Biomechanical analysis of Goel technique for C1-2 fusion

The Goel technique, in which C1-2 intraarticular spacers are used, may be performed to restore stability to a disrupted atlantoaxial complex in conjunction with the Harms technique of placing polyaxial screws and bilateral rods. However, it has yet to be determined biomechanically whether the addition of the C1-2 joint spacers increases the multiaxial rigidity of the fixation construct. The goal of this study was to quantify changes in multiaxial rigidity of the combined Goel-Harms technique with the addition of C1-2 intraarticular spacers.

Seven cadaveric cervical spines (occiput-C2) were submitted to nondestructive flexion-extension, lateral bending, and axial rotation tests in a material testing machine spine tester. The authors applied 1.5 Nm at a rate of 0.1 Nm/second and held it constant for 10 seconds. The specimens were loaded 3 times, and data were collected on the third cycle. Testing of the specimens was performed for the following groups: 1) intact (I); 2) with the addition of C-1 lateral mass/C-2 pedicle screws and rod system (I+SR); 3) with C1-2 joint capsule incision, decortication (2 mm on top and bottom of each joint [that is, the C-1 and C-2 surface) and addition of bilateral C1-2 intraarticular spacers at C1-2 junction to the screws and rods (I+SR+C); 4) after removal of the posterior rods and only the bilateral spacers in place (I+C); 5) after removal of spacers and further destabilization with simulated odontoidectomy for a completely destabilized case (D); 6) with addition of posterior rods to the destabilized case (D+SR); and 7) with addition of bilateral C1-2 intraarticular spacers at C1-2 junction to the destabilized case (D+SR+C). The motion of C-1 was measured by a 3D motion tracking system and the motion of C-2 was measured by the rotational sensor of the testing system. The range of motion (ROM) and neutral zone (NZ) across C-1 and C-2 were evaluated.

For the intact spine test groups, the addition of screws/rods (I+SR) and screws/rods/cages (I+SR+C) significantly reduced ROM and NZ compared with the intact spine (I) for flexion-extension and axial rotation (p < 0.05) but not lateral bending (p > 0.05). The 2 groups were not significantly different from each other in any bending mode for ROM and NZ, but in the destabilized condition the addition of screws/rods (D+SR) and screws/rods/cages (D+SR+C) significantly reduced ROM and NZ compared with the destabilized spine (D) in all bending modes (p < 0.05). Furthermore, the addition of the C1-2 intraarticular spacers (D+SR+C) significantly reduced ROM (flexion-extension and axial rotation) and NZ (lateral bending) compared with the screws and rods alone (D+SR).

Study result indicated that both the Goel and Harms techniques alone and with the addition of the C1-2 intraarticular spacers to the Goel-Harms technique are advantageous for stabilizing the atlantoaxial segment. The Goel technique combined with placement of a screw/rod construct appears to result in additional construct rigidity beyond the screw/rod technique and appears to be more useful in very unstable cases.