Clinical StudyClinical and radiological Comparison of treatment of atlantoaxial instability by posterior C1–C2 transarticular screw fixation or 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.
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Cited by (68)
C1–C2 type Harms internal fixation for unstable C2 fracture in a 6-year-old boy: Case report
2019, NeurochirurgieCitation Excerpt :Dedicated fixation materials for pediatric populations of different ages could be worth developing. Lee et al. compared C1–C2 transarticular screw fixation and C1 lateral mass-C2 pedicle screw fixation: both produced excellent results for reduction and stabilization of the atlantoaxial complex, but he radiological outcome tended to be better in C1 lateral mass-C2 pedicle screw fixation [13]. In children, the Harms technique appears to be the safest, being outside the medullary canal and avoiding injury to the vertebral arteries.
Anatomical variations of vertebral artery and C2 isthmus in atlanto-axial fusion: Consecutive surgical 100 cases
2018, Journal of Clinical NeuroscienceCitation Excerpt :Turning a blind eye to these facts and figures may prove disastrous as the course of the vertebral artery in and around C2 varies in disease free populations [14,19,20], those with CSA [14,21,22] and in patients with acquired disease [23,24] at the CVJ. This led to the development of the pedicle screw technique, which was thought to carry less of a risk, however studies show same rates [25]. Previous studies have shown VA anomalies in the extra- and intraosseous regions of C2 closely relating to CSA [21], possibly from embryological origins [22,26–29].