Alexander R. Vaccaro and Kush Singh

Goals of Surgical Treatment

Wiring techniques of the spine affords semirigid stabilization of the vertebral elements. It is often used as the primary method of fixation in the cervical spine when combined with a rigid external orthosis. Wiring techniques of the thoracolumbar spine are often used in conjunction with other modes of internal fixation (e.g., rods) to allow rigid segmental stabilization. If the spinal elements are excessively loaded or the posterior elements are osteoporotic, wire stabilization alone may not afford adequate immobilization even with supplemental external brace or cast application.

Several techniques have been described to stabilize the occipital-cervical/upper cervical spine. Occipital-cervical and upper cervical spine wiring techniques include the technique of Wertheim and Bohlman (occipitalcervical) and Gallie’s and Brooks‘ methods. Lower cervical wiring techniques include the Rogers, Bohlman, and Dewar methods. Modifications and adaptations of each method have also been described.

Surgical Approach for Posterior Occipital and Cervical Wire Application

Posterior occipital and lower cervical wiring procedures are performed through a midline incision with careful dissection through the fascial raphe to avoid muscular bleeding. This allows for subsequent exposure of the intended occipital and posterior cervical elements in a subperiosteal manner. To avoid excessive vascular bleeding in the upper cervical region between the C1 and C2 articulation, the thin-walled cavernous venous plexus is gently elevated at its medial margin with a small patty. Taking care to avoid disruption of this plexus is important due to its lack of discrete endothelial channels, as this plexus represents a confluence of venous sinusoids. A bipolar forceps is useful if a small venotomy is encountered. During the exposure of the subaxial spine, only the lateral margin of the lateral masses should be exposed, taking care not to go beyond this boundary, especially in an anterior direction. One may encounter dense arterial and venous networks in this area that are difficult to control without temporary packing. At the completion of the surgical exposure, any manipulative reduction may be performed followed by placement of internal fixation (wires) and bone grafting.

Figure 11–1
Wertheim and Bohlman technique for occipitocervical fusion. The occiput, C1, and C2 are fused with midline wires and a pair of bone struts.

Figure 11–2
(A–C) Modified Gallie technique. A bone graft is secured over the posterior arches of C1 and C2 by passing a single wire under the arch of C1 and looping it over the spinous process of C2.

Figure 11–3
Modified Brooks fusion. (A) C1 and C2 are fused by placing bone wedges posteriorly in between their lamina. (B) Wires are then passed from below under the lamina of C2 and C1, securing the two segments and bone graft together.

Figure 11–4
Rogers technique. Two adjacent cervical spinal segments are secured by the passage of a looped interspinous process wire.

Figure 11–5
(A,B) The Bohlman’s triple wire technique is similar to the Roger’s technique except for the addition of spinous process wires that function to secure two cortical cancellous bone graft stents over the posterior elements of the intended fusion area.

Figure 11–6
(A–C) Subaxial cervical sublaminar wire technique. Sublaminar wires are carefully passed under the lamina of each segment only with direct visualization of the dura to prevent neural compression.

Figure 11–7
Dewar fusion. (A) The cervical vertebrae are initially decorticated and then stabilized with Steinmann pins. (B) These are then passed through both the vertebrae and adjacent corticocancellous strut-grafts.

Figure 11–8
Oblique facet wiring. A wire is passed through a drill hole in the inferior cervical articular process. The wire is then passed through the spinous process of the inferior vertebra to secure the vertebral interspace.

Figure 11–9
Thoracolumbar sublaminar wire passage. The wire utilized is often a 16- or 18-gauge wire looped on itself to allow the smooth looped cord to be the leading surface during passage.

Figure 11–10
(A–C) Scott technique. A bone graft is secured in the decorticated pars interarticularis defect by looping a wire around the transverse process and spinous process of the respective vertebrae.

1. Spinal stenosis

2. Posterior (C1 or C2) element insufficiency

Advantages

1. Technically simple

2. Greater resistance to translation, rotation, and extension than the Gallie fusion (White and Panjabi, 1978).

Disadvantages

Risk of neural injury with C1 and C2 sublaminar wire passage

Procedure