Modification of C1–C2 Transarticular Screw Fixation By Image-Guided Surgery

Study Design. This is a feasibility study of image-guided surgery for C1–C2 transarticular screw fixation comparing postoperative screw position in a nonrandomized prospective cohort with a historic control group in which fluoroscopic guidance was used alone. Objectives. To evaluate the potential benefits and disadvantages of image-guided surgery for C1–C2 screw placement. Summary of Background Data. C1–C2 transarticular screw fixation is biomechanically superior to other current surgical stabilization procedures. The original technique for C1–C2 screw placement relies on anatomic landmarks and intraoperative fluoroscopy. Screw misplacement or anatomic variations can result in vertebral artery injury. Image-guided surgery involves using computed tomography (CT) data to plan the optimal screw trajectory before surgery and then use this data to guide screw placement during the actual surgery. Promising results of this technique are reported in the literature, but no direct comparison between image-guided surgery and conventional surgical techniques has been previously reported. Methods. The image-guided surgery group consisted of 37 prospective patients. The historic control group included 78 patients who had similar surgeries performed using only fluoroscopic guidance. For the image-guided surgery group, subluxation was reduced by positioning at the time of CT examination. The CT data were transferred to a StealthStation (Sofamor–Danek, Memphis, TN) surgical planning and guidance computer system, and an optimal screw trajectory was determined for the right and left transarticular screws. After matching the surgical field to the virtual computer field, C2 was drilled according to the planned screw trajectory, and screws were placed. Plain radiographs and CT were used for postoperative evaluation of the image-guided surgery group. Results. Image-guided surgery reduced but did not eliminate the risk of screw misplacement. Surgical time was not increased overall. Conclusions. Image-guided surgery is an effective tool for the achievement of correct screw placement in C1–C2 transarticular screw fixation procedures. The procedure remains technically demanding.

[1]  F. Magerl,et al.  Stable Posterior Fusion of the Atlas and Axis by Transarticular Screw Fixation , 1987 .

[2]  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. American Association of Neurological Surgeons/Congress of Neurological Surgeons. , 1998, Journal of neurosurgery.

[3]  R. Yeasting,et al.  Morphology of the Second Cervical Vertebra and the Posterior Projection of the C2 Pedicle Axis , 1995, Spine.

[4]  Guy Marchal,et al.  3D-CT based, personalized drill guide for posterior transarticular screw fixation at C1-C2: Technical note , 1999 .

[5]  Crockard Ha,et al.  Peroperative determination of safe superior transarticular screw trajectory through the lateral mass. , 1999 .

[6]  M. Aebi,et al.  Atlanto-axial fusion with transarticular screw fixation. , 1991, The Journal of bone and joint surgery. British volume.

[7]  F. Langlotz,et al.  Clinical evaluation of a system for precision enhancement in spine surgery. , 1995, Clinical biomechanics.

[8]  F. Cammisa,et al.  The placement of lumbar pedicle screws using computerised stereotactic guidance. , 1999, The Journal of bone and joint surgery. British volume.

[9]  B. Jeanneret,et al.  Safety and Accuracy of Transarticular Screw Fixation C1‐C2 Using an Aiming Device: An Anatomic Study , 1998, Spine.

[10]  H A Crockard,et al.  Radiological and anatomical evaluation of the atlantoaxial transarticular screw fixation technique. , 1997, Journal of neurosurgery.

[11]  L. Claes,et al.  In vitro investigations of internal fixation systems of the upper cervical spine , 1992, European Spine Journal.

[12]  Y. Rampersaud,et al.  Radiation Exposure to the Spine Surgeon During Fluoroscopically Assisted Pedicle Screw Insertion , 2000, Spine.

[13]  K. Foley,et al.  Image-guided spine surgery. , 1996, Neurosurgery clinics of North America.

[14]  K. Smith,et al.  The NeuroStation--a highly accurate, minimally invasive solution to frameless stereotactic neurosurgery. , 1994, Computerized medical imaging and graphics : the official journal of the Computerized Medical Imaging Society.

[15]  Y. Aydın,et al.  Posterior C1-C2 transarticular screw fixation for atlantoaxial arthrodesis. , 1999, Neurosurgery.

[16]  R. Yeasting,et al.  The Reliability of the Lateral Radiograph in Determination of the Optimal Transarticular C1‐C2 Screw Length , 1998, Spine.

[17]  H. Crockard,et al.  Peroperative determination of safe superior transarticular screw trajectory through the lateral mass. , 1999, Spine.

[18]  H. Crockard,et al.  Variation of the groove in the axis vertebra for the vertebral artery. Implications for instrumentation. , 1997, The Journal of bone and joint surgery. British volume.

[19]  M. Heilbrun,et al.  Preliminary experience using an optimized three-point transformation algorithm for spatial registration of coordinate systems: a method of noninvasive localization using frame-based stereotactic guidance systems. , 1994, Journal of neurosurgery.

[20]  N. Ebraheim,et al.  The Quantitative Anatomy of the Vertebral Artery Groove of the Atlas and Its Relation to the Posterior Atlantoaxial Approach , 1998, Spine.

[21]  M M Panjabi,et al.  Biomechanical Evaluation of Four Different Posterior Atlantoaxial Fixation Techniques , 1992, Spine.

[22]  M. Bernstein,et al.  C1-C2 posterior cervical fusion: long-term evaluation of results and efficacy. , 1995, Neurosurgery.

[23]  L. Nolte,et al.  Improved Accuracy of Pedicle Screw Insertion With Computer-Assisted Surgery: A Prospective Clinical Trial of 30 Patients , 1997, Spine.

[24]  E. Kosnik,et al.  Pediatric Atlantoaxial Instability: Management with Screw Fixation , 1999, Pediatric Neurosurgery.

[25]  Kevin T. Foley,et al.  O-17-255 Frameless stereotactic guidance of C1-2 transarticular screw placement: Clinical experience , 1997, Clinical Neurology and Neurosurgery.

[26]  K. Radermacher,et al.  Computer assisted orthopaedic surgery with image based individual templates. , 1998, Clinical orthopaedics and related research.

[27]  B Y Jun,et al.  Anatomic Study for Ideal and Safe Posterior C1‐C2 Transarticular Screw Fixation , 1998, Spine.

[28]  Volker K. H. Sonntag,et al.  Biomechanical Comparison of C1‐C2 Posterior Fixations: Cable, Graft, and Screw Combinations , 1998, Spine.

[29]  G H Barnett,et al.  Application of frameless stereotaxy to pedicle screw fixation of the spine. , 1995, Journal of neurosurgery.

[30]  H. Crockard,et al.  Variation of the Groove in the Axis Vertebra for the Vertebral Artery , 1997 .

[31]  P. Cinquin,et al.  Computer-assisted spine surgery: a technique for accurate transpedicular screw fixation using CT data and a 3-D optical localizer. , 1995, Journal of image guided surgery.

[32]  C. Dickman,et al.  The anatomical suitability of the C1-2 complex for transarticular screw fixation. , 1996, Journal of neurosurgery.

[33]  P. Vock,et al.  Radiation dose for pedicle screw insertion. Fluoroscopic method versus computer-assisted surgery. , 1999, Spine.