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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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24 Anterior Transarticular Screw Fixation C1/C2
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Fig. 24.2 K-wire along the side of the neck in the intended direction of
the screws and viewed on the image intensier
175
a
b
of C2 is usually sufcient. Preparation can often be carried out with the ngers.
24.6.2 Instrumentation
• The insertion point for the screws is at the midpoint of
the C2 vertebral body in the medial third of the C1–2
articulation, just below the sulcus on the anterior
side [9].
• After drilling and tapping, 3.5- or 4-mm small fragment
screws are placed across the joint in the C1 massa lateralis, diverging about 20° and inclined upward about 30°
(standard lag screw technique).
• It is absolutely essential that tissue protectors are used
when drilling and tapping.
• Note: The use of cannulated screws and predrilling
with a K-wire makes instrumentation much easier. The
cannulated screw technique can be used for this (see
Fig.24.3).
• A threaded K-wire of 1.2-mm diameter and 20-cm length
is advanced into the body of C2in a posterior and superior
direction at an angle of 20° to the coronal plane and 30° to
the sagittal plane (see Fig.24.3a, b).
• The length of the K-wire in the bone is measured with the
ruler, indicating the length of screw required.
• The screw length is 20–25 mm. When odontoid screws
are used, only the 28-mm screws may be readily avail-
Fig. 24.3 Orientation of anterior transarticular screws relative to
C1–2. (a) anteroposterior view (20°). (b) lateral view (30°)
able. It is possible to place these screws safely (see
Fig.24.4a–f).
• 3.5-mm cannulated fully threaded and short-thread screws
can be used.
• Cannulated screws are inserted after predrilling of the
subchondral bone of the joint surface of the lateral mass
of C2 and C1.
• The screws are inserted using a cannulated screwdriver.
Note: Observe the insertion of the cannulated screws on
the lateral image intensier to ensure that the K-wire does
not advance in an anterior direction.
• The ventral portions of the C1–2 joint are decorticated,
and spongiosa is applied (arthrodesis).
24.7 Tips andTricks
• Do not go too far in a cranial direction and cross into the
occipitoatlantal joint. If the screw trajectory is too lateral,
there is a risk of injuring the vertebral artery.
• Odontoid and bilateral C1–2 transarticular screw xation
through a small anterior skin incision is an alternative
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U. Vieweg and M. H. Schmidt
Fig. 24.4 Different CT
images of the transarticular
screws at C1–2 and the
odontoid screw of an
82-year-old woman show an
odontoid type II and C1 arc
fracture. (a) Screws in the
base of C2, (b) in the middle
of the corpus C2, (c) the tip of
the screws in the odontoid
process and in the joint C1/
C2, (d) lateral view of the
screw in the right joint C1/C2,
(e) odontoid screw, and (f)
lateral view of the screw in
the right joint C1/C2
ab
e f
24 Anterior Transarticular Screw Fixation C1/C2
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177
option for patients with odontoid fracture, worsened clinical state, and poor bone quality.
• This procedure is helpful in polytraumatized or elderly
patients where surgery needs to be limited, but stability of
the C1/C2 complex is absolutely essential.
References
1. Koller H, Kammermeier V, Ulbricht D, Assuncao A, Karolus S, van
den Berg B, Holz U.Anterior retropharyngeal xation C1–2 for stabilization of atlantoaxial instabilities: study of feasibility, technical
description and preliminary results. Eur Spine J. 2006;15:1326–38.
2. Lu J, Ebrahim NA, Yonk H, etal. Anatomic considerations of anterior transarticular screw xation for atlantoaxial instability. Point of
view. Spine. 1998;23:1229–36.
3. Pepin JW, Boune RB, Hawkins RJ. Odontoid fractures with special references to the elderly patients. Clin Orthop Relat Res.
1985;193:178–83.
4. Reindl R, Sen M, Aebi M.Anterior instrumentation for traumatic
C1-C2 instability. Spine. 2003;28:E329–33.
5. Dean Q, Jiefu S, Jie W, Yunxing S. Minimally invasive technique of triple anterior screw xation for an acute combination
atlas axis fracture: case report and literature review. Spinal Cord.
2009;48(2):174–7.
6. Kim SM, Lim TJ, Paterno J, Hwang TJ, et al. Biomechanical
comparison of anterior and posterior stabilization methods
in atlantoaxial instability. J Neurosurg. 2004;100(3 Suppl):
277–83.
7. Six E, Kelly DL.Technique for C1, C2 and C3 xation in cases of
odontoid fractures. Neurosurgery. 1981;8:374–7.
8. Vaccaro AR, Lehman AP, Ahlgren BD, Garn SR.Anterior C1-C2
screw xation and bony fusion through an anterior retropharyngeal
approach. Orthopedics. 1999;22:1165–70.
9. Sen MK, Steffen T, Beckman L, et al. Atlantoaxial fusion
using anterior transarticular screw xation of C1-C2: technical innovation and biomechanical study. Eur Spine J. 2005;14:
512–8.
Transoral Resection oftheOdontoid
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Process
MeicH.Schmidt andUweVieweg
25
25.1 Introduction and Core Messages
The transoral approach to anteriorly placed lesions at
the craniocervical junction is not new [1] but is still
infrequently used by neurosurgeons for tumors in this
region [2]. The anterior inferior aspect of the craniocervical junction constitutes the upper posterior wall
of the oral cavity. The open oral cavity can therefore be
used to access this region without disturbing the
medulla.
25.2 Indications
• Spinal column tumor with neural compression
• Extradural metastatic tumor
• Irreducible subluxations
• Os odontoideum
• Rheumatoid pannus
25.3 Contraindications
• Inability to open the mouth widely for the transoral
approach, that is, severe arthritis of the temporomandibular joints (TMJ)
• Intradural pathologies
M. H. Schmidt (*)
Department of Neurosurgery, University of New Mexico,
Albuquerque, NM, USA
e-mail: MHSchmidt@salud.unm.edu
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
25.4 Technical Prerequisites
Fluoroscope, retractor system, long forceps, dissectors, and
burrs are technical prerequisites. In general, any resection of
the odontoid process results in instability. It is therefore
most often performed in conjunction with posterior C1–2
fusion. Alternatively, the use of various screw systems and
plating systems for anterior plating has been described [3].
25.5 Planning, Preparation,
andPositioning
The transoral exposure of the clivus, atlas, and ventral aspect
of C2 is commonly performed in our practice. After induction
of general anesthesia, the patient is placed with the neck
extended in the supine position. For the transoral approach, it
is important to ensure that the patient can open his or her
mouth sufciently. This can frequently be a problem in
patients with arthritic temporomandibular joints, which are
common in rheumatoid patients. In such cases, the procedure
can be modied to include transmandibular splitting, but this
is not common. Regular intubation is performed, and we use
the Spetzler–Sonntag retraction system to allow exposure of
the oral cavity (Fig.25.1). It is important to protect the teeth
during the placement of this retractor. It is also important to
protect the tongue since signicant tongue swelling can occur
if retraction is performed against the teeth. Some authors
advocate nasal intubation, but we have found this unnecessary. Once the retractors are placed, the posterior pharynx is
sufciently exposed, and the C1 tubercle is palpated.
25.6 Operating Technique
25.6.1 Approach
• The surgical site is inltrated with lidocaine and epineph-
rine, and the midline is incised with a monopolar cautery,
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U. Vieweg, F. Grochulla (eds.), Manual of Spine Surgery, https://doi.org/10.1007/978-3-662-64062-3_25
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M. H. Schmidt and U. Vieweg
Fig. 25.2 Retraction of the soft palate with subsequent longitudinal
incision of the dorsal wall of the pharynx (1 Uvula, 2 palatum molle, 3
arcus palatoglossus, 4 arcus palatopharyngeus, 5 dorsal wall of pharynx
with mucosa, 6 tonsilla palatina)
Fig. 25.1 Diagram of the upper cervical resections that can be per-
formed cranially and caudally from a transoral approach
with the incision extending approximately 2–3cm from
the anterior arch of C1 to the bottom of C2.
• With this dissection, the bone is exposed, and the pharyngeal tissues are retracted laterally. This is greatly facilitated by placement of the retractor plate (see Figs.25.2
and 25.3).
• Once the retractors are placed, we use the Midas Rex drill
or remove the anterior aspect of the arch of C1.
• We then proceed with drilling of the C2 dens. It is important initially to preserve the outer shell of the C2 dens to
prevent the soft tissues from falling into the surgical site.
• Once the C2 dens are eggshell thin, we remove the
remaining tissues. This allows access for removal of the
pannus in rheumatoid patients and decompression of the
upper cervical canal.
25.6.2 Instrumentation (Additional)
• The transoral exposure of the posterior pharynx has been
described by Schmelzle and Harms [4] for treatment of
unstable Jefferson fractures.
• Reduction is achieved by placing the patient in traction.
C1 and C2 are then exposed anteriorly (Fig.25.4).
• Osteosynthesis is performed with a compression plate or
a screw/rod system.
Fig. 25.3 After incision has been made in dorsal wall of pharynx (1
longus colli muscle, 2 longus capitis muscle, 3 superior constrictor
pharyngis muscle)
• Polyaxial screws are placed into both C1 lateral masses
and then connected with a rod. This allows for preservation of the C1–2 motion segment in cases with Jefferson
fractures [5].
25 Transoral Resection oftheOdontoid Process
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Fig. 25.4 Atlas and axis (1 longus colli muscle, 2 longus capitis mus-
cle, 3 corpus axis, 4 tuberculum anterius atlantis, 5 membrana atlantooccipitalis anterior)
181
References
1. Hall JE, Dennis F, Murray J.Exposure of the upper cervical spine for
spinal decompression by mandible and tongue-splitting approach. J
Bone Joint Surg Am. 1977;59A:121.
2. Russo A, Albanese E, Quiroga M, etal. Submandibular approach to
the C2–3 disc level: microsurgical anatomy with clinical application. J Neurosurg Spine. 2009;10:380–9.
3. Vender JR, Harrison SJ, McDonnell DE. Fusion and instrumentation at C1–3 via the high anterior cervical approach. J Neurosurg.
2000;92:24–9.
4. Schmelzle R, Harms J.Craniocervical junction-diseases, diagnostic application of imaging procedures, surgical techniques. Fortschr
Kiefer Gesichtschir. 1987;32:206–8.
5. Ruf M, Melcher R, Harms J.Transoral reduction and osteosynthesis C1 as a function-preserving option in the treatment of unstable
Jefferson fractures. Spine. 2004;29:823–7.
6. Jeszenszky D, Harms J, Hadasch R, et al. C2 prosthesis allowing optimal stabilisation after C2 resection following destructive
lesions. Eur Spine J. 1999;8(Suppl 1):S40.
25.7 Tips andTricks
• Reconstruction of the dens using a C2 prosthesis, as
described by Jeszenszky etal. [6].
• Additional dorsal instrumentation and fusion of C1–C3.
• Primary dorsal instrumentation with decompression may
also be considered for patients with rheumatoid arthritis.
Cervical Tong Extension andtheHalo
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Fixator
UweVieweg, PiaBorgas, andKirilMladenov
26
26.1 Introduction and Core Messages
The cervical tong (Crutcheld, Gardner-Wells, Vinke) has
two slats, which pin the bony skull, in order to perform an
extension procedure such as a luxation of the upper cervical spine, or in preparation for scoliosis operations. Skull
tongs such as cone calipers are used in more severe cervical
injuries. A halo ring may be indicated as an alternative to
cervical tongs. Both instruments are inserted into the skull
such that weighted traction can be applied to the cervical
spine. A halo-ring with a vest forms a halo xator. This can
be used to immobilize the cervical spine after fractures and
instabilities (injuries, infections), but also for spinal extension treatment before surgically correcting spinal deformations. In these situations, the halo-ring can either be used in
combination with a halo-cast or a halo-vest. Extension
techniques including the halo-gravitation-extension or
halo-pelvic-apparatus are especially useful for the correction of spinal deformations. Furthermore, the halo xator is
largely used for pre-surgical extension treatments in
patients with paralytic scoliosis, as well as temporary retention in patients who have undergone complex spine deformity operations after ventral release or mobilized
osteotomies.
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
P. Borgas
Faculty of Medical Sciences, University College London,
London, UK
K. Mladenov
Department of Pediatric Orthopedic Surgery, AKK Altonaer
Children’s Hospital, Hamburg, Germany
26.2 Indications and Contraindications of
Cervical Tong and Halo Fixator
The cervical tong has two slats, which pin the bony skull, in
order to perform an extension, such as a luxation of the upper
cervical spine, or in preparation for scoliosis surgery (see
Fig.26.1). Skull tongs such as cone calipers are used in more
severe cervical injuries. Alfred S.Taylor rst used such traction
devices and skull-based traction in 1929 for cervical fractures
and spinal injuries [1]. Introduced in 1973 by J.Gardner, the
Gardner–Welss Tong (GWT) has become a popular method of
spinal traction [2]. Different apparatus have been utilized for
skeletal traction, including Crutcheld’s caliber, Cone’s caliber,
Bluckburn’s caliber, and halo traction [2, 3]. For traumatic
lesions of the cervical spinal cord, the cervical tong allows for a
dosed, temporary extension while the patient is on bed rest, with
the possibility to reposition the spine. However, complete healing is not possible. During longer term bed rest, patients are at
risk of cardiorespiratory, cerebrovascular, or thromboembolic
complications. Complex mal-alignments cannot be restored
using the cervical tong. It is also not possible to mobilize the
patient into a standing position. Perry and Nickel therefore
described the halo xator in 1959 [4]. A halo system is a construction of a ring, pins, a superstructure and a vest (see
Figs.26.3 and 26.7). The halo ring is xed to the skull with pins
and is the anchor point for the superstructure at the head. The
skull pins are fastened tight enough such that the halo ring is
stabilized, as they are the main xation points for the ring to the
head. The vest is connected to the ring by the superstructure,
which forms a rigid construction to immobilize the neck. The
vest extends to the waist and is designed to t comfortably and
tightly around the body to maintain the initial alignment of the
spine [5, 6]. The rst application of the device was for patients
for whom poliomyelitis had led to paralysis or the head and
neck musculature, with consequent loss of head control. In the
rst version of the halo xator, the ring was combined with a
plaster cast. Through the application of modern synthetic materials and carbon rods, an MRI examination with the device is
now possible. The device can be used to compress, distract, and
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Fig. 26.1 Cervical traction tong (Aesculap AG, Tuttlingen, Germany)
for extension of the neck vertebral, large size, pins adjustable hence not
initial drilling
move the spine. The external halo xator therefore offers an
improvement to the cervical tong [5–8]. The disadvantage of the
halo xator however is that patients are restricted at home.
Assistance with bodily hygienic care, as well as dietary intake is
required, and the halo vest also posits an enormous psychiatric
burden for patients. To protect the lining of the halo vest from
moisture, the upper body may only be cleaned using a wet
washcloth. One focus of application however remains the temporary immobilization and extension during a two-sided
approach, after an upstream release or a mobilizing osteotomy,
as part of complex corrective spinal interventions. However, the
introduction of modern spinal osteosynthesis procedures has
made the application of the halo xator uncommon. Before
rigid internal xation methods were introduced and became
more commonly used, the halo xator was used as the rst-line
treatment of choice to stabilize the cervical spine for many cervical injuries [5].
The indications and contraindications for halo vest, halo-,
and cervical tong extensions are largely identical. The indications are [3, 5, 6, 9–12]
• Injuries of the cervical spine,
• Temporary immobilization for patients with tumors and
infections,
• Halo extension before or between operative spinal correc-
tion procedures,
• Pre-surgical extension of paralytic scoliosis, and
• Temporary extension after ventral release.
U. Vieweg et al.
The contraindications are [7–9, 12–14]:
• Cranial fractures and intracranial injuries,
• Soft tissue infections of the skull,
• Children <3years,
• Thorax injuries, and
• Paraplegia with respiratory muscle impairments.
Halo use in elderly patients remains controversial as
recent evidence demonstrated extremely high mortality rates
in patients 79years and older [7, 8].
26.3 Cervical Tong Extension
26.3.1 Technical Prerequisites
Several different tongs are in common use. They always
consist of a stainless steel or graphite body with two sharptipped titanium pins; one attached at each end. Their material make-up makes them compatible with magnetic
resonance imaging (MRI). The pins are attached on each
side of the skull to its outer table. The commonly used cervical tongs include the Crutcheld (small size, medium,
large), Gardner–Wells, and Vinke tongs [1, 9, 15, 16]. The
Vinke tongs are placed on the parietal bones, near the widest transverse diameter of the skull. The Gardner–Wells
tongs are inserted slightly above the patient’s ears.
Alternative types include the Bremer Universal and Trippi–
Wells tongs.
26.3.2 Technique
• Place the patient in the bed. Shave the patient’s hair above
the ear region.
• Inltrate the skin with a local anesthetic.
• Avoid the temporal artery.
• Make a small incision superior to the ear in line with the
auditory meatus (see Fig.26.2a).
• The clamp is adapted to the cranial circumference of the
patient with this set screw. After the pins have been rmly
anchored in the cranial bone, the clamp is turned on with
a wrench.
• Screw in the pin until it perforates the outer skull table.
• Tie the tong to a rope and attach weights (see Fig.26.2b, c).
26.3.3 Direction ofTraction andCalculated
Weight
• Continuous traction is provided by weights applied to the
external cervical xation device via a rope and pulley
system.
26 Cervical Tong Extension andtheHalo Fixator
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185
cab
Fig. 26.2 (a–c) The xation point for the pins is approximately 2cm above the porus acusticus externus (a) before installation of the cervical
tong; (b and c) after installation of the cervical tong
• Calculate the force required: 2.5 kg for the head and
1/2kg per vertebra.
• Adjust the height of the pulley, with the bed in antiTrendelenburg position. Then apply the weights.
• Start with 6kg and increase by 1kg every 6h until a maximum weight of 15kg has been reached.
• Add the weights gradually while proceeding with radiographic imaging to determine reduction.
• The direction of extension must be in line with the auditory meatus.
26.3.4 Complications ofCervical Tong
Extension
Possible complications of a cervical traction include bleeding of the temporal artery, pressure sores on the skull (this is
preventable by avoiding a downward vector to the rope), skin
sepsis or sepsis due to a subdural abscess, declining neurological status, and a squint due to fall out of the sixth cranial
nerve [9, 10, 15, 16]. Saleh etal. [3] reported in a systematic
literature review a 37.5% incidence rate of minor complications with the usage of a Gardner–Wells tongs which includes
pin loosening, asymptomatical pin positioning, and supercial infections. Various cases reported more serious complications including perforation of the skull brain, brain
abscesses, and neurovascular damage.
26.4 Halo Fixator
26.4.1 Technical Prerequisites
A halo xator (see Figs. 26.3 and 26.7) may be required in
adults or children. Different companies provide halo xators
(e.g., Bremer ACE Halo System; Johnson and Johnson Halo
ring with vest; DAONSA, ReSolve Halo Vest; OSSUR
ORTHOTICS, etc.). Some of these have special skull pins,
which utilize a unique cutting head to signicantly reduce bone
destruction. Importantly, both halo vest and ring have to be
Fig. 26.3 A patient with a halo vest
sized prior to the procedure. The optimal ring size is 1–2cm
greater than the circumference of the patient’s head [17].
Different variables inuence the stability and comfort of the
construct, as well as the complication rate. These variables
include the pin location and the design of the pin, ring, and vest
[2, 5, 13, 18]. The interaction site between pin and bone is the
most likely and common location at which the halo xator may
fail. Ideally, the pin should be positioned 0.5cm proximal to
the eyebrow. Pins that were instead positioned 1 and 1.5cm
proximal were 10% and 30% less stable, respectively [18].
Thus, the xation strength and pin–bone relationship are deter-
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U. Vieweg et al.
mined by the angle at which the pin contacts the bone [3, 5, 18].
Very important is the “safe zone” for placement of halo-xator
pins. Anterior pins are placed anterolaterally, approximately
1cm above the orbital ring below the equator (area of widest
circumferences) of the skull (see Figs.26.4, 26.5 and 26.6).
26.4.2 Technique
• Halo traction is a two-stage procedure; rst, attach the
halo ring to the skull, subsequently apply the body cast
and suspension construction to the ring (see Figs.26.4,
26.5 and 26.6).
• In conscious patients, the halo ring can be placed under
local anesthesia. Closed reductions, especially, should
only be performed in conscious patients.
• Gloves should be worn and antiseptic swabs or a disinfectant used to clean the pin insertion areas. The skin and
periosteal is then inltrated with a local anesthetic.
• Stabilizing plates hold the ring in place. The optimal position of the ring is such that its lower margin lies just above
the ears and approximately 0.5cm above the eyebrows. It
should be positioned inferior to the skull’s equator (see
Figs.26.4, 26.5 and 26.6).
• When applying the ring, the patient should be sitting or in
a supine position.
• While inserting the screws into the skull, the patient’s
eyelids should remain closed.
• Insert the anterior pins in the shallow groove on the forehead between the supraorbital ridges and frontal protuberances [17]. Note that four screws are required for adults,
while six to eight are necessary for children.
• Screw the threaded skull pins into the skull’s lamina
externa with dened torque but without perforating the
lamina interna.
Fig. 26.5 With use of tongs, orient V over ears to t around base of
tong otherwise invert V to allow access to ears
Fig. 26.4 The appropriate halo ring is placed with temporary position-
ing stabilization pins. The ring should allow 1–2cm clearance from the
skull. Care should be taken to prevent contact between the halo ring and
the ears
Fig. 26.6 Anterior screws are inserted 1cm superior to the lateral 1/3
of the eyebrows. Initially, the permanent screws are tightened by hand,
followed by the use of a torque driver. Pins opposite each other are
tightened simultaneously
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