Journal of Clinical Neuroscience 13 (2006) 193198

www.elsevier.com/locate/jocn

Clinical study

Clinical experience with rigid occipitocervical fusion in the

management of traumatic upper cervical spinal instability
Sai-Cheung Lee, Jyi-Feng Chen, Shih-Tseng Lee

Department of Neurosurgery, Chang Gung University and Chang Gung Memorial Hospital, 5, Fu-Shing Street, 333, Kweishan, Taoyuan, Taiwan
Received 18 November 2004; accepted 4 March 2005

Abstract
Traumatic injuries of the craniovertebral junction or the upper cervical spine may result in occipitocervical (OC) or upper cervical
spinal instability. Internal xation can provide immediate stability to this region. Over a 6-year period, 16 patients with traumatic upper
cervical spinal instability underwent a posterior approach OC fusion, using a plate and screw system, at the neurosurgical department of
our institution. One patient died. The postoperative course of all the other patients was uncomplicated. At the most recent follow-up
examination, all patients had satisfactory fusion. OC fusion with a plate and screw system is a safe and eective method for the treatment
of traumatic craniovertebral and high cervical spine instability. Accurate imaging diagnosis and strict patient selection are the keys to a
successful outcome.
2006 Elsevier Ltd. All rights reserved.
Keywords: Spinal trauma; Occipitocervical fusion; Posterior spinal instrumentation

1. Introduction
Traumatic injuries of the craniovertebral junction (CVJ)
and the atlantoaxial complex are notoriously dicult diagnostic and therapeutic problems due to the complex anatomical structures and diverse mechanisms of trauma
involved.110 These injuries may cause immediate fatality
or delayed deterioration of neurological function.3,1113 Rigid internal xation can provide immediate stability to the
unstable CVJ or the upper cervical spine. Several reports
have been published describing excellent results obtained
when treating CVJ and upper cervical instability with
occipitocervical (OC) xation using a plate and screw system.59 However, the surgical indications for this method
in trauma have not yet been established. This study critically analyses our clinical experience of 16 patients with

Corresponding author. Tel.: +886 3 3281200x2119; fax: +886 3

3285818.
E-mail address: yun0710@adm.cgmh.org.tw (S.-T. Lee).
0967-5868/$ - see front matter 2006 Elsevier Ltd. All rights reserved.
doi:10.1016/j.jocn.2005.03.031

traumatic upper cervical spinal injuries using OC fusion

with plate and screw instrumentation.
2. Materials and methods
Over a 6-year period, 16 patients with traumatic upper
cervical spinal instability underwent a posterior approach
OC fusion with a plate and screw system at the neurosurgical department of our institution (Table 1). Pre-operative
imaging included cervical radiographs (anteriorposterior
(AP), lateral and exionextension views) and cervical
CT and MRI. Treatment was chosen considering a number
of dierent factors, including the general medical condition
of the patient, the severity and location of the fracture,
compression of the spinal cord, stability of the joints and
the neurological status.
If there was cervical spinal mal-alignment, we attempted
rst to reduce the dislocation using GardnerWells tong
skull traction. Cervical MRI was performed to evaluate
spinal cord compression. In patients with mal-positioning
of the dens with anterior compression of the spinal cord,

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S.-C. Lee et al. / Journal of Clinical Neuroscience 13 (2006) 193198

Table 1
Clinical data of the 16 patients undergoing occipitocervical fusion
Sex

Male
Female

Mechanism
of injury

Motorcycle accident
Fall
Motor vehicle accident

6
5
5

Diagnosis

Old and irreducible C12 subluxation

Old and irreducible C1-2 subluxation and C1 or 2
fracture
Old and irreducible C2 type II fracture
Old C2 burst fracture
Acute miscellaneous C2 fracture
Acute complex C1-2 fracture
Acute complex C1-2-3 fracture dislocation

3
3

Operative
procedure

13
3

Occipitocervical instrumentation with fusion

Transoral odontoid decompression
C1 laminectomy

2
1
3
3
1
16
6
3

and failure of skull traction reduction with concomitant

neurologic decits, a transoral decompression with resection of the dens was performed as rst-stage surgery, 2 to
3 days prior to the posterior OC fusion. The need for a
laminectomy was evaluated based on the clinical ndings
of either cervical myelopathy or radiculopathy, and the
presence of spinal cord compression on MRI. If posterior
decompression of the spinal cord was necessary, posterior
decompression was performed at the same surgery as the
OC fusion procedure.
All patients underwent OC fusion with titanium alloy or
stainless steel contoured plates and screws (Syntec Scientic Corporation, Taiwan). We used various instrumentation techniques, depending on the spinal level. Our
preference for instrumentation methods used at dierent
spinal levels is summarized in Fig. 1.
AP and lateral radiographs were taken immediately
after surgery and monthly for at least 6 months, and a
hard cervical collar was worn for at least 3 months postoperatively. Clinical follow-up was performed at least
once every month for 6 months, and then once every 6
months thereafter. Satisfactory union was dened as the
absence of pathological movement of the occipitalC1
Level
Occipital bone

C1

3. Results
There were 13 male and three female patients with a
mean age of 41 years (range, 2060 years) (Table 1). All
the patients had sustained major trauma. The time elapsed
between the trauma and the day of surgery ranged from 4
days to 6 months. Motorcycle accidents were the mechanism of injury for six patients; falls and motor vehicle accidents accounted for ve patients each. Associated injuries
included traumatic brain injury with loss of consciousness
(2), skull fracture (3), clavicle fracture (2) and long bone
fracture (3). Table 1 shows the cervical spine injuries as
diagnosed on imaging. One patient with C12 subluxation
had undergone C12 Halifax clamps and an allograft
fusion 6 months previously at another hospital, but the
fusion failed and there was persistent C12 instability on
serial follow-up cervical spine radiographs.
Preoperatively, all patients suered from signicant
neck pain, stiness or abnormal posture. Eight patients
had neurological decits, one had a grade C lesion and seven a grade D lesion on the Frankel grading scale. Six patients underwent anterior transoral decompression surgery
prior to the posterior xation procedure, and three patients
required a C1 laminectomy with the OC fusion procedure.
One patient died. This patient had an old C12 subluxation
with a 3-month history of progressive quadriparesis, with
2/5 power in all limbs immediately pre-operatively. This
patient had been bedridden for 2 months prior to the surgery. The patient underwent a transoral odontoidectomy
prior to posterior OC fusion. Infection of the oral anterior
odontoidectomy wound with septic shock developed. The
patient died of multiple organ failure due to sepsis 14 days
after the posterior OC fusion. No surviving patient had
neurological deterioration postoperatively.
The postoperative course of the surviving patients was
uncomplicated, and they were discharged 5 to 14 days after

Decreasing preference
Occipital
screw
C12
transarticular
screw

C2

Subaxial
vertebrae

C2 complex or, in cases of where a bone graft was placed,

the presence of a homogeneous fusion mass visualized on
lateral radiographs. The follow-up period ranged from 8
to 18 months.

C12
sublaminar wire
Transpedicle
screw

Lateral mass

Sublaminar
wire to plate
Sublaminar
wire to plate

Sublaminar
wire to plate

Fig. 1. Outline of our preference for instrumentation in the surgical management of C1-2 and upper cervical unstable traumatic fractures.

S.-C. Lee et al. / Journal of Clinical Neuroscience 13 (2006) 193198

surgery wearing a hard cervical collar for 3 months. Of the

patients who had a myelopathy preoperatively, three improved from Frankel grade D to grade E. The other four
patients remained at the same Frankel grade, but symptoms of spinal cord compression improved to some extent
in all. Neck pain improved in all patients and no new instability developed at adjacent levels. At the most recent follow-up examination, all patients had a satisfactory fusion
and were independent in daily activity.
4. Discussion
Craniovertebral junction instability represents the primary indication for OC fusion. Traumatic atlanto-occipital
dislocation (AOD) with survival is rare, as the neurological
consequences are usually immediately fatal.3,11 However,
the use of OC fusion in trauma patients is not limited to
the stabilization of AOD in clinical practice.510 The indication for OC fusion in trauma patients, an extensive posterior instrumentation xation procedure that sacrices the
motion of the occipital and C12 complex and a variable
amount of subaxial motility, is still controversial.410 The
clinical experience gained in this series helped us to obtain
useful information to develop treatment guidelines for this
type of trauma patient.
Patients with atlantoaxial instability may need OC fusion under certain circumstances. Six cases of old and
irreducible C12 subluxation were included in this series,
and three of them were associated with a C1 or C2 fracture. If complete reduction of the C12 subluxation is
possible, we usually perform a transarticular screw xation of C12 so that occipitalC1 motion is preserved.
However, irreducible C12 subluxation may necessitate
OC fusion for stability. As incomplete reduction of C1
2 subluxation is a statistically signicant risk factor for
C12 transarticular screw mal-positioning, screw breakage
may occur, even with a well-positioned contralateral
screw.14 Moreover, the risk of vertebral artery injury is increased during the placement of transarticular screws if
the C12 subluxation has not been not well reduced.
Additionally, intact C1 and C2 laminae are necessary
for C12 posterior fusion; any fracture of the posterior
elements of C1 or C2 may preclude C12 sublaminar wire
xation. Thus the instrumentation must be extended upward to the occiput, and OC fusion is necessary
(Fig. 2).15 We thus recommend OC fusion for patients
with C12 instability, in which C12 cannot be completely
reduced, or in those cases in which instrumentation or fusion limited to the C12 level is impossible.
Of the 16 patients in this series, only two cases of odontoid type II fracture required OC fusion. Both of the patients had old and irreducible fractures. One patient has
undergone C1 laminectomy and so fusion had to be extended to the occiput. Another patient underwent transoral
decompression with resection of the C1 anterior arch and
dens. Recently, an number of strategies have been used
to treat type II odontoid fractures.1,1623 When type II

195

and rostral type III fractures are acute and reducible, they
are best treated by anterior odontoid screw xation as rigid
internal stabilization and preservation of intrinsic C12
motion can be achieved.1,1821 C12 arthrodesis using transarticular screws is reserved for old but reducible type II
odontoid fractures.12,24 Extensive internal xation, with
OC fusion of the CVJ is only required for old and irreducible C2 fractures, for patients who have had a transoral
odontoidectomy, or those who have an incompetent C1
lamina, all of which make a C12 posterior fusion
impossible.1
Transoral odontoidectomy results in severe ligamentous and osseous destruction.2530 Six patients in this series underwent transoral resection of the anterior arch of
the C1 and dens of C2, with one mortality due to wound
infection which progressed to septic multi-organ failure.
This procedure alters the CVJ anatomy and aects the
biomechanics of the region. The resultant occiputC1
and C12 hypermobility requires OC xation.25 The risk
of infection should be remembered, as the approach is
through a contaminated eld. Severe septic complications
may arise in seriously ill patients,28 as was the case for
our quadriparetic and bedridden patient, whose general
condition was poor prior to surgery. Local infection can
be avoided with meticulous preoperative oral antisepsis,
with early removal of the tracheal cannula and early uid
feeding. However, the risk of wound infection remains
high in immunocompromised patients and those in poor
general condition.
Miscellaneous axis fractures include the non-odontoid,
non-hangmans C2 fractures, most of which involve the
vertebral body or lateral mass. Few reports in the literature describe the treatment of these fractures, but they
are usually treated non-operatively.23,31 Hadley et al. recommended 8 to 12 weeks of halo vest or similar immobilization for patients with signicant fractures of the C2
vertebral body, pedicle or lateral mass. Immobilization
with a rigid collar for 6 weeks was recommended for patients with less severe or more stable injuries.31 But a
cumbersome rigid external orthosis, such as a halo vest,
worn for 2 to 3 months, results in psychological and physical suering for the patient. If the patient cannot tolerate
this xation, we are reluctant to subject them to prolonged periods of immobilization (Fig. 3). We oer two
options for miscellaneous unstable axis fractures to these
patients. To permit the quickest resumption of the patients pre-morbid activities, instrumented internal xation
is the method of choice. Halo immobilization is an
alternative.
Three patients with miscellaneous C2 fractures underwent OC fusion in this series, aged 23, 30 and 33 years.
None of them had major systemic disease, and all were psychologically intolerant to rigid halo vest immobilization.
Surgery creates a solid construct-augmented xation at
the time of operation so the use of cumbersome and poorly
tolerated external orthoses is avoided. All three patients
went back to their previous occupation within 3 weeks of

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S.-C. Lee et al. / Journal of Clinical Neuroscience 13 (2006) 193198

Fig. 2. This 60-year-old male patient had an old, irreducible C12 subluxation. He had been involved in a motor vehicle accident 3 months previously, and
had subsequently developed progressive numbness in all four limbs. Pre-operative lateral X-rays in extension (a) and exion (b) show C12 subluxation. (c)
Preoperative cervical spinal CT scan with reconstruction reveals a fracture of the anterior arch, both sides of the posterior arch and the left lateral mass of
C1. An increase in the pre-odontoid space (7.1 mm) indicates C12 subluxation. (d) Postoperative lateral cervical X-ray.

surgery, wearing a hard cervical collar, and had achieved

satisfactory fusion within 3 months. These patients were
satised with the operative result. We emphasize that only
in highly selected cases, those who are relatively young,
with low anaesthesia and surgical risks, should OC fusion
followed by a hard cervical collar for 3 months be considered an alternative treatment strategy to halo vest
immobilization.

The principles of the surgical management of acute,

complex C12 fractures are similar to those that govern
the management of isolated atlas and axis fractures.3234
Most patients can be treated successfully with an external
orthosis. Specic treatment recommendations depend on
the extent of injury to the atlas, axis and transverse atlantal
ligament.33 Type II odontoid fractures with a displacement
of more than 5.06.0 mm have a high non-union rate when

S.-C. Lee et al. / Journal of Clinical Neuroscience 13 (2006) 193198

197

Fig. 3. This 33-year-old male patient suered severe neck pain, but was neurologically intact after a motorcycle accident 4 days before surgery.
Preoperative lateral X-rays in (a) extension and (b) exion show a C2 dens fracture; (c) Preoperative cervical spine CT scan with reconstruction shows a
miscellaneous C2 fracture including comminuted fractures of the base of the odontoid process and the body of the C2, involving the right vertebral
foramen and right lateral mass. There is no pathway for transarticular screw xation on the right but transarticular screw placement on the left is possible.
(d) Postoperative lateral cervical spine X-ray.

treated non-surgically, and should be treated by early internal xation.32 When these fractures are combined with
multiple C1 fractures, instrumentation limited to the C1
2 level is impossible, and OC fusion is necessary.
Some complex C12 fractures may include a miscellaneous C2 fracture as described above. Our treatment for

this type of complex C12 fracture is similar to that of isolated miscellaneous C2 fractures. Four patients with complex C12 or C123 fractures in this series underwent
OC fusion. Two had miscellaneous C2 fractures combined
with a C1 fracture and the other two had displaced type II
odontoid fractures combined with C1 fractures. Patients

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S.-C. Lee et al. / Journal of Clinical Neuroscience 13 (2006) 193198

achieved immediate stability after the operation and successful bone fusion after wearing a hard cervical collar
for 3 months; a halo vest was avoided.
5. Conclusion
OC fusion with a plate and screw system is a safe and
eective method for the treatment of traumatic CVJ and
high cervical spine instability. We recommend that the
spinal xation technique should be individually selected
based on the location and extent of the injury. Accurate
imaging diagnosis and strict patient selection are the keys
to a successful outcome.
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