C2 Vertebra: An Enigma for Young Spine/Neurosurgeons

 

 Buy Article Permissions and Reprints

Abstract

Background Instrumentation of C2 vertebra is considered the most difficult for young neurosurgeons and trainees due to its complex anatomical structures, variety of surgical approaches and techniques, and proximity to important neurovascular structures. Key points from a surgical perspective for midline posterior approach is described in the era of neuroradiological advancements.

Method Computed tomography angiographies (CTAs) of a total of 92 patients were evaluated with special attention to the key findings for insertion of screws for craniovertebral junction (CVJ) fixations. All these patients were operated though midline posterior approach in past 4 years.

Results CTAs included various CVJ disorders, which included traumatic (n = 14), congenital (n = 55), and rheumatoid arthritis (n = 2) patients. Established landmarks for screw insertion sites do not prove safe for congenital anomalous CVJ conditions. Instead of highlighting screw insertion entry points, part of the corridor, which is relevant, should be stressed up on.

Conclusion Midpoint of portion of bone segment medial to vertebral artery foramen should be the focus, which is important for pars interarticularis (and transarticular) and pedicle screws. A laminar screw should cross the midpoint of the lamina on each side.

Previous Presentation

This study was presented at the All India Institute of Medical Sciences Neurotrauma Conference 2022, New Delhi, India.

Publication History

Received: 20 October 2023

Accepted: 10 January 2024

Accepted Manuscript online:
12 January 2024

Article published online:
09 February 2024

© 2024. Thieme. All rights reserved.

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany

• References

• 1 Shah A, Vutha R, Prasad A, Goel A. Central or axial atlantoaxial dislocation and craniovertebral junction alterations: a review of 393 patients treated over 12 years. Neurosurg Focus 2023; 54 (03) E13
  Google Scholar
• 2 Goel A, Sharma P. Craniovertebral junction realignment for the treatment of basilar invagination with syringomyelia: preliminary report of 12 cases. Neurol Med Chir (Tokyo) 2005; 45 (10) 512-517 , discussion 518
  Google Scholar
• 3 Goel A, Desai KI, Muzumdar DP. Atlantoaxial fixation using plate and screw method: a report of 160 treated patients. Neurosurgery 2002; 51 (06) 1351-1356 , discussion 1356–1357
  Google Scholar
• 4 Goel A, Sharma P, Dange N, Kulkarni AG. Techniques in the treatment of craniovertebral instability. Neurol India 2005; 53 (04) 525-533
  Google Scholar
• 5 Goel A. A review of a new clinical entity of ‘central atlantoaxial instability’: expanding horizons of craniovertebral junction surgery. Neurospine 2019; 16 (02) 186-194
  Google Scholar
• 6 Chun HJ, Bak KH. Targeting a safe entry point for C2 pedicle screw fixation in patients with atlantoaxial instability. J Korean Neurosurg Soc 2011; 49 (06) 351-354
  Google Scholar
• 7 Zhang B, Qi M, Xin Z. et al. Intra-articular distraction versus decompression to treat basilar invagination without atlantoaxial dislocation: a retrospective cohort study of 54 patients. Neurospine 2023; 20 (02) 498-506
  Google Scholar
• 8 Salunke P, Karthigeyan M, Malik P. Foramen magnum decompression without bone removal: C1-C2 posterior fixation for Chiari with congenital atlantoaxial dislocation/basilar invagination. Surg Neurol Int 2019; 10: 38
  Google Scholar
• 9 Patkar S. Anterior retropharyngeal cage distraction and fixation for basilar invagination: “the wedge technique”. Neurospine 2019; 16 (02) 286-292
  Google Scholar
• 10 Sarat Chandra P, Bajaj J, Singh PK, Garg K, Agarwal D. Basilar invagination and atlantoaxial dislocation: reduction, deformity correction and realignment using the DCER (distraction, compression, extension, and reduction) technique with customized instrumentation and implants. Neurospine 2019; 16 (02) 231-250
  Google Scholar
• 11 Shukla K, Patidar RK, Garg M. et al. Volume rendering technique (VRT) for planning and learning cranio-vertebral junction (CVJ) surgeries: technical note. Turk Neurosurg 2021; 31 (05) 807-812
  Google Scholar
• 12 Jha DK, Khera P, Bhaskar S, Garg M. Three-dimensional volume rendering: an underutilized tool in neurosurgery. World Neurosurg 2019; 130: 485-492
  Google Scholar
• 13 Jeanneret B, Magerl F. Primary posterior fusion C1/2 in odontoid fractures: indications, technique, and results of transarticular screw fixation. J Spinal Disord 1992; 5 (04) 464-475
  Google Scholar
• 14 Magerl F, Seemann P-S. Stable posterior fusion of the atlas and axis by transarticular screw fixation. In: Cervical Spine I. Springer; 1987: 322-327
  Google Scholar
• 15 Huang DG, Hao DJ, He BR. et al. Posterior atlantoaxial fixation: a review of all techniques. Spine J 2015; 15 (10) 2271-2281
  Google Scholar
• 16 Grob D, Jeanneret B, Aebi M, Markwalder TM. Atlanto-axial fusion with transarticular screw fixation. J Bone Joint Surg Br 1991; 73 (06) 972-976
  Google Scholar
• 17 Mishra R, Narayanan MDK, Umana GE, Montemurro N, Chaurasia B, Deora H. Virtual reality in neurosurgery: beyond neurosurgical planning. Int J Environ Res Public Health 2022; 19 (03) 1719
  Google Scholar
• 18 Tagaytayan R, Kelemen A, Sik-Lanyi C. Augmented reality in neurosurgery. Arch Med Sci 2018; 14 (03) 572-578
  Google Scholar
• 19 Pipolo DO, Luzzi S, Baldoncini M. et al. Virtual preoperative planning and 3D tumoral reconstruction with Horos open-source software. Surg Neurol Int 2023; 14: 32
  Google Scholar
• 20 Cassinelli EH, Lee M, Skalak A, Ahn NU, Wright NM. Anatomic considerations for the placement of C2 laminar screws. Spine 2006; 31 (24) 2767-2771
  Google Scholar
• 21 Yadav YR, Ratre S, Parhihar V, Dubey A, Dubey NM. Endoscopic technique for single-stage anterior decompression and anterior fusion by transcervical approach in atlantoaxial dislocation. Neurol India 2017; 65 (02) 341-347
  Google Scholar