Biomechanical Analysis Comparing Three C1-C2 Transarticular Screw Salvaging Fixation Techniques

Engineering Center for Orthopaedic Research Excellence, Department of Bioengineering, College of Engineering, University of Toledo, Toledo, OH, USA.
Spine (Impact Factor: 2.3). 02/2010; 35(4):378-85. DOI: 10.1097/BRS.0b013e3181bc9cb5
Source: PubMed


This is an in vitro biomechanical study.
To compare the biomechanical stability of the 3 C1-C2 transarticular screw salvaging fixation techniques.
Stabilization of the atlantoaxial complex is a challenging procedure because of its complicated anatomy. Many posterior stabilization techniques of the atlantoaxial complex have been developed with C1-C2 transarticular screw fixation been the current gold standard. The drawback of using the transarticular screws is that it has a potential risk of vertebral artery injury due to a high riding transverse foramen of C2 vertebra, and screw malposition. In such cases, it is not recommended to proceed with inserting the contralateral transarticular screw and the surgeon should find an alternative to fix the contralateral side. Many studies are available comparing different atlantoaxial stabilization techniques, but none of them compared the techniques to fix the contralateral side while using the transarticular screw on one side. The current options are C1 lateral mass screw and short C2 pedicle screw or C1 lateral mass screw and C2 intralaminar screw, or C1-C2 sublaminar wire.
Nine fresh human cervical spines with intact ligaments (C0-C4) were subjected to pure moments in the 6 loading directions. The resulting spatial orientations of the vertebrae were recorded using an Optotrak 3-dimensional Motion Measurement System. Measurements were made sequentially for the intact spine after creating type II odontoid fracture and after stabilization with unilateral transarticular screw placement across C1-C2 (TS) supplemented with 1 of the 3 transarticular salvaging techniques on the contralateral side; C1 lateral mass screw and C2 pedicle screw (TS+C1LMS+C2PS), C1 lateral mass and C2 intralaminar screw (TS+C1LMS+C2ILS), or sublaminar wire (TS + wire).
The data indicated that all the 3 stabilization techniques significantly decreased motion when compared to intact in all the loading cases (left/right lateral bending, left/right axial rotation, flexion) except extension. All the 3 instrumented specimens were equally stable in extension/flexion and lateral bending modes. TS+C1LMS+C2PS was equivalent to TS+C1LMS+C2ILS (P > 0.05) and superior to TS + wire in axial rotation (P < 0.05). Also, TS+C1LMS+C2ILS was superior to TS + wire in axial rotation (P < 0.05).
Fixation of atlantoaxial complex using unilateral transarticular screw supplemented with contralateral C1 lateral mass and C2 intralaminar screws is biomechanically equivalent to C1 lateral mass and C2 pedicle screws and both are biomechanically superior to C1-C2 sublaminar wire in axial rotation.

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    • "Instrumentation in the upper cervical spine has changed substantially in the past two decades. Previous stand-alone wiring techniques like Brooks or Gallie’s fusion (Brooks and Jenkins 1978; Gallie 1939) have been made largely obsolete with the development of occipital plating, transarticular screws of Magerl (Ahmed et al 2008; Claybrooks et al 2007; Elgafy et al 2010; Goel 2004; Gunnarsson et al 2007; Haid 2001; Henriques et al 2000; Lee et al 2010) and C1 lateral mass screws, as well as C2 pedicle, pars, and translaminar screws. Polyaxial screws and segmental fixation are more user-friendly than stand-alone wiring and provide a stronger construct (Bransford et al 2011). "
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