title: A finite element investigation of upper cervical instrumentation.
abstract: METHODS
  The finite element technique was used to predict changes in biomechanics that accompany the application of a novel instrumentation system designed for use in the upper cervical spine.
  
  
  OBJECTIVE
  To determine alterations in joint loading, kinematics, and instrumentation stresses in the craniovertebral junction after application of a novel instrumentation system. Specifically, this design was used to assess the changes in these parameters brought about by two different cervical anchor types: C2 pedicle versus C2-C1 transarticular screws, and unilateral versus bilateral instrumentation.
  
  
  BACKGROUND
  Arthrodesis procedures can be difficult to obtain in the highly mobile craniovertebral junction. Solid fusion is most likely achieved when motion is eliminated. Biomechanical studies have shown that C1-C2 transarticular screws provide good stability in craniovertebral constructs; however, implantation of these screws is accompanied by risk of vertebral artery injury. A novel instrumentation system that can be used with transarticular screws or with C2 pedicle screws has been developed. This design also allows for unilateral or bilateral implantation. However, the authors are unaware of any reports to date on the changes in joint loading or instrumentation stresses that are associated with the choice of C2 anchor or unilateral/bilateral use.
  
  
  METHODS
  A ligamentous, nonlinear, sliding contact, three-dimensional finite element model of the C0-C1-C2 complex and a novel instrumentation system was developed. Validation of the model has been previously reported. Finite element models representing combinations of cervical anchor type (C1-C2 transarticular screws vs. C2 pedicle screws) and unilateral versus bilateral instrumentation were evaluated. All models were subjected to compression with pure moments in either flexion, extension, or lateral bending. Kinematic reductions with respect to the intact (uninjured and without instrumentation) case caused by instrumentation use were reported. Changes in loading profiles through the right and left C0-C1 and C1-C2 facets, transverse ligament-dens, and dens-anterior ring of C1 articulations were calculated by the finite element model. Maximum von Mises stresses within the instrumentation were predicted for each model variant and loading scenario.
  
  
  RESULTS
  Bilateral instrumentation provided greater motion reductions than the unilateral instrumentation. When used bilaterally, C2 pedicle screws approximate the kinematic reductions and instrumentation stresses (except in lateral bending) that are seen with C1-C2 transarticular screws. The finite element model predicted that the maximum stress was always in the region in which the plate transformed into the rod.
  
  
  CONCLUSIONS
  To the best of the authors' knowledge, this is the first report of predicting changes in loading in the upper cervical spine caused by instrumentation. The most significant conclusion that can be drawn from the finite element model predictions is that C2 pedicle screw fixation provides the same relative stability and instrumentation stresses as C1-C2 transarticular screw use. C2 pedicle screws can be a good alternative to C2-C1 transarticular screws when bilateral instrumentation is applied.
authors.affiliation: Department of Orthopaedic Surgery, University of California, San Francisco 94143-0514, USA. puttlit@itsa.ucsf.edu
authors.forename: C M
authors.initials: CM
authors.lastname: Puttlitz
authors.forename: V K
authors.initials: VK
authors.lastname: Goel
authors.forename: V C
authors.initials: VC
authors.lastname: Traynelis
authors.forename: C R
authors.initials: CR
authors.lastname: Clark
mesh_terms: D001696:Biomechanical Phenomena; D001863:Bone Screws; D002574:Cervical Vertebrae / Q000503:physiopathology / Q000601:surgery*; D004867:Equipment Design; D020342:Finite Element Analysis; D005544:Forecasting; D006801:Humans; D008954:Models, Biological; D009038:Motion; D009984:Orthopedic Fixation Devices; D013314:Stress, Mechanical