Biomechanical evaluation of segmental occipitoatlantoaxial stabilization techniques

Jonathan T Nassos, Alexander J Ghanayem, Rick C Sasso, Michael N Tzermiadianos, Leonard I Voronov, Robert M Havey, Anthony S Rinella, Gerard Carandang, Avinash G Patwardhan
Spine 2009 December 1, 34 (25): 2740-4

STUDY DESIGN: Biomechanical study using human cadaveric cervical spines.

OBJECTIVE: To evaluate the construct stability of 3 different segmental occipitoatlantoaxial (C0-C1-C2) stabilization techniques.

SUMMARY OF BACKGROUND DATA: Different C0-C1-C2 stabilization techniques are used for unstable conditions in the upper cervical spine, all with different degrees of risk to the vertebral artery. Techniques with similar stability but less risk to the vertebral artery may be advantageous.

METHODS: Six human cadaveric cervical spines (C0-C5) (age: 74 +/- 5.0 years) were used. After testing the intact spines, instability was created by transecting the transverse and alar ligaments. The spines were instrumented from the occiput to C2 using 3 different techniques which varied in their attachment to C2. All spines had 6 screws placed into the occiput along with lateral mass screws at C1. The 3 variations used in attachment to C2 were (1) C2 crossing laminar screws, (2) C2 pedicle screws, and (3) C1-C2 transarticular screws. The C1 lateral mass screws were removed before placement of the C1-C2 transarticular screws. Range of motion across C0-C2 was measured for each construct. The data were analyzed using repeated measures ANOVA. The following post hoc comparisons were made: (1) intact spine versus each of the 3 techniques, (2) laminar screw technique versus the pedicle screw technique, and (3) laminar screw technique versus the transarticular screw technique. The level of significance was alpha = 0.01 (after Bonferroni correction for 5 comparisons).

RESULTS: All 3 stabilization techniques significantly decreased range of motion across C0-C2 compared to the intact spine (P < 0.01). There was no statistical difference among the 3 stabilization methods in flexion/extension and axial rotation. In lateral bending, the technique using C2 crossing laminar screws demonstrated a trend toward increased range of motion compared to the other 2 techniques. CT scans in both axial and sagittal views demonstrated greater proximity to the vertebral artery in the pedicle and transarticular screw techniques compared to the crossing laminar screw technique.

CONCLUSION: Occipitoatlantoaxial stabilization techniques using C2 crossing laminar screws, C2 pedicles screws, and C1-C2 transarticular screws offer similar biomechanical stability. Using the C2 crossing laminar screw technique may offer an advantage over the other techniques due to the reduction of the risk to the vertebral artery during C2 screw placement.

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