A biomechanical analysis of atlantoaxial stabilization methods using a bovine model: C1/C2 fixation analysis

The reliability and initial postoperative stability of six widely used C1- C2 surgical constructs were evaluated by nondestructive biomechanical testing of ten fresh bovine upper cervical spine segments. The six fixation techniques were the simple midline sublaminar C1 wiring (SMW), the modified Gallie wiring (MGW), the Brook wedge arthrodesis (BWA), the bilateral lateral mass screw (LMS), and the Clark arthrodesis without (CWO) and with (CW) the adjunctive use of polymethylmethacrylate (PMMA) cement. Instability was produced by resection of the base of the dens. Intact, destabilized, and instrumented constructs were tested in unconstrained flexion, extension, torsion, anterior, and posterior shear forces. The LMS and CW techniques proved the most effective in achieving C1-C2 stability. Sublaminar C2 wiring methods tended to have greater torsional and shear stiffness. Less rigid fixation techniques frequently loosened. All non-PMMA-enhanced wired constructs failed to restore the ability to adequately resist the posterior translation of C1 on C2. Stabilization of an unstable atlantoaxial articulation is best accomplished by a lateral mass screw or sublaminar C1- C2 PMMA-enhanced technique. Other techniques provided less consistent and reliable surgical fixation. Because of the inadequacy of wired constructs to resist posterior shear in patients with this instability pattern, the usual treatment may need to be modified to include more prolonged or protective external immobilization or more rigid fixation techniques. Although less rigid, the SMW and the MGW techniques are safer because they require less- frequent passage of sublaminar wires, avoid potential problems with PMMA, and obviate the hazards of further lateral dissection and insertion of the transarticular screws.