title: C2 laminar screw and C1-2 transarticular screw combined with C1 laminar hooks for atlantoaxial instability with unilateral vertebral artery injury.
abstract: Transarticular screw fixation (TASF) is technically demanding, with high risk of vertebral artery (VA) injury. How to manage intraoperative VA injury and choose optimal alternative fixation becomes a concern of spinal surgeons. In this study, the management strategy for a patient with suspected intraoperative VA injury was analyzed. A 53-year-old woman developed type II odontoid fracture and brain stem injury due to a motor vehicle accident 3 months earlier. After conservative treatments, the brain stem injury improved, but with residual ocular motility defect in the right eye. The odontoid fracture did not achieve fusion with displacement and absorption of fracture fragments. After admission, atlantoaxial fixation using bilateral C1-2 transarticular screws (TASs) combined with C1 laminar hooks was planed. The first TAS was inserted successfully. Unfortunately, suspected VA injury developed during tapping the tract for the second TAS. Considering the previous brain stem injury and that directly inserting the screw to tamponade the hemorrhage might cause VA stenosis or occlusion, we blocked the screw trajectory with bone wax. C2 laminar screw was implanted instead of intended TAS on the injured side. The management strategy for suspected VA injury should depend on intraoperative circumstances and be tailored to patients. Blocking screw trajectory with bone wax is a useful method to stop bleeding. Atlantoaxial fixation using C2 laminar screw and C1-2 TAS combined with C1 laminar hooks is an ideal alternative procedure.
authors.affiliation: Department of Orthopedics, Changzheng Hospital, The Second Military Medical University, Huangpu District, Shanghai, People's Republic of China.
authors.forename: Qunfeng
authors.initials: Q
authors.lastname: Guo
authors.forename: Jun
authors.initials: J
authors.lastname: Liu
authors.forename: Bin
authors.initials: B
authors.lastname: Ni
authors.forename: Xuhua
authors.initials: X
authors.lastname: Lu
authors.forename: Fengjin
authors.initials: F
authors.lastname: Zhou
mesh_terms: D001268:Atlanto-Axial Joint / Q000473:pathology / Q000601:surgery*; D001863:Bone Screws; D005260:Female; D005593:Fracture Fixation, Internal / Q000009:adverse effects / Q000295:instrumentation* / Q000379:methods; D006490:Hemostatics; D006801:Humans; D007593:Joint Instability / Q000209:etiology / Q000601:surgery; D008875:Middle Aged; D009809:Odontoid Process / Q000293:injuries / Q000601:surgery; D010168:Palmitates; D016103:Spinal Fractures / Q000150:complications / Q000601:surgery; D057772:Vascular System Injuries / Q000188:drug therapy / Q000209:etiology*; D014711:Vertebral Artery / Q000293:injuries*; D014885:Waxes
chemical_list: D006490:Hemostatics; D010168:Palmitates; D014885:Waxes; C055480:bone wax