A biomechanical evaluation of occipitocervical instrumentation: screw compared with wire fixation

The purpose of this study was to compare cable techniques used in occipitocervical fixation with two types of screw fixation. The authors hypothesized that screw fixation would provide superior immobilization compared with cable methods.

Ten cadaveric specimens were prepared for biomechanical analyses by using standard techniques. Angular and linear displacement data were recorded from the occiput to C-6 with infrared optical sensors after conditioning runs. Specimens underwent retesting after fatiguing. Six methods of fixation were analyzed: Steinmann pin with and without C-1 incorporation; Cotrel-Dubousett horseshoe with and without C-1 incorporation; Mayfield loop with C1-2 transarticular screw fixation; and a custom-designed occipitocervical transarticular screw-plate system. Sublaminar techniques were extended to include C-3 in the fusion construct, whereas transarticular techniques incorporated the occiput, C-1, and C-2 only. All methods of fixation provided significant immobilization in all specimens compared with the nonconstrained destabilized state. Despite incorporation of an additional vertebral segment, sublaminar techniques performed worse as a function of applied load than screw fixation techniques. Following fatiguing, these differences were more pronounced. The sublaminar techniques failed most prominently in flexion-extension and in axial rotation. On gross inspection, increased angular displacement associated with loosening of the sublaminar cables was observed.

Occipitocervical fixation can be performed using a variety of techniques; all bestow significant immobilization compared with the destabilized spine. All methods tested in this study were susceptible to fatigue and loss of reduction and were weakest in resisting vertical settling. Screw fixation of the occiput-C2 reduces the number of vertebral segments that are necessary to incorporate into the fusion construct while providing superior immobilization and resistance to fatigue and vertical settling compared with sublaminar methods.