Markus R Konieczny1, Arnold Gstrein2, Ernst J Müller2. 1. Department of Orthopedic Surgery, University Hospital Düsseldorf, Moorenstrasse 5, 40225 Düsseldorf, Germany. E-mail address: Markus@Konieczny.net. 2. Department of Traumatology, General Hospital Klagenfurt, Feschnigstrasse 11, 9020 Klagenfurt, Austria. E-mail address for A. Gstrein: Arnold.Gstrein@lkh-klu.at. E-mail address for E.J. Müller: Ernst.Mueller@lkh-klu.at.
Abstract
INTRODUCTION: Direct anterior screw fixation of the dens preserves C1-C2 rotation, and the reported fusion rates range from 88% to 100%. STEP 1 POSITIONING OF THE PATIENT: Exact positioning of the patient and use of image intensifiers are mandatory to obtain perfect anteroposterior and lateral views of the axis. STEP 2 SURGICAL APPROACH: The surgical approach is standardized, and the pretracheal layer can be exposed without violating any essential anatomic structures. STEP 3 ENTRY POINT OF THE SCREW: The perfect entry point is directly anterior-inferior at the base of C2; therefore, the anterior rim of the C2-C3 intervertebral disc must be penetrated. STEP 4 SCREW INSERTION: We use a single cannulated screw in most cases: insert the screw in the center of the dens with its tip perforating the cranial, cortical bone of the dens just posterior to the apex. STEP 5 WOUND CLOSURE: Precise and anatomic closure of the platysma determines the quality of the scar that will be visible after the operation. STEP 6 FOLLOW-UP: The patient wears a rigid collar for six weeks, removing it for body care; radiographic evaluations should be performed regularly. RESULTS: In a study of sixty-nine patients with a fracture of the dens, three of the thirteen patients who underwent direct anterior screw fixation had persistent instability and nonunion of the dens four months after surgery. Indications Contraindications Pitfalls & Challenges.
INTRODUCTION: Direct anterior screw fixation of the dens preserves C1-C2 rotation, and the reported fusion rates range from 88% to 100%. STEP 1 POSITIONING OF THE PATIENT: Exact positioning of the patient and use of image intensifiers are mandatory to obtain perfect anteroposterior and lateral views of the axis. STEP 2 SURGICAL APPROACH: The surgical approach is standardized, and the pretracheal layer can be exposed without violating any essential anatomic structures. STEP 3 ENTRY POINT OF THE SCREW: The perfect entry point is directly anterior-inferior at the base of C2; therefore, the anterior rim of the C2-C3 intervertebral disc must be penetrated. STEP 4 SCREW INSERTION: We use a single cannulated screw in most cases: insert the screw in the center of the dens with its tip perforating the cranial, cortical bone of the dens just posterior to the apex. STEP 5 WOUND CLOSURE: Precise and anatomic closure of the platysma determines the quality of the scar that will be visible after the operation. STEP 6 FOLLOW-UP: The patient wears a rigid collar for six weeks, removing it for body care; radiographic evaluations should be performed regularly. RESULTS: In a study of sixty-nine patients with a fracture of the dens, three of the thirteen patients who underwent direct anterior screw fixation had persistent instability and nonunion of the dens four months after surgery. Indications Contraindications Pitfalls & Challenges.