• Steinmann Pins for C1 Lateral Mass Screw Placement in Atlantoaxial Stabilization

    Final Number:

    Joshua Meyers MD; Kunal Vakharia MD; John Pollina MD; Vassilios Georgios Dimopoulos MD

    Study Design:

    Subject Category:

    Meeting: Congress of Neurological Surgeons 2017 Annual Meeting

    Introduction: Multiple methods for C1-2 arthrodesis have been described. The use of a polyaxial screw and rod construct was popularized by Harms and Melcher in 2001. However, the placement of C1 lateral mass screws increases the risk of venous blood loss and injury to the C2 nerve root. The authors describe a technique for placement of C1 lateral mass screws using a Steinmann pin as a guide. The drill is inserted over the pins with a smooth protected guide canula over the drill bit minimizing dissection and providing atlantoaxial stabilization during arthrodesis.

    Methods: In our technique, a non-threaded 1.6mm spade-tip Steinmann pin is placed into the lateral mass of C1 to serve as a guide over which a powered drill is used for screw insertion. Perioperative data were collected for 93 consecutive patients who underwent a C1-2 arthrodesis that involved the modified technique between March 2010 and July 2016. Data included blood loss, operative times, and C2 nerve root injury.

    Results: The data for 93 patients were reviewed. Most (91.4%) patients presented with a fracture from an acute trauma. A mean of 1.97 levels was fused in these patients with a mean blood loss of 76 ml and a mean operative time of 144 minutes. The overall morbidity and mortality rate was 10.7%. The morbidity rate of 7.5% included 30 day postoperative respiratory failure and dysphasia. There were no postoperative vertebral artery injuries, hardware failures, or instances of occipital neuralgia.

    Conclusions: The use of Steinmann pins to guide the placement of C1 lateral mass screws is safe and effective in C1-2 arthrodesis. Limiting dissection minimizes blood loss and injury, maintains efficient operative time, and assists in accurate placement of the screws. With less manipulation and retraction of the C2 nerve root, postoperative occipital neuralgia and the need for C2 root transection are avoided.

    Patient Care: This research will be able to expand the options available for safe and effective placement of C1 lateral mass screws. By minimizing blood loss, operative time, injury to the soft tissues, and C2 nerve root retractions patients can experience safe and effective C1-2 arthrodesis.

    Learning Objectives: By the conclusion of this session, participants should be able to 1. Describe the method of C1 lateral mass screw placement using Steinmann pins. 2. Discuss the perioperative complications associated with its use 3. Discuss the intraoperative advantages including operative time, blood loss, and C2 root injury.

    References: 1.Bourdillon P, Perrin G, Lucas F, Debarge R, Barrey C: C1-C2 stabilization by Harms arthrodesis: indications, technique, complications and outcomes in a prospective 26-case series. Orthop Traumatol Surg Res 100:221-227, 2014 2.Bransford RJ, Freeborn MA, Russo AJ, Nguyen QT, Lee MJ, Chapman JR, et al: Accuracy and complications associated with posterior C1 screw fixation techniques: a radiographic and clinical assessment. Spine J 12:231-238, 2012 3.Dewan MC, Godil SS, Mendenhall SK, Devin CJ, McGirt MJ: C2 nerve root transection during C1 lateral mass screw fixation: does it affect functionality and quality of life? Neurosurgery 74:475-480; discussion 480-471, 2014 4.Elliott RE, Tanweer O, Frempong-Boadu A, Smith ML: Impact of starting point and C2 nerve status on the safety and accuracy of C1 lateral mass screws: meta-analysis and review of the literature. J Spinal Disord Tech 28:171-185, 2015 5.Fiore AJ, Haid RW, Rodts GE, Subach BR, Mummaneni PV, Riedel CJ, et al: Atlantal lateral mass screws for posterior spinal reconstruction: technical note and case series. Neurosurg Focus 12:E5, 2002 6.Gautschi OP, Payer M, Corniola MV, Smoll NR, Schaller K, Tessitore E: Clinically relevant complications related to posterior atlanto-axial fixation in atlanto-axial instability and their management. Clin Neurol Neurosurg 123:131-135, 2014 7.Goel A, Laheri V: Plate and screw fixation for atlanto-axial subluxation. Acta Neurochir (Wien) 129:47-53, 1994 8.Hamilton DK, Smith JS, Sansur CA, Dumont AS, Shaffrey CI: C-2 neurectomy during atlantoaxial instrumented fusion in the elderly: patient satisfaction and surgical outcome. J Neurosurg Spine 15:3-8, 2011

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