Transarticular screw fixation C1/C2 in traumatic atlantoaxial instabilities. Comparison between percutaneous and open procedures

For posttraumatic atlantoaxial instabilities posterior transarticular screw fixation according to Magerl represents the treatment of choice. In order to be able to insert the screws steep enough the soft tissues of the neck have to be dissected down to C7. Several authors therefore described a percutaneous technique. We analysed 30 patients with a sagittal atlantoaxial instability treated with one of both methods between the years 1995 and 1998 to detect amny differences of either technique. In 19 cases we used a modified percutaneous technique with special instruments as has been published by McGuire and Harkey. On lateral plain films the angle between the screws and the lower endplate of C2 was measured. 6 to 24 months after the accident 26 patients could be seen clinically and controlled radiologically, 4 patients had died in the meanwhile. The angle of the screws were significantly different with 10 degrees (percutaneous group 73,9 degrees, open group 63,9 degrees, p = 0,001). Time needed for the operativ procedure averaged 35 minutes shorter with the canulated technique (93 to 128 minutes, p = 0.05). All posterior fusions had healed radiologically. Active motion of the c-spine was restricted in both groups equally. We checked subjective criteria concerning pain and function with a visual analog scale and a special score. With these instruments advantages for the percutaneous procedure could be found (freedom of pain 43 points (percutaneous) versus 39 points (open), p = 0.05). We conclude that the soft tissue preserving percutaneous technique of screw application for C1/C2 posterior fusion allows for a better and easier placement of screws. It also leads to a shorter operating time and better subjective results. The method offers particularly advantages in cases where only a temporary satbilization of the C1/C2 complex without a regular fusion is needed.