Occipital-Cervical-Thoracic Fixation Techniques
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1 Occipital-Cervical-Thoracic Fixation Techniques Neill M. Wright, M.D. Herbert Lourie Professor of Neurological Surgery Professor of Orthopaedic Surgery Washington University School of Medicine
2 Disclosures Nuvasive: Royalties, Consulting, Stock Ulrich Medical: Consulting Vertebral Technologies: Stock Options
3 FDA notice All of the devices seen in this talk are approved for use by the FDA for spinal fixation. However, some screw constructs shown are off-label (ie, lateral mass screws)
4 Occipital-Cervical-Thoracic Fixation Many fixation options: Occiput Atlas/C1 Axis/C2 Sub-axial/C3-6/7 C/T junction
5 Occipital-Cervical-Thoracic Fixation Many fixation options: Occiput Atlas/C1 Axis/C2 Sub-axial/C3-6/7 C/T junction
6 Occipital Fixation Many fixation options: Occiput Occipital Keel plate
7 Occipital Fixation Many fixation options: Measure length on pre-op CT Normally 8-14 mm Drill and tap entire length If CSF leak, insert screw to tamponade Consider placement before sub-occipital decompression Be aware of torcula!
8 Occipital Fixation Many fixation options: Occiput Occipital Condyle Screws Dr. Juan Uribe
9 Occipital-Cervical-Thoracic Fixation Many fixation options: Atlas/C1 C1 lateral mass
10 C1 Lateral Mass Fixation Trajectory: 10 medially (to avoid VA) Aim towards anterior arch C1 (but stop short to avoid pharynx)
11 C1 Lateral Mass Fixation Tips: Drill small match-stick hole first to hold hand-drill CORD Plenty of Flo-seal or equivilent hemostatic agent Venous plexus around C2 root Use lag screw to avoid irritation of C2 root
12 C1 Lateral Mass Fixation Many fixation options: C1 lateral mass Option: ligate C2 root to minimize blood loss and to better access C1/2 joint
13 Occipital-Cervical-Thoracic Fixation Many fixation options: Axis/C2 C2 pedicle C2 pars C2 laminar
14 C2 pedicle screws Insertion technique: Use penfield dissector to palpate medial aspect of pedicle Entry point is in cranial and medial quadrant of the isthmus surface of C2 Screw is directed medially and rostrally 20-30
15 C2 pedicle screws Laude, Saillart, Bouchet Fluoro and/or navigation is used to adjust rostral angle. Howington, Kruse, Awasthi, LSU HSC Navigation is useful to safely avoid VA
16 C2 pedicle screws
17 C2 pedicle screws Potential complications: Pedicle breakout (loss of fixation point) VA injury Ebraheim, et al. Anatomic consideration of C2 pedicle screw placement. Spine 21:291-5, Yoshida, et al. Comparison of the anatomic risk for VA injury associated with C2 pedicle screw and atlantoaxial transarticular screw. Spine 31(15):513-7, patients evaluated with navigation system for safe placement Equivilent risk to C1-2 screw (20% patients with unacceptable anatomy)
18 C2 pedicle screws Reported risk of VA in C2 pedicle screws varies in literature: Ondra et al. Safety and efficacy of C2 pedicle screws... Spine 31(9):263-7, Less than 2.7% complication rate in 71 patients
19 Occipital-Cervical-Thoracic Fixation Many fixation options: Axis/C2 C2 pedicle C2 pars C2 laminar
20 C2 Pars Screws
21 C2 Pars screws
22 Occipital-Cervical-Thoracic Fixation Many fixation options: Axis/C2 C2 pedicle C2 pars C2 laminar
23 C2 translaminar screw
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25
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27 Occipital-Cervical-Thoracic Fixation Many fixation options: Sub-axial/C3-6/7 Lateral mass screws
28 Lateral Mass Fixation Entry point is 1 mm medial and 1 mm caudal to center of mass
29 Lateral Mass Fixation Aimed 45 rostrally to avoid exiting nerve root Aimed 45 lateral to avoid vertebral artery
30 Occipital-Cervical-Thoracic Fixation Many fixation options: Sub-axial/C3-6/7 Sub-axial pedicle screws
31 Occipital-Cervical-Thoracic Fixation Many fixation options: C/T junction Pedicle screws
32 Cervicothoracic Pedicle Screws Cervicothoracic pedicle screws Consider laminotomy to palpate pedicle margins if you are not familiar with screw placement in this area Fluoroscopy limited due to shoulders. Primary utility is visualizing disc space to help with trajectory? Spinal navigation systems
33 OCT Fixation Technique: Depending on length of construct, can use cervical system in thoracic spine (4.0 or 4.5mm diameter screws with mm rod) or tie into thoracolumbar system (with dual-diameter rod, dominoes to connect different diameter rods, etc...) Difficult to switch from lateral mass to pedicle without skipping level.
34 OCT Fixation Complications: Failure of rod (if using cervical system down into thoracic area) Failure of rod-connector (if tying into thoracolumbar system) Breech of thoracic pedicles requiring extension to more levels
35
36 Thank you
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