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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_583_Библиотеки_им_академика_М_И_Перельмана
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M. H. Schmidt
a
halo. We always place a shoulder roll between the shoulder
blades to maximally extend the neck. To get a good AP view
of the odontoid process, a radiolucent mouth gag is frequently
used (a wine bottle cork can be notched into the teeth).
23.6 Operating Technique
23.6.1 Approach
• Lateral uoroscopy is used to ensure the proper trajectory; we place a K-wire along the neck of the patient to
ensure that the sternum does not interfere with the screw
placement.
• Once this is done, we inltrate the skin with epinephrine
and perform a standard Cloward approach to the anterior
b
c
spine (see Fig.23.2).
• At the C5 level, we place a small unilateral midcervical
incision in the skin crease. Then the platysma muscle is
divided horizontally, and the plane between the pharynx
and esophagus medially and the carotid sheath laterally is
developed.
• We use blunt nger dissection to expose the cervical
spine.
• The longus colli muscle is then incised and bilaterally
elevated, and sharp-tooth cervical retractor blades are
inserted rmly under these muscles and attached to a special retractor blade.
• Firm xation is important because a fair amount of tension is placed on the retractor during the drilling and
screw placement. After this retractor is placed, we use a
Kittner dissector to sweep up the anterior cervical spine to
approximately the level of C1.
• Once this dissection is completed, we place a superior
angled retractor blade (see Fig.23.2). This blade should
reach up approximately to C1. A choice of six different
blades is available.
• This retractor blade is then connected via a special retractor system to the lateral retractor blades. Once the retractor is in place, a working tunnel is created for the drilling
and placement of the odontoid screws.
Fig. 23.1 Classication based on the direction of the slope of the frac-
ture: anterior oblique (a), posterior oblique (b), and horizontal (c)
23.6.2 Instrumentation
• Using a sharp K-wire, we nd the entry site at the inferior
anterior edge of C2 on the lateral and AP uoroscopy (see
Fig.23.3a). The entry point location is chosen based on
whether one or two screws will be placed: If only one
screw is placed, the entry point should be at the anterior
23 Odontoid Screw Fixation
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Fig. 23.2 The C5 skin
incision and the position of
the soft tissue retractors (with
permission of Aesculap AG,
Tuttlingen, Germany)
165
inferior edge of C2 at the midline. We place the entry
point slightly laterally about 2–3mm off the midline if
two screws are to be placed.
• The K-wire is then manipulated under biplanar uoroscopy and impacted approximately 5mm into the C2 vertebral body (see Fig.23.3a).
• Once the K-wire is impacted, we use a hollow cord drill
that is passed over the K-wire, and a shallow groove is cut
into the anterior face of C3 and the C2–3 annulus
(Fig.23.3).
• We then put together the inner and outer drill guides and
pass them over the K-wire. The outer drill guide has spikes
(see Fig.23.4), which are carefully maneuvered over the C3
vertebral body under uoroscopy.
• At this point, the K-wire frequently needs to be shortened
with a wire cutter since it protrudes over the inner tube
guide. It is important to leave at least 1cm of the K-wire
protruding beyond the inner tube guide in order to be able
to remove it.
• The plastic impact sleeve is then tted over the guide wire
assembly, and a mallet is used to impact the spikes into
the C3 vertebral body (see Fig.23.5).
• The inner tube guide is then advanced until it contacts the
inferior edge of C2. The surgeon at this point can manipulate the handle and adjust the cervical spine to the appropriate trajectory (see Fig.23.6).
• The K-wire then can be removed without loss of alignment and positional stability. By lifting and depressing
the guide tube assembly that is impacted into C3, the
alignment between C1 and C2 can be carefully manipulated. If the odontoid process is retrolisthesed, the guide
tube assembly can be depressed to get the optimal angle
for drilling. This is monitored under uoroscopy.
• Next, the drill is inserted through the drill guide and
through the C2 odontoid process under AP and lateral
uoroscopy. The drill guide can be adjusted before the
fracture site is crossed by depressing or elevating the
C2–3 complex (see Fig.23.7).
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Fig. 23.3 After dissection of
the retropharyngeal space, the
K-wire is placed (a) and the
entry site at C2/3 is drilled
(b, c, d) (with permission of
Aesculap AG, Tuttlingen,
Germany)
M. H. Schmidt
Fig. 23.4 Inner and outer
drill guide assembly (with
permission of Aesculap AG,
Tuttlingen, Germany)
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Fig. 23.5 Advancing the inner drill
guide in the previously created C2/3
groove (with permission of Aesculap
AG, Tuttlingen, Germany)
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Fig. 23.6 Securing of the
teeth of the guide tube to C3
with impactor (with
permission of Aesculap AG,
Tuttlingen, Germany)
M. H. Schmidt
Fig. 23.7 The guide tube is
secured into the C3 vertebral
body to drill through C2 into
the apex of the odontoid tip
(with permission of Aesculap
AG, Tuttlingen, Germany)
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Fig. 23.8 After the drill is
withdrawn, the hole is tapped,
and the length of the screw is
determined (with permission
of Aesculap AG, Tuttlingen,
Germany)
169
• Once the desired alignment has been achieved, the
drill can be advanced through the tip of the odontoid
process. In osteoporotic bone, in particular, it is important that the drill is placed bicortically through
the apical cortex, which will prevent back out of the
screw.
• The appropriate screw length is determined from the calibrated marks at the proximal end of the drill. A partially
threaded screw is initially selected. Then, the drill is withdrawn, and a tap is inserted. In general, we tap the entire
drill path bicortically through the tip of the odontoid process. The length of the screw can then be conrmed with
the tap (see Fig.23.8).
• After the tap is removed, we place the titanium screw
under bilateral uoroscopy until the distal cortex of the
odontoid is fully engaged and sometimes draws back
slightly to pull together the bone fragments. The “lag
effect” assists with closing the fracture gap and the healing process (see Fig.23.9).
• If a second screw is to be placed, the same process is
repeated (see Fig.23.10).
• Then, the retractors are removed, and the muscle is lightly
approximated with 3.0 absorbable stitches, and the skin is
closed. We generally do not place drains. The immediate
stability can be conrmed by extending and exing the
neck under lateral uoroscopy.
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M. H. Schmidt
Fig. 23.9 Illustration of screw insertion (a) and the lag effect (arrows, b) (with permission of Aesculap AG, Tuttlingen, Germany)
Fig. 23.10 Postoperative X-rays of odontoid screws (with permission of Klimo etal. [8])
23 Odontoid Screw Fixation
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171
References
1. Bohler J.Anterior stabilization for acute fractures and non-unions
of the dens. J Bone Joint Surg Am. 1982;64:18–27.
2. Aebi M, Etter C, Coscia M. Fractures of the odontoid process.
Treatment with anterior screw xation. Spine. 1989;14:1065–70.
3. Apfelbaum RI.Anterior screw xation for odontoid fractures. In:
Rengachary SS, Wilkins RH, editors. Neurosurgery operative atlas,
vol. 2. 3rd ed. Park Ridge: American Association of Neurological
Surgeons; 1992. p.189–99.
4. Apfelbaum RI, Lonser RR, Veres R, Casey A.Direct anterior screw
xation for recent and remote odontoid fractures. J Neurosurg.
2000;93:227–36.
5. Dunn ME, Seljeskog EL.Experience in the management of odontoid process injuries: an analysis of 128 cases. Neurosurgery.
1986;18:306–10.
6. Etter C, Coscia M, Jaberg H, et al. Direct anterior xation of dens fractures with a cannulated screw system. Spine.
1991;16:S25–32.
7. Jenkins JD, Coric D, Branch CL Jr. A clinical comparison of oneand two-screw odontoid xation. J Neurosurg. 1998;89:366–70.
8. Klimo P, Rao G, Apfelbaum RI.Microsurgical treatment of odontoid fractures. In: Mayer HM, editor. Minimally invasive spinal surgery. NewYork: Springer; 2005.
9. Montesano PX, Anderson PA, Schlehr F, etal. Odontoid fractures treated by anterior odontoid screw xation. Spine.
1991;16:S33–7.
Anterior Transarticular Screw
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Fixation C1/C2
UweVieweg andMeicH.Schmidt
24
24.1 Introduction and Core Messages
Anterior transarticular screw xation is a useful minimally invasive technique for achieving C1–2 stabilization. This chapter describes the anterior transarticular
screw xation of the atlantoaxial joints using an anterior (Smith–Robinson) approach to the cervical spine.
Cannulated or noncannulated screws can be inserted
with a lateral angulation of 20° relative to the sagittal
plane and a posterior angulation of 30° relative to the
coronal plane. The advantages of this method are
immediate stability, the elimination of external orthosis, and cost-effectiveness. This form of anterior transarticular screw xation is as stable and rigid as
posterior transarticular screw xation [1–4].
24.2 Indications [5–8]
• Atlantoaxial instabilities (acute and chronic)
• C1–2 instability in cases where a posterior approach is
impossible
• Failure of previous posterior treatment
• C1 type II odontoid combination fracture [5]
24.3 Contraindications
• Fracture of the C1–2 joint complex
• Vertebral artery with atypical course
• Some cases where neck is very short or thick
• Some cases with high barrel-shaped thorax
24.4 Equipment
Two C-arms for simultaneous anteroposterior and lateral
uoroscopy are essential for this technique. The settings and
other equipment, and the operative approach, are the same as
those for osteosynthesis using expansion screws (e.g., positioning device, rechargeable drill, appropriate screws for
small fragments, Synthes odontoid screw system).
U. Vieweg (*)
Department of Conservative and Surgical Spine Therapy with
Interdisciplinary Spinal Deformities Centre and Rummelsberg
Sectional Center, Hospital Rummelsberg, Schwarzenbruck,
Germany
e-mail: uwe.vieweg@sana.de
M. H. Schmidt
Department of Neurosurgery, University of New Mexico,
Albuquerque, NM, USA
e-mail: MHSchmidt@salud.unm.edu
© Springer-Verlag GmbH Germany 2023
U. Vieweg, F. Grochulla (eds.), Manual of Spine Surgery, https://doi.org/10.1007/978-3-662-64062-3_24
24.5 Planning, Preparation,
andPositioning
The planning of the operation requires a CT to ensure that
the C1–2 joint complex is intact (look out for rotational
malalignment). The patient is put in a supine position, and
the head is stabilized using a Mayeld headholder. Two
C-arms are necessary to identify the anatomical structures
of the upper cervical spine in the anteroposterior and lateral
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U. Vieweg and M. H. Schmidt
Fig. 24.1 (a) Patient
positioned on operating table.
(b) Note the placement of two
C-arm uoroscopic units for
anteroposterior (transoral) and
lateral uoroscopic control
a
b
projections (see Fig.24.1a, b). The site of the incision (usually at the C4/C5 level) is determined by placing a K-wire
along the side of the neck in the intended direction of the
screw and viewing it with the image intensier (see
Fig.24.2).
24.6 Surgical Technique
24.6.1 Approach
• A transverse skin incision is recommended as, in most
cases, only one segment is involved (for C3/C4, two n-
gerbreadths caudal to the mandible at the level of the lingual bone; for C4/C5, at the level of the Adam’s apple).
• Using a routine anterior approach to the cervical spine at
the C4–5 level, the anterior side of the C2 vertebral body
is exposed.
• The platysma is cut, and the supercial nuchal fascia is
exposed. This is then cut longitudinally at the anterior
edge of the sternocleidomastoid muscle.
• The sternocleidomastoid muscle is then moved to the
side, exposing the two longus colli muscles beneath.
• Blunt dissection is carried out in the prevertebral facial
plane using a side sweeping motion with a small gauze
pad. Exposure of the upper half of C3 and the lower half
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