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Spine

C1-2 Fusion

Aims

Indications

Contraindications

Consent / Preop Planning

Principles

Options

Position

Landmarks

Incision

  • midline skin incision from occiput to C3
  • arch of C1 should not be exposed beyond 1.5 cm from midline in adults & 1 cm in children to avoid injury to vertebral artery

Internervous Plane

Superficial Dissection

Deep Dissection

Dangers

Nerves

Vessels

Procedure

Gallie Technique

  • Gallie technique is safer because spinous process of C2 is used in place of sublaminar wire
  • Less stable than Brooks or Magerl
  • wire is passed beneath arch of C1 & from inferior to superior
  • bone block is shaped to fit between posterior elements of C1 & C2 & wires
  • loop is passed beneath C2 spinous process & wires tightened over bone block

Brooks Technique

  • provides additional rotational stability when compared with Gallie technique
  • for extension injuries & in cases where more rigid fixation is required
  • passage of double wire loop beneath laminae of C1 & C2 in craniocaudal fashion
  • autologous bone graft is fashioned on either side of C1-C2 interval & then double wire is tightened sequentially over surface of each graft
  • halo vest external support for 3 months if wiring techniques are used

Posterior transarticular fixation

  • Use
    • can be used even in absence of integrity of posterior arch of C1 & allows for minimal postoperative immobilization
  • Technique
    • expose C1-C2 facets & interior articular process of C2
    • screws are inserted at inferior aspect of laminae approximately 2 mm cranial & lateral of medial border of caudal articular process of C2
    • special drill guide & precise fluoroscopic imaging are used as screw is advanced across posterior aspect of upper articular process across facet into lateral mass of C1
    • Can use posterior wiring in addition to transarticular fixation
  • Postoperative
    • immobilization in Philadelphia collar for 6 weeks if wiring was performed & 12 weeks if wiring was not performed
  • Contraindications
    • cases where lateral masses of C2 have been destroyed, collapsed, & subluxed about C1 as consequence of inflammatory arthropathy

Vertebral artery

    • out laterally, then crosses over posterior arch of C1 (avoid dissecting up here) before going up into cranium
    • K-wire begins in middle of facet (medial/lateral) & is directed STRAIGHT AHEAD. Do not aim out laterally, or you risk hitting artery

Postop / Rehab

Results

Complications / Dangers

Perioperative

General
Local

Postoperative

Early
Late
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