title: C-2 neurectomy during atlantoaxial instrumented fusion in the elderly: patient satisfaction and surgical outcome.
abstract: OBJECTIVE
  The originally described technique of atlantoaxial stabilization using C-1 lateral mass and C-2 pars screws includes a C-2 neurectomy to provide adequate hemostasis and visualization for screw placement, enable adequate joint decortication and arthrodesis, and prevent new-onset postoperative C-2 neuralgia. However, inclusion of a C-2 neurectomy for this procedure remains controversial, likely due in part to a lack of studies that have specifically addressed whether it affects patient outcome. The authors' objective was to assess the surgical and clinical impact of routine C-2 neurectomy performed with C1-2 segmental instrumented arthrodesis in a consecutive series of elderly patients with C1-2 instability.
  
  
  METHODS
  Forty-four consecutive patients (mean age 71 years) underwent C1-2 instrumented fusion, including C-1 lateral mass screw insertion. Bilateral C-2 neurectomies were performed. Standardized clinical assessments were performed both pre- and postoperatively. Numbness or discomfort in a C-2 distribution was documented at follow-up. Fusion was assessed using the Lenke fusion grade.
  
  
  RESULTS
  Among all 44 patients, mean blood loss was 200 ml (range 100-350 ml) and mean operative time was 129 minutes (range 87-240 minutes). There were no intraoperative complications, and no patients reported new postoperative onset or worsening of C-2 neuralgia postoperatively. Outcomes for the 30 patients with a minimum 13-month follow-up (range 13-72 months) were assessed. At a mean follow-up of 36 months, Nurick grade and pain numeric rating scale scores improved from 3.7 to 1.0 (p < 0.001) and 9.4 to 0.6 (p < 0.001), respectively. The mean postoperative Neck Disability Index score was 7.3%. The fusion rate was 97%, and the patient satisfaction rate was 93%. All 24 patients with preoperative occipital neuralgia reported relief. Seventeen patients noticed C-2 distribution numbness only during examination in the clinic, and 2 patients reported C-2 numbness, but it did not affect their daily function.
  
  
  CONCLUSIONS
  In this series of C1-2 instrumented arthrodesis in elderly patients, excellent fusion rates were achieved, and patient satisfaction was not negatively affected by C-2 neurectomy. In the authors' experience, C-2 neurectomy enhanced surgical exposure of the C1-2 joint, thereby facilitating hemostasis, placement of instrumentation, and decortication of the joint space for arthrodesis. Importantly, with C-2 neurectomy in the present series, no cases of new onset postoperative C-2 neuralgia occurred, in contrast to a growing number of reports in the literature documenting new-onset C-2 neuralgia without C-2 neurectomy. On the contrary, 80% of patients in the present series had preoperative occipital neuralgia and in all of these patients this neuralgia was relieved following C1-2 instrumented arthrodesis with C-2 neurectomy.
authors: Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland, USA.
authors: D Kojo
authors: DK
authors: Hamilton
authors: Justin S
authors: JS
authors: Smith
authors: Charles A
authors: CA
authors: Sansur
authors: Aaron S
authors: AS
authors: Dumont
authors: Christopher I
authors: CI
authors: Shaffrey
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001268:Atlanto-Axial Joint / Q000601:surgery*; D001368:Axis, Cervical Vertebra / Q000601:surgery*; D001863:Bone Screws; D005260:Female; D006801:Humans; D007593:Joint Instability / Q000601:surgery; D008297:Male; D019635:Neurosurgical Procedures / Q000379:methods*; D009809:Odontoid Process / Q000293:injuries; D017060:Patient Satisfaction; D016103:Spinal Fractures / Q000601:surgery; D013123:Spinal Fusion / Q000295:instrumentation*; D016896:Treatment Outcome