In gratitude of the loyal support of our members, the CNS is offering complimentary 2021 Annual Meeting registration to all members! Learn more.

  • Occipitocervical fixation: A single surgeon experience with 120 patients.

    Final Number:

    Eduardo Martinez del Campo Oviedo MD; Samuel Kalb MD; Jay D. Turner MD, PhD; Luis Perez-Orribo; Leonardo Rangel-Castilla MD; Hector Enrique Soriano-Baron MD; Nicholas Theodore MD, FACS

    Study Design:

    Subject Category:

    Meeting: Congress of Neurological Surgeons 2014 Annual Meeting

    Introduction: Occipitocervical junction instability can lead to serious neurologic injury or death if left untreated. Open surgical fixation is often necessary in order to provide definitive stabilization.

    Methods: The charts of all patients undergoing posterior internal fixation by the senior author were retrospectively reviewed. One hundred and twenty consecutive patients were identified for analysis. Patient demographics, occipitocervical junction pathology, surgical indications, clinical and radiographic outcomes are reported.

    Results: The study population consisted of 64 males and 56 females, mean age of 39.9 years (range 7 months - 88 years). Trauma was the most common cause of instability, occurring in 56 patients (46.7%). Ninety patients (75%) were treated with screw/rod constructs; wiring was used in 30 patients (25%)., The median number of fixated segments was 5 (O-C4). Structural bone grafts were implanted in most patients (83.3%). Pre-operative neurological deficits were present in 83 patients (69.2%). Overall neurological improvement was 90.9%. Mean follow-up was 16.1 months (range 4-107 months). There was radiographic evidence of fusion in all patients (100%). One patients suffered neurological deterioration and none died during the first year after surgery. The overall complication rate was 10.8%, including 3 patients with vertebral artery injuries and 2 patients with hardware failures which required surgical correction.

    Conclusions: OC fixation is a durable treatment option with acceptable morbidity for patients with OC instability.

    Patient Care: Internal occipitocervical fixation has good clinical outcomes in patients with instability. Complication rates allow for detailed preoperative surgical-risk assessment and decision making.

    Learning Objectives: The authors review the causes of occipitocervical instability, discuss the indications for surgical intervention, and evaluate long-term surgical outcomes after occipitocervical fixation.

    References: 1. Abumi K, Shono Y, Ito M, Taneichi H, Kotani Y, Kaneda K: Complications of pedicle screw fixation in reconstructive surgery of the cervical spine. Spine 25:962-969, 2000. 2. Ahmed R, Menezes AH: Management of operative complications related to occipitocervical instrumentation. Neurosurgery 72:ons214-228; discussion ons228, 2013. 3. Ahmed R, Traynelis VC, Menezes AH: Fusions at the craniovertebral junction. Childs Nerv Syst 24:1209-1224, 2008. 4. Anderson RC, Kan P, Gluf WM, Brockmeyer DL: Long-term maintenance of cervical alignment after occipitocervical and atlantoaxial screw fixation in young children. J Neurosurg 105:55-61, 2006. 5. Anderson RC, Ragel BT, Mocco J, Bohman LE, Brockmeyer DL: Selection of a rigid internal fixation construct for stabilization at the craniovertebral junction in pediatric patients. J Neurosurg 107:36-42, 2007. 6. Apostolides PJ, Dickman CA, Golfinos JG, Papadopoulos SM, Sonntag VK: Threaded steinmann pin fusion of the craniovertebral junction. Spine (Phila Pa 1976) 21:1630-1637, 1996. 7. Bambakidis NC, Feiz-Erfan I, Horn EM, Gonzalez LF, Baek S, Yuksel KZ, Brantley AG, Sonntag VK, Crawford NR: Biomechanical comparison of occipitoatlantal screw fixation techniques. J Neurosurg Spine 8:143-152, 2008. 8. Bambakidis NC, Feiz-Erfan I, Horn EM, Gonzalez LF, Baek S, Yuksel KZ, Brantley AG, Sonntag VK, Crawford NR: Biomechanical comparison of occipitoatlantal screw fixation techniques. Journal of neurosurgery. Spine 8:143-152, 2008. 9. Bekelis K, Duhaime AC, Missios S, Belden C, Simmons N: Placement of occipital condyle screws for occipitocervical fixation in a pediatric patient with occipitocervical instability after decompression for Chiari malformation. J Neurosurg Pediatr 6:171-176, 2010. 10. Benke M, Yu WD, Peden SC, O'Brien JR: Occipitocervical junction: imaging, pathology, instrumentation. Am J Orthop (Belle Mead NJ) 40:E205-215, 2011. 11. Benzel EC, Lancon J, Kesterson L, Hadden T: Cervical laminectomy and dentate ligament section for cervical spondylotic myelopathy. J Spinal Disord 4:286-295, 1991. 12. Bono CM, Vaccaro AR, Fehlings M, Fisher C, Dvorak M, Ludwig S, Harrop J, Spine Trauma Study G: Measurement techniques for upper cervical spine injuries: consensus statement of the Spine Trauma Study Group. Spine (Phila Pa 1976) 32:593-600, 2007. 13. Brockmeyer DL, Brockmeyer MM, Bragg T: Atlantal hemi-rings and craniocervical instability: identification, clinical characteristics, and management. J Neurosurg Pediatr 8:357-362, 2011. 14. Dvorak J, Hayek J, Zehnder R: CT-functional diagnostics of the rotatory instability of the upper cervical spine. Part 2. An evaluation on healthy adults and patients with suspected instability. Spine (Phila Pa 1976) 12:726-731, 1987. 15. Dvorak J, Panjabi M, Gerber M, Wichmann W: CT-functional diagnostics of the rotatory instability of upper cervical spine. 1. An experimental study on cadavers. Spine (Phila Pa 1976) 12:197-205, 1987. 16. Feiz-Erfan I, Gonzalez LF, Dickman CA: Atlantooccipital transarticular screw fixation for the treatment of traumatic occipitoatlantal dislocation. Technical note. J Neurosurg Spine 2:381-385, 2005. 17. Fenoy AJ, Menezes AH, Fenoy KA: Craniocervical junction fusions in patients with hindbrain herniation and syringohydromyelia. J Neurosurg Spine 9:1-9, 2008. 18. Finn MA, Bishop FS, Dailey AT: Surgical treatment of occipitocervical instability. Neurosurgery 63:961-968; discussion 968-969, 2008. 19. Garrido BJ, Sasso RC: Occipitocervical fusion. Orthop Clin North Am 43:1-9, vii, 2012. 20. Garrido BJ, Sasso RC: Occipitocervical fusion. The Orthopedic clinics of North America 43:1-9, vii, 2012. 21. Gonzalez LF, Crawford NR, Chamberlain RH, Perez Garza LE, Preul MC, Sonntag VK, Dickman CA: Craniovertebral junction fixation with transarticular screws: biomechanical analysis of a novel technique. J Neurosurg 98:202-209, 2003. 22. Gonzalez LF, Sonntag VK, Dickman CA, Crawford NR: Technique for fixating the atlantooccipital complex with a transarticular screw. Spine (Phila Pa 1976) 27:219-220, 2002. 23. Grabb PA, Mapstone TB, Oakes WJ: Ventral brain stem compression in pediatric and young adult patients with Chiari I malformations. Neurosurgery 44:520-527; discussion 527-528, 1999. 24. Grob D: Transarticular screw fixation for atlanto-occipital dislocation. Spine (Phila Pa 1976) 26:703-707, 2001. 25. Grob D, Dvorak J, Panjabi M, Froehlich M, Hayek J: Posterior occipitocervical fusion. A preliminary report of a new technique. Spine (Phila Pa 1976) 16:S17-24, 1991. 26. Hirabayashi K, Miyakawa J, Satomi K, Maruyama T, Wakano K: Operative results and postoperative progression of ossification among patients with ossification of cervical posterior longitudinal ligament. Spine (Phila Pa 1976) 6:354-364, 1981. 27. Horn EM, Feiz-Erfan I, Lekovic GP, Dickman CA, Sonntag VK, Theodore N: Survivors of occipitoatlantal dislocation injuries: imaging and clinical correlates. J Neurosurg Spine 6:113-120, 2007. 28. Horn EM, Feiz-Erfan I, Lekovic GP, Dickman CA, Sonntag VK, Theodore N: Survivors of occipitoatlantal dislocation injuries: imaging and clinical correlates. Journal of neurosurgery. Spine 6:113-120, 2007. 29. Hurlbert RJ, Crawford NR, Choi WG, Dickman CA: A biomechanical evaluation of occipitocervical instrumentation: screw compared with wire fixation. Journal of neurosurgery 90:84-90, 1999. 30. Hurlbert RJ, Crawford NR, Choi WG, Dickman CA: A biomechanical evaluation of occipitocervical instrumentation: screw compared with wire fixation. J Neurosurg 90:84-90, 1999. 31. Hwang SW, Gressot LV, Rangel-Castilla L, Whitehead WE, Curry DJ, Bollo RJ, Luerssen TG, Jea A: Outcomes of instrumented fusion in the pediatric cervical spine. J Neurosurg Spine 17:397-409, 2012. 32. Lall R, Patel NJ, Resnick DK: A review of complications associated with craniocervical fusion surgery. Neurosurgery 67:1396-1402; discussion 1402-1393, 2010. 33. Martin MD, Bruner HJ, Maiman DJ: Anatomic and biomechanical considerations of the craniovertebral junction. Neurosurgery 66:2-6, 2010. 34. Matsumaru Y, Pongpech S, Laothamas J, Alvarez H, Rodesch G, Lasjaunias P: Multifocal and metameric spinal cord arteriovenous malformations. Review of 19 cases. Interventional neuroradiology : journal of peritherapeutic neuroradiology, surgical procedures and related neurosciences 5:27-34, 1999. 35. Maughan PH, Ducruet AF, Elhadi AM, Martirosyan NL, Garrett M, Mushtaq R, Albuquerque FC, Theodore N: Multimodality management of vertebral artery injury sustained during cervical or craniocervical surgery. Neurosurgery 73:271-281; discussion 281-272, 2013. 36. Maughan PH, Horn EM, Theodore N, Feiz-Erfan I, Sonntag VK: Avulsion fracture of the foramen magnum treated with occiput-to-c1 fusion: technical case report. Neurosurgery 57:E600; discussion E600, 2005. 37. Menezes AH: Craniocervical fusions in children. J Neurosurg Pediatr 9:573-585, 2012. 38. Menezes AH, Traynelis VC: Anatomy and biomechanics of normal craniovertebral junction (a) and biomechanics of stabilization (b). Childs Nerv Syst 24:1091-1100, 2008. 39. Mummaneni PV, Haid RW, Traynelis VC, Sasso RC, Subach BR, Fiore AJ, Rodts GE: Posterior cervical fixation using a new polyaxial screw and rod system: technique and surgical results. Neurosurgical focus 12:E8, 2002. 40. Niimi Y, Uchiyama N, Elijovich L, Berenstein A: Spinal arteriovenous metameric syndrome: clinical manifestations and endovascular management. AJNR. American journal of neuroradiology 34:457-463, 2013. 41. Nockels RP, Shaffrey CI, Kanter AS, Azeem S, York JE: Occipitocervical fusion with rigid internal fixation: long-term follow-up data in 69 patients. J Neurosurg Spine 7:117-123, 2007. 42. Ogihara N, Takahashi J, Hirabayashi H, Hashidate H, Kato H: Long-term results of computer-assisted posterior occipitocervical reconstruction. World Neurosurg 73:722-728, 2010. 43. Oppenlander ME, Clark JC, Sonntag VK, Theodore N: Pediatric craniovertebral junction trauma. Adv Tech Stand Neurosurg 40:333-353, 2014. 44. Oppenlander ME, Kalyvas J, Sonntag VK, Theodore N: Technical advances in pediatric craniovertebral junction surgery. Adv Tech Stand Neurosurg 40:201-213, 2014. 45. Papadopoulos SM, Dickman CA, Sonntag VK, Rekate HL, Spetzler RF: Traumatic atlantooccipital dislocation with survival. Neurosurgery 28:574-579, 1991. 46. Sawin PD, Traynelis VC, Menezes AH: A comparative analysis of fusion rates and donor-site morbidity for autogeneic rib and iliac crest bone grafts in posterior cervical fusions. J Neurosurg 88:255-265, 1998. 47. Singh SK, Rickards L, Apfelbaum RI, Hurlbert RJ, Maiman D, Fehlings MG: Occipitocervical reconstruction with the Ohio Medical Instruments Loop: results of a multicenter evaluation in 30 cases. J Neurosurg 98:239-246, 2003. 48. Smoker WR: Craniovertebral junction: normal anatomy, craniometry, and congenital anomalies. Radiographics 14:255-277, 1994. 49. Theodore N, Aarabi B, Dhall SS, Gelb DE, Hurlbert RJ, Rozzelle CJ, Ryken TC, Walters BC, Hadley MN: The diagnosis and management of traumatic atlanto-occipital dislocation injuries. Neurosurgery 72 Suppl 2:114-126, 2013. 50. Theodore N, Aarabi B, Dhall SS, Gelb DE, Hurlbert RJ, Rozzelle CJ, Ryken TC, Walters BC, Hadley MN: Occipital condyle fractures. Neurosurgery 72 Suppl 2:106-113, 2013. 51. Traynelis VC, Marano GD, Dunker RO, Kaufman HH: Traumatic atlanto-occipital dislocation. Case report. J Neurosurg 65:863-870, 1986. 52. Vitzthum HE, Dalitz K: Analysis of five specific scores for cervical spondylogenic myelopathy. Eur Spine J 16:2096-2103, 2007. 53. Winegar CD, Lawrence JP, Friel BC, Fernandez C, Hong J, Maltenfort M, Anderson PA, Vaccaro AR: A systematic review of occipital cervical fusion: techniques and outcomes. J Neurosurg Spine 13:5-16, 2010. 54. Wright NM, Lauryssen C: Vertebral artery injury in C1-2 transarticular screw fixation: results of a survey of the AANS/CNS section on disorders of the spine and peripheral nerves. American Association of Neurological Surgeons/Congress of Neurological Surgeons. J Neurosurg 88:634-640, 1998. 55. American Spinal Injury Association. International Standards for Neurological Classification of Spinal Cord Injury, revised 2002. American Spinal Injury Association: Chicago, IL, 2002

We use cookies to improve the performance of our site, to analyze the traffic to our site, and to personalize your experience of the site. You can control cookies through your browser settings. Please find more information on the cookies used on our site. Privacy Policy