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Stability Analysis of Craniovertebral Junction Fixation Techniques
Christian M. Puttlitz, PhD1; Robert P. Melcher, MD2; Frank S. Kleinstueck, MD1; Juergen Harms, MD2; David S. Bradford, MD1; Jeffrey C. Lotz, PhD1
1 Department of Orthopaedic Surgery, University of California at San Francisco, 1001 Potrero Avenue, Room 3A36, San Francisco, CA 94110. E-mail address for C.M. Puttlitz: puttlit@itsa.ucsf.edu
2 Department of Orthopaedics and Traumatology, Center for Spinal Surgery, Klinikum Karlsbad-Langensteinbach Guttmannstrassel, 76307 Karlsbad-Langensteinbach, Germany
View Disclosures and Other Information
In support of their research or preparation of this manuscript, one or more of the authors received grants or outside funding from DePuy AcroMed, Inc. None of the authors received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.
Investigation performed at the Department of Orthopaedic Surgery, University of California at San Francisco, San Francisco, California

The Journal of Bone and Joint Surgery, Incorporated
J Bone Joint Surg Am, 2004 Mar 01;86(3):561-568
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Abstract

Background: Craniovertebral arthrodesis in the upper cervical spine is challenging because of the high degree of mobility afforded by this region. A novel method for achieving atlantoaxial fixation with use of polyaxial screws inserted bilaterally into the lateral masses of C1 and transpedicularly into C2 with longitudinal rod connection has recently been introduced. The question remains as to whether this technique provides adequate stability when extended cephalad to include the occiput. The purpose of this study was to determine the primary stability afforded by this novel construct and compare its stability with the current standard of bilateral longitudinal plates combined with C1-C2 transarticular screws.

Methods: We used ten fresh-frozen human cadaveric cervical spines (C0-C4). Pure moment loads were applied to the occiput, and C4 was constrained during the testing protocol. We evaluated four conditions: (1) intact, (2) destabilized by means of complete odontoidectomy, (3) stabilization with longitudinal plates with C1-C2 transarticular screw fixation, and (4) stabilization with a posterior rod system with C1 lateral mass screws and C2 pedicle screws. Rigid-body three-dimensional rotations were detected by stereophotogrammetry by means of a three-camera system with use of marker triads. The range of motion data (C0-C2) for each fixation scenario was calculated, and a statistical analysis was performed.

Results: Destabilization of the specimen significantly increased C0-C2 motion in both flexion-extension and lateral bending (p < 0.05). Both fixation constructs significantly reduced motion in the destabilized spine by over 90% for all motions tested (p < 0.05). No significant differences were detected between the two constructs in any of the three rotational planes.

Conclusions: Both hardware systems provide equivalent construct stability in the immediate postoperative period when it is critical for the eventual success of a craniovertebral arthrodesis. On the basis of this work, we believe that the decision to use either construct should be determined by clinical rather than biomechanical concerns.

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    References

    Accreditation Statement
    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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    Atul Goel
    Posted on March 31, 2004
    Cranio-vertebral Fixation Techniques
    Seth G.S. Medical College & KEM Hospital

    To The Editor:

    We read the above-mentioned manuscript with considerable concern and we wish to bring to your notice certain facts. In 2001, Harms and Melcher published a paper on C1-2 fixation using individual fixation of Cl lateral mass and C2 pedicle with screw and rods (1). They described this technique of fixation as new and novel.

    We had brought to the attention of the journal Spine (2) that we were the first to describe this technique and have used this method since 1987. Our experience now exceeds 300 cases during the last 16 years. We have multiple publications on this subject since 1994 indexed in Medline (3- 7,9) as well as in a textbook (8). Harms and Melcher chose not to respond to our letter, which was subsequently published in Spine without the authors' reply (2).

    We are surprised to note that in this paper, the authors still label this method as novel and new. The only difference in the present manuscript is that the authors have made a passing reference to our papers; which was missing in their earlier paper published in Spine (1). If there is any difference in their technique when compared to ours, it is that Harms and Melcher have used a commercially made rod instead of the custom made plates that we use.

    We have previously described the importance and relevance of sectioning of the C2 ganglion for wide exposure of the region; the opening up of the atlantoaxial facet joint and denuding the articular cartilage; and impacting bone graft into the joint space to provide stability to the construct and enhance ultimate bone fusion. In the present paper the authors have used an extension of C 1-2 fixation by our technique and included the occipital bone in the fixation construct. We also have described this construct in 1994 (7) and subsequently in 1995 (3) and 1997 (8). All these presentations have line drawings and case illustrations demonstrating the technique and its use in a variety of clinical conditions.

    We strongly believe that such omissions and misrepresentation of facts are against the norms of intellectual honesty and compromise scientific validity. Nevertheless, we are happy to read this well-structured manuscript, which validates our clinical experience and shows that the construct based on our concepts has sufficient biomechanical strength.

    Prof Atul Goel Dr Arvind G. Kulkarni

    References I .Harms J, Melcher P. Posterior C 1-C2 Fusion with Polyaxial Screw and Rod Fixation. Spine 2001;26: 2467-71. 2.Goel A, Laheri V. Posterior C1-C2 Fusion with Polyaxial Screw and Rod Fixation. (Letter). Spine 2002;27:1589-1590 3.Goe1 A, Achawal S. Surgical treatment for Arnold Chiari malformation associated with atlantoaxial dislocation. Br J Neurosurg 1. 995; 9: 67-72. 4.Goel A, Gupta S. Vertebral artery injury with transarticular screws [letter]. J Neurosurg 1999; 90: 376-7. 5.Goel A, Gupta S. Quantitative anatomy of the lateral masses of atlas and axis. Neurol India 2000; 48: 120-5. 6.Goel A, Laheri VK. Plate and screw fixation for atlanto-axial dislocation [technical report]. Acta Neurochir (Wien) 1994; 129: 47-53. 7.Goe1 A., Muzumdar D, Dindorkar K, et al. Atlantoaxial dislocation associated with stenosis of canal at atlas. J Postgrad Med 1997; 43: 75-7. 8.Goel A, Kobayashi S. Cramovertebral and spinal stability. In: Kobayashi S, Goel A, Hongo K (eds). Neurosurgery of Complex Tumors and Vascular Lesions. New York: Churchill Livingstone, 1997: 339-72. 9.Goel A, Desai KI, Muzumdar DP. Atlantoaxial fixation using plate and screw method: A report of 160 treated patients. Neurosurgery 2002;51: 1351 -1357.

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