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C1-C2 Fixation
Jeffrey S. Ross, MD
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KEY FACTS

  • Terminology

    TERMINOLOGY

    • Synonyms

      • Atlantoaxial fusion
    • Definitions

      • With sublaminar wires or clamp
        • Gallie fusion (1939)
          • Placement of bone graft between dorsal arch of C1 and spinous process of C2
          • Secured by sublaminar wires
          • Single midline point of fixation → poor stabilization with rotation
          • Halo required for postoperative immobilization
        • Brooks fusion (1979)
          • Bilateral interlaminar bone grafts, secured by bilateral sublaminar wires
          • Tightening wires will increase compression of grafts
          • More rotational stability than Gallie method
        • Locksley method uses 3-point fixation with bilateral autograft attached with sublaminar wires, tightened in "figure 8" pattern
          • Addition of midline plate attached by wires to posterior spinous processes
        • Halifax clamp (1975)
          • Claw-type construct allowing immediate fixation without risk of sublaminar wires
          • Bone graft placed in interlaminar spaces bilaterally
          • Requires intact arch of C1
        • Sublaminar wire in cervical spine associated with 7-17% risk of neurologic injury
      • Without sublaminar wires
        • Magerl transarticular screwfixation (1987)
          • Provides biomechanical stability, particularly against rotational motion and lateral bending
          • Immediate stabilization by C1-C2 transarticular lateral mass screws
          • ↑ fusion rate (> 90%)
          • No need for postoperative immobilization
          • Decreased malalignment
          • Meticulous operative planning/navigation required to miss vertebral artery (VA) with screws
            • 4-6% VA injury rate
          • 20% of patients have anatomy that precludes transarticular placement
        • Screw and rod fixation (Harms, 2001)
          • Lateral mass screws at C1, with pedicle/pars screws at C2 secured by rods bilaterally
          • No structural grafting or wiring required
          • VA injury risk similar to that of transarticular screws
          • Can be performed in patients with body habitus/anatomy unfavorable to transarticular screw
        • C2 translaminar screws
          • ↓ risk of VA injury
          • No challenges related to body habitus
          • ↑ pseudoarthrosis rate
          • ↓ rigidity of fixation

    PRE-PROCEDURE

    • Indications

      • Contraindications

        • Pre-Procedure Imaging

          OUTCOMES

          • Complications

            Selected References

            1. Denaro V et al: The best surgical treatment for type II fractures of the dens is still controversial. Clin Orthop Relat Res. 469(3):742-50, 2011
            2. Bahadur R et al: Transarticular screw fixation for atlantoaxial instability - modified Magerl's technique in 38 patients. J Orthop Surg Res. 5:87, 2010
            3. Conroy E et al: C1 lateral mass screw-induced occipital neuralgia: a report of two cases. Eur Spine J. 19(3):474-6, 2010
            4. Lall R et al: A review of complications associated with craniocervical fusion surgery. Neurosurgery. 67(5):1396-402; discussion 1402-3, 2010
            5. Ma W et al: Clinical application of C2 laminar screw technique. Eur Spine J. 19(8):1312-7, 2010
            6. Ni B et al: Bilateral C1 laminar hooks combined with C2 pedicle screws fixation for treatment of C1-C2 instability not suitable for placement of transarticular screws. Eur Spine J. 19(8):1378-82, 2010
            7. Park YS et al: Posterior atlantoaxial screw-rod fixation in a case of aberrant vertebral artery course combined with bilateral high-riding vertebral artery. J Korean Neurosurg Soc. 48(4):367-70, 2010
            8. Wang S et al: Pedicle versus laminar screws: what provides more suitable C2 fixation in congenital C2-3 fusion patients? Eur Spine J. 19(8):1306-11, 2010
            9. Heuer GG et al: Treatment of pediatric atlantoaxial instability with traditional and modified Goel-Harms fusion constructs. Eur Spine J. 18(6):884-92, 2009
            10. Ahmed R et al: Fusions at the craniovertebral junction. Childs Nerv Syst. 24(10):1209-24, 2008
            11. Menendez JA et al: Techniques of posterior C1-C2 stabilization. Neurosurgery. 60(1 Supp1 1):S103-11, 2007
            12. Hagino T et al: Fracture of the atlas through a synchondrosis of the anterior arch complicated by atlantoaxial rotatory fixation in a four-year-old child. J Bone Joint Surg Br. 88(8):1093-5, 2006
            13. Mummaneni PV et al: Atlantoaxial fixation: overview of all techniques. Neurol India. 53(4):408-15, 2005
            14. Rahimi SY et al: Treatment of atlantoaxial instability in pediatric patients. Neurosurg Focus. 15(6):ECP1, 2003
            15. Madawi AA et al: Radiological and anatomical evaluation of the atlantoaxial transarticular screw fixation technique. J Neurosurg. 86(6):961-8, 1997
            16. Coric D et al: Arteriovenous fistula as a complication of C1-2 transarticular screw fixation. Case report and review of the literature. J Neurosurg. 85(2):340-3, 1996
            17. Grob D: Principles of surgical treatment of the cervical spine in rheumatoid arthritis. Eur Spine J. 2(4):180-90, 1993
            Related Anatomy
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            References
            Tables

            Tables

            KEY FACTS

            • Terminology

              TERMINOLOGY

              • Synonyms

                • Atlantoaxial fusion
              • Definitions

                • With sublaminar wires or clamp
                  • Gallie fusion (1939)
                    • Placement of bone graft between dorsal arch of C1 and spinous process of C2
                    • Secured by sublaminar wires
                    • Single midline point of fixation → poor stabilization with rotation
                    • Halo required for postoperative immobilization
                  • Brooks fusion (1979)
                    • Bilateral interlaminar bone grafts, secured by bilateral sublaminar wires
                    • Tightening wires will increase compression of grafts
                    • More rotational stability than Gallie method
                  • Locksley method uses 3-point fixation with bilateral autograft attached with sublaminar wires, tightened in "figure 8" pattern
                    • Addition of midline plate attached by wires to posterior spinous processes
                  • Halifax clamp (1975)
                    • Claw-type construct allowing immediate fixation without risk of sublaminar wires
                    • Bone graft placed in interlaminar spaces bilaterally
                    • Requires intact arch of C1
                  • Sublaminar wire in cervical spine associated with 7-17% risk of neurologic injury
                • Without sublaminar wires
                  • Magerl transarticular screwfixation (1987)
                    • Provides biomechanical stability, particularly against rotational motion and lateral bending
                    • Immediate stabilization by C1-C2 transarticular lateral mass screws
                    • ↑ fusion rate (> 90%)
                    • No need for postoperative immobilization
                    • Decreased malalignment
                    • Meticulous operative planning/navigation required to miss vertebral artery (VA) with screws
                      • 4-6% VA injury rate
                    • 20% of patients have anatomy that precludes transarticular placement
                  • Screw and rod fixation (Harms, 2001)
                    • Lateral mass screws at C1, with pedicle/pars screws at C2 secured by rods bilaterally
                    • No structural grafting or wiring required
                    • VA injury risk similar to that of transarticular screws
                    • Can be performed in patients with body habitus/anatomy unfavorable to transarticular screw
                  • C2 translaminar screws
                    • ↓ risk of VA injury
                    • No challenges related to body habitus
                    • ↑ pseudoarthrosis rate
                    • ↓ rigidity of fixation

              PRE-PROCEDURE

              • Indications

                • Contraindications

                  • Pre-Procedure Imaging

                    OUTCOMES

                    • Complications

                      Selected References

                      1. Denaro V et al: The best surgical treatment for type II fractures of the dens is still controversial. Clin Orthop Relat Res. 469(3):742-50, 2011
                      2. Bahadur R et al: Transarticular screw fixation for atlantoaxial instability - modified Magerl's technique in 38 patients. J Orthop Surg Res. 5:87, 2010
                      3. Conroy E et al: C1 lateral mass screw-induced occipital neuralgia: a report of two cases. Eur Spine J. 19(3):474-6, 2010
                      4. Lall R et al: A review of complications associated with craniocervical fusion surgery. Neurosurgery. 67(5):1396-402; discussion 1402-3, 2010
                      5. Ma W et al: Clinical application of C2 laminar screw technique. Eur Spine J. 19(8):1312-7, 2010
                      6. Ni B et al: Bilateral C1 laminar hooks combined with C2 pedicle screws fixation for treatment of C1-C2 instability not suitable for placement of transarticular screws. Eur Spine J. 19(8):1378-82, 2010
                      7. Park YS et al: Posterior atlantoaxial screw-rod fixation in a case of aberrant vertebral artery course combined with bilateral high-riding vertebral artery. J Korean Neurosurg Soc. 48(4):367-70, 2010
                      8. Wang S et al: Pedicle versus laminar screws: what provides more suitable C2 fixation in congenital C2-3 fusion patients? Eur Spine J. 19(8):1306-11, 2010
                      9. Heuer GG et al: Treatment of pediatric atlantoaxial instability with traditional and modified Goel-Harms fusion constructs. Eur Spine J. 18(6):884-92, 2009
                      10. Ahmed R et al: Fusions at the craniovertebral junction. Childs Nerv Syst. 24(10):1209-24, 2008
                      11. Menendez JA et al: Techniques of posterior C1-C2 stabilization. Neurosurgery. 60(1 Supp1 1):S103-11, 2007
                      12. Hagino T et al: Fracture of the atlas through a synchondrosis of the anterior arch complicated by atlantoaxial rotatory fixation in a four-year-old child. J Bone Joint Surg Br. 88(8):1093-5, 2006
                      13. Mummaneni PV et al: Atlantoaxial fixation: overview of all techniques. Neurol India. 53(4):408-15, 2005
                      14. Rahimi SY et al: Treatment of atlantoaxial instability in pediatric patients. Neurosurg Focus. 15(6):ECP1, 2003
                      15. Madawi AA et al: Radiological and anatomical evaluation of the atlantoaxial transarticular screw fixation technique. J Neurosurg. 86(6):961-8, 1997
                      16. Coric D et al: Arteriovenous fistula as a complication of C1-2 transarticular screw fixation. Case report and review of the literature. J Neurosurg. 85(2):340-3, 1996
                      17. Grob D: Principles of surgical treatment of the cervical spine in rheumatoid arthritis. Eur Spine J. 2(4):180-90, 1993