Skip to main content
Download PDF
  • Technical note
  • Open access
  • Published:

Percutaneous anterior C1/2 transarticular screw fixation: salvage of failed percutaneous odontoid screw fixation for odontoid fracture

Journal of Orthopaedic Surgery and Research volume 12, Article number: 141 (2017) Cite this article

Abstract

Background

The objective of this study is to investigate the outcomes and safety of using percutaneous anterior C1/2 transarticular screw fixation as a salvage technique for odontoid fracture if percutaneous odontoid screw fixation fails.

Methods

Fifteen in 108 odontoid fracture patients (planned to be treated by percutaneous anterior odontoid screw fixation) were failed to introduce satisfactory odontoid screw trajectory. To salvage this problem, we chose the percutaneous anterior C1/2 transarticular screw fixation technique in treatment of these patients. The visual analogue score (VAS) of neck pain and Neck Disability Index (NDI) of all patients were scored at pre-operation, 3 months after operation, and final follow-up. Additional, technique-related complications were recorded and collected.

Results

Percutaneous C1/2 transarticular screw fixation was performed successfully in all 15 patients whose odontoid screw fixation failed. No technique-related complications (such as nerve injury, spinal cord injury, and esophageal injury) occurred. The VAS of neck pain and NDI score improved significantly (P = 0.000) after operation, and no significant differences were found when compared to 93 non-salvage patients who successfully performed the percutaneous anterior odontoid screw fixation. No screw loose or breakage occurred, all of the odontoid fractures achieve radiographic fusion, bony fusion bridge could be observed at the C1/2 lateral articular facet on 9/15 patients.

Conclusions

We suggest that percutaneous anterior C1/2 transarticular screw fixation is a good alternative salvage technique if percutaneous odontoid screw fixation failed, and it is a minimally invasive, feasible, and safe technique.

Background

Odontoid fractures are not uncommon injury, accounting for 9–18% of cervical spine fractures [1, 2], especially in elderly patients. Although the conservative methods were well described in treatment of odontoid fractures, type II fractures and shallow type III odontoid fractures [3] (according to the classification of Anderson and D’Alonzo) were recognized mechanically unstable with a high risk of nonunion or mortality [4, 5], and surgical stabilization was recommended [2, 6].

Many posterior surgical techniques were reported in previous literatures [7,8,9], including Gallie’s C1/2 wiring [10] and Magerl’s posterior C1/2 transarticular screw fixation and posterior C1 lateral mass + C2 pedicle screw fixation [11, 12]; however, these posterior techniques were performed via an open surgical approach, with disadvantages of considerable tissue trauma, blood loss, higher risk of vertebral arteries injury, and some other risks of pneumonia, acute respiratory distress syndrome, and decubitus ulcer [13]. Anterior odontoid screw fixation was first described by Bohler in 1980s [14], proved anatomic feasibility [15], and could preserve the C1/2 rotation and provide adequate stability [16, 17]. Furthermore, anterior odontoid screw fixation could be introduced percutaneously [18,19,20], with only about 10 mm skin wound, and have the advantages of being minimally invasive, having less blood loss, having shorter skin scar, and having quicker post-operative recovery.

However, anterior odontoid screw fixation is not suitable for all patients. In Grauer type IIC fracture [21], which is extending from anterior-inferior to posterior-superior or with significant comminution, the bone of C2 body for screw anchor is too small to introduce the odontoid screw [22, 23]. Sometimes, the trajectory of odontoid screw cannot be determined satisfactorily [24], such as the case reported by Salem et al. [25] that the fracture position was unacceptable, and other surgical techniques need to be considered [25, 26].

Materials and methods

Patient population

Between June 2006 and August 2012, 15 (male, 12 cases; female, 3 cases) in 108 odontoid fracture patients (planned to be treated by percutaneous anterior odontoid screw fixation) were failed to introduce satisfactory odontoid screw trajectory. To salvage this problem, we performed percutaneous anterior C1/2 transarticular screw fixation in treatment of these 15 patients. Eleven cases were type II odontoid fractures and four were shallow type III fractures according to the Anderson and D’Alonzo classification system [3], and three cases were type II B, eight cases were type II C according to Grauer classification [21]. The average age of included patients was 51.8 years (range from 32 to 73 years). The details of the included 15 patients compared to the 93 non-salvage patients who successful performed the percutaneous anterior odontoid screw fixation were showed in Table 1. Pre-operative AP (anteroposterior open mouth) and lateral views and computed tomography (CT) scans were obtained to evaluate the type of the injury and upper cervical spinal anatomy of the individual patient.

Table 1 The details of the included patients
Full size table

Ethic consideration

This study was approved by the IRB (Institutional Review Board) of the Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, and informed consent was obtained from every participant.

Operative procedure

We try to perform the percutaneous anterior odontoid screw fixation on all of 108 patients: firstly, the procedure of percutaneous anterior odontoid screw fixation was described by Chi et al. [18]. Briefly, the patient was placed supine on the operative table, and the head was pulled with Gardner-Wells skull tongs to achieve anatomic reduction of the odontoid fracture. After the clear intra-operative AP (open mouth) and lateral films were obtained, an initial 10-mm skin incision was made medial to the right sternocleidomastoid muscle at the level of C4–5, blunt dissection was performed via Smith-Robinson approach to reach the anteroinferior border of C2 body using the finger or hemostat.

Then, the protective tube (inner diameter = 6.1 mm, outer diameter = 7.0 mm) was inserted and the guide tube (inner diameter = 1.3 mm, outer diameter = 6.0 mm) was inserted inside of the protective tube, and the guide tube was placed to the anteroinferior of C2 body; a K-wire with a 1.2-mm diameter was drilled into the odontoid process. However, in the 15 patients included in present report, the trajectory of the K-wire was placed unsatisfactorily (Fig. 1a, b); if we continue to perform percutaneous anterior odontoid screw fixation, the screw will penetrate the cortex of the odontoid process and have a higher risk of injury around the soft tissue or spinal cord or cannot provide a stiff fixation. Worse, if we try to re-drill another optimal K-wire trajectory, the initial hole will be entered inadvertently.

Fig. 1
figure 1

The intra-operative images. a, b Percutaneous anterior odontoid screw fixation was tried to perform first, but the trajectory of the K-wire was placed unsatisfactorily. c, d To solve the problem, percutaneous C1/2 transarticular screw fixation was performed; two 3.5-mm self-tapping cannulated transarticular screws were introduced via the previous skin wound for percutaneous anterior odontoid screw fixation

Full size image

The percutaneous anterior odontoid screw fixation was defined failure at this time, we performed percutaneous C1/2 transarticular screw fixation on them as salvage technique. The procedure of percutaneous C1/2 transarticular screw fixation was referred to Li et al. [27]. No more skin wound was made, and only the tip of the guide tube was moved to about 5–10 mm lateral side of the mid-line anteroinferior C2 body on AP film. The angle of the K-wire was deemed to be about 20–30° to the mid-line on AP film and 20–28° to the vertical on the lateral view and drilled into C2 body, toward to the center of C1 lateral mass (Fig. 1c). Once the K-wire was placed on a satisfactory position, the guide tube will be removed, a recess for the screw head was fashioned, and a 3.5-mm self-tapping cannulated screw is then introduced over the K-wire. After the transarticular screw was well positioned, the K-wire was removed, and the same procedure was performed at the opposite site (Fig. 1d).

The patients were allowed ambulatory activities at day 2 after operation with a cervical collar, which was removed at 12 weeks after surgery.

Pain and functional assessment

Visual Analogue Score (VAS) of neck pain and Neck Disability Index (NDI) scores were obtained at the time points of pre-operation, 3 months after operation, and final follow-up.

Fusion assessment

CT scans were obtained at the final follow-up to assess the fusion of odontoid fractures and bony fusion bridge at the C1/2 lateral articular facet.

Statistics

The data were collected and analyzed with the software of SPSS (version 17.0, SPSS Inc., Chicago, IL). The data of pre-operation, 3 months after operation, and final follow-up were tested by the repeated measures analysis of variance (ANOVA), The comparisons of VAS of neck pain and NDI scores between two groups were tested by independent two-sampled t test. The level of significance was set at P < 0.05.

Results

Percutaneous C1/2 transarticular screw fixation was performed successfully in all 15 patients whose odontoid screw fixations failed. The mean operative time was 53 ± 15 min, which was 12 min more than the time cost in the 93 non-salvage patients whom were successfully performed the percutaneous anterior odontoid screw fixation (Table 1), and none of the patient had blood loss exceeding 20 ml. No technique-related complications (such as nerve injury, spinal cord injury, esophageal injury, and other around soft tissue injure) occurred. All of the 15 patients were followed up for an average of 30.5 months (range from 24 to 49 months); no screw loose or breakage was occurred, all of the odontoid fractures achieve radiographic fusion, and bony fusion bridge could be observed at the C1/2 lateral articular facet on 9/15 patients.

Pain and functional outcomes

For all the included 15 salvage patients, VAS of neck pain was relieved significantly from 5.93 ± 1.20 at pre-operation to 1.38 ± 0.63 at 3 months after operation (P = 0.000) and maintained at the final follow-up, with 1.29 ± 0.55 (P = 0.420). Similar pain relief was achieved at the 93 non-salvage patients, with 6.29 ± 1.44 at pre-operation to 1.44 ± 1.01 at 3 months after operation (P = 0.000), and maintained at the final follow-up, with 1.36 ± 0.91 (P = 0.451). When compared between the 15 salvage patients and 93 non-salvage patients, no statistically significant difference was found at pre-operation (P = 0.363), 3 months after operation (P = 0.804), and final follow-up (P = 0.738) (Table 2).

Table 2 The pain and functional outcomes of the included 15 patients
Full size table

The NDI scores was improved significantly from 34.5 ± 4.94 at pre-operation to 3.73 ± 2.25 at 3 months after operation (P = 0.000) and maintained at the final follow-up, with 3.13 ± 2.95 (P = 0.369) in the 15 salvage patients. And similarly, NDI improved from 35.35 ± 5.89 at pre-operation to 4.20 ± 2.90 at 3 months after operation (P = 0.000) and maintained at the final follow-up, with 4.42 ± 2.80 (P = 0.494) in the 93 non-salvage patients. No statistically significant difference was found at pre-operation (P = 0.610), 3 months after operation (P = 0.550), and final follow-up (P = 0.104) (Table 2).

Case presentation 1

A 73-year-old man presented to the emergency department after a fall from about 2 m high place, complaining of neck pain and right limb numbness. The pre-operative 2D CT images (Fig. 2a, b) showed type II odontoid fracture, and we plan to treat him with percutaneous anterior odontoid screw fixation; however, the K-wire trajectory was unsatisfactory, and at last, percutaneous C1/2 transarticular screw fixation was performed on him (Fig. 2c, d). The neck pain was immediately relieved after operation, and right limb numbness disappeared at about 2 weeks after operation. Thirty-eight months after operation, no screw loose or breakage was observed (Fig. 2e, f), radiographic bony fusion was observed at odontoid fracture site, and bony fusion bridge was observed at the C1/2 lateral articular facet (Fig. 2g, arrow), with only about 10 mm skin scar (Fig. 2h, arrow).

Fig. 2
figure 2

a, b The pre-operative 2D CT images of a 73-year-old man showed type II odontoid fracture. c, d Percutaneous anterior odontoid screw fixation was failed on him, and percutaneous C1/2 transarticular screw fixation was performed as salvage technique. e, f Thirty-eight months after operation, no screw loose or breakage was observed. g, h Radiographic bony fusion was observed at odontoid fracture site, and bony fusion bridge was observed at the C1/2 lateral articular facet (g, arrow), with only about 10-mm skin scar (h, arrow)

Full size image

Case presentation 2

A 57-year-old man was sent to the emergency department after a vehicle accident and experienced neck pain and both hands’ numbness. The pre-operative 2D CT images (Fig. 3a, b) showed type II odontoid fracture. We planned to treat him with percutaneous anterior odontoid screw fixation too but failed, and percutaneous C1/2 transarticular screw fixation was performed on him as salvage technique (Fig. 3c, d). The neck pain was immediately relieved after operation, and hand numbness disappeared at about 4 weeks after operation. Thirty-one months after operation, no screw loose or breakage was observed (Fig. 2e, f), radiographic bony fusion was observed at the odontoid fracture site (Fig. 3f, g), and bony fusion bridge was also observed at the C1/2 lateral articular facet (Fig. 3f, g, arrow), with only about 10 mm skin scar too (Fig. 3h, arrow).

Fig. 3
figure 3

a, b The pre-operative 2D CT images of a 57-year-old man showed type II odontoid fracture. c, d Percutaneous anterior odontoid screw fixation failed, and percutaneous C1/2 transarticular screw fixation was performed on him as salvage technique. e Thirty-one months after operation, no screw loose or breakage was observed. f, g Bony fusion was observed at the odontoid fracture site, and bony fusion bridge was also observed at the C1/2 lateral articular facet on 2D CT images (g, Arrow); h only about 10 mm skin scar at his neck (arrow)

Full size image

Discussion

The odontoid fracture remains a challenging injury in spine injury because of the high risk of potential complications owing to the complex cranio-cervical anatomy. Many conservative treatments including halo vests and cervical orthosis were reported [28, 29]. However, the Anderson and D’Alonzo type II fractures and shallow type III odontoid fractures [3] were recognized as mechanically unstable with a high risk of nonunion and mortality [4, 30, 31], and surgical intervention was recommended [32,33,34].

In 1982, Bohler [14] described using the anterior odontoid screw fixation in treatment of odontoid fracture, and this technique was widely used after then and could preserve the C1/2 rotational movement, with easier patient position, less tissue trauma (because of the natural gap of the Simth-Robinson approach), and high fusion rates [23, 35,36,37]. Hashizume et al. [38] reported that using endoscopic system to minimize the anterior skin wound avoid soft tissue injury, Kazan et al. [39] described the technique details of percutaneous anterior odontoid screw fixation on cadaveric specimen, and Chi et al. [18] and Wang et al. [19] reported the results of clinical investigation of percutaneous anterior odontoid screw fixation for odontoid fractures, found that percutaneous technique had the advantages of being minimally invasive, minimizing blood loss, having shorter skin wound, and having quick recovery.

However, the anterior odontoid screw fixation is not suitable for all types of odontoid fractures and is not always applied successfully in all odontoid fracture patients. Salem et al. [25] reported a healthy 66-year-old male who suffers odontoid fracture after falling off a bicycle, and they performed anterior odontoid screw fixation on him first; however, the initial odontoid screw failed to maintain the interfragmentary compression achieved intra-operatively, and therefore, they did anterior C1/2 transarticular screw fixation as revision procedure on him. Ni et al. reported [26] using posterior reduction and temporary fixation as salvage maneuver to anterior screw fixation for 22 odontoid fractures patients, which they felt that the anterior odontoid screw fixation was hard or could not performed. In this study, 15 in 108 patients failed to percutaneous anterior odontoid screw fixation, we did not choose the posterior approach and only use two anterior C1/2 transarticular screws to stabilize the atlantoaxial joint.

Anterior C1/2 transarticular screw fixation was firstly reported for patients with atlantoaxial instability in 1971 by Barbour [40]. And Lu et al. [41] studied the anatomic parameters of anterior C1/2 transarticular screw fixation on 30 dried human cervical spines and proved the feasibility of anterior C1/2 transarticular screw fixation. Compared to the posterior C1/2 transarticular screw fixation (Magerl technique), anterior C1/2 transarticular screw fixation had less risk of vertebral artery injury [42]. And Elgafy et al. [43] reported that about 10–23% of patients who required atlantoaxial arthrodesis were not suitable for posterior Magerl technique because of anatomic variations of the vertebral artery; in the study of Lau et al. [44], the rate of patients with anatomic variations that are not suitable for posterior Magerl technique was approximately 40, and anterior C1/2 transarticular screw fixation was safer for them. Moreover, the human cadaveric biomechanical study showed that the anterior C1/2 transarticular screw fixation had comparable biomechanical properties to the posterior C1/2 transarticular screw fixation [45, 46].

Additionally, the 15 patients in this study were planned to be treated by anterior odontoid screw fixation, the patients were already placed supine on an operative table, and an about 10-mm anterior skin wound was already made but percutaneous anterior odontoid screw fixation fails. If we chose a posterior approach as the salvage technique, we need to change the patient’s position and make a longer posterior skin wound. And in this study, we found that the change to percutaneous anterior C1/2 transarticular screws only adds a mean 12-min operative time. There is no need to change the patients’ position and add posterior wound incision. Therefore, we suggest that salvage of percutaneous anterior odontoid screw fixation through percutaneous anterior C1/2 transarticular screw fixation had many advantages: (1) avoid changing patient’s position; (2) avoid other more skin wound; (3) the minimally invasive was similar to the percutaneous anterior odontoid screw fixation only one 10-mm skin wound; (4) good results with a high fusion rate, 15/15 (100%) odontoid fusion, some of the patients with bony fusion bridge observed at the C1/2 lateral articular facet, for some other patients without the obvious bony fusion bridge at the C1/2 lateral articular facet, no screw breakage occurred, and space of the C1/2 lateral articular facet was decreased and tend to grow the bony bridge.

Same to some other minimally invasive spinal surgical technique, the percutaneous anterior C1/2 transarticular screw fixation had its limitations. Firstly, the group size is small, because all of the 15 salvage patients are failure of anterior odontoid screw fixation; secondly, the learning curve of this technique was longer than the traditional surgical technique; thirdly, this technique had the potential risk to injure the anterior soft tissue (carotid artery, esophagus, and trachea), and our experience was that the tip of the guide tube must be pressed tightly to the front of the C2 body to avoid allowing the soft tissue to enter the space between the tip of guide tube and C2 vertebral body.

Conclusion

Percutaneous anterior C1/2 transarticular screw fixation is a good alternative salvage technique if the percutaneous odontoid screw fixation is failure for odontoid fracture. And it is a minimally invasive, feasible, and safe technique.

Abbreviations

C1/2:

The first cervical spine/the second cervical spine

VAS:

Visual Analogue Score

NDI:

Neck Disability Index

ASIA:

American Spinal Injury Association

CT:

Computed tomography

References

  1. Maak TG, Grauer JN. The contemporary treatment of odontoid injuries. Spine (Phila Pa 1976). 2006;31(11 Suppl):S53–60. discussion S61

    Article  Google Scholar 

  2. Huybregts JG, Jacobs WC, Vleggeert-Lankamp CL. The optimal treatment of type II and III odontoid fractures in the elderly: a systematic review. Eur Spine J. 2013;22(1):1–13.

    Article  PubMed  Google Scholar 

  3. Anderson LD, D'Alonzo RT. Fractures of the odontoid process of the axis. J Bone Joint Surg Am. 1974;56(8):1663–74.

    Article  CAS  PubMed  Google Scholar 

  4. Chapman J, Smith JS, Kopjar B, Vaccaro AR, Arnold P, Shaffrey CI, Fehlings MG. The AOSpine North America Geriatric Odontoid Fracture Mortality Study: a retrospective review of mortality outcomes for operative versus nonoperative treatment of 322 patients with long-term follow-up. Spine (Phila Pa 1976). 2013;38(13):1098–104.

    Article  Google Scholar 

  5. Smith JS, Kepler CK, Kopjar B, Harrop JS, Arnold P, Chapman JR, Fehlings MG, Vaccaro AR, Shaffrey CI. Effect of type II odontoid fracture nonunion on outcome among elderly patients treated without surgery: based on the AOSpine North America geriatric odontoid fracture study. Spine (Phila Pa 1976). 2013;38(26):2240–6.

    Google Scholar 

  6. Wang L, Liu C, Zhao QH, Tian JW. Outcomes of surgery for unstable odontoid fractures combined with instability of adjacent segments. J Orthop Surg Res. 2014;9:64.

    Article  PubMed  PubMed Central  Google Scholar 

  7. Bisson EF, Mumert ML, Mazur MD, Dailey AT, Schmidt MH. The fate of type II odontoid fractures after posterior atlantoaxial fusion: where does healing occur? J Neurol Surg A Cent Eur Neurosurg. 2015;76(4):274–8.

    Article  PubMed  Google Scholar 

  8. Fiore AJ, Haid RW, Rodts GE, Subach BR, Mummaneni PV, Riedel CJ, Birch BD. Atlantal lateral mass screws for posterior spinal reconstruction: technical note and case series. Neurosurg Focus. 2002;12(1):E5.

    Article  PubMed  Google Scholar 

  9. Smith HE, Vaccaro AR, Maltenfort M, Albert TJ, Hilibrand AS, Anderson DG, Harrop J, Fehlings MG, Kopjar B, Brodke DS, et al. Trends in surgical management for type II odontoid fracture: 20 years of experience at a regional spinal cord injury center. Orthopedics. 2008;31(7):650.

    PubMed  Google Scholar 

  10. Gallie WE. Skeletal traction in the treatment of fractures and dislocations of the cervical spine. Ann Surg. 1937;106(4):770–6.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  11. Mummaneni PV, Lu DC, Dhall SS, Mummaneni VP, Chou D. C1 lateral mass fixation: a comparison of constructs. Neurosurgery. 2010;66(3 Suppl):153–60.

    Article  PubMed  Google Scholar 

  12. Wang L, Liu C, Zhao Q, Tian J. Posterior pedicle screw fixation for complex atlantoaxial fractures with atlanto-dental interval of ≥5 mm or C2-C3 angulation of ≥11 degrees. J Orthop Surg Res. 2014;9:104.

    Article  PubMed  PubMed Central  Google Scholar 

  13. Winkler EA, Yue JK, Burke JF, Mummaneni PV, Manley GT, Tarapore PE, Dhall SS. 188 morbidity and mortality associated with operative management of traumatic C2 fractures in octogenarians. Neurosurgery. 2016;63(Suppl 1):174–5.

    Article  PubMed  Google Scholar 

  14. Bohler J. Anterior stabilization for acute fractures and non-unions of the dens. J Bone Joint Surg Am. 1982;64(1):18–27.

    Article  CAS  PubMed  Google Scholar 

  15. Puchwein P, Jester B, Freytag B, Tanzer K, Maizen C, Gumpert R, Pichler W. The three-dimensional morphometry of the odontoid peg and its impact on ventral screw osteosynthesis. Bone Joint J. 2013;95-B(4):536–42.

    Article  CAS  PubMed  Google Scholar 

  16. Sasso R, Doherty BJ, Crawford MJ, Heggeness MH. Biomechanics of odontoid fracture fixation. Comparison of the one- and two-screw technique. Spine (Phila Pa 1976). 1993;18(14):1950–3.

    Article  CAS  Google Scholar 

  17. McBride AD, Mukherjee DP, Kruse RN, Albright JA. Anterior screw fixation of type II odontoid fractures. A biomechanical study. Spine (Phila Pa 1976). 1995;20(17):1855–9. discussion 1859-1860

    Article  CAS  Google Scholar 

  18. Chi YL, Wang XY, Xu HZ, Lin Y, Huang QS, Mao FM, Ni WF, Wang S, Dai LY. Management of odontoid fractures with percutaneous anterior odontoid screw fixation. Eur Spine J. 2007;16(8):1157–64.

    Article  PubMed  PubMed Central  Google Scholar 

  19. Wang J, Zhou Y, Zhang ZF, Li CQ, Zheng WJ, Liu J. Comparison of percutaneous and open anterior screw fixation in the treatment of type II and rostral type III odontoid fractures. Spine (Phila Pa 1976). 2011;36(18):1459–63.

    Article  Google Scholar 

  20. Wu AM, Wang XY, Chi YL, Xu HZ, Weng W, Huang QS, Ni WF. Management of acute combination atlas-axis fractures with percutaneous triple anterior screw fixation in elderly patients. Orthop Traumatol Surg Res. 2012;98(8):894–9.

    Article  CAS  PubMed  Google Scholar 

  21. Grauer JN, Shafi B, Hilibrand AS, Harrop JS, Kwon BK, Beiner JM, Albert TJ, Fehlings MG, Vaccaro AR. Proposal of a modified, treatment-oriented classification of odontoid fractures. Spine J. 2005;5(2):123–9.

    Article  PubMed  Google Scholar 

  22. Mazur MD, Mumert ML, Bisson EF, Schmidt MH. Avoiding pitfalls in anterior screw fixation for type II odontoid fractures. Neurosurg Focus. 2011;31(4):E7.

    Article  PubMed  Google Scholar 

  23. Aebi M, Etter C, Coscia M. Fractures of the odontoid process. Treatment with anterior screw fixation. Spine (Phila Pa 1976). 1989;14(10):1065–70.

    Article  CAS  Google Scholar 

  24. Wu AM, Wang XY, Xia DD, Luo P, Xu HZ, Chi YL. A novel technique of two-hole guide tube for percutaneous anterior odontoid screw fixation. Spine J. 2015;15(5):1141–5.

  25. Salem KM, Collins I, Boszczyk BM. Salvage of failed odontoid fixation through anterior C1/C2 transarticular screws. Eur Spine J. 2015;24(3):609–14.

    Article  CAS  PubMed  Google Scholar 

  26. Ni B, Guo Q, Lu X, Xie N, Wang L, Guo X, Chen F. Posterior reduction and temporary fixation for odontoid fracture: a salvage maneuver to anterior screw fixation. Spine (Phila Pa 1976). 2015;40(3):E168–74.

    Article  Google Scholar 

  27. Li WL, Chi YL, Xu HZ, Wang XY, Lin Y, Huang QS, Mao FM. Percutaneous anterior transarticular screw fixation for atlantoaxial instability: a case series. J Bone Joint Surg Br. 2010;92(4):545–9.

    Article  PubMed  Google Scholar 

  28. Lind B, Sihlbom H, Nordwall A. Halo-vest treatment of unstable traumatic cervical spine injuries. Spine (Phila Pa 1976). 1988;13(4):425–32.

    Article  CAS  Google Scholar 

  29. Schweigel JF. Management of the fractured odontoid with halo-thoracic bracing. Spine (Phila Pa 1976). 1987;12(9):838–9.

    Article  CAS  Google Scholar 

  30. Lewis E, Liew S, Dowrick A. Risk factors for non-union in the non-operative management of type II dens fractures. ANZ J Surg. 2011;81(9):604–7.

    Article  PubMed  Google Scholar 

  31. Koivikko MP, Kiuru MJ, Koskinen SK, Myllynen P, Santavirta S, Kivisaari L. Factors associated with nonunion in conservatively-treated type-II fractures of the odontoid process. J Bone Joint Surg Br. 2004;86(8):1146–51.

    Article  CAS  PubMed  Google Scholar 

  32. Kim DH, Vaccaro AR, Affonso J, Jenis L, Hilibrand AS, Albert TJ. Early predictive value of supine and upright X-ray films of odontoid fractures treated with halo-vest immobilization. Spine J. 2008;8(4):612–8.

    Article  PubMed  Google Scholar 

  33. Coyne TJ, Fehlings MG, Wallace MC, Bernstein M, Tator CH. C1-C2 posterior cervical fusion: long-term evaluation of results and efficacy. Neurosurgery. 1995;37(4):688–92. discussion 692-683

    Article  CAS  PubMed  Google Scholar 

  34. Fujii E, Kobayashi K, Hirabayashi K. Treatment in fractures of the odontoid process. Spine (Phila Pa 1976). 1988;13(6):604–9.

    Article  CAS  Google Scholar 

  35. ElSaghir H, Bohm H. Anderson type II fracture of the odontoid process: results of anterior screw fixation. J Spinal Disord. 2000;13(6):527–30. discussion 531

    Article  CAS  PubMed  Google Scholar 

  36. Fountas KN, Kapsalaki EZ, Karampelas I, Feltes CH, Dimopoulos VG, Machinis TG, Nikolakakos LG, Boev AN 3rd, Choudhri H, Smisson HF, et al. Results of long-term follow-up in patients undergoing anterior screw fixation for type II and rostral type III odontoid fractures. Spine (Phila Pa 1976). 2005;30(6):661–9.

    Article  Google Scholar 

  37. Apfelbaum RI, Lonser RR, Veres R, Casey A. Direct anterior screw fixation for recent and remote odontoid fractures. J Neurosurg. 2000;93(2 Suppl):227–36.

    CAS  PubMed  Google Scholar 

  38. Hashizume H, Kawakami M, Kawai M, Tamaki T. A clinical case of endoscopically assisted anterior screw fixation for the type II odontoid fracture. Spine (Phila Pa 1976). 2003;28(5):E102–5.

    Google Scholar 

  39. Kazan S, Tuncer R, Sindel M. Percutaneous anterior odontoid screw fixation technique. A new instrument and a cadaveric study. Acta Neurochir. 1999;141(5):521–4.

    Article  CAS  PubMed  Google Scholar 

  40. Barbour J. Screw fixation in fracture of the odontoid process. S Aust Clinics. 1971;5:20–4.

    Google Scholar 

  41. Lu J, Ebraheim NA, Yang H, Heck BE, Yeasting RA. Anatomic considerations of anterior transarticular screw fixation for atlantoaxial instability. Spine (Phila Pa 1976). 1998;23(11):1229–35. discussion 1236

    Article  CAS  Google Scholar 

  42. Xu H, Chi YL, Wang XY, Dou HC, Wang S, Huang YX, Xu HZ. Comparison of the anatomic risk for vertebral artery injury associated with percutaneous atlantoaxial anterior and posterior transarticular screws. Spine J. 2012;12(8):656–62.

    Article  PubMed  Google Scholar 

  43. Elgafy H, Potluri T, Goel VK, Foster S, Faizan A, Kulkarni N. Biomechanical analysis comparing three C1-C2 transarticular screw salvaging fixation techniques. Spine (Phila Pa 1976). 2010;35(4):378–85.

    Article  Google Scholar 

  44. Lau SW, Sun LK, Lai R, Luk MS, Ng YS, Wong NM, Lau PY. Study of the anatomical variations of vertebral artery in C2 vertebra with magnetic resonance imaging and its application in the C1-C2 transarticular screw fixation. Spine (Phila Pa 1976). 2010;35(11):1136–43.

    Article  Google Scholar 

  45. Sen MK, Steffen T, Beckman L, Tsantrizos A, Reindl R, Aebi M. Atlantoaxial fusion using anterior transarticular screw fixation of C1-C2: technical innovation and biomechanical study. Eur Spine J. 2005;14(5):512–8.

    Article  PubMed  PubMed Central  Google Scholar 

  46. Lapsiwala SB, Anderson PA, Oza A, Resnick DK. Biomechanical comparison of four C1 to C2 rigid fixative techniques: anterior transarticular, posterior transarticular, C1 to C2 pedicle, and C1 to C2 intralaminar screws. Neurosurgery. 2006;58(3):516–21. discussion 516-521

    Article  PubMed  Google Scholar 

Download references

Acknowledgements

Not applicable.

Funding

This work was supported by the National Natural Science Foundation of China (81372014, 81501933, 81572214), Wenzhou Municipal Science and Technology Bureau (Y20170389), Wenzhou leading talent innovative project (RX2016004), Zhejiang Provincial Natural Science Foundation of China (LY14H060008), and Zhejiang Provincial Medical Technology Foundation of China (2018254309, 2015111494). The funders had no role in the design, execution, and writing up of the study.

Availability of data and materials

Not applicable.

Author information

Authors and Affiliations

  1. Department of Spine Surgery, Zhejiang Spine Surgery Center, Orthopaedic Hospital, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, 109# XueYuan Western Road, Wenzhou, Zhejiang, 325027, China

    Ai-Min Wu, Hai-Ming Jin, Zhong-Ke Lin, Yong-Long Chi & Xiang-Yang Wang

Authors
  1. Ai-Min Wu
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Hai-Ming Jin
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Zhong-Ke Lin
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Yong-Long Chi
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Xiang-Yang Wang
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

AMW, YLC, and XYW designed the study. AMW, HMJ, and XYW performed the experiments. ZKL and HMJ performed the statistical analysis and interpreted the results. AMW, YLC, and XYW drafted the manuscript. All of the authors critically revised the manuscript. The final manuscript was approved by all authors.

Corresponding author

Correspondence to Xiang-Yang Wang.

Ethics declarations

Ethics approval and consent to participate

This study was approved by the IRB (Institutional Review Board) of the Second Affiliated Hospital and Yuying Children’s’ Hospital of Wenzhou Medical University, and informed consent was obtained from every participant.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Rights and permissions

Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Wu, AM., Jin, HM., Lin, ZK. et al. Percutaneous anterior C1/2 transarticular screw fixation: salvage of failed percutaneous odontoid screw fixation for odontoid fracture. J Orthop Surg Res 12, 141 (2017). https://doi.org/10.1186/s13018-017-0640-x

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: https://doi.org/10.1186/s13018-017-0640-x

Keywords

Journal of Orthopaedic Surgery and Research

ISSN: 1749-799X