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Does Transection of the C2 Nerve Roots During C1 Lateral Mass Screw Placement for Atlantoaxial Fixation Result in a Superior Outcome?: A Systematic Review of the Literature and Meta-analysis

Badhiwala, Jetan H. MD*; Nassiri, Farshad MD*; Witiw, Christopher D. MD*; Mansouri, Alireza MD*; Almenawer, Saleh A. MD; Fehlings, Michael G. MD, PhD, FRCS(C)*,‡

doi: 10.1097/BRS.0000000000002069
Literature Review

Study Design. Systematic review and meta-analysis.

Objective. To evaluate the clinical and functional outcomes of transection of the C2 roots during C1 lateral mass screw placement for atlantoaxial fixation.

Summary of Background Data. Transection of the C2 nerve roots has been recommended during atlantoaxial fixation to facilitate C1 lateral mass screw placement and possibly reduce postoperative occipital neuralgia, although this practice remains controversial.

Methods. We searched MEDLINE, EMBASE, Web of Science, and the Cochrane Library for studies evaluating the outcomes of C1-2 fixation involving sacrifice of the C2 roots. We calculated transformed proportions with 95% confidence intervals (CI) for the outcomes of occipital neuralgia, numbness, bony fusion, and procedural morbidity. For studies comparing C2 transection with nerve sparing surgery, we performed meta-analyses for the outcomes of occipital neuralgia, occipital numbness, blood loss, and operative time.

Results. Eight observational studies (N = 393) met eligibility criteria. The rate of postoperative occipital neuralgia among included studies was 0% to 25%; occipital numbness, 6.7% to100%; bony fusion, 96.7% to 100%; and procedural morbidity, 0% to 14.3%. Among comparative studies, C2 transection was associated with a higher rate of occipital numbness [odds ratio (OR) 178.6 (95% CI 26.6 to 1198.4)], lower blood loss [mean difference (MD) −195.3 mL (95% CI −317.7 to −72.8 mL)] and shorter operative times [MD −57.5 mins (95% CI −76.9 to −38.2 mins)] than when the C2 roots were spared. We found no difference in rates of occipital neuralgia [OR 1.44 (95% CI 0.45 to 4.68)].

Conclusion. Transection of the C2 nerve roots appears to be a viable, safe option when undertaking placement of C1 lateral mass screws. The procedure is associated with reduced operative duration and blood loss, increased rate of occipital numbness, and no change in the rate of occipital neuralgia. However, given the relatively low quality of evidence, prospective, controlled studies to evaluate this strategy are recommended.

Level of Evidence: N /A

*Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada

Division of Neurosurgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada

Division of Neurosurgery and Spinal Program, Department of Surgery, University of Toronto, Krembil Neuroscience Center, Toronto Western Hospital, Toronto, Ontario, Canada.

Address correspondence and reprint requests to Michael G. Fehlings, MD, PhD, FRCS(C), Division of Neurosurgery and Spinal Program, Department of Surgery, University of Toronto, Krembil Neuroscience Center, Toronto Western Hospital, 399 Bathurst St., Suite 4W-449, Toronto, Ontario, Canada M5T 2S8; E-mail: michael.fehlings@uhn.ca

Received 17 June, 2016

Revised 24 October, 2016

Accepted 12 December, 2016

The manuscript submitted does not contain information about medical device(s)/drug(s).

No funds were received in support of this work.

Relevant financial activities outside the submitted work: grants.

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