C1-C2 transarticular screw fixation: technical aspects

I review posterior atlantoaxial fusion with transarticular screw fixation, including indications, complications, and operative technique, emphasizing my experience.

The indications for C1-C2 transarticular screw fixation include traumatic injuries to the atlantoaxial complex, instability resulting from inflammatory disease (rheumatoid arthritis), and congenital abnormalities (os odontoideum). All patients underwent stabilization using cannulated C1-C2 transfacetal screws by the method described by Magerl. Supplemental interspinous fusion with bicortical autologous iliac crest graft and titanium cable was used to restore the posterior tension band by use of the method described by Sonntag's group. Preoperatively, all patients underwent imaging with plain radiographs, magnetic resonance imaging, and axial computed tomography. Patients were maintained in a rigid cervical orthosis postoperatively.

Measures used to improve safety and efficacy include patient positioning, fluoroscopic guidance, preoperative magnetic resonance imaging, axial computed tomography, and open reduction of C1-C2 subluxation before screw passage. In this series of 75 patients, fusion was obtained in 72 patients (96%). There were no instances of vertebral artery injury, errant screw placement, instrumentation failure, dural laceration, spinal cord injury, or hypoglossal nerve injury.

C1-C2 transarticular screw fixation with a posterior tension band construct provides excellent fusion rates with few perioperative complications. Preoperative imaging and meticulous surgical technique improve outcomes.