Translaminar screws of the axis—an alternative technique for rigid screw fixation in upper cervical spine instability

Abstract

C2 pedicle screws or transarticular atlantoaxial screws are technically demanding and carry an increased risk of vertebral artery injury. In up to 20% of cases, pedicle and transarticular screw placement is not possible due to a high-riding vertebral artery or very small C2 pedicles in addition to other anatomical variations. Translaminar screws have been reported to rigidly capture posterior elements of C2 and therefore appear to be a suitable alternative. We present our first experiences and clinical results with this new method in two neurosurgical spine centers. Twenty-seven adult patients were treated between 2007 and 2010 in two neurosurgical spine departments with C2 translaminar screw fixation for upper cervical spine instability of various origins (e.g., trauma, tumor, dens pseudarthrosis). Eight patients were men and 19 were women. Mean age was 68.9years. In most cases, translaminar screws were used because of contraindications for pedicle or transarticular screws as a salvage technique. All patients were clinically assessed and had CT scans postoperatively to verify correct screw placement. Follow-up was performed with reexamination on an ambulatory basis. Mean follow-up was 7.6months for all patients. In 27 patients, 52 translaminar screws were placed. There were no intraoperative complications. Postoperatively, we identified four screw malpositions using a new accuracy grading scale. One screw had to be revised because of violation of the spinal canal >4mm. None of the patients had additional neurological deficits postoperatively, and all showed stable cervical conditions at follow-up. Two patients died due to causes not associated with the stabilization technique. The fusion rate for patients with C1/C2 fixation is 92.9%. Translaminar screws can be used at least as an additional technique for cases of upper cervical spine instability when pedicle screw placement is contraindicated or not possible. The current data suggest comparable biomechanical stability and fusion rates of translaminar screws to other well-known posterior fixation procedures. In addition, translaminar screw placement is technically less demanding and reduces the risk of vertebral artery injury.