J Korean Neurotraumatol Soc.  2010 Dec;6(2):143-149. 10.13004/jknts.2010.6.2.143.

Atlantoaxial Transpedicular Screw Fixation for the Management of Traumatic Upper Cervical Spine Instability

• Kim BS
• Yoo DS
• Huh PW
• Cho KS
• Lee SB

• KMID: 2106801
• DOI: http://doi.org/10.13004/jknts.2010.6.2.143

Abstract

OBJECTIVE
The morbidity and mortality are high for traumatic upper cervical spine instability with cervico-medullary compression. In a clinical retrospective study, the clinical and radiographic results of occipitocervical (OC) fusion using posterior atlantoaxial transpedicular screw fixation in 12 patients with traumatic upper cervical spine instability was reviewed.
METHODS
Twelve patients with traumatic upper cervical spine instability (8 males and 4 females) were treated at our department over four years. Instability resulted from acute C1-C2 dislocation (4 cases), an acute unstable C2 fracture (1 case), acute C1-2-3 fracture dislocation (2 cases), acute C1 fracture (1 case), OC dislocation (2 cases) and old unstable C2 fracture (1 case). All 12 patients were internally fixed with occipital-/C1-C2 transpedicular screw fixation. The outcome (mean follow-up period, 16.5 months) was based on clinical and radiographic review using the Japanese Orthopedic Association (JOA) score.
RESULTS
Four neurologically intact patients remained the same after surgery. Among eight patients with cervical myelopathy, clinical improvement was noted in six cases (75%). The JOA score of the 8 patients were 9.4 (range, 0-16) before surgery and 12.1 (range, 0-17) with a recovery rate of 38.3% at the time of the last follow up. One patient died 2 months after the surgery because of pneumonia and sepsis. Fusion was achieved in 10 patients (90.9%) by the last follow-up.
CONCLUSION
Early OC fusion is recommended in cases with traumatic upper cervical spinal instability, OC fusion with posterior atlantoaxial transpedicular screw fixation was a safe and effective method for the treatment of traumatic cervical spine instability.

Keyword

Atlantoaxial fixation; Occipitocervical fusion; Transpedicular screw fixation

MeSH Terms

Asian Continental Ancestry Group
Dislocations
Follow-Up Studies
Humans
Male
Orthopedics
Pneumonia
Retrospective Studies
Sepsis
Spinal Cord Diseases
Spine

Figure

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  FIGURE 1 Illustrations of the C1-C2 3D-reformatted scan. Posterior and lateral views demonstrating the C1 and C2 entry points for the atlantoaxial transpedicular screw fixation technique (white circle: entry point, arrow: pathway of screw).

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  FIGURE 2 A 54-year-old woman presented with quadriplegia due to motor vehicle accident. A: Preoperative sagittal CT scan shows occipitocervical dislocation (Power's ratio: 0.96). B: Preoperative lateral cervical spine radiograph shows atlantoaxial dislocation and 10 mm of anterior translation of C1. C: Postoperative lateral radiograph shows occipitocervical fusion with C1-C2 transpedicular screw fixation. D: Axial (C1) and sagittal view shows placement of pedicle screws. The screws were in the proper position and did not traverse the vertebral artery foramen.

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  FIGURE 3 A 55-year-old male patient had an unstable Jefferson fracture. There was vertebral artery injury during the C1 arch dissection. A: Axial CT scan shows fracture of the anterior and posterior arch of C1. B: Immediate angiographic evaluation shows evidence of left vertebral artery injury that was occluded by thrombus. C: Angiogram after coil embolization shows the totally embolized artery with no flow. D: We underwent unilateral screw placement only to avoid bilateral vertebral artery injury.

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  FIGURE 4 A 49-year-old male patient had a C2-C3 fracture dislocation with a quadriparesis due to a fall from the roof. A: Preoperative lateral cervical spine radiograph shows unstable C3 comminuted fracture with C2-C3 dislocation. B: Pre-operative axial and sagittal CT scan shows C2-C3 fracture dislocation with displacement of C2 posteriorly. C: Preoperative MRI scan shows enlargement of the upper spinal cord with intramedullary T2 high signal intensity, suggesting cord edema and contusion. D: C2-C3 fracture dislocation reduction was attempted with the Gardner-well tongs but failed. An extended fusion upward from C1 and downward to C4 was performed. The lateral radiograph showed C1 to C4 fusion and restoration of bone alignment postoperatively, the patient had a partial recovery with resolution of symptoms at the last follow up.

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