[3D printing navigation template assisted pedicle screw placement for the treatment of typeâ ¡old odontoid fractures].

OBJECTIVE: To compare the safety and clinical efficacy of freehand and 3D printing navigation template assisted screw placement in patients with old odontoid fractures of typeⅡ. METHODS: Total of 38 patients with old odontoid fractures of typeⅡwere treated from November 2018 to December 2022, all of which presented as chronic neck pain. According to the different methods of screw insertion into the pedicle, the patients were divided into a navigation template group and a freehand group. In the navigation template group, there were 17 patients including 9 males and 8 females with an average age of (51.30±13.20) years old, disease duration was (22.18±7.59) months. In the freehand group, there 21 patients including 7 males and 14 females with an average age of (49.46±11.92) years old, disease duration was (19.52±9.17) months. The intraoperative blood loss, operation time, and postoperative drainage output were recorded and compared between two groups. The accuracy of screw placement was evaluated by CT scan. Before operation and 1 year after operation, cervical pain was assessed by visual analogue scale(VAS), neurological changes were evaluated by the Japanese Orthopaedic Association (JOA) score, and the degree of spinal cord injury was assessed by the American Spinal Injury Association (ASIA) injury scale. RESULTS: All patients were followed up for (25.31±1.21) months. The operation time of template group (112.00±20.48) min had significantly shorter than that of the freehand group(124.29±15.24) min(P<0.05), while there were no significant differences between two groups in terms of intraoperative blood loss, postoperative drainage, and hospital stay(P>0.05). At 1 year after operation, in template group and freehand group, the VAS [(2.88±0.86), (2.90±0.83)] and JOA [(14.94±1.82), (14.62±2.19)] improved with preoperative [VAS(4.71±0.92), (4.86±0.79) and JOA (12.18±2.30), (11.95±2.31)](P<0.05), with no significant difference between two groups (P>0.05). No significant improvement was observed in ASIA grading in either group at 1 year after operation(P>0.05), and there was no significant difference between two groups(P>0.05). The template group had significantly better accuracy of screw placement in the pedicle of the axis than the freehand group (P<0.05), while no significant difference was observed between two groups in the accuracy of screw placement in the pedicle of the atlas (P>0.05). CONCLUSION: In the treatment of typeⅡold odontoid fractures with posterior pedicle screw fixation, 3D printing navigation template screw placement can significantly shorten the operation time, achieve similar clinical efficacy as free-hand screw placement, and significantly improve the accuracy of screw placement in the pedicle of the axis.

Biomechanical evaluation of reinsertion and revision screws in the subaxial cervical vertebrae.

BACKGROUND: This study aimed to evaluate the biomechanical effects of reinserted or revised subaxial cervical vertebral screws. METHODS: The first part aimed to gauge the maximum insertional torque (MIT) of 30 subaxial cervical vertebrae outfitted with 4.0-mm titanium screws. A reinsertion group was created wherein a screw was wholly removed and replaced along the same trajectory to test its maximum pullout strength (MPOS). A control group was also implemented. The second part involved implanting 4.0-mm titanium screws into 20 subaxial cervical vertebrae, testing them to failure, and then reinserting 4.5-mm revision screws along the same path to determine and compare the MIT and MPOS between the test and revision groups. RESULTS: Part I findings: No significant difference was observed in the initial insertion's maximum insertion torque (MIT) and maximum pull-out strength (MPOS) between the control and reinsertion groups. However, the MIT of the reinsertion group was substantially decreased compared to the first insertion. Moderate to high correlations were observed between the MIT and MPOS in both groups, as well as between the MIT of the first and second screw in the reinsertion group. Part II, the MIT and MPOS of the screw in the test group showed a strong correlation, while a modest correlation was observed for the revision screw used in failed cervical vertebrae screw. Additionally, the MPOS of the screw in the test group was significantly higher than that of the revision screw group. CONCLUSION: This study suggests that reinsertion of subaxial cervical vertebrae screws along the same trajectory is a viable option that does not significantly affect fixation stability. However, the use of 4.5-mm revision screws is inadequate for failed fixation cases with 4.0-mm cervical vertebral screws.

Research into the anatomy of the subaxial cervical pedicle for ensuring screw insertion safety.

The study aimed to determine the optimal entry points and trajectories for posterior subaxial cervical pedicle screw (CPS) fixation. Computed tomography (CT) and Mimics software were used to evaluate the subaxial cervical pedicle in 42 cervical spine CT scans. The width of the cervical pedicle was measured and compared at medial angulations of 30°, 35°, 40°, 45°, 50°, 55°, and 60° relative to the midline sagittal plane. Based on an observational examination of the positions of all cervical 3-dimensional models and screws, the proposed entry point for C3-7 CPS was analyzed. Although the variations in C3-6 pedicle width (PW) among 45°, 50°, and 55° were not statistically significant, they were significantly larger than the differences among 30°, 35°, 40°, and 60° angles (P < .05). The differences in C7 PW between the 30°, 35°, 40°, and 45° angles were not statistically different even though the 30°, 35°, 40°, and 45° angles were significantly bigger. (P < .05). The proposed entry point for C3-7 CPS was below the junction of the lateral and lower borders of the superior articular process joint surface. The entry point for C3-7 levels was below the junction of the lateral and lower borders of the superior articular process joint surface. The optimal medial angulation for the posterior C3-6 CPS was 45°-55° and that for the posterior C7 CPS was 30°-45°. The sagittal angle of the posterior C3-7 CPS was parallel to the corresponding upper endplate.

A Novel Method to Improve the Accuracy and Stability of the 3D Guide Template Technique Applied in Upper Cervical Spine Surgery.

AIM: To evaluate the safety and accuracy of C1 and C2 pedicle screw placement using a three-dimensional (3D)-printed double template and compare them with those of the conventional method in a clinical study. MATERIAL AND METHODS: DICOM format data from 60 cases with C1-C2 instability were obtained after computed tomography (CT) was performed. A total of 32 cases underwent surgery via the free-hand technique, whereas 28 cases underwent surgery via a 3D-printed "pointing-drilling" guide template. The ideal trajectory of the C1 and C2 pedicle screws was designed using a baseplate as a separate complementary template for the corresponding posterior C1-C2 anatomical surface, after which the "pointingdrilling" guide template was materialized using a 3D printing machine. The 3D-printed "pointing-drilling" guide template, which was sterilized with low-temperature plasma, was used to locate the starting point and determine the drill trajectory during surgery. The positions of the screws in the axial and sagittal planes of the CT scan were observed and categorized into four grades, after which the operative time, fluoroscopy time, and intraoperative bleeding in the two groups were compared. RESULTS: No significant difference (p > 0.05) in each screw classification grade was observed between the free-hand and "pointingdrilling" template groups; however, a significant difference was observed (p=0.048) between these two groups. A significant difference (p < 0.05) in fluoroscopy times was observed between the free-hand and "pointing-drilling" template groups. Conversely, no significant differences were observed in bleeding (p=0.491) and operative time (p=0.309) between the free-hand and "pointingdrilling" template groups. CONCLUSION: The 3D-printed "pointing-drilling" guide template technique promoted more secure C1 and C2 pedicle screw placement compared with the free-hand technique in clinics.

Biomechanical Properties of Novel Lateral Hole Pedicle Screws and Solid Pedicle Screws: A Comparative Study in the Beagle Dogs.

OBJECTIVE: Although pedicle screws are widely used to reconstruct the stability of the spine, screw loosening is a common complication after spine surgery. The main objective of this study was to investigate whether the application of the hollow lateral hole structure had the potential to improve the stability of the pedicle screw by comparing the biomechanical properties of the novel lateral hole pedicle screws (LHPSs) with those of the solid pedicle screws (SPSs) in beagle dogs. METHODS: The cancellous bone of the distal femur, proximal femur, distal tibia, and proximal tibia were chosen as implantation sites in beagle dogs. In each of 12 dogs, four LHPSs, and four SPSs were implanted into both lower limbs. At 1, 2, and 3 months after surgery, four dogs were randomly sampled and sacrificed. The LHPS group and SPS group were subdivided into four subgroups according to the length of their duration of implantation (0, 1, 2, 3 months). The biomechanical properties of both pedicle screws were evaluated by pull-out and the cyclic bending tests. RESULTS: The results of the study showed that no significant difference was found between LHPSs (276.62 ± 50.11 N) and SPSs (282.47 ± 42.98 N) in pull-out tests at time 0 (P > 0.05). At the same time point after implantations, LHPSs exhibited significantly higher maximal pullout strength than SPSs (month 1: 360.51 ± 25.63 vs 325.87 ± 28.11 N; month 2: 416.59 ± 23.78 vs 362.12 ± 29.27 N; month 3: 447.05 ± 38.26 vs 376.63 ± 32.36 N) (P < 0.05). Moreover, compared with SPSs, LHPSs withstood more loading cycles (month 2: 592 ± 21 vs 534 ± 48 times; month 3: 596 ± 10 vs 543 ± 59 times), and exhibiting less displacement before loosening at month 2 (1.70 ± 0.17 vs 1.96 ± 0.10 mm) and 3 (1.69 ± 0.19 vs 1.92 ± 0.14 mm) (P < 0.05), but no significant difference in time 0 and month 1 (P > 0.05). CONCLUSIONS: The pedicle screw with the hollow lateral hole structure could allow bone to grow into the inner architecture, which improved biomechanical properties by extending the contact area between screw and bone tissue after implantation into the cancellous bone. It indicated that LHPS could reduce loosening of the pedicle screws in long term after surgery.

Clinical characteristic and surgical treatment of traumatic lumbar spondylolisthesis: A series of 28 patients.

OBJECTIVE: To explore the clinical characteristics and the short-term efficacy of posterior operation for traumatic lumbar spondylolisthesis. METHODS: All 28 patients (between January 2013 and June 2018) were treated with lumbar pedicle screw fixation combined with posterior intervertebral fusion. The clinical data and imaging materials of these patients were retrospectively analyzed. RESULTS: The mean follow-up period was 24.3 months (12-36 months). The average VAS score and JOA score were significantly improved after surgery, and the difference was statistically significant (P<0.05).The last follow-up X-ray showed that 16 cases were degree 0 and 12 cases were degree I according to Meyerding grading, which were statistically improved compared with preoperative. Postoperative CT indicated lumbar internal fixation well, and the lumbar fusion rate was 100%. The Frankel grading of neurological function was significantly improved compared with preoperative. CONCLUSION: Acute traumatic lumbar spondylolisthesis is caused by severe trauma and mostly occurred at L4/L5 and L5/S1 level. Early posterior reduction, decompression and intervertebral fusion can achieve satisfactory clinical and radiological outcome.

A Comparison Study of Three Posterior Fixation Strategies in Transforaminal Lumbar Interbody Fusion Lumbar for the Treatment of Degenerative Diseases.

BACKGROUND: There are various posterior fixations utilized with transforaminal lumbar interbody fusion (TLIF). Previous studies have focused on the comparison of two fixation techniques. MATERIALS AND METHODS: Sixty five patients with single-level lumbar disease were included in this retrospective study. Group A was treated by TLIF with bilateral pedicle screw (BPS), Group B treated by TLIF with unilateral pedicle screw (UPS), and Group C treated by TLIF with UPS plus contralateral translaminar facet screw (UPSFS). The operative time, blood loss, Oswestry disability index (ODI), Japanese Orthopaedic Association Scores (JOA), and visual analog scores (VAS) were recorded. Radiographic examination was used to assess fusion rates and incidence of screw failure. RESULTS: The blood loss and operative times were 188.69 ± 37.69 ml and 132.96.5 ± 8.69 min in BPS group, 117.27 ± 27.11 ml and 99.32 ± 12.94 min in UPS group, and 121.50 ± 22.54 ml and 112.55 ± 9.42 min in UPSFS group; UPS and UPSFS were better than BPS (P < 0.05). The mean followup time was 38.2 months. Fusion rates were - BPS group: 95.6%, UPS group: 90%, UPSFS: 95% (P > 0.05). Screw and/or rod failures were found in three groups (BPS group: 1, UPS group: 2 and UPSFS: 1, P > 0.05). The average postoperative VAS, ODI, and JOA scores of BPS, UPS, and UPSFS were improved significantly in each group compared to preoperative scores (P < 0.05); there were no significant differences between any two groups at each followup time point (P > 0.05). CONCLUSION: UPSFS with TLIF is a viable treatment option that provides satisfactory clinical results; the clinical outcome and the complication rate were comparable to BPS. In addition, the invasive of UPSFS cases was comparable to UPS and better than BPS cases. For UPS, it could be used in suitable patients.

[Clinical and radiological results of thoracic and lumbar fracture and dislocation treated with posterior transforaminal decompression and interbody fusion].

OBJECTIVE: To evaluate the clinical and radiological results of patients with thoracic and lumbar fracture and dislocation treated by posterior transforaminal decompression and interbody fusion. METHODS: From June 2010 to June 2017, posterior transforaminal decompression, interbody fusion combined with pedicle screw fixation were performed in 21 patients with thoracic and lumbar fracture and dislocation. Their clinical and radiological data were collected and retrospectively analyzed, including 15 males and 6 females, aged from 25 to 58 years with an average of 45 years old. According to the criterion of American Spinal Injury(ASIA), preoperative neurological function was graded A in 3 cases, B in 7 cases, C in 6 cases, D in 4 cases and E in 1 case. Operative time and intraoperative blood loss and correlative complications were recorded. And VAS score, ODI and Cobb angle were evaluated before and after surgery. The improvement of neurological function was also analyzed at the final follow-up. Intervertebral bony fusion was observed during the follow-up by CT three-dimensional reconstruction. RESULTS: The operative time was 150 to 240 min with an average of (192±47) min. The intraoperative blood loss was 380 to 750 ml with an average of(603±120) ml. Dura sac tearing and cerebral fluid leakage occurred in 3 cases and were repaired during operation; superficial wound infection occurred in 1 case, and got healing after dressing change. The postoperative follow-up duration was 24 to 45 months with an average of(37.0±9.5) months. VAS score was improved from preoperative 8.9±0.4 to immediately postoperative 4.2±1.3(P<0.05). At the final follow-up, VAS score decreased further to 3.6±0.8. ODI was decreased from preoperative (95.30±3.52)% to (32.51±6.30)% at the final follow-up (P<0.05). Cobb angle was corrected from preoperative (21.2±8.8)° to immediately postoperative(2.3±3.1)° (P<0.05). At the final follow-up, Cobb angle was (3.2±2.5)°, showing no significant difference with immediately postoperative value. The neurological function was grade A in 3 cases, B in 3 cases, C in 5 cases, D in 6 cases and E in 4 cases at the final follow-up. All the patients got solid intervertebral bone fusion in 8 to 13 months after operation, with an average fusion time of (10.3±2.5) months. CONCLUSIONS: For the patients with thoracic and lumbar fracture and dislocation mainly involving intervertebral disc and endplate plane, posterior transforaminal decompression and interbody fusion not only is less invasive, but also can effectively reconstruct spinal three column and obtain good biomechanical stability. And, it is beneficial for the good recovery of neurological function.

Optimal Entry Point and Trajectory for Anterior C1 Lateral Mass Screw.

STUDY DESIGN: A radiographic analysis of the anatomy of the C1 lateral mass using computed tomography (CT) scans and Mimics software. OBJECTIVE: To define the anatomy of the C1 lateral mass and make recommendations for optimal entry point and trajectory for anterior C1 lateral mass screws. SUMMARY OF BACKGROUND DATA: Although various posterior insertion angles and entry points for screw insertion have been proposed for posterior C1 lateral mass screws, no large series have been performed to assess the ideal entry point and optimal trajectory for anterior C1 lateral mass screw placement. MATERIALS AND METHODS: The C1 lateral mass was evaluated using CT scans and a 3-dimensional imaging application (Mimics software). Measuring the space available for the anterior C1 lateral mass screw (SAS) at different camber angles from 0 to 30 degrees (5-degree intervals) was performed to identify the ideal camber angle of insertion. Measuring the range of sagittal angles was performed to calculate the ideal sagittal angle. Other measurements involving the height of the C1 lateral mass were also made. RESULTS: The optimal screw entry point was found to be located on the anterior surface of the atlas 12.88 mm (±1.10 mm) lateral to the center of the anterior tubercle. This optimal entry point was found to be 6.81 mm (±0.59 mm) superior to the anterior edge of the atlas inferior articulating process. The mean ideal camber angle was 20.92 degrees laterally and the mean ideal sagittal angle was 5.80 degrees downward. CONCLUSIONS: These measurements define the optimal entry point and trajectory for anterior C1 lateral mass screws and facilitate anterior C1 lateral mass screw placement. A thorough understanding of the local anatomy may decrease the risk of injury to the spinal cord, vertebral artery, and internal carotid artery. Delineating the anatomy in each case with preoperative 3D CT evaluation is recommended.

Comparison of occipitocervical and atlantoaxial fusion in treatment of unstable Jefferson fractures.

BACKGROUND: Controversy exists regarding the management of unstable Jefferson fractures, with some surgeons performing reduction and immobilization of the patient in a halo vest and others performing open reduction and internal fixation. This study compares the clinical and radiological outcome parameters between posterior atlantoaxial fusion (AAF) and occipitocervical fusion (OCF) constructs in the treatment of the unstable atlas fracture. MATERIALS AND METHODS: 68 consecutive patients with unstable Jefferson fractures treated by AAF or OCF between October 2004 and March 2011 were included in this retrospective evaluation from institutional databases. The authors reviewed medical records and original images. The patients were divided into two surgical groups treated with either AAF (n = 48, F/M 30:18) and OCF (n = 20, F/M 13:7) fusion. Blood loss, operative time, Japanese Orthopaedic Association (JOA) score, visual analog scale (VAS) score, atlanto-dens interval, lateral mass displacement, complications, and the bone fusion rates were recorded. RESULTS: Five patients with incomplete paralysis (7.4%) demonstrated postoperative improvement by more than 1 grade on the American Spinal Injury Association impairment scale. The JOA score of the AAF group improved from 12.5 ± 3.6 preoperatively to 15.7 ± 2.3 postoperatively, while the JOA score of the OCF group improved from 11.2 ± 3.3 preoperatively to 14.8 ± 4.2 postoperatively. The VAS score of AAF group decreased from 4.8 ± 1.5 preoperatively to 1.0 ± 0.4 postoperatively, the VAS score of the OCF group decreased from 5.4 ± 2.2 preoperatively to 1.3 ± 0.9 postoperatively. CONCLUSIONS: The OCF or AAF combined with short-term external immobilization can establish the upper cervical stability and prevent further spinal cord injury and nerve function damage.

Construction of Finite Element Model for an Artificial Atlanto-Odontoid Joint Replacement and Analysis of Its Biomechanical Properties.

AIM: To investigate the stress distribution on artificial atlantoaxial-odontoid joint (AAOJ) components during flexion, extension, lateral bending and rotation of AAOJ model constructed with the finite element (FE) method. MATERIAL AND METHODS: Human cadaver specimens of normal AAOJ were CT scanned with 1 mm -thickness and transferred into Mimics software to reconstruct the three-dimensional models of AAOJ. These data were imported into Freeform software to place a AAOJ into a atlantoaxial model. With Ansys software, a geometric model of AAOJ was built. Perpendicular downward pressure of 40 N was applied to simulate gravity of a skull, then 1.53 N• m torque was exerted separately to simulate the range of motion of the model. RESULTS: An FE model of atlantoaxial joint after AAOJ replacement was constructed with a total of 103 053 units and 26 324 nodes. In flexion, extension, right lateral bending and right rotation, the AAOJ displacement was 1.109 mm, 3.31 mm, 0.528 mm, and 9.678 mm, respectively, and the range of motion was 1.6°, 5.1°, 4.6° and 22°. CONCLUSION: During all ROM, stress distribution of atlas-axis changed after AAOJ replacement indicating that AAOJ can offload stress. The stress distribution in the AAOJ can be successfully analyzed with the FE method.

A comparative study on the accuracy of pedicle screw placement assisted by personalized rapid prototyping template between pre- and post-operation in patients with relatively normal mid-upper thoracic spine.

PURPOSE: The aim of this study was to assess the accuracy of rapid prototyping drill template technique for placing pedicle screws in the mid-upper thoracic vertebrae in clinics. METHODS: 151 consecutive patients underwent thoracic instrumentation and fusion for a total of 582 pedicle screws placed in the mid-upper thoracic vertebrae. Using computer software, the authors constructed drill templates that fit onto the posterior elements of the mid-upper thoracic vertebrae with drill guides designed to instrument the pedicles. The start point and three dimensional location of the planned and inserted screws were measured and compared. RESULTS: Grading of the CT scans revealed 559 (96.1 %) out of 582 screws completely within the desired pedicle. The direction of pedicle violation included 5 medial, 2 airball, and 16 lateral. The paired t test suggested that these results were statistically significant in more than half of the locations (T1-left-TA(P = 0.024), T2-left-SA(P = 0.031), T3-left-SA(P = 0.014), T4-left-TA(P = 0.004), T5-left-TA(P = 0.034), T7-left-TA(P = 0.000). T1-right-TA(P = 0.049), T2-right-TA(P = 0.044), T3-right-TA(P = 0.014), T5-right-TA(P = 0.013)). The paired t-test suggested that these results were statistically significant at several locations (T4-left-Δy(P = 0.041), T5-left-Δx(P = 0.016), T3-right-Δy(P = 0.015)). CONCLUSION: Use of a rapid prototyping drill template to assist in the placement of mid and upper thoracic pedicle screws may lead to increased accuracy. This patient specific technology must be combined with an understanding of the patients' anatomy and carefully secured to the posterior elements intraoperatively to avoid nerve or vascular complications.

Conservative and Operative Treatment in Extension Teardrop Fractures of the Axis.

STUDY DESIGN: A retrospective case series describing teardrop fracture of the axis. OBJECT: The purpose of the study was to clarify the clinical features, the mechanism of injury, and the potential instability of extension teardrop fractures of the axis, so as to emphasize the importance of recognizing this injury as a separate entity. SUMMARY OF BACKGROUND DATA: Teardrop fractures of the axis are rare spinal fractures, comprising only a small percentage of all injuries of the cervical spine. The stability of this fracture pattern has been a matter of debate leading to controversy regarding treatment strategies and the need for stabilization. METHODS: We retrospectively reviewed data collected from 16 patients to document the mechanism of injury, neurological deficit, treatment and clinical outcome, and imaging findings. RESULTS: Extension teardrop fractures accounted for approximately 8.9% of the upper cervical spinal injuries and 12.7% of axis fractures at the authors' institution over the same period. Six patients (4 males and 2 females) underwent surgery (4 by an anterior approach, 2 by a posterior approach). Ten cases underwent Halo-vest immobilization for a period between 6 and 12 weeks. At final follow-up, 14 cases achieved excellent results, whereas 2 patients complained of mild residual neck pain. Maximum cranial-caudal dimensions of the fragments were between 5 and 24 mm (average, 12.9 mm), and the transverse dimensions were between 5 and 22 mm (average, 11.1 mm). Fragment displacement ranged from 1 to 9 mm (average, 3.5 mm), whereas fragment rotation ranged from 10 to 52 degrees (average, 24.4 degrees) in the sagittal plane. CONCLUSIONS: Most patients with an extension teardrop fracture of the axis can be treated conservatively. On the basis of this case series, the authors suggest that large fragment size, displacement or angulation, intervertebral disk injury, neurologic deficit, or signs of instability are reasonable indications for surgical treatment.

A Novel Anterior Odontoid Screw Plate for C1-C3 Internal Fixation: An In Vitro Biomechanical Study.

STUDY DESIGN: A biomechanical in vitro study was performed using a standardized experimental protocol in a biomechanical spine testing apparatus. OBJECTIVE: The aims of this study were to evaluate the biomechanical stability afforded by 4 cervical fixation techniques: anterior cervical plate+odontoid screw+cage (ACP+OS+cage), anterior odontoid screw plate+bone graft (AOSP+bone graft), posterior C2-3 fixation+odontoid screw (C2PS+C3LMS+OS), and posterior C1-3 fixation (C1PS+C2PS+C3LMS). SUMMARY OF BACKGROUND DATA: Unstable axis injuries with multiple fracture lines are uncommon injuries, and their management is still challenging for surgeons who aim to achieve primary stability, early mobilization, preserved cervical range of motion (ROM), and favorable outcome. We designed a novel AOSP to assist in this challenging clinical scenario. METHODS: Eight fresh-frozen cadaveric spine specimens (C1-C3) were subjected to stepwise destabilization of the C1-3 complex, with serial replication of a type II Hangman fracture, a type II odontoid fracture, and a C2 to C3 disc injury. Intact specimens, destabilized specimens, and destabilized specimens with various stabilization techniques including anterior and posterior techniques, some using our AOSP, were each tested for stability. Each spine was subjected to flexion, and extension testing, left and right lateral bending, and left and right rotation. RESULTS: After AOSP+bone graft fixation, the ROMC2-C3 during all loading modes were reduced to values that were significantly less than normal. During all loading modes, AOSP+bone graft fixation significantly outperformed the ACP+OS+cage fixation in limiting ROMC2-C3. During flexion and extension, AOSP+bone graft fixation significantly outperformed the C1PS+C2PS+C3LMS fixation and C2PS+C3LMS+OS fixation in limiting ROMC2-C3. CONCLUSION: The AOSP has excellent biomechanical performance when dealing with type I Hangman fractures, type II odontoid fractures, and C2-3 disc injuries. The AOSP+one graft fixation can preserve the function of atlanto-axial joint, which may be a valuable stabilization strategy for these unique injuries.

An anatomic study to determine the optimal entry point, medial angles, and effective length for safe fixation using posterior C1 lateral mass screws.

STUDY DESIGN: Anatomic study of the C1 lateral mass using fine-cut computed tomographic scans and Mimics software. OBJECTIVE: To investigate the optimal entry point, medial angles, and effective length for safe fixation using posterior C1 lateral mass screws. SUMMARY OF BACKGROUND DATA: Placing posterior C1 lateral mass screws is technically demanding, and a misplaced screw can result in injury to the vertebral artery, spinal cord, or internal carotid artery. Although various insertion angles have been proposed for posterior C1 lateral mass screw, no clear consensus has been reached on the ideal medial angle of the C1 lateral mass. METHODS: The C1 lateral masses were evaluated using computed tomographic scans and Mimics software in 70 patients. The effective width and effective screw length of posterior C1 lateral mass screws were measured at different medial angulations relative to the midline sagittal plane. The height (H) for screw entry point on the posterior surface of C1 lateral mass and the distance (D) between screw entry point and the intersection of the midline sagittal plane and the posterior arch of the atlas were also measured. RESULTS: The mean height (H) for screw entry on the posterior surface of the lateral mass was 4.25 mm, the mean distance (D) between screw entry point and the intersection of the midsagittal plane and the posterior arch of the atlas was 27.62 mm. The optimal medial angle was 20.86° with a corresponding effective width of 10.56 mm and effective screw length of 21.87 mm. CONCLUSION: This study helps to define the specific anatomy related to C1 posterior lateral mass screw placement in an effort to facilitate instrumentation. However, variation is seen in lateral mass anatomy, and this study must be combined with customized surgical planning that includes advanced imaging for safe and effective instrumentation. LEVEL OF EVIDENCE: 1.

Deviation analysis of atlantoaxial pedicle screws assisted by a drill template.

Although C1-C2 pedicle screw fixation provides an excellent fusion rate and rigid fixation, this technique has a potential risk. It is essential to develop an accurate screwing method to avoid this neurovascular injury. To develop and validate the accuracy of a novel navigational template for C1-C2 pedicle screw placement in cadaveric specimens, computed tomography scans with 1-mm-wide cuts were obtained of 32 cadaveric cervical specimens. The authors developed 64 three-dimensional full-scale templates that were created by computer modeling with a rapid prototyping technique from the computed tomography data. Drill templates were constructed with a custom trajectory for each level and side. The drill templates were used to guide the establishment of a pilot hole for screw placement. The average distances between ideal and actual entry points of the C1 pedicle screws in the x, y, and z axes were 0.16±0.46 mm, 0.11±0.52 mm, and -0.01±0.54 mm, respectively, on the left side and 0.11±0.49 mm, 0.01±0.56 mm, and -0.09±0.59 mm, respectively, on the right side. The average distances between ideal and actual entry points of the C2 pedicle screws in the x, y, and z axes were 0.05±0.54 mm, 0.20±0.59 mm, and -0.06±0.58 mm, respectively, on the left side and 0.17±0.55 mm, 0.1±0.58 mm, and -0.01±0.49 mm, respectively, on the right side. Factors related to human error and imprecision are responsible for most malpositioning of instrumentation. The rapid prototyping drill template for C1-C2 screw placement is described to minimize human error, although it introduces error related to computer software and variation in manufacturing.

Unstable Jefferson fractures: Results of transoral osteosynthesis.

BACKGROUND: Majority of C1 fractures can be effectively treated conservatively by immobilization or traction unless there is an injury to the transverse ligament. Conservative treatment usually involves a long period of immobilization in a halo-vest. Surgical intervention generally involves fusion, eliminating the motion of the upper cervical spine. We describe the treatment of unstable Jefferson fractures designed to avoid these problems of both conservative and invasive methods. MATERIALS AND METHODS: A retrospective review of 12 patients with unstable Jefferson fractures treated with transoral osteosynthesis of C1 between July 2008 and December 2011 was performed. A steel plate and C1 lateral mass screw fixation were used to repair the unstable Jefferson fractures. Our study group included eight males and four females with an average age of 33 years (range 23-62 years). RESULTS: Patients were followed up for an average of 16 months after surgery. Range of motion of the cervical spine was by and large physiologic: Average flexion 35° (range 28-40°), average extension 42° (range 30-48°). Lateral bending to the right and left averaged 30° and 28° respectively (range 12-36° and 14-32° respectively). The average postoperative rotation of the atlantoaxial joint, evaluated by functional computed tomography scan was 60° (range 35-72°). Total average lateral displacement of the lateral masses was 7.0 mm before surgery (range 5-12 mm), which improved to 3.5 mm after surgery (range 1-6.5 mm). The total average difference of the atlanto-dens interval in flexion and extension after surgery was 1.0 mm (range 1-3 mm). CONCLUSIONS: Transoral osteosynthesis of the anterior ring using C1 lateral mass screws is a viable option for treating unstable Jefferson fractures, which allows maintenance of rotation at the C1-C2 joint and restoration of congruency of the atlanto-occipital and atlantoaxial joints.

Deviation analysis of C1-C2 transarticular screw placement assisted by a novel rapid prototyping drill template: a cadaveric study.

STUDY DESIGN: Cadaveric study. OBJECTIVE: The aim of this study was to develop and validate the accuracy of a novel navigational template for C1-C2 transarticular screw (C1C2TAS) placement in cadaveric specimens. SUMMARY OF BACKGROUND DATA: Currently, C1C2TASs are primarily positioned using a free-hand technique or under fluoroscopic guidance. Screw placement is challenging owing to the small size of the C2 isthmus, which places technical demands on the surgeon. Screw insertion carries a potential risk of neurovascular injury, magnifying the importance of using a precise technique for screw insertion. MATERIALS AND METHODS: Computed tomography (CT) scans with 0.625-mm wide cuts were obtained from the 32 cadaveric cervical specimens. The CT data were imported into a computer navigation system. We developed 32 three-dimensional drill templates, which were created by computer modeling using a rapid prototyping technique based on the CT data. We constructed drill templates using a custom trajectory for each level and side based on specimen anatomy. The drill templates were used to guide establishment of a pilot hole for screw placement. The entry point and angular direction of the intended screw positions and inserted screw positions were measured by comparing postoperative and preoperative images after the coordinate axes were synchronized. RESULTS: The average displacement of the entry point of the left and right C1C2TAS in the x-, y-, and z-axis was 0.13±0.90 mm, 0.50±1.50 mm, and -0.22±0.71 mm on the left, and 0.21±1.03 mm, 0.46±1.55 mm, and -0.29±0.58 mm on the right. There was no statistically significant difference in entry point and direction between the intended and actual screw trajectory. CONCLUSIONS: The small deviations seen are likely due to human error in the form of small variations in the surgical technique and use of software to design the prototype. This technology improves the safety profile of this fixation technique and should be further studied in clinical applications.

Function-preserving reduction and fixation of unstable Jefferson fractures using a C1 posterior limited construct.

STUDY DESIGN: This is a retrospective, clinical, and radiologic study of posterior reduction and fusion of the C1 arch in the treatment of unstable Jefferson fractures. OBJECTIVE: The aim of the study was to describe a new motion-preserving surgical technique in the treatment of unstable Jefferson fracture. SUMMARY OF BACKGROUND DATA: The management of unstable Jefferson fractures remains controversial. The majority of C1 fractures can be effectively treated nonoperatively with external immobilization unless there is an injury to the transverse atlantal ligament (TAL). Conservative treatment usually involves immobilization for a long time in Halo vest, whereas surgical intervention generally involves C1-C2 fusion, eliminating the range of motion of the upper cervical spine. We propose a novel method for the treatment of unstable Jefferson fractures without restricting the range of motion. METHODS: A retrospective review of 12 patients with unstable C1 fractures between April 2008 and October 2011 was performed. They were treated by inserting bilateral posterior C1 pedicle screws or lateral mass screws interconnected by a transversal rod to achieve internal fixation. There were 8 men and 4 women, with an average age of 35.6 years (range, 20-60 y). Presenting symptoms included neck pain, stiffness, and decreased range of motion but none had neurological injury. Seven patients had bilateral posterior arch fractures associated with unilateral anterior arch fractures (posterior 3/4 Jefferson fracture, Landells type II), and 5 had unilateral anterior and posterior arch fractures (half-ring Jefferson fracture, Landells type II). Seven patients had intact TAL, and 5 patients had fractures and avulsion of the attachment of TAL (Dickman type II). RESULTS: A total of 24 screws were inserted. Five cases had screws placed in the lateral mass: 3 because of posterior arch breakage, and 2 because the height of the posterior arch at the entry point was <4 mm. The remaining 7 cases had pedicle screw fixation. One patient had venous plexus injury during exposure of lower margin of the posterior arch; however, successful hemostasis was achieved with Gelfoam. Postoperative x-ray and computed tomography scan showed partial breach of the transverse foramen caused by a screw in 1 case, and breach of the inner cortex of the pedicle caused by screw displacement in 1 case; however, no spinal cord injury or vertebral artery injury was found. The remaining screws were in good position. Patients were followed up for 6-40 months (average, 22 mo). All cases had recovery of range of motion of the cervical spine to the preinjury level by 3-6 months after surgery, with resolution of pain. At 6 months follow-up, plain radiographs and computed tomography scans revealed satisfactory cervical alignment, no implant failure, and satisfactory bony fusion of the fractures; no C1-C2 instability was observed on the flexion-extension radiographs. CONCLUSIONS: C1 posterior limited construct is a valid technique and a feasible method for treating unstable Jefferson fractures, which allows preservation of the function of the craniocervical junction, without significant morbidity.