Potential intraoperative factors of screw-related complications following posterior transarticular C1-C2 fixation: a systematic review and meta-analysis

Percutaneous C1C2 transarticular screw fixation for atlantoaxial osteoarthritis with 3D navigation: technical note and functional outcomes

PURPOSE

Atlantoaxial osteoarthritis is a debilitating condition often resistant to conservative management. In refractory cases, C1-C2 fusion becomes a surgical option. Recent advancements, particularly in 3D navigation, have allowed for more precise and minimally invasive approaches, though there are limited reports on isolated percutaneous C1-C2 arthrodesis for osteoarthritis. This study aims to evaluate the feasibility, accuracy, and clinical outcomes of percutaneous C1-C2 transarticular screw fixation using 3D navigation in patients with disabling atlantoaxial osteoarthritis.

METHODS

Ten patients (median age: 75.5 years), all female, underwent percutaneous C1-C2 screw fixation using the Magerl technique, guided by 3D navigation. Preoperative assessment included CT and contrast-enhanced imaging to ensure safe screw placement. Postoperative evaluations included pain assessment, radiographic analysis, and patient satisfaction.

RESULTS

Transarticular screws were inserted in all of patients, with no significant intraoperative complications. Median operative time was 65 min with blood loss under 100 mL. Postoperative pain improved with the median VAS decreasing from 10 preoperatively to 1 at one year. Screw backout was observed in one patient without clinical repercussions. All patients expressed satisfaction and would undergo the procedure again.

CONCLUSION

Percutaneous C1-C2 transarticular screw fixation with 3D navigation is a safe and effective treatment for severe atlantoaxial osteoarthritis. It offers significant pain relief, accurate screw placement, and reduced postoperative morbidity. Preoperative anatomical evaluation remains critical to minimize risks. Level of Evidence Level III, Retrospective Cohort.

Fully percutaneous posterior transarticular C1-C2 stand-alone screw instrumentation: A case series and technical note

Magerl's technique remains a widely accepted method for achieving C1-C2 fusion. Although two approaches using intermuscular corridors and biplanar X-ray guidance have been reported, there are no published studies dedicated to fully percutaneous techniques employing cannulated screws.

OBJECTIVE

To demonstrate the feasibility of a fully percutaneous C1-C2 fixation technique using cannulated screws and to analyze the short- and long-term outcomes of the initial case series.

MATERIAL AND METHODS

This case series included patients over 15 years of age who were presented with acute or subacute atlantoaxial instability at C1-C2 due to fractures of the odontoid process, C1 vertebra, or C2 vertebral body. Surgical details and fusion criteria were described. Due to the absence of comparison groups, only descriptive statistical methods were employed.

RESULTS

A total of 11 patients (8 men, 3 women; mean age 41.5 ± 18.2 years) underwent fully percutaneous transarticular C1-C2 fixation. The mean operative time was 115.0 ± 30.8 min for patients stabilized using a Halo device and 80.6 ± 33.2 min for those immobilized with a Mayfield clamp. The mean blood loss across all cases was 38.8 ± 8.7 mL. One patient died from concurrent cardiac pathology. Two patients were lost to follow-up due to relocation, leaving 8 patients for final assessment. At final follow-up, the mean VAS score was 2 ± 1.5 and the mean NDI score was 5.3 ± 5.2. All patients with preoperative neurological deficits improved by one level on the ASIA scale. Fusion was achieved in 7 of 8 cases (87.5%), and 1 patient (12.5%) developed a stable C1-C2 pseudoarthrosis.

CONCLUSION

Our initial clinical experience demonstrated that fully percutaneous posterior transarticular C1-C2 stand-alone screw fixation using cannulated instruments could be a feasible and safe procedure. Critical requirements for this technique include complete reduction of atlantoaxial dislocation, compression in the lateral joint region, adequate intraoperative visualization, and strict adherence to specific screw trajectories.

Stroke Following Blunt Head Trauma: A Case Report and Review of the Literature

Ischemic stroke due to blunt traumatic cerebrovascular injury (TCVI) is rare and often overlooked, particularly in patients without any typical predisposing factors. Approximately 1-2% of patients with blunt cerebrovascular trauma experience extracranial injuries, and around 10% of these patients develop strokes, resulting in an estimated 4,800 cases annually in the United States. These strokes can present with atypical symptoms, causing a delay in diagnosis. We report a case of a 36-year-old female who experienced headaches, left-sided weakness, and numbness following a football-related injury, and frequent use of a neck massager. Initially, her symptoms were attributed to a complex migraine; however, an MRI revealed a right thalamic infarct caused by the occlusion of the right posterior cerebral artery (PCA). Subsequent imaging showed further ischemic changes. As the patient's condition progressed, her management required a change to include heparin after initial treatments with aspirin and clopidogrel proved ineffective. This report highlights the challenges in diagnosing TCVI-induced stroke due to its uncommon presentation, atypical symptoms, and low clinical suspicion, especially in young adults. It underscores the importance of considering ischemic stroke in patients who have experienced neck trauma and raises awareness about the potential risks of unregulated neck massagers, which may cause vascular injury. Early cerebrovascular imaging, such as CT angiography (CTA), should be considered for trauma patients who present with neurological symptoms to facilitate timely diagnosis and treatment.

Cirq® robotic assistance for percutaneous kyphoplasty of C1: report on feasibility

BACKGROUND

To report the feasibility and safety of C1 kyphoplasty using the Cirq® robotic assistance coupled to the AIRO® intraoperative computed tomography (iCT)-scan and BrainLab® navigation system.

METHODS

A 47-year-old woman with C1 osteolytic lesion responsible of intractable left-sided suboccipital pain was admitted. She underwent a percutaneous kyphoplasty of left lateral mass of C1 using Cirq® robotic assistance. She reported postoperative substantial pain relief. CT scan showed adequate filling of the osteolytic lesion without obvious leakage of cement.

CONCLUSION

Percutaneous kyphoplasty of C1 using Cirq® robotic assistance is a safe and effective alternative in selected patients with C1 lateral mass metastasis.

Incidence of vertebral artery injury in patients undergoing cervical spine trauma surgery in correlation with surgical approach: A review

Spinal cord injuries at the cervical spine level represent the most consequential of the related injuries at all levels of the spine. They can trigger permanent unilateral or bilateral damage with conspicuous disability. Regarding unstable injuries, the gold standard approach is open reduction and osteosynthesis, which can select between anterior and posterior surgical access. Each of the aforementioned approaches demonstrates both advantages and disadvantages; thus, it is up to the surgeon to determine the optimal option concerning the patient's safety. Diligent intraoperative control of anatomical reduction is pivotal to obtaining the best feasible postoperative outcomes. Literature data delineate copious complications following surgical intervention in the cervical spine. Indubitably, the most crucial intraoperative complication accounts for vascular injuries, with the most preponderant being the corrosion of the vertebral artery, as it is potentially life-threatening. This paper aims to provide a succinct and compendious review of the existing literature regarding cervical spinal cord injuries and to deduce many inferences concerning the incidence of iatrogenic vertebral artery injuries in relation to the surgical approach for fracture reduction.

Efficacy and Safety of Goel-Harms Technique in Upper Cervical Spine Surgery: A Systematic Review and Meta-Analysis

OBJECTIVE

The main purpose of this systematic review and meta-analysis was to estimate the incidence of implant-associated complications and fusion rates for the Goel-Harms technique (GHT) and to show potential factors affecting the complications and nonunion development.

METHODS

A systematic search of the PubMed database according to PRISMA guidance was performed. The main inclusion criteria comprised description of fusion rate and/or implant-associated complications rate.

RESULTS

This systematic review included 86 articles focused on the results of surgery in 4208 patients. The rate of screw-related complications was as follows: 1) vertebral artery (VA) injury, 2.8%; 2) screw malposition in the direction of the VA, 5.8%; and 3) C2 nerve root irritation, 6.1%. The nonunion rate was 4.2%. Transpedicular screw insertion to the C1 and C2 vertebrae were the safest regarding VA injury and correlated with lower blood loss. For C1-C2 fusion, there was no statistical difference for the different bone graft localization. C2 nerve root irritation rate did not depend on screw insertion technique. The use of a freehand technique did not correlate with a high rate of screw-related complications.

CONCLUSIONS

The Goel-Harms technique is a promising method of C1-C2 fusion, with a relatively low nonunion and VA injury rate. It can be performed safely without C-arm or navigation system assistance. Transpedicular screw insertion trajectories to the C1 and C2 vertebrae were safest regarding VA injury and blood loss volume. Further comparative studies of various C1-C2 stabilization methods with a high level of significance should be carried out to identify the optimal approach.

The Comparison Between Transarticular Screw Fixation and Segmental Screw-Rod Fixation for Posterior Fusion of the C1-2 Segment: A Systematic Review and Meta-Analysis

OBJECTIVE

Both transarticular screw fixation (TAS) and segmental screw-rod fixation (SF) have been widely performed for C1-2 fusion; however, just only small clinical studies and a few meta-analyses comparing the 2 surgical techniques for C1-2 posterior fusion have been reported.

METHODS

We searched the Cochrane, Embase, and Medline databases for articles comparing the intraoperative and postoperative outcomes of TAS and SF for C1-2 posterior fusion with April 14, 2022, as the publication cutoff date. The odds ratio (OR) and standardized mean difference were used to analyze differences in outcomes between the 2 abovementioned surgical techniques. A P value < 0.05 was considered statistically significant.

RESULTS

A total of 5101 publications were assessed, and 6 studies were finally included in the study. In terms of the fusion rate, SF produced significantly better outcomes than TAS did (OR = 2.96, P = 0.02). With respect to surgical outcomes, blood loss and operation times were significantly lower in the TAS group than those in the SF group (P = 0.008 and P < 0.00001, respectively). The rate of vertebral artery injury was significantly lower in the SF group than that in the TAS group (OR = 3.95, P = 0.04). However, other complications, such as screw malposition, infection, hardware failure, and nonunion, were not significantly different between the 2 groups.

CONCLUSIONS

SF showed a greater fusion rate and lower risk of vertebral artery injury than TAS did, but TAS showed less blood loss and lower operation times than SF.

Comparison of Accuracy and Clinical Outcomes of Robot-Assisted Versus Fluoroscopy-Guided Pedicle Screw Placement in Posterior Cervical Surgery

STUDY DESIGN

This was a prospective controlled study.

OBJECTIVE

To compare the accuracy and clinical outcomes of robot-assisted (RA) and fluoroscopy-guided (FG) pedicle screw placement in posterior cervical surgery.

METHODS

This study included 58 patients. The primary outcome measures were the 1-time success rate and the accuracy of pedicle screw placement according to the Gertzbein-Robbins scales. The secondary outcome measures, including the operative time, intraoperative blood loss, hospital stay, cumulative radiation time, radiation dose, intraoperative advent events, and postoperative complications, were recorded and analyzed. The Japanese Orthopedics Association (JOA) scores and Neck Disability Index (NDI) were used to assess the neurological function of patients before and at 3 and 6 months after surgery.

RESULTS

The rate of grade A was significantly higher in the RA group than in the FG group (90.6% and 71.1%; P < .001). The clinically acceptable accuracy was 97.2% in the RA group and 90.7% in the FG group (P = .009). Moreover, the 1-time success rate was significantly higher in the RA group than in the FG group. The RA group had less radiation time (P < .001) and less radiation dose (P = .002) but longer operative time (P = .001). There were no significant differences in terms of intraoperative blood loss, hospital stay, intraoperative adverse events, postoperative complications, JOA scores, and NDI scores at each follow-up time point between the 2 groups.

CONCLUSIONS

The RA technique achieved higher accuracy and 1-time success rate of pedicle screw placement in posterior cervical surgery while achieving comparable clinical outcomes.

The limitations of fully threaded screws in isolated percutaneous transarticular screw fixation of C1/C2

Demographic aging accompanied by increased falls inevitably leads to an increased incidence of atlantoaxial instabilities (AAI). Minimally invasive surgical procedures decrease the perioperative risk and regarding the treatment of AAI, percutaneous transarticular screw fixation of C1/C2 was more frequently considered in the past. This study aims to investigate the outcome of patients treated for AAI by isolated percutaneous transarticular screw fixation of C1/C2 (IPTSFC1/C2) using 3.5 mm fully threaded screws to identify its chances and limitations. In this retrospective study, data from patients who underwent IPTSFC1/C2 were analyzed. 23 patients (17 females and 6 males) with an average age of 73.1 years (y) were included. Mean VAS decreased significantly from preoperative 3.9 ± 1.8 to the last follow-up 2.6 ± 2.5 (p = 0.020) and neurological functions were preserved. In the radiological follow-up, we saw a single malposition of an inserted screw (2.27%) and one single bony fusion (4.54%). However, in 6 of 7 patients (85.71%), there was a loosening of the inserted screws due course. We demonstrated that the use of 3.5 mm fully threaded screws for IPTSFC1/C2 results in low rates of osseous fusions between C1 and C2. Therefore, their use in IPTSFC1/C2 is not suitable, especially for geriatric patients with impaired bone status.

Fluoroscopy-Assisted C1-C2 Posterior Fixation for Atlantoaxial Instability: A Single-Center Case Series of 78 Patients

Background and Objectives: Posterior C1-C2 fixation, with trans-articular screws (TAS) or screw-rod-construct (SRC), is the main surgical technique for atlantoaxial instability, and can be performed with a fluoroscopy-assisted free-handed technique or 3D navigation. This study aimed to evaluate complications, radiological and functional outcome in patients treated with a fluoroscopy-assisted technique. Materials and Methods: A single-center consecutive cohort study was conducted of all adult patients who underwent posterior C1-C2 fixation, using TAS or CRS, between 2005-2019. Results: Seventy-eight patients were included, with a median follow-up time of 6.8 years. Trauma was the most common injury mechanism (64%), and cervicalgia the predominant preoperative symptom (88%). TAS was used in 33%, and SRC in 67% of cases. Surgery was associated with a significant reduction in cervicalgia (from 88% to 26%, p < 0.001). The most common complications were vertebral artery injury (n = 2, 2.6%), and screw malposition (n = 5, 6.7%, of which 2 were TAS and 3 were SRC). No patients deteriorated in their functional status following surgery. Conclusions: Fluoroscopy-assisted C1-C2 fixation with TAS or SRC is a safe and effective treatment for atlantoaxial instability, with a low complication rate, few surgical revisions, and pain relief in the majority of the cases.

Percutaneous Vertebroplasty for C1 Osteolytic Lesions via Lateral Approach Under Fluoroscopic Guidance

Objective

To report our experience of treating painful C1 osteolytic lesions with cement augmentation via a lateral approach under fluoroscopic guidance.

Materials and Methods

Nine consecutive patients (eight men and one woman; mean age: 56.7±13.2 years) with osteolytic lesions of the atlas who underwent cementoplasty via a lateral approach were enrolled in this study. The technical success rate, operation time, and complications were recorded. Visual analogue scale (VAS) and Neck disability index (NDI) were used to evaluate the pain relief and neck function status pre-procedure (baseline) and post-procedure (at 3 days; after 1, 3, 6, 12, 18, and 24 months; and at the last follow-up).

Results

The procedure was technically successful without any complications in all patients. The mean procedure time was 44.3±7.8 min. There were three cases of bone cement leakage, but no clinical symptoms. The mean VAS score decreased from 6.7±1.0 before the procedure to 3.7 three days after the procedure. The mean NDI score decreased from 67.3±11.2 before the procedure to 39.3±13.7 three days after the procedure. The VAS and NDI scores decreased at each follow-up time point, and the difference was statistically significant compared with the scores before the procedure (P<0.01).

Conclusion

Fluoroscopy-guided lateral approach is a feasible, safe, and effective method for treatment of osteolytic lesions of the atlas and can relieve pain and stabilize the bone.

The impact of odontoid screw fixation techniques on screw-related complications and fusion rates: a systematic review and meta-analysis

PURPOSE

The primary goal of this study was to conduct a systematic review and meta-analysis of articles focused on odontoid screw fixation (OSF) and screw-related complications or non-union rates.

METHODS

We conducted a systematic review of the PubMed and Crossref databases between January 1982 and December 2019. Inclusion criteria comprised detailed descriptions of the surgical technique and screw-related complications (screw cut-out, loosening, breakage, malposition) or fusion rates.

RESULTS

The initial selection consisted of 683 abstracts. A total of 150 full texts were chosen for detailed study, and 83 articles were included in the analysis. The point estimates for screw-related complications were as follows: 1. screw malposition frequency-4.8%; 2. screw cut-out rate-5.0%; 3. screw loosening/pull-out-3.8%; and 4. screw fracture rate-3.1%. The point estimate for the non-union rate was 9.7%. Statistical analysis of the screw-related complications rate based on surgical technique details was also performed CONCLUSIONS: Double-screw OSF performance in elder patients resulted in a higher risk of post-operative screw cut-out. In other cases, the development of screw-related complications did not depend on the method of intraoperative head fixation, selection of the implant entry point for OSF, type of the used screws, or cannulated instruments application. The outcomes of single-screw fixation through the anterior lip of the C2 vertebra were comparable to other techniques of OSF. Further, statistically reliable studies should be carried out to identify the optimal technique of OSF.

Posterior percutaneous transarticular stand-alone screw instrumentation of C1-C2 with endoscopic assistance: A report of two cases

We present two cases of minimally invasive posterior transarticular screw fixation of C1-C2. The points for screw insertion were visualized by endoscopy via the instrumental port. A patient with a type III odontoid fracture with subluxation underwent a minimally invasive posterior stand-alone transarticular screw fixation. Despite the application of compression screws, for technical reasons, only minimal compression on the anterior third of the C1-C2 lateral joint was achieved. However, complete fracture fusion was achieved with stable fibrous C1-C2 fusion 2.5 years postoperatively. A second patient with a chronic type II odontoid fracture underwent percutaneous C1-C2 fixation by the same method. After 2 years, fracture fusion and C1-C2 lateral mass ankylosis were achieved. The use of a tubular retractor and endoscopy in stand-alone screw fixation of C1-C2 allows direct visualization of the screw entry point and decreases surgical trauma. This procedure might be an alternative to other methods of transarticular instrumentation.