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17/12/2015
1
Craniocervical StabilizationCraniocervical Stabilization
Mehmet Zileli, M.D.,
Izmir, Turkey
SummarySummarySummarySummary
Craniocervical instability Craniocervical instability -- definitiondefinition Stabilization techniquesStabilization techniques
Odontoid Screw FixationOdontoid Screw FixationC1-C2 Wire FixationC1C1--C2 Transarticular Screw FixationC2 Transarticular Screw FixationC1C1--C2 Segmental Screw FixationC2 Segmental Screw FixationOccipito Cervical FixationOccipito Cervical Fixation
Craniocervical instability Craniocervical instability -- definitiondefinition Stabilization techniquesStabilization techniques
Odontoid Screw FixationOdontoid Screw Fixation
SummarySummary
C1-C2 Wire FixationC1C1--C2 Transarticular Screw FixationC2 Transarticular Screw FixationC1C1--C2 Segmental Screw FixationC2 Segmental Screw FixationOccipito Cervical FixationOccipito Cervical Fixation
11-- TraumaTraumaOdontoid fractureOdontoid fractureLigamentous injuriesLigamentous injuriesCombined C1Combined C1--C2 fractureC2 fracture
CranioCranio--cervical instabilitycervical instabilityEtiologyEtiology
22-- Rheumatoid arthritisRheumatoid arthritis33-- Congenital abnormalitiesCongenital abnormalities44-- TumorsTumors55-- IatrogenicIatrogenic
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PainPain Deformity Deformity -- TorticollisTorticollis
N l i l tN l i l t
CranioCranio--cervical instabilitycervical instabilitySymptomsSymptoms
Neurological symptomsNeurological symptoms
Craniocervical instability Craniocervical instability -- definitiondefinition Stabilization techniquesStabilization techniques
Odontoid Screw FixationOdontoid Screw Fixation
SummarySummarySummarySummary
C1-C2 Wire FixationC1C1--C2 Transarticular Screw FixationC2 Transarticular Screw FixationC1C1--C2 Segmental Screw FixationC2 Segmental Screw FixationOccipito Cervical FixationOccipito Cervical Fixation
Craniocervical instability Craniocervical instability -- definitiondefinition Stabilization techniquesStabilization techniques
Odontoid Screw FixationOdontoid Screw Fixation
SummarySummarySummarySummary
C1-C2 Wire FixationC1C1--C2 Transarticular Screw FixationC2 Transarticular Screw FixationC1C1--C2 Segmental Screw FixationC2 Segmental Screw FixationOccipito Cervical FixationOccipito Cervical Fixation
IndicationsIndications
Anderson and D’Alonzo type II fr withAnderson and D’Alonzo type II fr with
Odontoid Screw FixationOdontoid Screw FixationOdontoid Screw FixationOdontoid Screw Fixation
Type IIFirst described in 1975 by BohlerFirst described in 1975 by BohlerA physiological procedure since it maintains A physiological procedure since it maintains
rotationrotationNo need to take a bone graftNo need to take a bone graftNo Halo fixationNo Halo fixation
Anderson and D Alonzo type II fr withAnderson and D Alonzo type II fr with Greater than 4 mm displacement Greater than 4 mm displacement Greater than 10 degrees of angulationGreater than 10 degrees of angulation Age greater than 40Age greater than 40 Posterior displacement (anterior displacement Posterior displacement (anterior displacement
may also be screwed)may also be screwed) First 8 weeks after traumaFirst 8 weeks after trauma Multilevel trauma Multilevel trauma NonunionNonunion
Type IIA
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1-Obliquety – anterior caudal to posterior cranial w/o buttress plate
ContraindicationsContraindicationsOdontoid Screw FixationOdontoid Screw FixationOdontoid Screw FixationOdontoid Screw Fixation
2-Transvers ligament rupture3-Nonreduced fractures4-Anterior dislocations?
Odontoid Screw FixationOdontoid Screw FixationSurgical Technique
Odontoid Screw FixationOdontoid Screw FixationSurgical Technique
Supine positionAwake nasotracheal intubation with slight neck extensionMayfield head holderPosition AP/lateral fluoroscopy with monitors placed opposite the operating surgeon
Ensure that anatomic reduction and an unobstructed drill approach angle has been achieved; image the K-wire superimposed over the screw trajectory.
the operating surgeon Two plane fluoroscopy and extensive setup
Place radiolucent bite block for AP imaging.Anterolateral retropharyngeal approach at C5-C6 level.
Odontoid Screw FixationSurgical Technique
Odontoid Screw FixationSurgical Technique
Odontoid Screw FixationOdontoid Screw FixationSurgical TechniqueSurgical Technique
Odontoid Screw FixationOdontoid Screw FixationSurgical TechniqueSurgical Technique
Reduction may be achieved by pushing the distal or proximal fractured segment
Some surgeons do not perform in anterior dislocations
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Two screw technique
Odontoid Screw FixationOdontoid Screw FixationSurgical TechniqueSurgical Technique
Odontoid Screw FixationOdontoid Screw FixationSurgical TechniqueSurgical Technique
AlternativesAnterior C1-C2 transarticular screwing
AlternativesAnterior C1-C2 transarticular screwing
May be used after anterior odontoid resectionMay be used after anterior odontoid resection Technically demandingTechnically demanding
AlternativesC1-C2 plateAlternativesC1-C2 plate
Craniocervical instability Craniocervical instability -- definitiondefinition Stabilization techniquesStabilization techniques
Odontoid Screw FixationOdontoid Screw FixationC1-C2 Wire Fixation
SummarySummary
C1C1--C2 Transarticular Screw FixationC2 Transarticular Screw FixationC1C1--C2 Segmental Screw FixationC2 Segmental Screw FixationOccipito Cervical FixationOccipito Cervical Fixation
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Site preperation and wire passing
C1C1--C2 Wire FixationC2 Wire FixationC1C1--C2 Wire FixationC2 Wire Fixation
Gallie fusionC1-C2 Wire FixationC1-C2 Wire Fixation
Need however a postop halo brace....
C1C1--C2 Halifax Clamp FixationC2 Halifax Clamp FixationC1C1--C2 Halifax Clamp FixationC2 Halifax Clamp FixationBecame popular and then abandoned because of high failure rate....
SummarySummarySummarySummary
Craniocervical instability Craniocervical instability -- definitiondefinition Stabilization techniquesStabilization techniques
Odontoid Screw FixationOdontoid Screw FixationC1-C2 Wire FixationC1C1--C2 Transarticular Screw FixationC2 Transarticular Screw FixationC1C1--C2 Segmental Screw FixationC2 Segmental Screw FixationOccipito Cervical FixationOccipito Cervical Fixation
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Anterior (Barbeour 1971)Anterior (Barbeour 1971)
Lateral (Du Doit 1976)Lateral (Du Doit 1976)
C1C1--C2 transarticular screw fixationC2 transarticular screw fixation
Lateral (Du Doit 1976)Lateral (Du Doit 1976)
Posterior (Magerl 1986)Posterior (Magerl 1986)
IndicationsIndicationsIndicated for Indicated for atlantoatlanto--axial instabilityaxial instability. A . A goodgood alternativealternative toto occipitocervicaloccipitocervicalfixationfixationBiomechanically stronger than wiringBiomechanically stronger than wiringObtain & maintain reductionObtain & maintain reductionC2 arch not necessaryC2 arch not necessaryTechnically demandingTechnically demanding
C1C1--C2 transarticular screw fixationC2 transarticular screw fixation
Normal Normal atlantoatlanto--axialaxial anatomyanatomy confirmedconfirmed in CT in CT scanscanLigamentousLigamentous ((nonnon--traumatictraumatic) ) instabilityinstability of of thethe atlantoatlanto--axialaxial segmentsegment duedue toto
RheumatoidRheumatoid arthritisarthritis InfectionInfection DegenerationDegeneration
TraumaTrauma RuptureRupture of of thethe transversetransverse ligamentligament FracturesFractures of of thethe atlas and atlas and axisaxis
C1C1--C2 C2 instabilityinstability duedue toto lossloss of bone (of bone (tumortumor, , infectioninfection))OsOs odontoideumodontoideumAfterAfter transoraltransoral densdens resectionresection ????
ContraindicationsContraindications Congenital malformations (illCongenital malformations (ill--defined anatomy)defined anatomy) Very high vertebral artery grooveVery high vertebral artery groove Missing pedicles of the axis, bony abnormality on the Missing pedicles of the axis, bony abnormality on the
entrance of screwentrance of screw
C1C1--C2 transarticular screw fixationC2 transarticular screw fixation
entrance of screwentrance of screw Severe osteoporosisSevere osteoporosis Upper thoracic kyphosisUpper thoracic kyphosis
Preoperative cautions:Preoperative cautions:* Variations of the vertebral artery* Variations of the vertebral artery* Severe cervical * Severe cervical lordosislordosis* Cervico* Cervico--thoracic kyphosisthoracic kyphosis
(Magerl 1986)(Magerl 1986)C1C1--C2 transarticular screw fixationC2 transarticular screw fixation
* Unreducible pathology* Unreducible pathology
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Medial to the pedicleC2 isthmus
(Pars interarticularis)
C2 root
Vertebral Artery Injury?
C1C1--C2 transarticular screw fixationC2 transarticular screw fixation
C1-C2 wire may be added to transarticular screw fixation. A tricortical bone graft is also placed.
C1C1--C2 transarticular screw fixationC2 transarticular screw fixation
ComplicationsComplications
Injury to the vertebral artery (Injury to the vertebral artery (inappropriateinappropriatein 20% of cases)in 20% of cases)(if one artery is injured the other side should not be(if one artery is injured the other side should not be
C1C1--C2 transarticular screw fixationC2 transarticular screw fixation
(if one artery is injured, the other side should not be (if one artery is injured, the other side should not be drilled and fusion with conventional techniques drilled and fusion with conventional techniques should be applied)should be applied)
Injury to the spinal cord Injury to the spinal cord Hardware failureHardware failure
SummarySummarySummarySummary
Craniocervical instability Craniocervical instability -- definitiondefinition Stabilization techniquesStabilization techniques
Odontoid Screw FixationOdontoid Screw FixationC1-C2 Wire FixationC1C1--C2 Transarticular Screw FixationC2 Transarticular Screw FixationC1C1--C2 Segmental Screw FixationC2 Segmental Screw FixationOccipito Cervical FixationOccipito Cervical Fixation
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* First introduced by * First introduced by Goel* An alternative to posterior transarticular screw fixation* An alternative to posterior transarticular screw fixation* Lower risk of injury to the vertebral artery* Lower risk of injury to the vertebral artery
C1-C2 Segmental FixationC1-C2 Segmental FixationHarms 2001Harms 2001 GoelGoel--HarmsHarms
C1-C2 Segmental FixationC1-C2 Segmental Fixation
Grup A Basilary invagination Grup A Basilary invagination Posterior ReductionPosterior Reduction
Goel
65 y.o female, 565 y.o female, 5--6 months R arm and leg weakness,6 months R arm and leg weakness, gait gait disturbance, sphincter problemdisturbance, sphincter problem. . Quadriparetic,Quadriparetic, babassililaarryyinvaginainvaginatition on andand C1C1--2 2 dislodisloccaatition. on.
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Functional X rays: slight increase of dislocation during flexion. C1 asimilation
PostopPreop
PreopPreop PostopPostop
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SummarySummarySummarySummary
Craniocervical instability Craniocervical instability -- definitiondefinition Stabilization techniquesStabilization techniques
Odontoid Screw FixationOdontoid Screw FixationC1-C2 Wire FixationC1C1--C2 Transarticular Screw FixationC2 Transarticular Screw FixationC1C1--C2 Segmental Screw FixationC2 Segmental Screw FixationOccipito Cervical FixationOccipito Cervical Fixation
IndicationsIndications Extensive occipitoExtensive occipito--cervical bony destruction cervical bony destruction
(Craniectomy in foramen magnum, upper (Craniectomy in foramen magnum, upper cervical laminectomy) cervical laminectomy)
Abscence of C1 arch due to a congenital Abscence of C1 arch due to a congenital malformation or after decompression.malformation or after decompression.
Congenital abnormalities of the occipitoCongenital abnormalities of the occipito--cervical articulationcervical articulation
OccipitoOccipito CervicalCervical FixationFixation
cervical articulationcervical articulation Basilary invaginationBasilary invagination Nonreduced subluxations of C1Nonreduced subluxations of C1--C2C2 Complex fractures of C1 and C2Complex fractures of C1 and C2 Unstable Unstable complex Jefferson fracturescomplex Jefferson fractures
ContraindicationsContraindications Osteoporosis ??Osteoporosis ?? DestructionDestruction ––iatrogeniciatrogenic-- of occipital boneof occipital bone
DisadvantagesDisadvantages
Reduced head and neck movements due to Reduced head and neck movements due to restriction of Ocrestriction of Oc--C1C1--C2 articulationsC2 articulations
FlexionFlexion--extensionextension 30%30%
OccipitoOccipito CervicalCervical FixationFixation
FlexionFlexion extension extension 30% 30% Lateral rotationLateral rotation 10 degrees10 degreesLateral deviationLateral deviation 8 degrees8 degrees
High nonunion ratesHigh nonunion rates
Surgical Preperation and PositionSurgical Preperation and Position
Prone position, neck is neutralProne position, neck is neutral Lateral C arm controlLateral C arm control Mayfield head holderMayfield head holder Reduction with tractionReduction with traction
OccipitoOccipito CervicalCervical FixationFixation
Reduction with tractionReduction with traction Preop CT: Thickness of occipital bone, VA Preop CT: Thickness of occipital bone, VA
anomaliesanomalies Bone graft should be placed between Bone graft should be placed between
occiput and cervical vertebraeocciput and cervical vertebrae
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Fixation techniquesFixation techniques
WiresWires with with Loops/platesLoops/platesHartshill rectangleHartshill rectangle Threaded Steinmann pinThreaded Steinmann pin Titanium rodTitanium rod
OccipitoOccipito CervicalCervical FixationFixation
Titanium rodTitanium rod Titanium frame Titanium frame Ransford loopRansford loop
ScrewsScrews and platesand platesCD rod/screw plateCD rod/screw plate
ScrewsScrews and rodsand rods
WireWire--Rod/Plate Rod/Plate combinationcombinationOccipitoOccipito CervicalCervical FixationFixation
Luque-Hartshill rectangle Hartshill-Ransford loop
Wires with loops/plates & bone cementOccipitoOccipito CervicalCervical FixationFixation
C2 osteoblastoma - Ventro-lateral retropharyngeal approach
Occipito-cervical fixation using two axis plates and titanium wires
Case with plate and wires
October 1997 June 1998
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18 y.o. Female, basilary invagination and Chiari type I, tetraparesis, 9th and 10th nerve palsy, tonsillar herniation, PB-C2 9 mm
Case with plate and hooks
Transoral odontoid resection, Foramen magnum decompression, Duraplasty, Occipitocervical fusion
PlatePlate--Screw systemsScrew systems
OccipitoOccipito CervicalCervical FixationFixation
Two plates Less rigid
Y plateMore rigid
PlatePlate--Screw systemsScrew systemsOccipitoOccipito CervicalCervical FixationFixation
U shaped plateU shaped plate Y shaped platePlatePlate--Screw systemsScrew systemsOccipitoOccipito CervicalCervical FixationFixation
Distances between two loops are 30 or 35 mm
Three different lengths of cervical plates with 3-4 and 5 holes
Plates ha e 120 degreesPlates have 120 degrees of angulation to fit the occipito-cervical inclination
33--4 occipital screws (64 occipital screws (6--8 mm cortical screws)8 mm cortical screws)
C2 isthmus screwC2 isthmus screw
C3C3--C5 lateral mass C5 lateral mass screwsscrews
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Cervical screw directions
C2 screw may be directed to pedicle or isthmus
C3-C6 lateral mass screws
C2 screw may be directed to pedicle or isthmus(25 degree medial and rostral)
A wire may be added to C1 arch. 51 y.o., male, Tetraparesis, Chiari type I (tonsillar herniation), Basilary invagination , PB C2 12 mm
Case with plate and screws
Transoral odontoid resectionForamen magnum decompressionDuraplastyOccipitocervical fixation
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Y plateMidline occiput has a thicker bone.
Screw purchase is more stabile.
There are long and short plates. A midline screw may hold the graft
Case with Y plate and screws
32 y.o. Male. Neck pain and headache32 y.o. Male. Neck pain and headache.. Hemihypesthesia on right. Hemihypesthesia on right. Assimilation of atlas to occiput.Assimilation of atlas to occiput.
Case with Y plate and Screws
Transoral dens resection, Transoral dens resection, occipitocervical fixation with Y plateoccipitocervical fixation with Y plate
RodRod--Screw systemsScrew systems
More rigid fixation
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RodRod--screw combinationscrew combination
Occipital Plate
Egyptian Spine Review2007, Cairo
ComplicationsComplications
CSF fistulaCSF fistula Cerebellar haematomaCerebellar haematoma Hardware related complicationsHardware related complications
OccipitoOccipito CervicalCervical FixationFixation
Hardware related complicationsHardware related complicationsScrew looseningScrew looseningPseudoarthrosisPseudoarthrosisInstrument breakageInstrument breakage
ConclusionConclusion OccipitoOccipito--cervical fixation can be achieved cervical fixation can be achieved
using many different methods.using many different methods. It causes great restriction in cervical It causes great restriction in cervical
movementsmovements
OccipitoOccipito CervicalCervical FixationFixation
FlexionFlexion--extensionextension 30% 30% Lateral rotationLateral rotation 10 degree10 degreeLateral bendingLateral bending 8 degree8 degree
Nonunion rate is highNonunion rate is high
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Thank youThank you