Highlights
- •Biomodelling is a useful tool for pre-surgical planning and intraoperative stereotaxy.
- •Surgeons can develop patient specific tools and titanium implants using 3D printing.
- •Patient specific tools simplify atlantoaxial transarticular screw placement.
- •Pre-surgical planning and 3D printing can improve operative ergonomics.
- •This patient specific process is a viable technique for atlantoaxial fixation.
Abstract
Atlantoaxial transarticular screw fixation is an effective technique for arthrodesis.
Surgical accuracy is critical due to the unique anatomy of the atlantoaxial region.
Intraoperative aids such as computer-assisted navigation and drilling templates offer
trajectory guidance but do not eliminate screw malposition. This study reports the
operative and clinical performance of a novel process utilising biomodelling and 3D
printing to develop patient specific solutions for posterior transarticular atlantoaxial
fixation surgery. Software models and 3D printed 1:1 scale biomodels of the patient's
bony atlantoaxial spine were developed from computed tomography data for surgical
planning. The surgeon collaborated with a local medical device manufacturer using
AnatomicsC3D to design patient specific titanium posterior atlantoaxial fixation implants
using transarticular and posterior C1 arch screws. Software enabled the surgeon to
specify screw trajectories, screw sizes, and simulate corrected atlantoaxial alignment
allowing patient specific stereotactic drill guides and titanium posterior fixation
implants to be manufactured using 3D printing. Three female patients with unilateral
atlantoaxial osteoarthritis were treated using patient specific implants. Transarticular
screws were placed using a percutaneous technique with fluoroscopy and neural monitoring.
No screw malposition and no neural or vascular injuries were observed. Average operating
and fluoroscopy times were 126.0 ± 4.1 min and 36.7 ± 11.5 s respectively. Blood loss
was <50 ml per patient and length of stay was 4–6 days. Clinical and radiographic
follow up data indicate satisfactory outcomes in all patients. This study demonstrates
a safe, accurate, efficient, and relatively inexpensive process to stabilise the atlantoaxial
spine using transarticular screws.
Keywords
To read this article in full you will need to make a payment
Purchase one-time access:
Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online accessOne-time access price info
- For academic or personal research use, select 'Academic and Personal'
- For corporate R&D use, select 'Corporate R&D Professionals'
Subscribe:
Subscribe to Journal of Clinical NeuroscienceAlready a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
References
- Stable posterior fusion of the atlas and axis by transarticular screw fixation.in: Kehr P. Weidner A. Cerv. Spine I. Springer Vienna, Vienna1987: 322-327 (doi:10.1007/978-3-7091-8882-8_59)
- Biomechanical evaluation of four different posterior atlantoaxial fixation techniques.Spine. 1992; 17: 480-490
- Dorsal atlanto-axial screw fixation. A stability test in vitro and in vivo.Orthopade. 1991; 20: 154-162
- Biomechanical comparison of five different atlantoaxial posterior fixation techniques.Spine. 2000; 25: 2877-2883
- Biomechanical comparison of C1–C2 posterior fixations. Cable, graft, and screw combinations.Spine. 1998; 23 (discussion 1955–1956): 1946-1955
- Anatomic and biomechanical assessment of transarticular screw fixation for atlantoaxial instability.Spine. 1991; 16: 1141-1145
- Atlantoaxial transarticular screw fixation: a review of surgical indications, fusion rate, complications, and lessons learned in 191 adult patients.J Neurosurg Spine. 2005; 2: 155-163https://doi.org/10.3171/spi.2005.2.2.0155
- Atlantoaxial fusion with screw-rod constructs: meta-analysis and review of literature.World Neurosurg. 2014; 81: 411-421https://doi.org/10.1016/j.wneu.2012.03.013
- Biomechanical analysis of screw constructs for atlantoaxial fixation in cadavers: a systematic review and meta-analysis.J Neurosurg Spine. 2015; 22: 151-161https://doi.org/10.3171/2014.10.SPINE13805
- Posterior atlantoaxial fixation: a review of all techniques.Spine J Off J North Am Spine Soc. 2015; 15: 2271-2281https://doi.org/10.1016/j.spinee.2015.07.008
- Outcomes following arthrodesis for atlanto-axial osteoarthritis.Spine. 2017; 42: E294-E303https://doi.org/10.1097/BRS.0000000000001783
- Radiological and anatomical evaluation of the atlantoaxial transarticular screw fixation technique.J Neurosurg. 1997; 86: 961-968https://doi.org/10.3171/jns.1997.86.6.0961
- Morphologic considerations of C2 isthmus dimensions for the placement of transarticular screws.Spine. 2000; 25: 1542-1547
- The anatomical suitability of the C1–2 complex for transarticular screw fixation.J Neurosurg. 1996; 85: 221-224
- Study of the anatomical variations of vertebral artery in C2 vertebra with magnetic resonance imaging and its application in the C1–C2 transarticular screw fixation.Spine. 2010; 35: 1136-1143https://doi.org/10.1097/BRS.0b013e3181bb4f21
- Posterior C2 instrumentation: accuracy and complications associated with four techniques.Spine. 2011; 36: E936https://doi.org/10.1097/BRS.0b013e3181fdaf06
- Isocentric C-arm three-dimensional navigation versus conventional C-arm assisted.Arch Orthop Trauma Surg. 2015; 135: 1083-1092https://doi.org/10.1007/s00402-015-2249-z
- Use of an aiming device in posterior atlantoaxial transarticular screw fixation. Technical note.J Neurosurg. 2002; 97: 123-127
- Image-based planning and validation of C1–C2 transarticular screw fixation using personalized drill guides.Comput Aided Surg Off J Int Soc Comput Aided Surg. 2002; 7: 41-48https://doi.org/10.1002/igs.10027
- Three-dimensional computed tomography-based, personalized drill guide for posterior cervical stabilization at C1–C2.Spine. 2001; 26: 1343-1347
- Percutaneous placement of posterior cervical screws using three-dimensional fluoroscopy.Spine. 2006; 31: 536-540https://doi.org/10.1097/01.brs.0000201297.83920.a1
- Biomodeling as an aid to spinal instrumentation.Spine. 2005; 30: 2841-2845
- Deviation analysis of C1–C2 transarticular screw placement assisted by a novel rapid prototyping drill template: a cadaveric study.J Spinal Disord Tech. 2014; 27: E181-E186https://doi.org/10.1097/BSD.0000000000000087
- A novel screw guiding method with a screw guide template system for posterior C-2 fixation: clinical article.J Neurosurg Spine. 2014; 21: 231-238https://doi.org/10.3171/2014.3.SPINE13730
- A novel method of C1–C2 transarticular screw insertion for symptomatic atlantoaxial instability using a customized guiding block: a case report and a technical note.Medicine (Baltimore). 2016; 95e5100https://doi.org/10.1097/MD.0000000000005100
- Development of a new technique for pedicle screw and Magerl screw insertion using a 3-dimensional image guide.Spine. 2012; 37: 1983-1988https://doi.org/10.1097/BRS.0b013e31825ab547
- Robot-assisted posterior C1–2 transarticular screw fixation for atlantoaxial instability: a case report.Spine. 2016; 41: B2-B5https://doi.org/10.1097/BRS.0000000000001674
- Intraoperative, full-rotation, three-dimensional image (O-arm)-based navigation system for cervical pedicle screw insertion.J Neurosurg Spine. 2011; 15: 472-478https://doi.org/10.3171/2011.6.SPINE10809
- Accuracy and safety in pedicle screw placement in the thoracic and lumbar spines : comparison study between conventional C-Arm fluoroscopy and navigation coupled with O-Arm® guided methods.J Korean Neurosurg Soc. 2012; 52: 204-209https://doi.org/10.3340/jkns.2012.52.3.204
- Image-guided spine surgery: state of the art and future directions.Eur Spine J. 2010; 19: 25-45https://doi.org/10.1007/s00586-009-1091-9
- A review of surgical robots for spinal interventions.Int J Med Robot Comput Assist Surg MRCAS. 2013; 9: 407-422https://doi.org/10.1002/rcs.1469
- Spinal biomodeling.Spine. 1999; 24: 1247-1251
- The use of physical biomodelling in complex spinal surgery.Eur Spine J. 2007; 16: 1507-1518https://doi.org/10.1007/s00586-006-0289-3
- Posterior C1-C2 transarticular screw fixation for atlantoaxial arthrodesis.Neurosurgery. 1998; 43 (discussion 280-281): 275-280
- Surgical management of atlantoaxial nonunions.J Neurosurg. 1995; 83: 248-253https://doi.org/10.3171/jns.1995.83.2.0248
- C1-C2 posterior cervical fusion: long-term evaluation of results and efficacy.Neurosurgery. 1995; 37 (discussion 692-693): 688-692
- Primary posterior fusion C1/2 in odontoid fractures: indications, technique, and results of transarticular screw fixation.J Spinal Disord. 1992; 5: 464-475
- Atlantoaxial fusion using C1 sublaminar cables and C2 translaminar screws.Oper Neurosurg Hagerstown Md. 2017; https://doi.org/10.1093/ons/opx164
- Vertebral artery injury during cervical spine surgery: a survey of more than 5600 operations.Spine. 2008; 33: 779-785https://doi.org/10.1097/BRS.0b013e31816957a7
- Subaxial sagittal alignment and adjacent-segment degeneration after atlantoaxial fixation performed using C-1 lateral mass and C-2 pedicle screws or transarticular screws.J Neurosurg Spine. 2010; 13: 443-450https://doi.org/10.3171/2010.4.SPINE09662
- Modification of technique and results of atlantoaxial transfacet stabilization.Orthopedics. 1995; 18: 1029-1032
- Posterior atlantoaxial fixation: the Magerl screw technique.Orthopedics. 1998; 21: 455-459
- Frameless stereotactic guidance for surgery of the upper cervical spine.Neurosurgery. 1997; 40 (discussion 963-964): 958-963
- Stereotactic atlantoaxial transarticular screw fixation.J Clin Neurosci Off J Neurosurg Soc Australas. 2005; 12: 62-65https://doi.org/10.1016/j.jocn.2004.03.003
- Image-guided transarticular atlanto-axial screw fixation.Int J Med Robot Comput Assist Surg MRCAS. 2006; 2: 154-160https://doi.org/10.1002/rcs.92
- Robotic system for cervical spine surgery.Int J Med Robot Comput Assist Surg MRCAS. 2012; 8: 184-190https://doi.org/10.1002/rcs.446
- Computer-assisted C1–C2 transarticular screw fixation “Magerl Technique” for atlantoaxial instability.Asian Spine J. 2012; 6: 168-177https://doi.org/10.4184/asj.2012.6.3.168
- Atlantoaxial transarticular screw fixation with posterior wiring using polyethylene cable: facet fusion despite posterior graft resorption in rheumatoid patients.Spine. 2008; 33: 1655-1661https://doi.org/10.1097/BRS.0b013e31817b5c07
- Differences between manufacturers of computed tomography-based computer-assisted surgery systems do exist: a systematic literature review.Glob Spine J. 2017; 7: 83-94https://doi.org/10.1055/s-0036-1583942
- Efficacy of computer-assisted pedicle screw insertion for cervical instability in RA patients.Rheumatol Int. 2007; 27: 567-574https://doi.org/10.1007/s00296-006-0256-7
Article info
Publication history
Published online: July 15, 2018
Accepted:
June 24,
2018
Received:
March 21,
2018
Identification
Copyright
© 2018 Elsevier Ltd. All rights reserved.