Atlanto occipital dissociation is a highly unstable injury which is a life threatening condition. It is produced by high intensity trauma.
As these patients are often polytrauma patients, this lesion may be missed during patient assessment. Once identified immediate reduction and fixation is mandatory if the clinical condition allow surgery.
The following points are generally considered as criteria for occipitocervical instability:
There are several plate systems available for the occiput (examples shown on the left). Their application is based on the same principles and to illustrate these concepts, we will show the use of plate placed in the midline which allows for modularity and rotation when connecting to the rods.
If plates are not available, wiring techniques may also be used. These will not be described in detail here.
Independently of the plate system used, its placement should be close to but still caudal to the external occipital protuberance (EOP).
Placement of the plate at the EOP will increase the risk of erosion of the skin.
A too caudal position may compromise the foramen magnum.
The thickest part of the cranium is the dense ridge which runs vertically in line with the internal occipital crest.
The thickness of this crest is 11.5-15 mm in males and 10-12 mm in females, and provides the best bone stock for screw purchase.
As you move laterally this crest becomes thinner and around 7-8 laterally to the midline, the bone thins out to a thickness of only 5-6 mm.
Another landmark with thicker bone is the superior nuchal line which runs horizontally.
An occipital condyle screw may provide added stability in cases where additional occipital or skull fixation is needed (skull fracture).
A consideration is given to use pedicle or interlaminar screws when doing an occiput to C2 fusion as oftentimes the starting point for the pars screws may compromise the facet joint.
6. Alignment in the occipital cervical region
If there is a preoperative X-ray available the surgeon can use this as a guide to properly align the occipito cervical junction during fusion. Ideally proper alignment allows for horizontal gaze.
7. Rod contouring
When the correct alignment is verified, rods are temporarily placed.
Some systems have the advantage of rod with a ball point which allows for easier placement and contour of the occipito cervical region (which can be relatively difficult when bending straight rods to the proper contour). If these rod-screw systems are not available a standard rod can be bent.
Prior to final placement of the rods, decortication of lamina facets, and posterior aspects of the skull is performed.
When using intralaminar screw fixation at C2, care must be taken not to decorticate deeply which might compromise screw fixation.
The rods are inserted.
There are several options for bone grafting material including:
Autograft (iliac crest cancellous bone)
Allograft (cortico cancellous or cortical onlay graft).
Bone grafting material is placed against the decorticated dorsal elements of the spine.
Transverse rod connectors may be used to enhance axial stability and help hold cortical-onlay graft in place.
Patients are made to sit up in the bed on the evening following the operation.
A collar is commonly used following surgical stabilization to moderate patient activity.
The purpose of a collar is to prevent ranges of motion outside of limits deemed unfavorable for fracture healing. Collar is optional.
Patients with intact neurological status are made to stand and walk on the first day after surgery. Patients can be discharged when medically stable or sent to a rehabilitation center if further care is necessary. This depends on the comfort levels and presence of other associated injuries.
Patients are generally followed with periodical x-rays at 6 weeks, 3 months, 6 months, and 1 year.