The Spine Journal - (2015) -

Review Article

Posterior atlantoaxial fixation: a review of all techniques

Da-Geng Huang, MD, Ding-Jun Hao, MD*, Bao-Rong He, MD, Qi-Ning Wu, MD,
Tuan-Jiang Liu, MD, Xiao-Dong Wang, MD, Hua Guo, MD, Xiang-Yi Fang, MD
Department of Spine Surgery, Honghui Hospital, Xi’an Jiaotong University Health Science Center, No. 76 Nanguo Rd, Xi’an, Shaanxi, 710054, China
Received 11 December 2014; revised 24 April 2015; accepted 1 July 2015

Abstract BACKGROUND CONTEXT: Posterior atlantoaxial fixation is an effective treatment for atlan-
toaxial instability. Great advancements on posterior atlantoaxial fixation techniques have been made
in the past decades. However, there is no article reviewing all the posterior atlantoaxial fixation
techniques yet.
PURPOSE: The aim was to review the evolution and advancements of posterior atlantoaxial
fixation.
STUDY DESIGN: This was a literature review.
METHODS: The application of all posterior fixation techniques in atlantoaxial stabilization, in-
cluding wiring techniques, interlaminar clamp fixation, transarticular fixation, screw-plate systems,
screw-rod systems, and hook-screw systems, are reviewed and discussed. Recent advancements on
the novel technique of atlantoaxial fixation are described. The combination of the C1 and C2 screws
in screw-rod systems are described in detail.
RESULTS: All fixation techniques are useful. The screw-rod system appears to be the most pop-
ular approach. However, many novel or modified fixation methods have been introduced in recent
years.
CONCLUSIONS: Great advancements on posterior atlantoaxial fixation techniques have been
made in the past decades. The wiring technique and interlaminar clamps technique have fallen
out of favor because of the development of newer and superior fixation techniques. The C1–C2
transarticular screw technique may remain the gold standard for atlantoaxial fusion, whereas
screw-rod systems, especially the C1 pedicle screw combined with C2 pedicle/pars screw fixation,
have become the most popular fixation techniques. Hook-screw systems are alternatives for atlan-
toaxial fixation. Ó 2015 Elsevier Inc. All rights reserved.

Keywords: Atlantoaxial instability; Posterior fixation; Clamp; Screw fixation; Wires; Lateral mass screw; Pedicle screw

Introduction instability is extremely dangerous and can be caused by

The atlantoaxial junction, including the atlas (C1) and
the axis (C2), is a highly specialized area of the spine.
The atlas and the axis are quite different from other verte-
brae, and very complex anatomically. Atlantoaxial
FDA device/drug status: Not applicable.
Author disclosures: D-GH: Nothing to disclose. D-JH: Nothing to dis-
close. B-RH: Nothing to disclose. Q-NW: Nothing to disclose. T-JL:
Nothing to disclose. X-DW: Nothing to disclose. HG: Nothing to disclose.
X-YF: Nothing to disclose.
* Corresponding author. Department of Spine Surgery, Honghui Hospi-
tal, Xi’an Jiaotong University Health Science Center, No. 76 Nanguo Rd,
Xi’an, Shaanxi, 710054, China. Tel./fax: (86) 29 33571457.
E-mail address: hdgrichard@sina.com (D.-J. Hao)
http://dx.doi.org/10.1016/j.spinee.2015.07.008
1529-9430/Ó 2015 Elsevier Inc. All rights reserved.
trauma, congenital malformation, tumor, or inflammation.
Posterior atlantoaxial fixation is an effective treatment for
atlantoaxial instability.
Since Gallie [1] first reported the use of sublaminar
wires for atlantoaxial fixation in 1939, great advancements
have been made in posterior atlantoaxial stabilization tech-
niques, especially in recent years. In the present study, we
review all posterior atlantoaxial fixation techniques, in-
cluding traditional, popular, and novel techniques. Posteri-
or atlantoaxial fixation techniques are categorized into six
main types: wiring, interlaminar clamps, atlantoaxial
transarticular screws, screw-plate system fixation, screw-
rod system fixation, and hook-screw system fixation
techniques.
2 D.-G. Huang et al. / The Spine Journal - (2015) -

Fig. 1. Gallie technique for atlantoaxial fusion. Fig. 3. Sonntag technique for atlantoaxial fusion.

The use of all wiring techniques requires an intact atlas

Wiring techniques posterior arch and axis lamina; the sublaminar passage of
the wire risks spinal cord injury. No wiring technique pro-
Posterior wiring was the initial atlantoaxial fixation vides sufficient stabilization, and thus supplemented rigid
technique. In 1939, Gallie [1] first described the use of sub- external fixation, which may reduce patients’ quality of life,
laminar wires for atlantoaxial fixation, also called Gallie fu- is required [1,4,7]. Furthermore, new fixation methods pro-
sion (Fig. 1). This is the simplest posterior atlantoaxial vide stronger stability. Therefore, wiring techniques are
fusion technique, but also uses the poorest quality biome- rarely used alone for atlantoaxial fixation currently.
chanical instrumentation [2]. The inferior stabilization dur-
ing rotation results in a very high nonunion rate (25%) [3].
In 1978, the Brooks-Jenkins technique was reported [4]. Interlaminar clamps techniques
In this technique, two separate iliac crest autografts are
placed between C1 and C2 and wrapped with wires The first use of interlaminar clamps in atlantoaxial fixa-
(Fig. 2). Brooks-Jenkins fixation provides more rotational tion was reported in 1984, and was called the Halifax tech-
stability than Gallie fixation [5], while providing similar nique [8]. After that, the Apofix clamps technique was
stability in flexion and extension [6]. A fusion rate of developed. Many studies reported the application of
93% was reported in the study by Brooks and Jenkins
[4]. However, the passage of bilateral sublaminar cables
under both the C1 and C2 lamina causes a higher potential
rate of spinal cord injury.
In 1991, Dickman et al. [7] reported a modification of
the Gallie technique, known as the Sonntag technique.
First, a sublaminar cable is passed under the atlas posterior
arch; next, a portion of the iliac crest is placed in between
the spinous process of the axis and wedged underneath the
atlas posterior arch (Fig. 3). With rigid external fixation, the
fusion rate with this technique was reported to be as high as
97%.

Fig. 4. Apofix clamps for atlantoaxial stabilization. The red arrow shows
Fig. 2. Brooks-Jenkins technique for atlantoaxial fusion. nonunion of graft bone.
 D.-G. Huang et al. / The Spine Journal
Fig. 5. A C1–C2 claw for atlantoaxial stabilization reported by Hanimo-
glu et al. [13]. A transverse connector was used to connect the bilateral
hooks to reinforce the stability. This modified technique might be an alter-
native method for atlantoaxial fusion when both the C1 and C2 screws are
difficult to place.
interlaminar clamps for atlantoaxial fixation, with accept-
able results [9–11]. These techniques provide similar fusion
results to that of the Brooks-Jenkins technique, but without
the disadvantage of sublaminar wires. However, clamp fix-
ation provides poor rotational stability and allows transla-
tional deformation along the sagittal plane, despite
excellent anteroposterior stability. Thus, hardware failure
and nonunion comprise the majority of complications of
the interlaminar clamps technique [12]. We used Apofix
clamps for atlantoaxial stabilization for many years. In
our experience, clamp slippage and pseudarthrosis were
common problems (Fig. 4). Late fractures of the C1 poste-
rior ring after atlantoaxial fusion with Halifax clamps were
also reported [12]. As with the wiring technique, clamp fix-
ation also requires an intact atlas posterior arch and axis
lamina [9]. Therefore, its application has fallen out of favor.
Recently, Hanimoglu et al. [13] reported the application
of a C1–C2 claw for atlantoaxial stabilization, with good
results in a small number of cases. The C1–C2 claw system
is actually a modification of the interlaminar clamps techni-
que, where C1 and C2 hooks are interconnected with a
Fig. 6. (Left) Posterior view of Magerl’s transarticular screw technique for atlantoaxial stabilization. (Right). Lateral view of Magerl’s transarticular screw
technique for atlantoaxial stabilization.
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transverse connector, thereby reinforcing the stability of
the construct against rotational forces (Fig. 5). This modi-
fied technique might be an alternative method for atlantoax-
ial fusion when both the C1 and C2 screws are difficult to
place.
Atlantoaxial transarticular screw technique
In 1992, Jeanneret and Magerl [14] first reported atlan-
toaxial transarticular screw fixation for C1–C2 stabilization
(Fig. 6), also called Magerl transarticular screw technique.
They had actually used this technique since 1979. Two
transarticular screws are inserted into the bilateral atlan-
toaxial lateral joints to immobilize C1 and C2. The entry
point is 3 mm lateral and 2 mm cephalad from the medial
C2–C3 joint line; the screw is directed toward the anterior
arch of the atlas sagittally, and 0 –10 medially. After this,
Gallie fusion is usually performed. If the posterior arch
of the atlas is not intact and Gallie fusion is unable to be
completed, direct atlantoaxial lateral joint fusion may be re-
quired [14]. Recently, some authors suggested the use of a
combination of a C1–C2 transarticular screw and a C1 hook
instead of Gallie fusion (Fig. 7) [15,16], whereas others re-
ported that additional internal fixation was not required
[17]. It has been reported that this modification avoided
the potential risk of spinal cord injury caused by the pas-
sage of sublaminar wires.
Atlantoaxial transarticular screw fixation provides excel-
lent stability and contributes to a high fusion rate [17,18]. It
is generally considered the ‘‘gold standard’’ of posterior at-
lantoaxial fusion [19]. This technique can be used in pa-
tients without intact C1 and C2 posterior elements. Rigid
external fixation, such as a halo-vest, is not required after
transarticular screw fixation, and improves patients’ quality
of life [20].
However, C1–C2 transarticular screw fixation requires
preliminary reduction of the atlantoaxial joint and cannot
be used in patients with thoracic kyphosis because of
4 D.-G. Huang et al. / The Spine Journal
Fig. 7. C1 hook combined with C1–C2 transarticular screw for atlantoax-
ial fusion.
difficult placement of the transarticular screw [14]. An ana-
tomic study indicated that bilateral transarticular screws
could not be completed in up to 20% of patients because
of anatomic variations of the foramen transversarium
[21]. Although effective, atlantoaxial transarticular screw
fixation is technically demanding and associated with a
steep learning curve. Disadvantages include the potential
risk of injury to the vertebral artery, the spinal cord, and
the hypoglossal nerve [22,23]. Jeanneret and Magerl [14]
reported one case of postoperative bilateral hypoglossal
nerve paresis in their original study.
A meta-analysis showed that the atlantoaxial transartic-
ular screw technique contributes to a fusion rate as high as
94.6%, as well as a 0.2% incidence of neurologic injury, a
3.1% incidence of vertebral artery injury, and a 7.1% inci-
dence of clinically significant malpositioned screws [24].
Screw-plate system
Goel’s screw-plate system
In 1994, Goel and Laheri [25] first described the use of a
screw-plate system for atlantoaxial stabilization (Fig. 8).
The famous C1 lateral mass screw technique was men-
tioned for the first time in their original study. In Goel’s
screw-plate technique, two screws were inserted into the
Fig. 8. Goel’s screw-plate system for atlantoaxial fusion; sacrifice of the
C2 nerve root is unavoidable.
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C1 lateral mass bilaterally; another two screws were in-
serted into the C2 pars bilaterally; and finally, the ipsilateral
C1 and C2 screws were connected by a metal plate. This
type of fixation provides rigid immobilization and obtains
excellent clinical results. Other authors reported the use
of a screw-plate system for atlantoaxial stabilization [26].
In Goel’s technique, sacrifice of the C2 ganglion is required
to place the instruments and prepare the facet joints for ar-
throdesis, thus resulting in postoperative scalp numbness in
some patients [27]. The screw-plate system has never been
widely used since it was first reported. Harms and Melcher
[28] later popularized this technique by modifying it into a
screw-rod system (Fig. 9).
Novel screw-plate system—C1 posterior locking plate
combined with C2 translaminar screw
In 2008, Kelly et al. introduced a novel screw-plate sys-
tem for C1–C2 fusion (Fig. 10), which was designed to de-
crease surgical risk [29]. In this technique, a C1 posterior
locking plate was combined with C2 translaminar screws
to immobilize C1 and C2. An in vitro biomechanical test
showed that this screw-plate system provided similar stabil-
ity to the Harms screw-rod system. However, there have
thus far been no reported clinical applications of this
technique.
Screw-rod system
In 2001, Harms and Melcher [28] first introduced the ap-
plication of a screw-rod system (Fig. 9) for C1–C2 fixation.
This instrument provides excellent immobilization with
fewer complications compared with other posterior atlan-
toaxial fixation instruments [2,30–34]. Since then, this tech-
nique has become increasingly popular [35]. It is currently
the most widely used technique for atlantoaxial fixation.
Many modifications of the original screw-rod system have
been reported [36–40]. All screw-rod systems are made
up of C1 screws, C2 screws, and rods connecting the C1
and C2 screws. In the present study, we review all the cur-
rent C1 and C2 screw techniques. And it is important to re-
member that to insert screws into atlas and axis safely, the
surgeon should have a good understanding of the vertebral
artery course at the C1~C2 level (Fig. 11).
C1 screw techniques
C1 lateral mass screw technique
The C1 lateral mass screw fixation was first reported by
Goel and Laheri in 1994 [25], and modified and popular-
ized by Harms and Melcher in 2001 [28]. In the widely
used Harms technique, the entry point is the middle of
the junction of the C1 posterior arch and the midpoint of
the posteroinferior portion of the C1 lateral mass
(Fig. 12). The screw is inserted in a straight or slightly con-
vergent trajectory in an anteroposterior direction, parallel to
 D.-G. Huang et al. / The Spine Journal - (2015) - 5

Fig. 9. (Left) Schematic plot of screw-rod system. (Right) Intraoperative picture of screw-rod system for atlantoaxial fixation.

the plane of the posterior arch of C1 in the sagittal direction
[28]. The Harms technique allows for preservation of the
C2 ganglion, as compared with Goel’s technique. However,
massive bleeding from the venous plexus and postoperative
C2 nerve dysfunction remain the challenges of the C1 lat-
eral mass screw technique [41–45]. Currently, we have in-
troduced a preoperative evaluation to predict the
development of C2 nerve dysfunction after C1 lateral mass
screw fixation, which may help to prevent this complication
[46].
C1 pedicle screw technique (C1 via posterior arch lateral
mass screw technique or C1 posterior arch screw
technique)
C1 pedicle screw fixation, first reported by Resnick and
Benzel in 2002, is actually inserting the C1 lateral mass
screw via the posterior arch (Fig. 12), and is also called
C1 via posterior arch lateral mass screw fixation or C1 pos-
terior arch screw fixation [47–49]. This technique provides
stronger pullout strength than C1 lateral mass screw fixa-
tion and successfully avoids bleeding from the venous
plexus and irritation to C2 nerve root [39,48,50–52]. Our
prospective, self-controlled comparative study demonstra-
ted the advantages of the C1 pedicle screw technique, as
superior to the C1 lateral mass screw technique; including
less blood loss, shorter operative times, and fewer postoper-
ative complications [53]. Thus, the C1 pedicle screw tech-
nique has become the most popular C1 screw technique
[48,52,54–56]. Many strategies of C1 pedicle screw place-
ment have been introduced [36–38,57,58]. Recently, a
study compared these different strategies and concluded
that Tan’s technique had the highest success rate of C1
pedicle placement (92%). However, none of these strategies
is universally safe due to significant anatomic variability
between atlas vertebrae [57]. It is generally accepted that
the 4 mm height of the C1 pedicle (defined as the C1 verte-
bral artery groove) is a limitation of the application of this
technique [38,57,59]. According to that point of view, the
C1 pedicle screw technique is not feasible for approxi-
mately 8% to 53.8% of patients [37,38,49,58,60–62].
Nevertheless, we find that the existence of a medullary ca-
nal facilitates successful C1 pedicle insertion [63,64]. Our
previous study demonstrated that if there is a medullary ca-
nal in the C1 pedicle, a 3.5-mm diameter pedicle screw can
be safely placed into the atlas, even if the pedicle height is
less than 4 mm [64].
C1 notching technique
Some authors modified the C1 lateral mass screw tech-
nique by using a high entry point (at the junction between

Fig. 10. (Left) C1 posterior locking plate reported by Kelly et al. [29]. (Right) A C1 posterior locking plate was combined with C2 translaminar screws to
immobilize C1 and C2.
6 D.-G. Huang et al. / The Spine Journal - (2015) -

Fig. 11. The vertebral artery (red arrow) course at upper cervical spine.

the midpoint of the C1 lateral mass and the inferior aspect
of the posterior arch; Fig. 13) [39,40,65]. A 2 to 3 mm
notch at the entry point is made to allow the screw to be
placed farther away from the C2 ganglion than the Harms
technique. This modified technique is called the notching
technique, and has been reported to successfully avoid post-
operative C2 nerve dysfunction [40]. Some authors point
out that such a C1 notching technique is actually a kind
of C1 posterior arch screw technique, which has been well
described by Yeom et al. [48].

Fig. 12. (Top Left) C1 lateral mass screw technique. (Top Right) C1 pedicle screw technique. (Bottom) The yellow point shows the entry point of C1 lateral
mass screw; and the blue point shows the entry point of C1 pedicle screw.
 D.-G. Huang et al. / The Spine Journal - (2015) - 7

Fig. 15. C2 pars screw technique.

C2 screw techniques
C2 pars screw technique
The placement of the C2 pars screw (Fig. 15) is similar
Fig. 13. C1 notching technique. to that of an atlantoaxial transarticular screw. The entry
point is 3 mm rostral and 3 mm lateral to the inferomedial
C1 posterior arch crossing screw technique aspect of the inferior articular surface. The screw trajectory
A recent study has demonstrated that it is possible to in- parallels the C2 pars but stops short of the joint. The
sert a crossing screw into the C1 posterior arch in 89% of
patients. In vitro biomechanical testing has shown that the
C1 posterior arch crossing screw-rod system (Fig. 14) can
provide rigid stabilization in C1–C2 fixation [66]. This
technique reduces the risk of injury to neurovascular struc-
tures, in theory. However, no clinical application of this
technique has been reported as of yet.

Fig. 14. Schematic plot of C1 posterior arch crossing screw technique for
atlantoaxial fixation. Fig. 16. C2 pedicle screw technique.
8 D.-G. Huang et al. / The Spine Journal
Fig. 17. Schematic plot of C2 translaminar screw technique.
potential risks are similar to those of posterior atlantoaxial
transarticular screw insertion, mainly including vertebral
artery injury [22,23,67].
C2 pedicle screw technique
C2 pedicle screw fixation (Fig. 16) was also first de-
scribed by Goel and Laheri [25], and later popularized by
Harms and Melcher [28]. The entry point is midway be-
tween the superior and inferior articular processes. The di-
rection of the screw is 15 –30 medial and 20 –
25 cephalad. Although a biomechanical study has shown
that C2 pedicle screws have twice the pullout strength of
C2 pars screws [68], the clinical results of the two fixation
techniques are similar [69]. Both the C2 pedicle screw and
C2 pars screw are widely used for screw-rod system fixa-
tion of C1–C2 fusion [69].
Fig. 18. C1 hook combined with the C2 pedicle screw for atlantoaxial
fixation.
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C2 translaminar screw
Wright first described the C2 translaminar screw techni-
que (Fig. 17) in 2004 [70]. Since then, many authors have
reported both the anatomical study and clinical application
of this technique [71–75]. In this technique, screws are in-
serted into the lamina of C2 in a crossed trajectory and then
connected with rods to C1 lateral mass screws, C1 pedicle
screws, or even the C1 locking plate [29]. The biomechan-
ical study showed that it was superior to the pars screw in
both pullout strength and insertional torque [76]. It is tech-
nically simple and eliminates the risk of vertebral artery in-
jury. Thus, the C2 translaminar screw technique is
considered to be a viable salvage in failed C2 pedicle inser-
tion and in cases of high-riding anomalous vertebral ar-
teries [77]. Excellent clinical outcomes of this technique
have been reported in many studies recently [73–75].
Hook-screw system
Currently, there are three combinations of the hook and
screw in atlantoaxial fixation: C1 hook combined with C2
screw; C1 hook combined with C1–C2 transarticular screw;
and C1 screw combined with C2 hook. Usually, these tech-
niques are alternatives for atlantoaxial stabilization when
the screw-rod system is not feasible.
C1 hook combined with C2 screw
The application of the C1 hook combined with the C2
pedicle/pars screw for atlantoaxial fusion (Fig. 18) has been
reported in some studies [78–80]. Mostly, it is used as an
alternative when the screw-rod system or the Magerl’s
transarticular screw technique is not feasible. The hook-
screw technique is less technically demanding compared
with the screw-rod technique or transarticular screw techni-
que and has gained excellent results in the limited cases re-
ported [80].
C1 hook combined with C1–C2 transarticular screw
The technique of the C1 hook combined with the C1–C2
transarticular screw (Fig. 7) is actually a modification of
Magerl’s transarticular screw fixation technique, which
combines the C1 hooks instead supplementing with Gallie
fusion [15,16]. Recently, Guo et al. [16] reported excellent
long-term outcomes of a case series treated by this
technique.
C1 screw combined with C2 hook
Recently, a novel hook-screw technique for C1–C2 fixa-
tion was reported: a C1 lateral mass screw combined with a
C2 claw formed by opposing laminar hooks (Fig. 19) [81].
Biomechanical tests showed that this novel fixation techni-
que provides similar stability to the Harms screw-rod sys-
tem [81]. It is compelling because it eliminates the risk
 D.-G. Huang et al. / The Spine Journal
Fig. 19. C1 screw combined with C2 hooks for atlantoaxial fixation reported by Reis et al. [81].
of vertebral artery injury; additionally, the transarticular
screw technique is not feasible for 20% of patients, and
C2 pedicle screw fixation is not feasible for 9%of patients
due to the high risk of vertebral artery injury. However, a
clinical application of this technique has not been reported
as of yet.
Conclusions
Great advancements in posterior atlantoaxial fixation
techniques have been made in the past decades. The wiring
technique and interlaminar clamps technique have fallen
out of favor because of the development of newer and supe-
rior fixation techniques. The C1–C2 transarticular screw
technique may remain the gold standard for atlantoaxial fu-
sion, whereas screw-rod systems, especially the C1 pedicle
screw combined with C2 pedicle/pars screw fixation, have
become the most popular fixation techniques. Hook-screw
systems are alternatives for atlantoaxial fixation.
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