Spinal navigation for posterior instrumentation of C1-2 instability using a mobile intraoperative CT scanner.

OBJECTIVE Spinal navigation techniques for surgical fixation of unstable C1-2 pathologies are challenged by complex osseous and neurovascular anatomy, instability of the pathology, and unreliable preoperative registration techniques. An intraoperative CT scanner with autoregistration of C-1 and C-2 promises sufficient accuracy of spinal navigation without the need for further registration procedures. The aim of this study was to analyze the accuracy and reliability of posterior C1-2 fixation using intraoperative mobile CT scanner-guided navigation. METHODS In the period from July 2014 to February 2016, 10 consecutive patients with instability of C1-2 underwent posterior fixation using C-2 pedicle screws and C-1 lateral mass screws, and 2 patients underwent posterior fixation from C-1 to C-3. Spinal navigation was performed using intraoperative mobile CT. Following navigated screw insertion in C-1 and C-2, intraoperative CT was repeated to check for the accuracy of screw placement. In this study, the accuracy of screw positioning was retrospectively analyzed and graded by an independent observer. RESULTS The authors retrospectively analyzed the records of 10 females and 2 males, with a mean age of 80.7 ± 4.95 years (range 42-90 years). Unstable pathologies, which were verified by fracture dislocation or by flexion/extension radiographs, included 8 Anderson Type II fractures, 1 unstable Anderson Type III fracture, 1 hangman fracture Levine Effendi Ia, 1 complex hangman-Anderson Type III fracture, and 1 destructive rheumatoid arthritis of C1-2. In 4 patients, critical anatomy was observed: high-riding vertebral artery (3 patients) and arthritis-induced partial osseous destruction of the C-1 lateral mass (1 patient). A total of 48 navigated screws were placed. Correct screw positioning was observed in 47 screws (97.9%). Minor pedicle breach was observed in 1 screw (2.1%). No screw displacement occurred (accuracy rate 97.9%). CONCLUSION Spinal navigation using intraoperative mobile CT scanning was reliable and safe for posterior fixation in unstable C1-2 pathologies with high accuracy in this patient series.

[1]  Y. Orz,et al.  Role of the O-arm and Computer-assisted Navigation of Safe Screw Fixation in Children with Traumatic Rotatory Atlantoaxial Subluxation , 2012, Asian spine journal.

[2]  P. Suchomel,et al.  CT-guided internal fixation of a hangman’s fracture , 2000, European Spine Journal.

[3]  K. Schaller,et al.  Accuracy of freehand fluoroscopy-guided placement of C1 lateral mass and C2 isthmic screws in atlanto-axial instability , 2011, Acta Neurochirurgica.

[4]  F. Magerl,et al.  Primary posterior fusion C1/2 in odontoid fractures: indications, technique, and results of transarticular screw fixation. , 1992, Journal of spinal disorders.

[5]  A. Levine,et al.  The management of traumatic spondylolisthesis of the axis. , 1985, The Journal of bone and joint surgery. American volume.

[6]  T. Kretschmer,et al.  Translaminar screws of the axis—an alternative technique for rigid screw fixation in upper cervical spine instability , 2012, Neurosurgical Review.

[7]  Kazuhisa Takahashi,et al.  Medially-shifted rather than high-riding vertebral arteries preclude safe pedicle screw insertion , 2016, Journal of Clinical Neuroscience.

[8]  A. Baker.  Fractures of the Odontoid Process of the Axis , 2014 .

[9]  J. Harrop.  Type II odontoid fractures: what to do? , 2013, World neurosurgery.

[10]  Ji Min Ling,et al.  Surgical treatment of adult and pediatric C1/C2 subluxation with intraoperative computed tomography guidance , 2013, Surgical neurology international.

[11]  M. Takayasu,et al.  Vertebral artery variations and osseous anomaly at the C1-2 level diagnosed by 3D CT angiography in normal subjects , 2014, Neuroradiology.

[12]  T. Wright,et al.  Biomechanical analysis of screw constructs for atlantoaxial fixation in cadavers: a systematic review and meta-analysis. , 2015, Journal of neurosurgery. Spine.

[13]  R. Chaloupka,et al.  [Injury of upper cervical spine]. , 2016, Soudni lekarstvi.

[14]  Xinguang Yu,et al.  Intraoperative Computed Tomography With an Integrated Navigation System in Stabilization Surgery for Complex Craniovertebral Junction Malformation , 2014, Journal of spinal disorders & techniques.

[15]  Deepak Gupta,et al.  Computed Tomography-Guided C2 Pedicle Screw Placement for Treatment of Unstable Hangman Fractures , 2014, Spine.

[16]  John A. Engler,et al.  Use of intraoperative fluoroscopy for the safe placement of C2 laminar screws: technical note , 2015, European Spine Journal.

[17]  J. Vital,et al.  Management of a major atlanto-axial instability secondary to a lytic lesion of C2 , 2014, European Spine Journal.

[18]  L. Anderson,et al.  Fractures of the odontoid process of the axis. 1974. , 1974, The Journal of bone and joint surgery. American volume.

[19]  The Clinical Experience of Computed Tomographic-Guided Navigation System in C1-2 Spine Instrumentation Surgery , 2014, Journal of Korean Neurosurgical Society.

[20]  Ding-Jun Hao,et al.  Posterior atlantoaxial fixation: a review of all techniques. , 2015, The spine journal : official journal of the North American Spine Society.

[21]  Bernd Hamm,et al.  Accuracy and workflow of navigated spinal instrumentation with the mobile AIRO® CT scanner , 2016, European Spine Journal.

[22]  Jia‐xin Xu,et al.  The options of C2 fixation for os odontoideum: a radiographic study for the C2 pedicle and lamina anatomy , 2011, European Spine Journal.

[23]  G. Schiffer,et al.  The accuracy of 3D fluoroscopy-navigated screw insertion in the upper and subaxial cervical spine , 2015, European Spine Journal.

[24]  L. Holly,et al.  Evaluation of registration techniques for spinal image guidance. , 2006, Journal of neurosurgery. Spine.

[25]  Y. Sakai,et al.  The correlation between cervical range of motion and misplacement of cervical pedicle screws during cervical posterior spinal fixation surgery using a CT-based navigation system , 2013, European Spine Journal.

[26]  Sang-Hun Lee,et al.  Analysis of 3-Dimensional Course of the Intra-axial Vertebral Artery for C2 Pedicle Screw Trajectory: A Computed Tomographic Study , 2014, Spine.

[27]  T. Vordemvenne,et al.  Current concepts in the treatment of Anderson Type II odontoid fractures in the elderly in Germany, Austria and Switzerland. , 2012, Injury.

[28]  T. Nakayama,et al.  Is Rheumatoid Arthritis a Risk Factor for a High-Riding Vertebral Artery? , 2008, Spine.

[29]  N. Wright,et al.  Vertebral artery injury in C1-2 transarticular screw fixation: results of a survey of the AANS/CNS Section on Disorders of the Spine and Peripheral Nerves , 1998 .

[30]  Hsien-Te Chen,et al.  The Surgical Treatment Principles of Atlantoaxial Instability Focusing on Rheumatoid Arthritis , 2015, BioMed research international.

[31]  Jesse T. Lim,et al.  Biomechanical Evaluations of Various C1-C2 Posterior Fixation Techniques , 2011, Spine.

[32]  H. Richter,et al.  Complications of transpedicular screw fixation in the cervical spine , 2006, European Spine Journal.

[33]  Paul M. Arnold,et al.  Screw Placement Accuracy and Outcomes Following O-Arm-Navigated Atlantoaxial Fusion: A Feasibility Study , 2015, Global spine journal.

[34]  C. Bowers,et al.  An Odontoid Fracture Causing Apnea, Cardiac Instability, and Quadriplegia , 2012, Case reports in critical care.

[35]  Wei Tian,et al.  Minimally Invasive Pedicle Screw Fixation Using Intraoperative 3-dimensional Fluoroscopy-based Navigation (CAMISS Technique) for Hangman Fracture , 2016, Spine.

[36]  M. Neo,et al.  The Clinical Risk of Vertebral Artery Injury From Cervical Pedicle Screws Inserted in Degenerative Vertebrae , 2005, Spine.

[37]  David M. Brandman,et al.  Posterior C1-C2 Fusion with Polyaxial Screw and Rod Fixation * , 2018, 50 Landmark Papers.