C2 Pars Screws Research Articles

Seven Years of Experience With C2 Translaminar Screw Fixation: Clinical Series and Review of the Literature

C2 translaminar screws offer biomechanical stability similar to that of other C2 fixation methods but with minimal risk to neural and vascular structures. To report our experience with the technique since 2002 and to review the pertinent literature to advance the understanding of C2 translaminar screw fixation. Fifty-two consecutive adult patients with disorders requiring axis stabilization were treated with C2 translaminar screws by a single surgeon. All patients underwent preoperative computed tomography scans to confirm the feasibility of screw placement. Patients were followed up with serial flexion/extension radiographs and/or computed tomography scans. The average age in our series was 58.1 years. One hundred three C2 translaminar screws were placed (average length, 28.9 mm). No vascular or neurological injuries occurred. Of 41 patients with sufficient follow-up (average, 13.3 months) to evaluate fusion, 1 instrumentation failure/pseudoarthrosis was observed. Five patients (average age, 78.7 years) died of complications related to medical comorbidities. In the literature, 169 cases of C2 translaminar fixation have been reported, with a fusion rate of 95.3% and no vertebral artery injuries. In biomechanical studies, C2 translaminar screws perform similarly to C2 pedicle screws and may outperform C2 pars screws in intact spine models. With disrupted atlantoaxial ligaments, constructs with C2 translaminar screws may not resist lateral bending as well as those with other screws, although they have more stability than uninstrumented, intact spines. This study reports 103 C2 translaminar screws, the largest single-surgeon series to date. C2 translaminar screws are a technically feasible, low-risk option for C2 fixation, with a 97.6% fusion rate in this series.

Biomechanical Effect of the C2 Laminar Decortication on the Stability of C2 Intralaminar Screw Construct and Biomechanical Comparison of C2 Intralaminar Screw and C2 Pars Screw

There have been no reports of biomechanical stability of C1-2 constructs after decortication of the C2 lamina. In addition, few studies have compared the stability of C2 laminar screw and pars screw constructs. To compare the biomechanical stability of 3 different C1-2 construct conditions (C2 pars screw, C2 intralaminar screw, C2 intralaminar construct with C2 laminar decortication). Fourteen fresh-frozen cadaveric cervical specimens (C1-3) were used. In 7 specimens, pure moments of 1.5 Nm were applied in flexion/extension, lateral bending, and axial rotation. Each specimen was tested in the normal state, in the destabilized state (after odontoidectomy and resection of transverse atlantal ligament), and after application of constructs. After kinematic study, these 7 specimens underwent axial pullout strength testing of pars screw and 50% decorticated C2 intralaminar screws. In another 7 specimens, insertion torque and pullout strength were measured to compare the pars screw and intact C2 intralaminar screw. : There were no statistically significant differences between the intact C2 intralaminar and 50% decorticated C2 intralaminar screw constructs in terms of range-of-motion limitations. The C2 pars screw construct was significantly superior to the C2 laminar screw construct in lateral bending (P < .01) and axial rotation (P < .01) and equivalent to the C2 laminar screw construct in flexion/extension (P = .42). There was no significant pullout strength difference between the 3 kinds of C2 screw. The C1 lateral mass-C2 pars screws construct was stronger than the C1 lateral mass-C2 intralaminar screw construct. Decortication of C2 laminar (up to 50%) did not affect the immediate stability of the C1-2 construct.

Posterior Rotating Rod Reduction Strategy for Irreducible Atlantoaxial Subluxations With Congenital Odontoid Aplasia

Applying rotating rod techniques to reduce irreducible atlantoaxial dislocation. To spare the occipital-C1 motion by the strategy in reduction of before surgery irreducible atlantoaxial dislocation with obvious neurologic symptoms and congenital odontoid aplasia. The treatment of atlantoaxial dislocation (AAD) is a challenging problem for most surgeons. Posterior surgical stabilization of C1 and C2 include C1-C2 transarticular screws, or C1 lateral with C2 pars screws. These constructs, however, are based on preoperative reductions. When preoperative skull reduction fails and myelopathic symptoms coexist, long-segment cervico-occipital fusion and decompression are usually the only practical choice. The authors explored a different surgical technique to spare the axial occipital joints by rotating rods in polyaxial C1, C3 lateral mass, and C2 pars screws, functioning as a lever analogue. Three before surgery irreducible AAD cases with obvious neurologic symptoms and congenital odontoid aplasia were successfully reduced and fused with this procedure. The authors used intraoperative somatosensory-evoked potential monitoring and intraoperative fluoroscopy. Preoperative skull traction was employed to distract and help extend the atlantoaxial complexes. Three C1-C2 dislocations were reduced completely without any deterioration of neurologic signs. Cervical myelopathic symptoms recovered soon after the operation. No atlantoaxial subluxation recurred. They returned to their normal work and/or activities. The rotating rod strategy is a viable option to reduce and fuse C1-C3 for AAD with odontoid aplasia. It spares the occipital-C1 motion.

Is Intraoperative CT of Posterior Cervical Spine Instrumentation Cost-effective and Does It Reduce Complications?

Symptomatic multilevel cervical myelopathy is often addressed using posterior decompression using two-dimensional fluoroscopy. Intraoperative three-dimensional fluoroscopy provides more accurate information on the position of instrumentation to prevent screw-related complications. We documented the incidence of hardware-related complications and evaluate cost-effectiveness when using intraoperative three-dimensional fluoroscopy (ISO-C CT) in posterior cervical spine surgery. Records from 87 patients who underwent posterior cervical decompression and instrumented fusion for multilevel cervical spondylosis with myelopathy were retrospectively reviewed. Patients in whom a lateral mass, pars, or pedicle screw was removed or revised based on intraoperative ISO-C CT was recorded. Cost analysis was performed using 2008 Medicare reimbursements and was compared against cost estimates for ISO-C CT. Seven patients (8%) had screws changed based on the results of the three-dimensional fluoroscopy: 0.5% of lateral mass screws, 3.1% of thoracic pedicle screws, and 15% of C2 pars screws. No patients who had evaluation of hardware with the ISO-C CT required a return to surgery for complications secondary to hardware failure, malposition, or cutout. Cost savings are achieved if use of intraoperative ISO-C CT prevents eight patients from requiring a return to the operating room. If every malpositioned screw has the potential to be symptomatic, then 240 patients must have screws placed to be cost-effective. ISO-C CT can safely replace postoperative CT as the standard of care in patients undergoing posterior cervical spinal fusion. Level III, economic and decision analyses. See Guidelines for Authors for a complete description of levels of evidence.

Clinical application of C2 laminar screw technique

C2 laminar screws have become an increasingly used alternative method to C2 pedicle screw fixation. However, the outcome of this technique has not been thoroughly investigated. A total of 35 cases with upper cervical spinal instability undergoing C2 laminar screw fixation were reviewed. All cases had symptoms of atlantoaxial instability, such as craniocervical junction pain, and were fixed with the Vertex cervical internal fixation system. A total of 68 screws were placed and hybrid constructs (a C2 translaminar screw combined with a C2 pars screw) were incorporated in two patients. In this series, there were no intraoperative complications and no cases of neurological worsening or vascular injury from hardware placement. Computed tomographic scans demonstrated a partial dorsal laminar breach in ten patients. None of these resulted in neurological symptoms. None of the patients was found to have a breach of the ventral laminar cortex. All the C2 laminar screws fixations were performed successfully. There was no instability seen on the films with no evidence of hardware failure or screw loosening during the follow-up period in all patients. In conclusion, C2 laminar screw technique is straightforward and easily adopted; it can efficiently and reliably restore upper cervical stability. It is an alternative method to C2 pedicle screw fixation, especially in patients with unilateral occlusion of vertebral artery and pedicle deformity of C2.

Biomechanical Implications of Extending Occipitocervical Instrumentation to Include the Subaxial Spine

No clear biomechanical data exist regarding where to place the caudal end of a screw-rod occipitocervical instrumentation construct. This study examines whether range of motion (ROM) from the occiput to C2 is altered by subaxial extension of occipitocervical instrumentation constructs. Cadaver specimens underwent intact biomechanical testing followed by destabilization via an odontoid osteotomy. Subsequent biomechanical testing was performed of four occipitocervical constructs: occipital plate + C2 pars screws (construct 1), occipital plate + C2 pars screws + C4 lateral mass screws (construct 2), occipital plate + C1-C2 transarticular screws (construct 3), and occipital plate + C1-C2 transarticular screws + C4 lateral mass screws (construct 4). All constructs significantly reduced occiput-C2 ROM in all loading modes compared with the intact cervical spine, with one exception (construct 1, lateral bending). No significant ROM differences were noted when C4 lateral mass screws (construct 4) were added to construct 3. Addition of C4 lateral mass screws (construct 2) to construct 1 decreased the ROM in the flexion mode only. No significant ROM differences were seen between construct 2 and construct 3 in any loading mode. The addition of subaxial instrumentation to occipitocervical instrumentation constructs in this study decreased occiput-C2 ROM only when the construct was anchored by C2 pars screws and only in flexion. Screws that cross the C1 to C2 articulation provide stable fixation when combined with an occipital plate, and the addition of subaxial instrumentation to this construct for stabilizing the occipitocervical junction does not significantly decrease ROM.

Craniocervical Fixation With Occipital Condyle Screws

A human cadaveric biomechanical study comparing craniocervical fixation techniques. To quantitatively compare the biomechanical stability of a new technique for occipitocervical fixation using the occipital condyles with an established method for craniocervical spine fusion. Stabilization of the occipitocervical junction remains a challenge. The occiput does not easily accommodate instrumentation because of access and spatial constraints. In fact, the area available for the implant fixation is limited and can be restricted further when a suboccipital craniectomy has been performed, posing a challenge to current fixation techniques. Occipital screws are also associated with the potential for intracranial complications. Six fresh frozen cadaveric specimens occiput-C4 were tested intact, after destabilization and after fixation as follows: (1) occipital plate with C1 lateral mass screws and C2 pars screws and (2) occipital condyle screws with C1 lateral mass screws and C2 pars screws. Specimens were loaded in a custom spine testing apparatus and subjected to the following tests, all performed under 50-N unconstrained axial preload: flexion, extension, lateral bending, and axial rotation at 1.5 Nm. The constructs were statistically compared with a one-way analysis of variance and compared with the intact condition. Motions were reduced by approximately 80% compared with the intact condition for both configurations under all motions. There were no statistically significant differences in the range of motion (ROM) between the 2 instrumentation conditions. The mean values indicated decreased ROM with the novel occipital condyle screw construct in comparison with the standard occipital plate and rod system. Craniocervical stabilization using occipital condyle screws as the sole cephalad fixation point is biomechanically equivalent with regard to the modes tested (ROM and stiffness) to the standard occipital plate construct.

C1 Lateral Mass Fixation

Abstract OBJECTIVE We review our experience and technique for C1 lateral mass screw fixation. We compare the results of 3 different constructs incorporating C1 lateral mass screws: occipitocervical (OC) constructs, C1–C2 constructs, and C1 to mid/low cervical constructs. METHODS We performed a retrospective chart review of 42 consecutive patients who underwent C1 lateral mass fixation by 2 of the authors (PVM and DC). The patient population consisted of 24 men and 18 women with a mean age of 64 years. Twenty-two patients had C1–C2 constructs. Twelve patients had constructs that started at C1 and extended to the mid/low cervical spine (one extended to T1). Eight patients underwent OC fusions incorporating C1 screws (2 of which were OC-thoracic constructs). All constructs were combined either with a C2 pars screw (38 patients), C2 translaminar screw (1 patient), or C3 lateral mass screw (3 patients). No C2 pedicle screws were used. Fusion was assessed using flexion-extension x-rays in all patients and computed tomographic scans in selected cases. Clinical outcomes were assessed with preoperative and postoperative visual analog scale neck pain scores and Nurick grading. The nuances of the surgical technique are reviewed, and a surgical video is included. RESULTS Two patients (5%) were lost to follow-up. The mean follow-up for the remaining patients was 2 years. During the follow-up period, there were 4 deaths (none of which were related to the surgery). For patients with follow-up, the visual analog scale neck pain score improved a mean of 3 points after surgery (P &amp;lt; .001). For patients with myelopathy, the Nurick score improved by a mean of 1 grade after surgery (P &amp;lt; .001). The postoperative complication rate was 12%. The complication rate was 38% in OC constructs, 17% in C1 to mid/low cervical constructs, and 0% for C1–C2 construct cases. Patients with OC constructs had the statistically highest rate of complications (P &amp;lt; .001). Patients with C1 to mid/low cervical constructs had more complications than those with C1–C2 constructs (P &amp;lt; .001). Of the 42 cases, there were 3 pseudoarthroses (1 in an OC case, 1 in a C1 to midcervical construct, and 1 in a C1–C2 construct). OC constructs had the highest risk of pseudoarthrosis (13%) (P &amp;lt; .001). CONCLUSION Patients treated with C1 lateral mass fixation constructs have a high fusion rate, reduced neck pain, and improved neurologic function. Constructs using C1 lateral mass screws do not need to incorporate C2 pedicle screws. Constructs incorporating C1 lateral mass screws are effective when combined with C2 pars screws, C2 translaminar screws, and C3 lateral mass screws. Constructs using C1 screws are associated with a higher complication rate and a higher pseudoarthrosis rate if extended cranially to the occiput or if extended caudally below C2.

USE OF AXIAL AND SUBAXIAL TRANSLAMINAR SCREW FIXATION IN THE MANAGEMENT OF UPPER CERVICAL SPINAL INSTABILITY IN A SERIES OF 7 CHILDREN

The management of upper cervical spinal instability in children continues to represent a technical challenge. Traditionally, a number of wiring techniques followed by halo orthosis have been applied; however, they have been associated with a high rate of nonunion and poor tolerance for the halo. Alternatively, C1-C2 transarticular screws and C2 pars/pedicle screws allow more rigid fixation, but they are technically demanding and associated with vertebral artery injuries. Recently, C2 translaminar screws have been added to the armamentarium of the pediatric spine surgeon as a technically simple and biomechanically efficient method of fixation. However, subaxial translaminar screws have not been described in the pediatric population. We describe our experience with axial and subaxial translaminar screws in 7 pediatric patients. Seven pediatric patients with the diagnosis of upper cervical spinal instability required surgical fixation (age, 19 months-14 years; sex, 4 boys and 3 girls; follow-up, 4-21 months; etiology, trauma [3 patients], os odontoideum/os terminale [2 patients], hypoplastic dens [2 patients]). All patients underwent axial and/or subaxial translaminar screw insertion. Iliac crest bone graft was used for fusion in 4 patients; bone morphogenic protein and cancellous morselized allograft was used for fusion in 3 patients. A rigid cervical collar was applied for 12 weeks postoperatively in all cases. No intraoperative image guidance was used for insertion of the translaminar screws. All patients had a postoperative computed tomographic scan. Two patients underwent placement of bilateral crossing C2 translaminar screws. Two patients had subaxial translaminar screw placement at C3 and the upper thoracic spine, respectively. Hybrid constructs (a C2 translaminar screw combined with a C2 pars screw) were incorporated in 3 patients. No patients were found to have a breach of the ventral laminar cortex. All patients achieved solid fusion. One patient had a perioperative complication: prolonged dysphagia probably related to C1 lateral mass screw insertion rather than C2 translaminar screw placement. To our knowledge, this report represents the only series of pediatric patients treated with axial and subaxial translaminar screws. This series shows that axial and subaxial translaminar screw fixation is a viable option for upper cervical spinal fusion in children. The technique is safe and results in adequate fixation with high fusion rates and minimal complications.

Posterior atlanto-axial fixation with polyaxial C1 lateral mass screws and C2 pars screws

C1-C2 instability or painful osteoarthritis are recognised indications for posterior atlanto-axial fixation. In the traditional trans-articular C1-C2 screw fixation, up to 20% of patients cannot have safe placement of bilateral screws in the event of a medially located vertebral artery and a straight screw trajectory in the sagittal plane. The more recently developed C1-C2 fixation technique with individual C1 lateral mass screws and converging C2 pars screws can be employed in case of a medially located vertebral artery and has comparable biomechanical strength. This is a prospective observational study to investigate the advantages, the safety, and the drawbacks of posterior atlanto-axial fixation with polyaxial C1 lateral mass screws and C2 pars screws. Twelve consecutive patients with C1-2 instability (n = 11) and painful osteoarthritis (n = 1) underwent a posterior atlanto-axial fixation with polyaxial C1 lateral mass screws and C2 pars screws. The average follow-up was 16 months and all patients reached the 12-month follow-up. No hardware failure occurred in any of the patients. Correct screw placement and construct stability was found in all 12 patients (100%) at 6 and 12 months after surgery. Mean neck pain on a visual analogue scale (VAS) was 2.1 at 6 months and 2.0 at 12 months. Only transient complications were observed: one patient presented with progressive intestinal herniation through the iliac crest scar; one suffered from severe pain at the posterior iliac crest for 3 months and three patients complained of annoying pain/dysaesthesia in the C2 dermatome for 3-6 months after surgery. This study confirms that posterior atlanto-axial fixation with polyaxial C1 lateral mass screws and C2 pars screws is a safe and effective surgical option in the treatment of atlanto-axial instability or painful osteoarthritis.

Acute and Long-term Stability of Atlantoaxial Fixation Methods

In vitro human cadaveric biomechanical study. The aims of this project were to evaluate the acute segmental fixation and long-term screw stability afforded by 3 C2 fixation techniques: intralaminar, pars, and pedicle. C2 intralaminar screws offer the advantages of avoiding the vertebral artery; however, direct biomechanical comparison of this technique to the other methods of instrumenting C2 has not been performed. Fourteen cadaveric specimens were dual energy radiograph absorptiometry scanned and segregated into 2 groups (n = 7/group) matching the C2 bone mineral density. All specimens were instrumented with C1 lateral mass and C2 intralaminar screws while measuring the insertional torque (IT). In group 1 C2 pars screws were inserted while in group 2 pedicle screws were placed. Nondestructive testing was performed in axial rotation, flexion/extension (FE), and lateral bending. The odontoid was then resected and loading repeated. Subsequently, specimens were disarticulated about C2 and individually loaded for 2000 cycles in the cephalocaudad plane. The screws were then failed by a tensile load directed in the parasagittal plane. Full range of motion over C1-C2 and peak screw pull-out force was quantified. RESULTS.: Transpedicular technique generated significantly higher IT than the pars screws and marginally greater IT than intralaminar screws. With the intact atlantoaxial ligamentous complex, intralaminar fixation was superior to pars and similar to pedicle instrumentation at limiting axial torsion. After odontoid destabilization, however, this technique was less effective at reducing the lateral bending range of motion. Destructive loading revealed the highest pull-out forces with the pedicle screws, followed by intralaminar and pars screws. Our results suggest that C2 intralaminar fixation provides a viable alternative to pedicle screws and is superior to pars instrumentation in cases with preserved atlantoaxial ligamentous attachments. In the presence of a traumatic dens fracture, however, intralaminar fixation may not be the optimal choice.

Use of Axial and Subaxial Translaminar Screws in the Management of Upper Cervical Spinal Instability in Children

INTRODUCTION: The management of upper cervical spinal instability in children represents a technical challenge. A number of wiring techniques followed by halo orthosis have been applied; however, they have been associated with a high nonunion rate and poor tolerance for the halo. Screw fixation allows more rigid fixation, but it is technically demanding and associated with vertebral artery injuries. Recently, C2 translaminar screws have been added to the armamentarium of the pediatric spine surgeon as a safe and efficacious method of fixation. However, subaxial translaminar screws have not been described in children. We describe axial and subaxial translaminar screw fixation in six pediatric patients. METHODS: Six pediatric patients with the diagnosis of upper cervical spinal instability required surgical fixation (age, 19 mo–10 yr; sex, three males and three females; follow-up duration, 2–18 mo). The etiologies were trauma (n = 2), os odontoideum/os terminale (n = 2), and hypoplastic dens (n = 2). All patients underwent axial and/or subaxial translaminar screw insertion. Iliac crest bone graft was used for fusion in three patients, and BMP and cancellous morselized allograft was used in three patients. A rigid cervical collar was applied postoperatively in all cases for 12 weeks. RESULTS: All patients had postoperative computed tomographic scans. Subaxial translaminar screws were placed at C3 and in the upper thoracic spine. Hybrid constructs (C2 translaminar screw plus C2 pars screw) were incorporated in three patients. There were no perioperative complications related to translaminar screw placement. No patients were found to have a breach of the ventral laminar cortex. All patients with at least a 3-month follow-up achieved solid fusion. CONCLUSION: This represents the only series of pediatric patients treated with axial and subaxial translaminar screws to date. Axial and subaxial translaminar screw fixation is a viable option for upper cervical spinal fusion in children. The technique is safe and results in high fusion rates.

Salvage of C2 Pedicle and Pars Screws Using the Intralaminar Technique

Human cadaveric biomechanical analysis. The purpose of this study is to evaluate the ability of using 1 of the remaining 2 methods of instrumenting C2, should the initial method fail. Although 3 different methods of C2 fixation (pedicle, pars, and laminar screws) are possible, occasionally an attempt at screw insertion fails. In such cases, the surgeon needs a viable alternative to salvage/obtain fixation to obviate the need to instrument an additional motion segment. METHODS.: Eleven fresh-frozen cadaveric specimens (Occ-C4) were DEXA scanned for bone mineral density. On the left side, pedicle screws were first inserted, then pulled out. Then, "salvage" pars screws were inserted, then pulled-out, followed by laminar screws. On the right, a similar sequence was repeated, except that a pars screw was followed by a pedicle screw, then a laminar screw. All screws were placed by experienced cervical spine surgeons. Insertional torque (IT) was measured in Newton-meters (Nm). Tensile loading to failure was performed "in-line"with the screw axis at a rate of 0.25 mm/s using a MTS 858 MiniBionix II System with data recorded as peak pull-out strength (POS) in newtons "N". Pedicle screws generated statistically greater IT and POS than other techniques as the initial fixation type (P < 0.0001). Similar trends were observed with transpedicular fixation as a salvage procedure (P > 0.05). Laminar screws yielded consistently higher POS values than pars fixation when applied in a salvage scenario (POS range: LS = 146-707 N; PrS = 8-548 N); however, high standard deviation precluded statistical significance (P > 0.05). Significant predictive relationship was established between IT and POS for all screws using Pearson correlation coefficient and bivariate linear regression analysis (r = 0.75 and r = 0.511, respectively; P < 0.01). Our results suggest that pedicle screws provide the strongest fixation for both initial and salvage applications. If they should fail, lamina screws appear to provide stronger and more reproducible fixation than pars screws.

COMPARISON OF CONTEMPORARY OCCIPITOCERVICAL INSTRUMENTATION TECHNIQUES WITH AND WITHOUT C1 LATERAL MASS SCREWS

This study was designed to test the kinematic properties of three occiput-C2 instrumentation constructs with and without supplemental rigid C1 fixation. The results are compared with intact specimens and with constructs incorporating contemporary cabling techniques. Five unembalmed human cadaver specimens underwent range of motion (ROM) testing in the intact condition, followed by destabilization with odontoid osteotomy. Destabilized specimens then underwent ROM testing with each of seven occipitocervical instrumentation constructs, all incorporating occipital screws: C1 and C2 sublaminar cables with cable connectors, C2 pars screws +/- C1 lateral mass screws, C2 lamina screws +/- C1 lateral mass screws, and C1-C2 transarticular screws +/- C1 lateral mass screws. All seven constructs demonstrated significantly lower ROM in all loading modes than intact specimens (P < 0.05). With a single exception, the addition of C1 lateral mass screws to the screw-based constructs produced no significant change in ROM in any of the loading modes. Compared with intact specimens, constructs anchored by C1-C2 transarticular screws demonstrated the greatest decrease in ROM, and those anchored by sublaminar cables demonstrated the least decrease in ROM. Any of the tested screw-based constructs are likely to provide adequate support for the patient with an unstable craniocervical junction. Therefore, the choice of construct should be based on anatomic considerations. The routine incorporation of C1 lateral mass screws into occipitocervical instrumentation constructs does not seem necessary.

4:04 Circumferential reconstruction of the cervical spine

Purpose of study: A significant number of adults have pain, cosmetic deformity or neurologic injury related to cervical malalignment. The majority of such cases involve sagittal plane malalignment with loss of lordosis, kyphosis or double curve (swan-neck) deformity of the subaxial spine. A smaller number of patients have coronal plane malalignment or scoliosis in the subaxial spine or various anomalies of the occipitoatlantoaxial complex. In the following, we describe 50 cases within the past 5 years in which circumferential approaches have been applied for the correction of cervical deformities.Methods used: At our institution, more than 50 cases of multisegmental cervical or occipitocervical deformity corrections have been performed since 1995. Thirty cases have at least 24 months of follow-up. Causative pathologies include rheumatoid arthritis, congenital dysplasias, late posttraumatic deformity, iatrogenic postsurgical deformity, severe degenerative disease, tumors, vascular malformations and infections. All subaxial cases involved sagittal plane restoration. One in four also required coronal or axial realignment. Two thirds of occipitoatlantoaxial cases involved sagittal corrections; half with axial or coronal restoration as well. Two thirds of all cases, including 540 degree reconstructions, could be completed in a single day with a single anesthetic.of findings: An aggressive approach to anterior and posterior osteotomy followed by anterior distraction and posterior compression allowed correction of kyphotic deformity in all subaxial cases. Partial loss of correction occurred in one third of cases secondary to cage or strut settling or telescoping, despite rigid fixation. Intraoperative correction of coronal or axial deformities was maintained with little, if any, subsequent loss. Rigid screw fixation to the suboccipital keel and to the C1–C2 region with long C2 pars screws or C1–C2 transarticular screws allowed maintenance of intraoperative correction with no apparent late loss. There were no deaths and no spinal cord or nerve root injuries in this series. Two vertebral artery injuries related to C1–C2 transarticular screw placement occurred; one resulted in a delayed Wallenburg's syndrome. Two next-segment failures occurred, requiring reoperation for extension of fusion. There was a measurable loss of anterior distractive height restoration in one third of cases over time. In no case was this clinically significant. Anterior cage or strut settling occurred with both rigid and dynamic anterior buttresses and in the face of rigid anterior and posterior hardware.Relationship between findings and existing knowledge: The literature on spinal deformity is largely concerned with thoracic and thoracolumbar pathology. Traditional surgical approaches to cervical deformity using nonrigid internal fixation with wire or cable and/or semirigid external fixation in halo vests or Minerva casts were of limited use in the correction of deformity in any plane either above or below C2.Overall significance of findings: Modern reconstructive techniques allow for clinically significant correction of cervical and occipitocervical deformities associated with chronic pain, cosmetic deformity and neurologic deficit. An aggressive circumferential approach to decompression and osteotomy allows near-anatomic correction of geometric deformity in any plane.Disclosures: No disclosures.Conflict of interest: No conflicts.