    Posterior C1–C2 transarticular screw fixation for atlantoaxial arthrodesis

    Neurosurgery

    (1998)
  • I.D. Farey et al.

    Modified Gallie technique versus transarticular screw fixation in C1–C2 fusion

    Clin Orthop

    (1999)
  • W.M. Gluf et al.

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

    J Neurosurg Spine

    (2005)
  • R.W. Haid et al.

    C1–C2 transarticular screw fixation for atlantoaxial instability: a 6-year experience

    Neurosurgery

    (2001)
  • F. Magerl et al.

    Stable posterior fusion at the atlas and axis by transarticular screw fixation

  • T.M. Reilly et al.

    Atlantoaxial stabilization: clinical comparison of posterior cervical wiring technique with transarticular screw fixation

    J Spinal Disord Tech

    (2003)
  • D. Grob et al.

    Atlanto-axial fusion with transarticular screw fixation

    J Bone Joint Surg Am

    (1991)
  • J. Harms et al.

    Posterior C1–C2 fusion with polyaxial screw and rod fixation

    Spine

    (2001)
  • A.T. Casey et al.

    Is the technique of posterior transarticular screw fixation suitable for rheumatoid atlanto-axial subluxation?

    Br J Neurosurg

    (1997)
  • C.G. Paramore et al.

    The anatomical suitability of the C1–2 complex for transarticular screw fixation

    J Neurosurg

    (1996)
  • A. Goel et al.

    Plate and screw fixation for atlantoaxial subluxation

    Acta Neurochir (Wien)

    (1994)
  • H.E. Aryan et al.

    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

    (2008)
  • A.J. Fiore et al.

    Atlantal lateral mass screws for posterior spinal reconstruction: technical note and case series

    Neurosurg Focus

    (2002)
  • A. Goel et al.

    Atlantoaxial fixation using plate and screw method: a report of 160 treated patients

    Neurosurgery

    (2002)
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