summary craniocervical stabilization - lnhneurosurgerylnh.com/uploads/spine...

17/12/2015

1

Craniocervical StabilizationCraniocervical Stabilization

Mehmet Zileli, M.D.,

Izmir, Turkey

SummarySummarySummarySummary

Craniocervical instability Craniocervical instability -- definitiondefinition Stabilization techniquesStabilization techniques

Odontoid Screw FixationOdontoid Screw FixationC1-C2 Wire FixationC1C1--C2 Transarticular Screw FixationC2 Transarticular Screw FixationC1C1--C2 Segmental Screw FixationC2 Segmental Screw FixationOccipito Cervical FixationOccipito Cervical Fixation


Odontoid Screw FixationOdontoid Screw Fixation

SummarySummary

C1-C2 Wire FixationC1C1--C2 Transarticular Screw FixationC2 Transarticular Screw FixationC1C1--C2 Segmental Screw FixationC2 Segmental Screw FixationOccipito Cervical FixationOccipito Cervical Fixation

11-- TraumaTraumaOdontoid fractureOdontoid fractureLigamentous injuriesLigamentous injuriesCombined C1Combined C1--C2 fractureC2 fracture

CranioCranio--cervical instabilitycervical instabilityEtiologyEtiology

22-- Rheumatoid arthritisRheumatoid arthritis33-- Congenital abnormalitiesCongenital abnormalities44-- TumorsTumors55-- IatrogenicIatrogenic

17/12/2015

2

PainPain Deformity Deformity -- TorticollisTorticollis

N l i l tN l i l t

CranioCranio--cervical instabilitycervical instabilitySymptomsSymptoms

Neurological symptomsNeurological symptoms









IndicationsIndications

Anderson and D’Alonzo type II fr withAnderson and D’Alonzo type II fr with

Odontoid Screw FixationOdontoid Screw FixationOdontoid Screw FixationOdontoid Screw Fixation

Type IIFirst described in 1975 by BohlerFirst described in 1975 by BohlerA physiological procedure since it maintains A physiological procedure since it maintains

rotationrotationNo need to take a bone graftNo need to take a bone graftNo Halo fixationNo Halo fixation

Anderson and D Alonzo type II fr withAnderson and D Alonzo type II fr with Greater than 4 mm displacement Greater than 4 mm displacement Greater than 10 degrees of angulationGreater than 10 degrees of angulation Age greater than 40Age greater than 40 Posterior displacement (anterior displacement Posterior displacement (anterior displacement

may also be screwed)may also be screwed) First 8 weeks after traumaFirst 8 weeks after trauma Multilevel trauma Multilevel trauma NonunionNonunion

Type IIA

17/12/2015

3

1-Obliquety – anterior caudal to posterior cranial w/o buttress plate

ContraindicationsContraindicationsOdontoid Screw FixationOdontoid Screw FixationOdontoid Screw FixationOdontoid Screw Fixation

2-Transvers ligament rupture3-Nonreduced fractures4-Anterior dislocations?

Odontoid Screw FixationOdontoid Screw FixationSurgical Technique

Odontoid Screw FixationOdontoid Screw FixationSurgical Technique

Supine positionAwake nasotracheal intubation with slight neck extensionMayfield head holderPosition AP/lateral fluoroscopy with monitors placed opposite the operating surgeon

Ensure that anatomic reduction and an unobstructed drill approach angle has been achieved; image the K-wire superimposed over the screw trajectory.

the operating surgeon Two plane fluoroscopy and extensive setup

Place radiolucent bite block for AP imaging.Anterolateral retropharyngeal approach at C5-C6 level.

Odontoid Screw FixationSurgical Technique

Odontoid Screw FixationSurgical Technique

Odontoid Screw FixationOdontoid Screw FixationSurgical TechniqueSurgical Technique


Reduction may be achieved by pushing the distal or proximal fractured segment

Some surgeons do not perform in anterior dislocations

17/12/2015

4

Two screw technique



AlternativesAnterior C1-C2 transarticular screwing

AlternativesAnterior C1-C2 transarticular screwing

May be used after anterior odontoid resectionMay be used after anterior odontoid resection Technically demandingTechnically demanding

AlternativesC1-C2 plateAlternativesC1-C2 plate


Odontoid Screw FixationOdontoid Screw FixationC1-C2 Wire Fixation

SummarySummary

C1C1--C2 Transarticular Screw FixationC2 Transarticular Screw FixationC1C1--C2 Segmental Screw FixationC2 Segmental Screw FixationOccipito Cervical FixationOccipito Cervical Fixation

17/12/2015

5

Site preperation and wire passing

C1C1--C2 Wire FixationC2 Wire FixationC1C1--C2 Wire FixationC2 Wire Fixation

Gallie fusionC1-C2 Wire FixationC1-C2 Wire Fixation

Need however a postop halo brace....

C1C1--C2 Halifax Clamp FixationC2 Halifax Clamp FixationC1C1--C2 Halifax Clamp FixationC2 Halifax Clamp FixationBecame popular and then abandoned because of high failure rate....




17/12/2015

6

Anterior (Barbeour 1971)Anterior (Barbeour 1971)

Lateral (Du Doit 1976)Lateral (Du Doit 1976)

C1C1--C2 transarticular screw fixationC2 transarticular screw fixation

Lateral (Du Doit 1976)Lateral (Du Doit 1976)

Posterior (Magerl 1986)Posterior (Magerl 1986)

IndicationsIndicationsIndicated for Indicated for atlantoatlanto--axial instabilityaxial instability. A . A goodgood alternativealternative toto occipitocervicaloccipitocervicalfixationfixationBiomechanically stronger than wiringBiomechanically stronger than wiringObtain & maintain reductionObtain & maintain reductionC2 arch not necessaryC2 arch not necessaryTechnically demandingTechnically demanding


Normal Normal atlantoatlanto--axialaxial anatomyanatomy confirmedconfirmed in CT in CT scanscanLigamentousLigamentous ((nonnon--traumatictraumatic) ) instabilityinstability of of thethe atlantoatlanto--axialaxial segmentsegment duedue toto

RheumatoidRheumatoid arthritisarthritis InfectionInfection DegenerationDegeneration

TraumaTrauma RuptureRupture of of thethe transversetransverse ligamentligament FracturesFractures of of thethe atlas and atlas and axisaxis

C1C1--C2 C2 instabilityinstability duedue toto lossloss of bone (of bone (tumortumor, , infectioninfection))OsOs odontoideumodontoideumAfterAfter transoraltransoral densdens resectionresection ????

ContraindicationsContraindications Congenital malformations (illCongenital malformations (ill--defined anatomy)defined anatomy) Very high vertebral artery grooveVery high vertebral artery groove Missing pedicles of the axis, bony abnormality on the Missing pedicles of the axis, bony abnormality on the

entrance of screwentrance of screw


entrance of screwentrance of screw Severe osteoporosisSevere osteoporosis Upper thoracic kyphosisUpper thoracic kyphosis

Preoperative cautions:Preoperative cautions:* Variations of the vertebral artery* Variations of the vertebral artery* Severe cervical * Severe cervical lordosislordosis* Cervico* Cervico--thoracic kyphosisthoracic kyphosis

(Magerl 1986)(Magerl 1986)C1C1--C2 transarticular screw fixationC2 transarticular screw fixation

* Unreducible pathology* Unreducible pathology

17/12/2015

7

Medial to the pedicleC2 isthmus

(Pars interarticularis)

C2 root

Vertebral Artery Injury?


C1-C2 wire may be added to transarticular screw fixation. A tricortical bone graft is also placed.


ComplicationsComplications

Injury to the vertebral artery (Injury to the vertebral artery (inappropriateinappropriatein 20% of cases)in 20% of cases)(if one artery is injured the other side should not be(if one artery is injured the other side should not be


(if one artery is injured, the other side should not be (if one artery is injured, the other side should not be drilled and fusion with conventional techniques drilled and fusion with conventional techniques should be applied)should be applied)

Injury to the spinal cord Injury to the spinal cord Hardware failureHardware failure




17/12/2015

8

* First introduced by * First introduced by Goel* An alternative to posterior transarticular screw fixation* An alternative to posterior transarticular screw fixation* Lower risk of injury to the vertebral artery* Lower risk of injury to the vertebral artery

C1-C2 Segmental FixationC1-C2 Segmental FixationHarms 2001Harms 2001 GoelGoel--HarmsHarms

C1-C2 Segmental FixationC1-C2 Segmental Fixation

Grup A Basilary invagination Grup A Basilary invagination Posterior ReductionPosterior Reduction

Goel

65 y.o female, 565 y.o female, 5--6 months R arm and leg weakness,6 months R arm and leg weakness, gait gait disturbance, sphincter problemdisturbance, sphincter problem. . Quadriparetic,Quadriparetic, babassililaarryyinvaginainvaginatition on andand C1C1--2 2 dislodisloccaatition. on.

17/12/2015

9

Functional X rays: slight increase of dislocation during flexion. C1 asimilation

PostopPreop

PreopPreop PostopPostop

17/12/2015

10




IndicationsIndications Extensive occipitoExtensive occipito--cervical bony destruction cervical bony destruction

(Craniectomy in foramen magnum, upper (Craniectomy in foramen magnum, upper cervical laminectomy) cervical laminectomy)

Abscence of C1 arch due to a congenital Abscence of C1 arch due to a congenital malformation or after decompression.malformation or after decompression.

Congenital abnormalities of the occipitoCongenital abnormalities of the occipito--cervical articulationcervical articulation

OccipitoOccipito CervicalCervical FixationFixation

cervical articulationcervical articulation Basilary invaginationBasilary invagination Nonreduced subluxations of C1Nonreduced subluxations of C1--C2C2 Complex fractures of C1 and C2Complex fractures of C1 and C2 Unstable Unstable complex Jefferson fracturescomplex Jefferson fractures

ContraindicationsContraindications Osteoporosis ??Osteoporosis ?? DestructionDestruction ––iatrogeniciatrogenic-- of occipital boneof occipital bone

DisadvantagesDisadvantages

Reduced head and neck movements due to Reduced head and neck movements due to restriction of Ocrestriction of Oc--C1C1--C2 articulationsC2 articulations

FlexionFlexion--extensionextension 30%30%


FlexionFlexion extension extension 30% 30% Lateral rotationLateral rotation 10 degrees10 degreesLateral deviationLateral deviation 8 degrees8 degrees

High nonunion ratesHigh nonunion rates

Surgical Preperation and PositionSurgical Preperation and Position

Prone position, neck is neutralProne position, neck is neutral Lateral C arm controlLateral C arm control Mayfield head holderMayfield head holder Reduction with tractionReduction with traction


Reduction with tractionReduction with traction Preop CT: Thickness of occipital bone, VA Preop CT: Thickness of occipital bone, VA

anomaliesanomalies Bone graft should be placed between Bone graft should be placed between

occiput and cervical vertebraeocciput and cervical vertebrae

17/12/2015

11

Fixation techniquesFixation techniques

WiresWires with with Loops/platesLoops/platesHartshill rectangleHartshill rectangle Threaded Steinmann pinThreaded Steinmann pin Titanium rodTitanium rod


Titanium rodTitanium rod Titanium frame Titanium frame Ransford loopRansford loop

ScrewsScrews and platesand platesCD rod/screw plateCD rod/screw plate

ScrewsScrews and rodsand rods

WireWire--Rod/Plate Rod/Plate combinationcombinationOccipitoOccipito CervicalCervical FixationFixation

Luque-Hartshill rectangle Hartshill-Ransford loop

Wires with loops/plates & bone cementOccipitoOccipito CervicalCervical FixationFixation

C2 osteoblastoma - Ventro-lateral retropharyngeal approach

Occipito-cervical fixation using two axis plates and titanium wires

Case with plate and wires

October 1997 June 1998

17/12/2015

12

18 y.o. Female, basilary invagination and Chiari type I, tetraparesis, 9th and 10th nerve palsy, tonsillar herniation, PB-C2 9 mm

Case with plate and hooks

Transoral odontoid resection, Foramen magnum decompression, Duraplasty, Occipitocervical fusion

PlatePlate--Screw systemsScrew systems


Two plates Less rigid

Y plateMore rigid

PlatePlate--Screw systemsScrew systemsOccipitoOccipito CervicalCervical FixationFixation

U shaped plateU shaped plate Y shaped platePlatePlate--Screw systemsScrew systemsOccipitoOccipito CervicalCervical FixationFixation

Distances between two loops are 30 or 35 mm

Three different lengths of cervical plates with 3-4 and 5 holes

Plates ha e 120 degreesPlates have 120 degrees of angulation to fit the occipito-cervical inclination

33--4 occipital screws (64 occipital screws (6--8 mm cortical screws)8 mm cortical screws)

C2 isthmus screwC2 isthmus screw

C3C3--C5 lateral mass C5 lateral mass screwsscrews

17/12/2015

13

Cervical screw directions

C2 screw may be directed to pedicle or isthmus

C3-C6 lateral mass screws

C2 screw may be directed to pedicle or isthmus(25 degree medial and rostral)

A wire may be added to C1 arch. 51 y.o., male, Tetraparesis, Chiari type I (tonsillar herniation), Basilary invagination , PB C2 12 mm

Case with plate and screws

Transoral odontoid resectionForamen magnum decompressionDuraplastyOccipitocervical fixation

17/12/2015

14

Y plateMidline occiput has a thicker bone.

Screw purchase is more stabile.

There are long and short plates. A midline screw may hold the graft

Case with Y plate and screws

32 y.o. Male. Neck pain and headache32 y.o. Male. Neck pain and headache.. Hemihypesthesia on right. Hemihypesthesia on right. Assimilation of atlas to occiput.Assimilation of atlas to occiput.

Case with Y plate and Screws

Transoral dens resection, Transoral dens resection, occipitocervical fixation with Y plateoccipitocervical fixation with Y plate

RodRod--Screw systemsScrew systems

More rigid fixation

17/12/2015

15

RodRod--screw combinationscrew combination

Occipital Plate

Egyptian Spine Review2007, Cairo

ComplicationsComplications

CSF fistulaCSF fistula Cerebellar haematomaCerebellar haematoma Hardware related complicationsHardware related complications


Hardware related complicationsHardware related complicationsScrew looseningScrew looseningPseudoarthrosisPseudoarthrosisInstrument breakageInstrument breakage

ConclusionConclusion OccipitoOccipito--cervical fixation can be achieved cervical fixation can be achieved

using many different methods.using many different methods. It causes great restriction in cervical It causes great restriction in cervical

movementsmovements


FlexionFlexion--extensionextension 30% 30% Lateral rotationLateral rotation 10 degree10 degreeLateral bendingLateral bending 8 degree8 degree

Nonunion rate is highNonunion rate is high

17/12/2015

16

Thank youThank you

summary craniocervical stabilization - lnhneurosurgerylnh.com/uploads/spine...

Documents