Atlantoaksiyel eklem instabilitesinde sublaminar sarmal ipekle yapılan redüksiyon ve artrodez

Öz

Amaç: Bu yazıda atlantoaksiyel eklem instabilitesinde sublaminar telleme yerine kalın sarmal ipek kullanılarak yapılan C1-C2 artrodez tekniğinin klinik ve radyolojik sonuçlarının değerlendirilmesi amaçlandı.

Çalışma planı: Atlantoaksiyel instabilitesi bulunan ve redüksiyonları yapıldıktan sonra sublaminar sarmal ipekle C1-C2 füzyonu gerçekleştirilen 16 hasta (10 kadın, 6 erkek; ortalama yaş: 43.4, ortalama takip süresi: 34 ay) retrospektif olarak incelendi. Açık redüksiyondan sonra tel yerine sarmal ipekle iki taraflı laminaları bağlanan ve sonrasında otogreftle artrodezi yapılan bu olguların, redüksiyon oranları, vidaların pozisyonları ve füzyon değerleri bilgisayarlı tomografiyle değerlendirildi.

Bulgular: Cerrahi öncesi ortalama atlantodental açıklık (ADA) değeri 8 (dağılım: 6-11) mm, cerrahi sonrasında ise ortalama 2.1 (dağılım: 0.5-2.5) mm olarak ölçüldü. Dural veya spinal kord yaralanmasına bağlı bir komplikasyon gözlenmedi. Tüm olgularda redüksiyonun tam olduğu görüldü. Sadece bir olguda füzyon oluşmadı (%6.25). Olguların cerrahi sonrası fleksiyonda ortalama 10 mm olan ADA değeri, ekstansiyonda 1 mm olarak ölçüldü. Tomografik ince kesitlerde C1-C2 arasında bir olgu hariç greft ayrışmasına ait bulguya rastlanmadı. İki adet vidada (%4) malpozisyon belirlendi.

Çıkarımlar: Sublaminar sarmal ipek tekniği güvenli anatomik redüksiyon sağlaması, ucuz ve basit bir yöntem olması, ekstra implant gerektirmemesi, gevşememesi, nörolojik hasar yaratmaması ve radyolojik kirlilik oluşturmaması nedeniyle sublaminar tellemeye alternatif bir cerrahi uygulamadır.

Anahtar Kelimeler

• Atlantoaksiyel stabilizasyon; servikal omurga; interlaminar füzyon.

Reduction and arthrodesis with sublaminar spiral silk in atlantoaxial joint instability

Öz

Objective: The aim of this study was to evaluate the clinical and radiologic results of the use of thick spiral silk knotting instead of sublaminar wiring for C1-C2 arthrodesis in patients with atlantoaxial instability.

Methods: We retrospectively evaluated 16 patients (10 females, 6 males; mean age: 43.4 years; mean follow-up: 34 months) with atlantoaxial instability who underwent C1-C2 fusion by reduction and sublaminar spiral silk knotting. All patients underwent open reduction, bounding both laminae with thick spiral silk instead of wiring and arthrodesis with autografting. Reduction rates, screw position and fusion rates were evaluated using computed tomography.

Results: Preoperative mean atlantodental interval (ADI) was 8 (range: 6 to 11) mm and postoperative ADI was 2.1 (range: 0.5 to 2.5) mm. There was no dural or spinal cord injury. Complete reduction was observed in all cases. Fusion was unsuccessful in 1 case (6.25%). Postoperative mean flexion ADI was 10 mm and mean extension ADI was 1 mm. Graft separation between C1-C2 was observed in slice tomographic examination in one patient. Malposition was observed in 2 screws (4%).

Conclusion: The sublaminar silk knotting technique appears to provide safe anatomical reduction. As this method is cheap and simple and does not require extra implantation, loosen, create neurologic compromise or cause radiologic crowding, it can be considered an alternative surgical technique to sublaminar wiring.

Anahtar Kelimeler

• Atlantoaxial stabilization
• cervical spine
• interlaminar fusion

Kaynakça

1. Kotil K, Kalayci M, Bilge T. Management of cervicome- dullary compression in patients with congenital and ac- quired osseous-ligamentous pathologies. J Clin Neurosci 2007;14:540-9.
2. Kotil K, Köksal NS, Kayacı S. Posterior transodontoid fixation: A new fixation (Kotil) technique. J Craniovertebr Junction Spine 2011;2:41-5.
3. Dickman CA, Sonntag VK. Posterior C1-C2 transarticu- lar screw fixation for atlantoaxial arthrodesis. Neurosur- gery 1998;43:275-81.
4. Gluf WM, Brockmeyer DL. Atlantoaxial transarticular screw fixation: a review of surgical indications, fusion rate, complications, and lessons learned in 67 pediatric patients. J Neurosurg Spine 2005;2:164-9.
5. Gluf WM, Schmidt MH, Apfelbaum RI. Atlantoaxial transarticular screw fixation: a review of surgical indica- tions, fusion rate, complications, and lessons learned in 191 adult patients. J Neurosurg Spine 2005;2:155-63.
6. Paramore CG, Dickman CA, Sonntag VK. The anatomi- cal suitability of the C1-2 complex for transarticular screw fixation. J Neurosurg 1996;85:221-4.
7. Madawi AA, Casey AT, Solanki GA, Tuite G, Veres R, Crockard HA. Radiological and anatomical evaluation of the atlantoaxial transarticular screw fixation technique. J Neurosurg 1997;86:961-8.
8. Melcher RP, Puttlitz CM, Kleinstueck FS, Lotz JC, Harms J, Bradford DS. Biomechanical testing of posterior atlantoaxial fixation techniques. Spine 2002;27:2435-40.

9. Gallie WE. Fracture and dislocations of the cervical spine. Am J Surg 1939;46:495-9.
10. Fraser AB, Sen C, Casden AM, Catalano PJ, Post KD. Cervical transdural intramedullary migration of a sub- laminar wire. A complication of cervical fixation. Spine 1994;19:456-9.
11. Geremia GK, Kim KS, Cerullo L, Calenoff L. Complica- tions of sublaminar wiring. Surg Neurol 1985;23:629-35.
12. Lundy DW, Murray HH. Neurological deterioration after posterior wiring of the cervical spine. J Bone Joint Surg Br 1997;79:948-51.
13. Schrader WC, Bethem D, Scerbin V. The chronic lo- cal effects of sublaminar wires. An animal model. Spine 1988;13:499-502.
14. Kakarla UK, Valdivia JV, Sonntag VK, Bambakidis NC. Intracranial hemorrhage and spinal cord injury from a fractured C1-C2 sublaminar cable: case report. Neurosur- gery 2010;66:E1203-4.
15. Grob D, Crisco JJ 3rd, Panjabi MM, Wang P, Dvorak J. Biomechanical evaluation of four different posterior atlan- toaxial fixation techniques. Spine 1992;17:480-90.
16. Harms J, Melcher RP. Posterior C1-C2 fusion with poly- axial screw and rod fixation. Spine 2001;26:2467-71.
17. Henriques T, Cunningham BW, Olerud C, Shimamoto N, Lee GA, Larsson S, et al. Biomechanical comparison of five different atlantoaxial posterior fixation techniques. Spine 2000;25:2877-83.
18. Lapsiwala SB, Anderson PA, Oza A, Resnick DK. Biome- chanical comparison of four C1 to C2 rigid fixative tech- niques: anterior transarticular, posterior transarticular, C1 to C2 pedicle, and C1 to C2 intralaminar screws. Neuro- surgery 2006;58:516-21.
19. Matsumoto M, Chiba K, Nakamura M, Ogawa Y, Toyama Y, Ogawa J. Impact of interlaminar graft materials on the fusion status in atlantoaxial transarticular screw fixation. J Neurosurg Spine 2005;2:23-6.
20. Garcia R Jr, Gorin S. Failure of posterior titanium atlanto- axial cable fixation. Spine J 2003;3:166-70.
21. Bahadur R, Goyal T, Dhatt SS, Tripathy SK. Transar- ticular screw fixation for atlantoaxial instability - modi- fied Magerl’s technique in 38 patients. J Orthop Surg Res 2010;5:87.
22. Ito T, Hayashi M, Takei H. Loosening of supplemental cable in transarticular screw fixation and bone grafting. J Orthop Surg 1998;6:71-4.
23. Ito H, Neo M, Fujibayashi S, Miyata M, Yoshitomi H, Nakamura T. Atlantoaxial transarticular screw fixation with posterior wiring using polyethylene cable: facet fu- sion despite posterior graft resorption in rheumatoid pa- tients. Spine 2008;33:1655-61.
24. Stillerman CB, Wilson JA. Atlanto-axial stabilization with posterior transarticular screw fixation: technical descrip- tion and report of 22 cases. Neurosurgery 1993;32:948- 55.