A technique for frameless stereotaxy and placement of transarticular screws for atlanto-axial instability in rheumatoid arthritis

The aim of the present study was to outline a new surgical technique and describe how, in a clinical setting, computer-generated image-guidance can assist in the planning and accurate placement of transarticular C1/C2 screws inserted using a minimally invasive exposure. Forty-six patients with atlanto-axial instability due to rheumatoid arthritis underwent posterior stabilisation with transarticular screws. This was achieved with a minimal posterior exposure limited to C1 and C2 and percutaneous screw insertions via minor stab incisions. The Stealth Station (Medtronic Sofamor Danek, Memphis, Tenn., USA) was used for image guidance to navigate safely through C2. Reconstructed computed tomographic (CT) scans of the atlanto-axial complex were used for image guidance. It was possible to perform preoperative planning of the screw trajectory taking into account the position of the intraosseous portion of the vertebral arteries, the size of the pars interarticularis and the quality of bone in C2. Screws could be inserted percutaneously over K-wires using a drill guide linked to the image-guidance system. Preoperative planning was performed in all 46 patients and accurate registration allowed proposed screw trajectories to be identified. Thirty-eight patients had bilateral screws inserted and eight had a unilateral screw. A total of 84 screws were inserted using the Stealth Station. There were no neurovascular injuries. This technique for placing transarticular screws is accurate and safe. It allows a minimally invasive approach to be followed. Image guidance is a useful adjunct for the surgeon undertaking complex spinal procedures.