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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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38 Posterior Transarticular C1/C2 Screw Technique
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ba
Fig. 38.4 (a) The patient is positioned while monitoring vertebral position under lateral uoroscopy. (b) Illustration of the midline skin incision
and the additional skin incisions lateral to C7
well. During surgery, the treatment of any anesthesiological emergency can be complicated by the prone position
of the patient and the sharp fixation of the head.
38.6 Surgical Technique
38.6.1 Approach
• A midline incision from the occiput to C7 is performed
(Fig.38.4a, b).
• Cut the subcutaneous tissue until you identify the nuchal
ligament.
• Stay accurately in the midline to reduce venous bleeding.
• Identify the spinous processes from C2 to C4.
• By electrocautery, remove the splenius and semispinalis
muscle from the spinous processes (Fig.38.5).
• Remove the muscles bilaterally from C3 and C4 by blunt
preparation.
• Leave the capsules from C2/3 and C3/4 protected. Identify
the C2/3 facet.
• Dissect bilaterally the lower part of the obliquus capitis
inferior muscle to identify the arch of C2.
• Remove the rectus capitis minor muscle insertions from
the dorsal arch of C1. With blunt preparation, the lamina
of C1 is dissected, stopping short of the sulcus of the ver-
tebral artery (Fig.38.5).
• Remove the atlanto-axial membrane. The preparation
should be done with a sharp dissector subperiosteally.
Fig. 38.5 Anatomical situation after resection of M. rectus capitis pos-
terior and M. obliquus capitis inferior
Now the lamina of C1 can be identied for later wiring.
Identify the joint of C1. During this step, the periradicular
venous plexus can be damaged. The bleeding can be controlled by bipolar coagulation, better by compression with
hemostatic substances.
• Identify the inner cortical border of the isthmus of C2
with a nerve hook, which will guide the later drilling
direction.
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ab c
Fig. 38.6 (a–c) Drill placement, starting point, and drilling direction for transarticular screwing
M. Winking
Fig. 38.7 Details of the surgical anatomy. The desired screw place-
ment is just lateral to the edge of the spinal canal. It will traverse the
isthmus of C2 and the C1–C2 articulation
38.6.2 Instrumentation
• The starting point for screw placement is typically
2–3mm cephalad to the lower border of the C2 facet and
2–3 mm lateral to the medial cortical border of the C2
isthmus (Fig.38.6a).
• The entry point is opened with an awl (Fig.38.7).
• Using lateral uoroscopy, a guide wire is drilled toward
the superior aspect of the anterior C1 ring (Fig.38.6b).
• Sometimes percutaneous skin incisions (beneath C7) are
necessary to ensure the right angulation toward C1
(Fig. 38.8). The drilling direction is orientated slightly
medially, parallel to the inner wall of the isthmus of C2.
During drilling, the direction is controlled with a nerve
hook attached to the isthmus.
• In cases of an osteochondrotic C1 joint, the guide wire
may drift from its planned direction as it passes the joint
space. Drilling with reduced pressure under continuous
Fig. 38.8 Introducing of the transarticular screw in the AP view. (With
permission of Aesculap AG, Tuttlingen, Germany)
uoroscopy will help keep the right trajectory. After positioning, a guide wire is used as a track for the cannulated
3.5mm drill. Use uoroscopic guidance to ensure that the
guide wire is not moved forward during drilling.
38 Posterior Transarticular C1/C2 Screw Technique
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269
Fig. 38.10 Drilling. (With permission of Aesculap AG, Tuttlingen,
Germany)
Fig. 38.9 Placement of the guide tube (with obturator) through a stab
wound into the eld
• After threading, screws with a length between 38 and
50mm are inserted.
• AP and lateral uoroscopy will assess the screw
direction.
• In case of a persistent dislocation between C1 and 2 joint,
C1 can be pulled back using a towel clamp which is xed
at the C1 lamina (Fig.38.9). Alternatively, you can push
C2 spinous process. Under lateral view uoroscopy, you
see the adjustment. Using a guide wire for rst drilling the
cannulated instruments and screws gives the advantage
that the drilling channel can be recovered at the temporarily xed C1–2 joint. After having inserted both screws,
the spinous process of C2 should be gripped with a towel
clamp and pulled back to check the C1–2 stability
(Figs.38.8, 38.10, 38.11, and 38.12).
38.6.3 Bone Graft
• For fusion and long-term stability, an additional bone
graft is necessary.
• Best stability will be achieved by a tricortical bone graft
from the iliac crest.
• To prepare the implantation bed, the surface of the C1 and
C2 lamina is decorticated. Proceed with caution with the thin
C1 lamina, which may be fractured by a brisk debridement.
• The cable loop passes beneath the dorsal arch of the atlas
in midline from caudally to cranially. A notch, which is
cut into the lamina near the spinous process of C2, will
hold the loop. The bone graft is clamped between both
laminae. The two free ends of the cable are pulled slightly
and crimped over the bone block. Additional spongious
bone chips can be used to cover the remaining decorticated areas (Fig.38.13).
• For closure, the detached deep cervical muscles are xed
to the spinous process of C2. The wound is closed in multilayer fashion.
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M. Winking
Fig. 38.11 Measurement of the screw length (With permission of
Aesculap AG, Tuttlingen, Germany)
Fig. 38.12 Taping and introducing of the transarticular screw in the
lateral view (With permission of Aesculap AG, Tuttlingen, Germany)
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38.7 Postoperative Treatment
A cervical (Philadelphia) collar is applied for 6weeks. For
follow-up, radiographs are taken immediately after surgery,
after 6 days and 6–8 weeks, respectively (Fig. 38.14a, b).
Especially in rheumatoid arthritis, a long-term follow-up is
necessary to detect a later subaxial instability. Isometric
exercises are started once it has been established that there is
no screw loosening.
38.8 Tips andTricks
The complication feared most of all is an injury of the vertebral artery. The symptom is severe bleeding (pulse synchronous) out of the borehole. In these cases, transarticular
screwing should be avoided on this side. Bleeding can be
stopped only by closing the hole with hemostatic agents. In
cases of heavy arterial bleeding, a shorter screw which does
not enter the canal of the vertebral artery may be the only
way to stop the bleeding. Unilateral screwing with bone graft
apposition will give sufcient stability in these cases. A postoperative angiography is recommended. In rare cases of split
atlas, bone apposition is limited. In those cases, bone graft
must be attached to the C1–2 facet. By using modern
computer- assisted navigation or a screw-guided template
system, the risk of malposition of the screws can be reduced
[12, 13].
Fig. 38.13 Illustration after transarticular xation and wiring C1/C2
with an additional bone graft between the arch of C1 and C2. (With
permission of Aesculap AG, Tuttlingen, Germany)
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ab
M. Winking
Fig. 38.14 (a and b) Postoperative X-ray after C1–C2 transarticular screwing in a patient with os odontoideum
References
1. Grob D, Crisco JJ, Panjabi MM, et al. Biomechanical evaluation
of four different posterior atlantoaxial xation techniques. Spine.
1992;17:480–90.
2. Grob D, Jeanneret B, Aebi M, Markwalder T. Atlanto-axial
fusion with transarticular screw xation. J Bone Joint Surg Br.
1991;73B:972–6.
3. Grob D, Magerl F.Operative Stabilisierung bei Frakturen von C1
und C2. Orthopade. 1987;16:46–54.
4. Brooks AL, Jenkins EB. Atlanto-axial arthrodesis by the wedge
compression method. J Bone Joint Surg Am. 1978;60:279–83.
5. Dickman CA, Sonntag VKH, Papadopoulos S, etal. The interspinous method of posterior atlantoaxial arthrodesis. J Neurosurg.
1991;74:190–8.
6. Gallie WE.Fractures and dislocations of the cervical spine. Am J
Surg. 1939;46:495–9.
7. Jeanneret B, Magerl F. Primary posterior fusion C1 in odontoid
fractures: indications, technique, and results of transarticular screw
xation. J Spinal Disord. 1992;5:464–75.
8. Magerl F, Seeman PS.Stable posterior fusion of the atlas and axis
by transarticular screw xation. In: Kehr P, Weidner A, editors.
Cervical spine. Berlin: Springer; 1987.
9. Mandel IM, Kambach BJ, Petersilge CA, et al. Morphologic considerations of C2 isthmus dimensions for the placement of transarticular screws. Spine. 2000;25:1542–7.
10. Marcotte P, Dickman CA, Sonntag VKH, etal. Posterior atlantoaxial facet screw xation. J Neurosurg. 1993;79:234–7.
11. Weidner A, Wähler M, Chiu ST, et al. Modication of C1-C2
transarticular screw xation by image-guided surgery. Spine.
2000;25:409–14.
12. Kaneyama S, Sugawara T, Sumi M, etal. A novel screw guiding
method with a screw guide template system for posterior C-2 xation: clinical article. J Neurosurg Spine. 2014;21:231–8.
13. Uehara M, Takahashi J, Hirabayashi H, et al. Computer-assisted
C1-C2 transarticular screw xation “Magerl technique” for atlantoaxial instability. Asian Spine J. 2012;6:168–77.
C1–C2 (Harms) Technique
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ChristianSchultz
39.1 Introduction and Core Messages
There is a broad range of options for stabilization of
the atlantoaxial complex. To achieve stability, often
fusion was used between the laminar arches C1/C2.
The persisting motion was the reason for the high failure rates for this kind of single posterior fusion. To
increase the fusion rate, Magerl introduced the transarticular screw xation C1/C2in 1987 [1]. The Harms
technique of stabilizing C1–C2 using xation of the
C1 lateral mass and the C2 pedicle with polyaxial
screws and rods is a further option when utilizing the
posterior approach. Advantages are reduction of C1/
C2, protection of the C1/C2 joint, and possibility of
screw removal after healing to regain C1/C2 range of
motion. Moreover, the Harms technique reduces the
risk of vertebral artery lesion in comparison to the
transarticular screw xation because the screw angulation is easier in patients with kyphotic spine compared
to the transarticular screw xation according to Magerl.
39
• Disruption or laxity of the transverse ligament caused by
trauma, local disease processes, or local effects of systemic diseases.
• Nonfusion, instability after alternative xation techniques.
39.3 Contraindications
• Anatomical variation of the vertebral artery.
39.4 Technical Prerequisites
Utilization of C-arm for intraoperatively lateral and AP uoroscopy control, the use of navigation could be useful.
Endotracheal anesthesia, positioning device (e.g., Mayeld
head clamp), and adequate implants and instruments (the
distal part of the screw should not be threaded to preserve the
C2 nerve). The S4 Cervical System (Aesculap) is one suitable implant for the C1/C2 Harms technique. Other suitable
implants are, for example, the Oasys System (Stryker) or the
Quartex Stabilization System (Globus Medical).
39.2 Indications
• C1/C2 instability caused by trauma, tumor, and inammatory conditions.
• Nonfusion of odontoid fractures.
• Revision after failed odontoid screw xation.
• Unstable Jefferson fractures.
C. Schultz (*)
Augsburg, Germany
e-mail: schultz.christian@gmx.de
© Springer-Verlag GmbH Germany 2023
U. Vieweg, F. Grochulla (eds.), Manual of Spine Surgery, https://doi.org/10.1007/978-3-662-64062-3_39
39.5 Planning, Preparation,
andPositioning
Preoperative CT scan is performed to estimate the pathology,
the run of the vertebral artery, and to examine anatomical
variation. Furthermore, information about the pedicle anatomy is obtained to choose suitable implant sizes. The patient
is placed in the prone position, head and neck are secured
with the desired sagittal alignment, and positioning is done
while monitoring vertebral position under lateral uoroscopy. Preoperative closed reduction may be done by positioning if possible. After nal supporting of the head in a pin
head holder, again preoperative alignment is conrmed by
using a lateral uoroscopy.
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39.6 Surgical Technique
39.6.1 Approach
• Surgical approach with a midline incision from the
occiput to the spinal process C3 and further preparation
similar to the C1/C2 transarticular screw xation.
• Preparation in lateral direction and exposure of the posterior elements of C1/C2. Dissection of the lamina of C2 and
the C2 pars interarticularis to remove soft tissue and to
identify the landmarks for the C2 pedicle screw insertion.
• To dissect the entry point in the C1 lateral mass, the
greater occipital nerve (dorsal ramus of C2) has to be
retracted in a caudal direction.
39.6.2 Instrumentation (Using theS4 Cervical
System)
C. Schultz
Insertion oftheC1 Lateral Mass Screw
• The landmarks for the C1 lateral mass screw are below
the posterior lamina of C1, above the C1/C2 joint in the
center of the posterior lateral mass (see Fig.39.1) [2].
• The use of a guiding tube is recommended to ensure a
safe procedure without endangering the greater occipital
nerve, as well as the vertebral artery which both lie very
close to the screw entry point.
• The cortical bone is opened by using a bone awl through
the guiding tube (see Fig.39.2).
• The hole is drilled with the 2.9-mm-diameter drill for
4.0-mm-diameter screws under uoroscopy control. The
appropriate trajectory is 10–20° ascending direction, parallel to the plane of the C1 posterior arch in the lateral
view and 10° toward the midline in the axial plane.
Drilling must be bicortical; the drill has a scale for length
measurement and the possibility of a safety stop (see
Fig.39.3).
• Although the screws are self-tapping, cortical tapping is
recommended (see Fig.39.4) [3].
• Bicortical screw insertion under uoroscopy control (see
Fig.39.5), to preserve the C2 nerve and the dorsal ramus,
the distal part of the screw is not threaded (smooth shank
screw) (see Fig.39.6).
Fig. 39.1 Landmarks for the C1 screw insertion (With permission of
Aesculap AG, Tuttlingen, Germany)
Insertion oftheC2 Pedicle Screw
• The landmarks for the C2 pedicle screws are the medial
and cranial part of the pars interarticularis in the middle
between the upper and lower articular surfaces of C2.
This technique was rst described by Judet in 1962 [3].
• After opening, the cortical bone drilling is performed
with the 2.4-mm-diameter drill for 3.5-mm-diameter
screws (if favored angle screw is preferred, 2.9-mm drill
Fig. 39.2 Opening the cortical bone by using a bone awl through the
guiding tube (With permission of Aesculap AG, Tuttlingen, Germany)
39 C1–C2 (Harms) Technique
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Fig. 39.3 Drilling the bicortical hole (With permission of Aesculap
AG, Tuttlingen, Germany)
Fig. 39.5 Screw insertion (With permission of Aesculap AG,
Tuttlingen, Germany)
Fig. 39.4 Cortical tapping (With permission of Aesculap AG,
Tuttlingen, Germany)
Fig. 39.6 Smooth shank screw (With permission of Aesculap AG,
Tuttlingen, Germany)
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C. Schultz
Fig. 39.7 Rod insertion (With permission of Aesculap AG, Tuttlingen,
Germany)
is used for 4.0-mm-diameter screw) under uoroscopy
control. The drill trajectory is 20–30° cranially under lateral uoroscopy control and 20–25° in a convergent direction in the axial plane.
• Bicortical insertion of a polyaxial screw with suitable
length.
• If necessary, reduce C1/C2 in the desired position by
adjusting the screws or by manipulation of the head.
Rod Insertion
• Insertion of the rod and with the rod in place the set
screws can be inserted to tighten the construct and x
the rod with the polyaxial screws (see Figs.39.7, 39.8,
and 39.9).
• To achieve fusion between the laminar arches, bone grafting can be considered.
39.7 Postoperative Care
Fig. 39.8 Set screw insertion (With permission of Aesculap AG,
Tuttlingen, Germany)
Fig. 39.9 Final construct (With permission of Aesculap AG, Tuttlingen,
Germany)
insertion of the screw and compression with the screw head
controls bleeding.
Soft collar for a period of 6–8weeks.
39.8 Tips andTricks
Opening the cortical bone and drilling frequently causes
bleeding of the venous plexus; bleeding control by bipolar
electrocautery may risk a nerve injury, as an alternative quick
References
1. Harms J, Melcher RP.Posterior C1-C2 fusion with polyaxial screw
and rod xation. Spine. 2001;26:2467–71.
2. Stulik J, Vyskocil T, Sebesta P, etal. Harms technique of C1-C2 xation with polyaxial screws and rods. Acta Chir Orthop Traumatol
Cechoslov. 2005;72:22–7.
3. Magerl F, Seeman PS.Stable posterior fusion of the atlas and axis
by transarticular screw xation. In: Kehr P, Weidner A, editors.
Cervical spine. Wien: Springer; 1987. p.322–7.
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