Clinical and radiological outcomes of image guided posterior C1-C2 fixation for atlantoaxial osteoarthritis (AAOA)

Mitchell Fung, Ellen Frydenberg, Leslie Barnsley, Joga Chaganti, Timothy Steel


Background: Atlantoaxial (C1-C2) osteoarthritis (AAOA) causes severe suboccipital pain exacerbated by lateral rotation. The pain is usually progressive and resistant to conservative therapy. Posterior fusion surgery is performed to stabilise the C1-C2 segment. This is the first Australian study reporting the outcome of posterior atlantoaxial fixation including hybrid fixations performed for AAOA.
Methods: All patients who underwent posterior atlantoaxial fixation surgery for AAOA from 2005 to 2015 at our institutions were enrolled (N=23). Patient demographics and surgical technique were recorded. These techniques included transarticular screw (TAS) fixation using image guidance with iliac crest bone graft and supplemental posterior Sonntag wiring, or C1-C2 lateral mass fixation (Harms technique). Some patients required a combination of fixation due to anatomical variation. Primary outcome measures including patient satisfaction, pain, disability scores and range of motion were recorded for all patients pre- and post-operatively. Post-operative assessment was supplemented with CT and X-ray imaging.
Results: Twenty-three patients (19 women, 4 males, mean age 71.8±6.3 years) underwent surgical fixation. Eight underwent TAS fixation, 8 had Harms fixation, and 7 had a hybrid fixation. All patients reported statistically significant improvement in pain scores [Visual Analogue Scale (VAS) 9.4 pre-op compared to 2.9 post-op, P<0.005]. Disability scores [Neck Disability Index (NDI)] were statistically significantly reduced from 72.2±12.9 pre-operatively to 18.9±11.9 post-operatively, P<0.005. Mean follow-up was 55.3±36.1 months. Results did not vary according to the construct type. Ninety-five point five percent of patients showed radiographic evidence of fusion. Ninety-one percent of patients said they would undergo the surgery again.
Conclusions: Posterior atlantoaxial fixation with TAS and Harms constructs are highly effective for the surgical treatment of intractable neck pain secondary to atlantoaxial lateral mass osteoarthritis (AAOA). Surgery offers a high rate of symptom relief. If anatomical variability exists, both transarticular and pedicle screw fixation could be safely used in the same patient.