Biomechanical comparison of C1-2 posterior fixation techniques

In a nondestructive, repeated-measures in vitro flexibility experiment, the authors compared the acute stability of C1-2 after placement of C-1 lateral mass and C-2 pars interarticularis (LC1-PC2) instrumentation with that of C1-2 transarticular screw fixation.

The effect of C-1 laminectomy and C1-2 interspinous cable/graft fixation on LC1-PC2 stability was studied. Screw pullout strengths were also compared. Seven human cadaveric occiput-C3 specimens were loaded nondestructively with pure moments while measuring nonconstrained atlantoaxial motion. Specimens were tested with graft alone, LC1-PC2 alone, LC1-PC2 combined with C-1 laminectomy, and graft-augmented LC1-PC2. Interspinous cable/graft fixation significantly enhanced LC1-PC2 stability during extension. After C-1 laminectomy, the LC1-PC2 construct allowed increased motion during flexion and extension. There was no significant difference in lax zone or range of motion between LC1-PC2 fixation and transarticular screw fixation, but graft-assisted transarticular screws yielded a significantly smaller stiff zone during extension. The difference in pullout resistance between C-1 lateral mass screws and C-2 pars interarticularis screws was insignificant. The LC1-PC2 region restricted motion to within the normal range during all loading modes. Atlantal laminectomy reduced LC1-PC2 stability during flexion and extension.

The instrumentation-augmented LC1-PC2 construct performed biomechanically similarly to the C1-2 transarticular screw fixation. The LC1-PC2 construct resisted flexion, lateral bending, and axial rotation well. The weakness of the LC1-PC2 fixation in resisting extension can be overcome by adding an interspinous graft to the construct.