Occipitocervical fixation in the management of craniocervical instabilities

Peer review under responsibility of Alexandria University Faculty of Medicine

Figures & data

Table 1 Frankel classification of 10 patients with occipitocervical instability.

Frankel grade	No. of cases
	Preop.	Postop.
A = complete paralysis	1
B = sensory function only below the injury level	1	2
C = incomplete motor function below injury level	3
D = fair to good motor function below injury level	3	5
E = normal function	2	3

Table 2 Summary data of 10 patients who underwent occiptocervical fixation.

No	Age	Sex	Clinical picture			Etiology	Radiological findings	Preop. tractin	Extent of fixation	Technique of surgery	Postoperative complications	>Frankel grading scale preop/postop	Fusion time (ms)
			Neck pain	Myel-opathy	N D
												Follow up (months)
1	48	M	+	+	+	Tumour	C1 C2 erosion + spinal compression		C0 + C2–C5	C 1Laminectomy Wire rod system	Wound infection	C → D 12 m	6
2	57	F	+	+	+	Tumour	C1 C2 erosion + spinal compression		C0 + C3–C5	C1 C2 laminectomy Rod-screw system (C3,4,5 lateral mass)	Neurological deficit	C → D 10 m	4
3	63	M	+			RA	AAS + SMO + SAS		C0 + C3 + C5	Rod-screw system (C3,5 lateral mass)		E → E 6 m	4
4	54	F	+			RA	AAS + SMO + SAS		C0 + C1–C4	Wire – rod system		E → E 18 m	5
5	41	M	+	+	+	RA	AAS + SMO + SAS	+	C0 + C1–C4	Rod-screw system (C1,3,4 lateral mass + C2 pedicle) + TO	Wound infection	D → E 4 m
6	16	M	+	+	+	Down Syndrome	AAS + AOD		C0–C2	Sublaminar wire	Neurological deficit	D → D 24 m	8
7	28	M	+		+	Down Syndrome	AAS + AOD		C0–C2	Sublaminar cable		D → D 16 m	8
8	35	M	+	+	+	Trauma	AAS + C2 fracture (pedicle + lamina)	+	C0 + C1 + C3	Sublaminar wire		A → B 20 m	7
9	54	F	+	+	+	Trauma	AAS + C2 C3 Sublaxation . + fracture C1 posterior arch		C0–C3	C1 laminectomy Rod-screw system (C1 + C3 lateral mass + C2 pedicle screw)	CSF leak	C → D 22 m	5
10	25	M	+	+	+	Trauma	AAS + fracture C1 lateral mass		C0 + C2–C3	Rod-screw system (C2 pedicle + C3 lateral mass)		B → B 15 m	6

SAS, subaxial sublaxation; AOD, atlanto-occipital dislocation; ND, neurological deficit; AAS, atlantoaxial subluxation; RA, rheumatoid arthritis; Preop, preoperative; postop, postoperative; C, cervical; C0, occiput; m, months; TO, Transoral odontoidectomy; SMO, superior migration of odontoid.

Table 3 Outcome of patients in relation to the etiology and the technique of fixation.

Outcome	Cases		Surgical technique		Etiology
	No.	%	Instrumentation	No.	Rheumatoid arthritis	Trauma	Tumour	Down syndrome
Improved	5	50	Sublaminar wire and cable	1
			Wire-rod system	1			1
			Rod screw system	3	1	1	1
Stationary	5	50	Sublaminar wire and cable	2				2
			Wire-rod system	1	1
			Rod screw system	2	1	1
Deteriorated	0	0
Total	10			10	3	3	2	2

Figure 1 (A) Preoperative plain-Xray cervical spine (lateral view) showing traumatic atlantoaxial sbaxation. (B) Preoperative CT scan (sxial view) showing fracture of both anerior and posterior arch of Atlas. (C) Preoperative MRI T2 weighted image (sagittal view) showing ligamentos injry and swelling of prevertebral tisse at the atlatoxial region. (D) Postoperative plain X-raycervical spine (lateral view) and (axial view) showing ocipitocervical fixation (C0C2C3).

Figure 2 (A) Preoperative plain-Xray cervical spine (lateral view and AP view) of patient with rheumatoid arthritis showing atlantoaxial sublaxation. (B) Preoperative MRI T2 weighted image (sagittal view) showing compression at cervicomedullary junction. (C) Postoperative plain X-ray cervical spine (lateral view) showing occipitocervical fixation (C0C3C5)

Figure 3 (A) Preoperative plain-Xray cervical spine (lateral view) showing neoplastic destruction of C1 C2 (B) Preoperative MRI T1 weighted image (sagittal view) showing neoplastic mass at C1 C2. (C) Preoperative MRI T2 weighted image (sagittal view) showing neoplastic mass at C1 C2 Postoperative plain X-ray cervical spine (lateral view) showing occipitocervical fixation (C0 C2 C3 C4 C5 fixation) and C1 laminectomy.