Comparative analysis of isocentric 3-dimensional C-arm fluoroscopy and biplanar fluoroscopy for anterior screw fixation in odontoid fractures

Study Design: Retrospective clinical study. Objective: To compare long-term radiographic and clinical outcomes of patients undergoing anterior odontoid screw placement using traditional biplanar fluoroscopy or isocentric 3-dimensional C-arm (iso-C) fluoroscopy-assisted techniques. Summary of Background Data: Anterior screw fixation of odontoid fractures preserves motion at the C1-C2 joint, but accurate screw positioning is essential for successful outcomes. Biplanar fluoroscopy image guidance is most often used; however, iso-C imaging improves the ease and accuracy of screw placement with less radiation exposure. Methods: Fifty-one patients underwent anterior odontoid screw fixation for type II (48 patients) and rostral type III fractures (3 patients). Procedures were guided by biplanar fluoroscopy in 25 (49%) patients, and with iso-C assistance in 26 (51%). Length of surgery, complications, and clinical outcomes based on the Smiley-Webster score were evaluated. Computed tomography confirmed adequate screw placement. Follow-up ranged from 3 to 9 months. Results: At 3-month follow-up, screw position and fusion across the fracture were evident in 87% of the cases treated with biplanar fluoroscopy and in 100% treated by iso-C. The average outcome score in the iso-C group was superior to that of the biplanar group (1.08 vs. 1.33, respectively), although not statistically significant. At last follow-up, the rate of successful fusion was 88% in the biplanar group and 95% in the iso-C group. Length of surgery was significantly lower in the iso-C group compared with the biplanar group (P=0.05). The significantly longer preparation time in the iso-C group (P=0.04) accounted for no overall difference in total operating room occupancy time between the 2 groups. Conclusions: Iso-C significantly decreased surgical time. At last follow-up iso-C assistance was associated with improved rates of radiographic fusion with comparable outcome and complication profiles. This series represents the largest cohort of patients treated with intraoperative real-time navigation assistance for odontoid fractures.