C2 Nerve Root Sectioning in Posterior Atlantoaxial Instrumented Fusions: A Structured Review of Literature

Elliott, Robert E.; Kang, Matthew M.; Smith, Michael L.; Frempong-Boadu, Anthony

doi:10.1016/j.wneu.2011.10.035

Cited by 39 publications

(24 citation statements)

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“…Also, there was no effect on the rates of fusion [17]. Similar results were found in other studies [9,11].…”

Section: Discussionsupporting

confidence: 86%

“…The C2 nerve, due to its positioning relative to the C1 lateral masses, often necessitates increased operative time in order to dissect out the surrounding structures, which can lead to increased EBL. Furthermore, C2 neurectomies can aid in visualization and feasibility in cases of C1 posterior arch nonunion or fractures as well as avoid cardiovascular instability in bleeding diathesis, aid in anterolateral access to the cervical segment of the spinal cord, and optimize decortication of the C1-C2 facet joint for successful fusion [17]. …”

Section: Discussionmentioning

confidence: 99%

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C2 and Greater Occipital Nerve: The Anatomic and Functional Implications in Spinal Surgery

Janjua

Zhou

Greenfield

et al. 2017

Cureus

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IntroductionPosterior C1-C2 fusion is a highly successful treatment for atlantoaxial instability and other pathologies of the cervical spine, with fusion rates approaching 95%-100%. However, poor visualization of the lateral masses of C1 secondary to the course of the C2 nerve root along with blood loss from the venous plexus and compression of the C2 nerve from lateral mass screws are technical obstacles that can arise during surgery. Thus, sacrifice of the C2 nerve root has long since been debated in fusions involving the C1 and C2 vertebral bodies. MethodsCadaveric dissections on four adult specimens were performed. Both intradural and extradural courses of C2 were studied in detail. The tentative site of C2 nerve root compression during placement of C1 lateral mass screws was studied in detail. Both the indication as well as the ease of C2 neurectomy were studied in relation to postoperative compression and entrapment.ResultsFour-six dorsal rootlets of C2 nerve were observed while studying the intradural course. The extradural course was studied with respect to the lateral mass of C1. The greater occipital nerve (GON) course was fairly consistent in all specimens. Transection of C2 around its ganglion would allow for proper C1 lateral mass screw placement as the course of C2 nerve interferes with proper placement of instrumentation.ConclusionC2 nerve root transection is associated with occipital numbness but this often has no effect on health-related quality of life (HRQOL). The C2 nerve root preservation is often associated with entrapment neuropathy or occipital neuralgia, which greatly affects HRQOL. The C2 nerve root transection helps in better visualization, aids in optimal placement of C1 lateral mass screws, minimizes estimated blood loss and improves surgical outcome with successful fusion.

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“…Also, there was no effect on the rates of fusion [17]. Similar results were found in other studies [9,11].…”

Section: Discussionsupporting

confidence: 86%

Section: Discussionmentioning

confidence: 99%

C2 and Greater Occipital Nerve: The Anatomic and Functional Implications in Spinal Surgery

Janjua

Zhou

Greenfield

et al. 2017

Cureus

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“…The mechanism of C 2 nerve dysfunction associated with C 1 lateral mass screw fixation is poorly understood. However, possible causes are as follows: (i) transection of the C 2 nerve root; however, the effects of this are unclear; (ii) excessive caudal retraction during exposure of the C 1 lateral mass screw entry point; (iii) damage to the C 2 nerve root during management of bleeding from the associated venous plexus; (iv) reduction of C 1 onto C 2 ; and (v) impingement or irritation from the C 1 lateral mass screw.…”

Section: C2 Nerve Dysfunction Associated With C1 Lateral Mass Screw Fmentioning

confidence: 99%

C₂ Nerve Dysfunction Associated with C₁ Lateral Mass Screw Fixation

Huang

Hao

et al. 2014

Orthopaedic Surgery

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The C1 lateral mass screw technique is widely used for atlantoaxial fixation. However, C2 nerve dysfunction may occur as a complication of this procedure, compromising the quality of life of affected patients. This is a review of the topic of C2 nerve dysfunction associated with C1 lateral mass screw fixation and related research developments. The C2 nerve root is located in the space bordered superiorly by the posterior arch of C1, inferiorly by the C2 lamina, anteriorly by the lateral atlantoaxial joint capsule, and posteriorly by the anterior edge of the ligamentum flavum. Some surgeons suggest cutting the C2 nerve root during C1 lateral mass screw placement, whereas others prefer to preserve it. The incidence, clinical manifestations, causes, management, and prevention of C2 nerve dysfunction associated with C1 lateral mass screw fixation are reviewed. Sacrifice of the C2 nerve root carries a high risk of postoperative numbness, whereas postoperative nerve dysfunction can occur when it has been preserved. Many surgeons have been working hard on minimizing the risk of postoperative C2 nerve dysfunction associated with C1 lateral mass screw fixation.

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“…Elliott et al 4 performed a review of the literature in 2011 studying the effects of C-2 nerve root sacrifice in C1-2 segment fusions. In total they reviewed 20 studies encompassing 732 patients with C-2 root preservation and 6 studies totaling 361 patients who underwent C-2 sacrifice.…”

Section: Discussionmentioning

confidence: 99%

Posterior arch C-1 screw technique: a cadaveric comparison study

Moisi

Fisahn

Tkachenko

et al. 2017

SPI

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OBJECTIVEPosterior atlantoaxial stabilization and fusion using C-1 lateral mass screw fixation has become commonly used in the treatment of instability and for reconstructive indications since its introduction by Goel and Laheri in 1994 and modification by Harms in 2001. Placement of such lateral mass screws can be challenging because of the proximity to the spinal cord, vertebral artery, an extensive venous plexus, and the C-2 nerve root, which overlies the designated starting point on the posterior center of the lateral mass. An alternative posterior access point starting on the posterior arch of C-1 could provide a C-2 nerve root–sparing starting point for screw placement, with the potential benefit of greater directional control and simpler trajectory. The authors present a cadaveric study comparing an alternative strategy (i.e., a C-1 screw with a posterior arch starting point) to the conventional strategy (i.e., using the lower lateral mass entry site), specifically assessing the safety of screw placement to preserve the C-2 nerve root.METHODSFive US-trained spine fellows instrumented 17 fresh human cadaveric heads using the Goel/Harms C-1 lateral mass (GHLM) technique on the left and the posterior arch lateral mass (PALM) technique on the right, under fluoroscopic guidance. After screw placement, a CT scan was obtained on each specimen to assess for radiographic screw placement accuracy. Four faculty spine surgeons, blinded to the surgeon who instrumented the cadaver, independently graded the quality of screw placement using a modified Upendra classification.RESULTSOf the 17 specimens, the C-2 nerve root was anatomically impinged in 13 (76.5%) of the specimens. The GHLM technique was graded Type 1 or 2, which is considered “acceptable,” in 12 specimens (70.6%), and graded Type 3 or 4 (“unacceptable”) in 5 specimens (29.4%). In contrast, the PALM technique had 17 (100%) of 17 graded Type 1 or 2 (p = 0.015). There were no vertebral artery injuries found in either technique. All screw violations occurred in the medial direction.CONCLUSIONSThe PALM technique showed statistically fewer medial penetrations than the GHLM technique in this study. The reason for this is not clear, but may stem from a more angulated ”up-and-in” screw direction necessary with a lower starting point.

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C2 Nerve Root Sectioning in Posterior Atlantoaxial Instrumented Fusions: A Structured Review of Literature

Cited by 39 publications

References 50 publications

C2 and Greater Occipital Nerve: The Anatomic and Functional Implications in Spinal Surgery

C2 and Greater Occipital Nerve: The Anatomic and Functional Implications in Spinal Surgery

C₂ Nerve Dysfunction Associated with C₁ Lateral Mass Screw Fixation

Posterior arch C-1 screw technique: a cadaveric comparison study

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C2 Nerve Root Sectioning in Posterior Atlantoaxial Instrumented Fusions: A Structured Review of Literature

Cited by 39 publications

References 50 publications

C2 and Greater Occipital Nerve: The Anatomic and Functional Implications in Spinal Surgery

C2 and Greater Occipital Nerve: The Anatomic and Functional Implications in Spinal Surgery

C2 Nerve Dysfunction Associated with C1 Lateral Mass Screw Fixation

Posterior arch C-1 screw technique: a cadaveric comparison study

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Product

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C₂ Nerve Dysfunction Associated with C₁ Lateral Mass Screw Fixation