Percutaneous Transarticular Atlantoaxial Screw Fixation Using a Cannulated Screw System and Image Guidance

Abstract

In 2000 a cannulated screw stabilization system for posterior cervical instrumentation was introduced in our department for use in complex cervical fixation procedures. A special feature of the system is the use of thin Kirschner wires for drilling the screw paths and then placing the self-drilling, cannulated screws securely over the wires. Percutaneous application of C1-C2 transarticular screws is possible through tubes. An optional “atlas-claw” provides additional stability in cases of C1-C2 stabilization. 17 patients (10 female, 7 male, mean age 60 years) with complex cervical disorders and instability of different origin were stabilized using the Neon System (Ulrich Co., Ulm, Germany). Pathology included atlantoaxial instability based on rheumatoid arthritis (n = 12), odontoid fracture (n = 4) and os odontoideum mobile (n = 1). Computed navigation (STN 4.0, Zeiss or vector vision spine, brain lab) was used in 14 cases. Transarticular C1-C2 screw fixation was performed in 14 cases (4 patients with direct C1 massa lateralis screw fixation), craniocervical fixation (C0-C2/C3) was done in 3 patients. Percutaneous application of the C1-C2 screws was used in 7 patients. Atlas claws were applied in 8 patients. There was one medial perforation of a C2 pedicle wall and one malposition of the screw in C2 without reaching the lateral mass of C1. After a mean follow-up of 9 months there were no hardware failures and stable fusion in those cases followed after 12 months or more. Clinical results were excellent or good in 14/16 patients. Cannulated screws are an effective alternative in complex stabilization procedures of the cervical spine. The presented system is technically comfortable and allows safe percutaneous screw application as well as inclusion of computed navigation with high accuracy.

Transarticular screw fixation - atlantoaxial instability - percutaneous screw application - cannulated screw - computer assisted spine surgery

References

• 1 Richter M, Schmidt R, Claes L, Puhl W, Wilke H J. Posterior atlantoaxial fixation: biomechanical in vitro comparison of six different techniques.  Spine. 2002;  27 1724-1732
• 2 Blauth M, Richter M, Lange U. Trans-articular screw fixation of C1/C2 in atlanto-axial instability. Comparison between percutaneous and open procedures.  Orthopäde. 1999;  28 651-661
• 3 Haid Jr R W. C1-C2 transarticular screw fixation: technical aspects.  Neurosurgery. 2001;  49 71-74
• 4 Cleynenbreugel J van, Schutyser F, Goffin J, Brussel K van, Suetens P. Image-based planning and validation of C1-C2 transarticular screw fixation using personalized drill guides.  Computer Aided Surgery. 2002;  7 41-48
• 5 Weidner A, Wähler M, Chiu S T, Ullrich C G. Modification of C1-C2 transarticular screw fixation by image-guided surgery.  Spine. 2000;  25 2668-2674
• 6 Wigfield C, Bolger C. A technique for frameless stereotaxy and placement of transarticular screws for atlanto-axial instability in rheumatoid arthritis.  Eur Spine J. 2001;  10 264-268
• 7 Braun V, Rath S A, Antoniadis G, Richter H-P. In vivo experiences with frameless stereotactically guided screw placement in the spine - results from 75 consecutive cases.  Neurosurg Rev. 2001;  24 74-79
• 8 Richter M, Amiot L, Neller S, Kluger P, Puhl W. Computer-assisted surgery in posterior instrumentation of the cervical spine: an in-vitro feasibility study.  Eur Spine J. 2000;  9 (Suppl 1) S65-S70
• 9 Herz T, Franz A, Giacomuzzi S M, Bale R, Krismer M. Accuracy of spinal navigation for Magerl screws.  Clin Orthop Relat R. 2003;  409 124-130
• 10 Dickman C A, Foley K T, Sonntag V K, Smith M M. Cannulated screws for odontoid screw fixation and atlantoaxial transarticular screw fixation. Technical note.  J Neurosurg. 1995;  83 1095-1100
• 11 McGuire Jr R A, Harkey H L. Modification of technique and results of atlantoaxial transfacet stabilization.  Orthopedics. 1995;  18 1029-1032
• 12 Richter M, Wilke H-J, Kluger P, Neller S, Claes L, Puhl W. Biomechanical evaluation of a new modular rod-screw implant system for posterior instrumentation of the occipito-cervical spine: in-vitro comparison with two established implant systems.  Eur Spine J. 2000;  9 417-425