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Occipito-Cervical Fusion System.Implants and instruments designed tooptimize fixation to the occiput.
Technique Guide
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Synthes 1
WarningThis description alone does not provide sufficient back-ground for direct use of the instrument set. Instruction by asurgeon experienced in handling these instruments is highlyrecommended.
Cleaning of instrumentsFor detailed information please refer to “Reprocessing,Care and Maintenance of Synthes Instruments”, ArticleNo. 035.000.090.
Table of Contents
Image intensifier control
Introduction
Product Information
Surgical Technique
Overview 2
AO ASIF Principles 4
Indications and Contraindications 5
Implants 6
Instruments 10
Set 14
Patient Positioning 15
Occipito-Cervical Fixation with Occipital Plate 16
Occipito-Cervical Fixation with Occipital Clamps 26
Occipito-Cervical Fixation with Occiput Rods 34
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The Synthes Occipito-Cervical Fusion System is intended toprovide stabilization and promote fusion of the occipito-cer-vical junction. The Occipito-Cervical Fusion System includes acomplete set of implants and instruments designed to opti-mize fixation to the occiput and easily connect with all Syn-thes posterior cervical and thoracic rod-screw systems.
Overview
2 Synthes Occipito-Cervical Fusion System Technique Guide
Occipital plate, medial Occipital plate, lateral
Occipito-Cervical Fusion System with Axon
Versatile fixation possibilities to the Occiput
The Occipito-Cervical Fusion System offers several implantoptions to maximize fixation to the occiput and minimize theimplant footprint.
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Synthes 3
Occipital clamps, 1 hole
Occiput rods
Occipital clamps, 2 holes
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AO ASIF Principles
In 1958, the Association for the Study of Internal Fixation(AO ASIF) formulated four basic principles1, which havebecome the guidelines for internal fixation. They are:
– Anatomical reduction– Stable internal fixation– Preservation of blood supply– Early, active pain-free mobilization
The fundamental aims of fracture treatment in the limbsand fusion of the spine are the same. A specific goal in thespine is returning as much function as possible to theinjured neural elements.
AO ASIF Principles as applied to the spine2
Anatomical reductionRestoration of normal spinal alignment to improve thebiomechanics of the spine.
Stable internal fixationStabilization of the spinal segment to promote bony fusion.
Preservation of blood supplyCreation of an optimal environment for fusion.
Early, active pain-free mobilizationMinimization of damage to the spinal vasculature, dura, andneural elements, which may contribute to pain reduction andimproved function for the patient.
1 Müller ME, Allgöwer M, Schneider R, Willenegger H (1995) Manual of InternalFixation. 3rd, exp. a. completely rev. ed. 1991. Corr. 3rd printing. Berlin,Heidelberg, New York: Springer
2 Aebi M, Thalgott JS, Webb JK (1998) AO ASIF Principles in Spine Surgery. Berlin,Heidelberg, New York: Springer
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Indications and Contraindications
The Synthes Occipito-Cervical Fusion System in combinationwith a Synthes posterior screw-rod system (e.g. Axon) isintended to provide stabilization to promote fusion of thecervical spine and occipito-cervical junction (Occiput-Th3) forthe following indications:
IndicationsOccipito-cervical and upper cervical spine instabilities:– Rheumatoid arthritis– Congenital anomalies– Posttraumatic conditions– Tumors– Infections
Instabilities in the lower cervical and upper thoracic spine:– Posttraumatic conditions– Tumors– Iatrogenic instabilities following laminectomy etc.
Degenerative and painful posttraumatic conditions in thelower cervical and upper thoracic spine.
Anterior cervical fusions requiring additional posteriorstabilization.
Contraindication– Spinal destruction accompanied by a loss of ventral sup-
port (caused by tumors, fractures and infections) results inmajor instability of the cervical spine and upper thoracicspine. In this situation, stabilization with this system aloneis not sufficient. Additional anterior stabilization is crucial.
– Severe osteoporosis
Synthes 5
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Implants
6 Synthes Occipito-Cervical Fusion System Technique Guide
Occipital plates
– Pure titanium (TiCP)– Allow 15° of screw angulation– Plates adapt to medial / lateral rod placement
Art. No. Type Width
04.161.001 Medial 50 mm
04.161.002 Medial 60 mm
04.161.011 Lateral 50 mm
04.161.012 Lateral 60 mm
Occipital clamps
– Pure titanium (TiCP)– One and two screw hole configuration– Allow 15° of screw angulation– Clamp facilitates easy connection to rod– Small footprint / low profile
Art. No. Type
04.161.023 1 hole
04.161.024 2 holes
Medial, 50 mm width Medial, 60 mm width
Lateral, 50 mm width Lateral, 60 mm width
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Synthes 7
Occiput rod � 3.5 mm
– Pure titanium (TiCP)
Art. No. Overall length
04.161.030 230 mm
Rod � 3.5mm
– Titanium alloy (TAN)– Stress relieved to maintain strength
Art. No. Type Overall length
04.161.032 Pre-bent 250 mm
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Implants
Occipital screws � 4.5 mm
– Titanium alloy (TAN)– Drill � 3.2 mm– Tap � 4.5 mm– Lengths 4 mm to 18 mm in 2 mm increments– Self-retaining Stardrive T15 interface– Blunt tip
Art. No. Bone purchase
04.601.104 4 mm
04.601.106 6 mm
04.601.108 8 mm
04.601.110 10 mm
04.601.112 12 mm
04.601.114 14 mm
04.601.116 16 mm
04.601.118 18 mm
8 Synthes Occipito-Cervical Fusion System Technique Guide
Occipital screws � 5.0 mm
– Titanium alloy (TAN)– Rescue screw for screws � 4.5 mm– Lengths 4 mm to 18 mm in 2 mm increments– Self-retaining Stardrive T15 interface– Blunt tip
Art. No. Bone purchase
04.601.204 4 mm
04.601.206 6 mm
04.601.208 8 mm
04.601.210 10 mm
04.601.212 12 mm
04.601.214 14 mm
04.601.216 16 mm
04.601.218 18 mm
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Synthes 9
Locking screw
– Titanium alloy (TAN)– Self-retaining Stardrive T15 interface
Art. No.
406.104
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03.161.001 Bending Template for Occipital Plate,medial, small
03.161.002 Bending Template for Occipital Plate,medial, large
03.161.011 Bending Template for Occipital Plate,lateral, small
03.161.012 Bending Template for Occipital Plate,lateral, large
388.868 Trial Rod � 3.5 mm
03.161.003 Occiput Trial Rod � 3.5 mm
Instruments
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Synthes 11
387.689 Plate Holder
391.880 Vice Grip
03.161.042 Bending Pliers for Occipital Plate
03.161.023 Drill and Tap Sleeve with Scale, forNos. 03.161.024 and 03.161.026
Drill and Tap depths can be adjusted from4 mm to 18 mm (in 2 mm increments).
324.107 Handle with Quick Coupling
For use with drill bit, taps and screwdrivers.
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03.161.024 Drill Bit � 3.2 mm with Stop, 2-flute, for Quick Coupling
Instruments
12 Synthes Occipito-Cervical Fusion System Technique Guide
03.161.026 Tap for Cortex Screw � 4.5 mm,for Quick Coupling
03.161.027 Tap for Cortex Screw � 4.5 mm, withCardan Joint, for Quick Coupling
03.161.028 Depth Gauge for Screws � 3.5 to 5.0 mm,measuring range to 50 mm
Provides direct measurement for screwselection.
388.392 Screwdriver Shaft Stardrive, T15, self-holding, for Quick Coupling
03.161.031 Screwdriver Shaft Stardrive T15, self-holding, with Cardan Joint, for QuickCoupling
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388.407 Holding Forceps for Rods � 3.5 mm
Provide a secure insertion of the rod intothe operative site.
03.161.041 Positioning Instrument for Occipital Plate
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Occipito-Cervical Fusion System inVario Case (01.601.010)
14 Synthes Occipito-Cervical Fusion System Technique Guide
68.601.010 Vario Case for Occipito-Cervical FusionSystem
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Synthes 15
Patient Positioning
1Position the patient
Patient positioning is critical for occipito-cervical fusionprocedures.
Place the patient in the prone position with the patient’shead securely immobilized. Confirm proper patient positionby direct visualization and radiograph prior to draping.
Note: Always use caution when positioning the patient, asphysiological alignment may not be attainable.
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16 Synthes Occipito-Cervical Fusion System Technique Guide
Occipito-Cervical Fixation withOccipital Plate(Shown in combination with Axon; can also be usedwith CerviFix or StarLock)
1Fixation to the cervical and upper thoracic spine
Recommended set
187.098 Axon
Insert bone screws and/or hooks into the cervical and upperthoracic spine as required by the patient’s pathology.The technique is described in the Axon Technique Guide(036.000.179)
2Determine shape and size of occipital plate
Instruments
03.161.001/03.161.002 Bending Template for OccipitalPlate, medial, small/large
03.161.011/03.161.012 Bending Template for OccipitalPlate, lateral, small/large
387.689 Plate Holder
Select a bending template of the plate style estimated tobest fit the occiput. Estimate the medial / lateral distance ofthe rods to determine the appropriate plate size. Contourthe plate template to fit the anatomy.
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Synthes 17
3Contour occipital plate
Instruments
03.161.042 Bending Pliers for Occipital Plate
Use the bending pliers for contouring the plate to fit theanatomy. They can be used across any section of the plateincluding the area lateral of the rod attachment bodies.
Optional instruments
391.880 Vice Grips
To create more acute bends vice grips can be used.
Notes:– Reverse bending of the plates should not be attempted.– Extreme bending over the rod attachment body travel slot
will limit the amount of medial / lateral adjustment in therod attachment body.
– Extreme bending over the screw holes will limit the abilityto insert the screw properly.
This side must point upwards
Rod AttachmentBody
Rod Attachment BodyTravel Slot
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4Drill pilot hole
Instruments
03.161.023 Drill and Tap Sleeve with Scale
03.161.024 Drill Bit � 3.2 mm with Stop, 2-flute,for Quick Coupling
324.107 Handle with Quick Coupling
387.689 Plate Holder
Set the drill and tap sleeve to the desired depth. Slide backthe latch of the drill and tap sleeve to release its inner tube.Adjust position of inner tube in window so that the mark onthe inner tube indicates the required depth. Release the latchto lock the drill and tap sleeve at the desired depth.
Drill to desired trajectory and depth using the drill bit and thedrill and tap sleeve. Drilling must occur through the occipitalplate to ensure proper drilling depth.
Occipito-Cervical Fixation with Occipital Plate
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Synthes 19
5Measure hole depth
Instruments
03.161.028 Depth Gauge
Use the depth gauge to confirm hole depth and selectthe corresponding screw length. The depth gauge must sitdirectly on the bone.
Note: The depth gauge measures the working length. Ifreading e.g. 10 mm on the depth gauge, select a 10 mmscrew.
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2
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Occipito-Cervical Fixation with Occipital Plate
6Tap
Instruments
03.161.023 Drill and Tap Sleeve with Scale
03.161.026 Tap for Screws � 4.5 mm, for QuickCoupling
324.107 Handle with Quick Coupling
Tap to desired depth using the tap and the drill and tapsleeve. Tapping must occur through the occipital plate toensure proper tapping depth.
Note: Tapping is recommended for all screws
Optional instruments
03.161.027 Tap for Screws � 4.5 mm, with CardanJoint, for Quick Coupling
388.407 Holding Forceps
Set the tap depth by turning the tap sleeve to the desireddepth (1). Lock the tap sleeve by turning down the lockingnut until it contacts the tap sleeve (2). Finger tighten thelocking nut. Use the holding forceps to provide axial forceand stability. Tapping must occur through the occipital plateto ensure proper tapping depth.
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Optional instruments
03.161.031 Screwdriver Shaft Stardrive T15,self-holding, with Cardan Joint,for Quick Coupling
388.407 Holding Forceps
Alternatively the screwdriver shaft with cardan joint may beused to insert the selected screw. Use the holding forceps toprovide axial force and stability.
7Insert screw
Instruments
388.392 Screwdriver Shaft Stardrive T15,self-holding, for Quick Coupling
324.107 Handle with Quick Coupling
Load the selected � 4.5 mm occipital screw from the screwrack. Insert screw and tighten it provisionally.
Note: A � 5.0 mm occipital screw may be used if the pri-mary screw has less than optimal fixation.
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8Insert remaining screws
Repeat steps 4 – 7 to insert the remaining screws.
Note: A minimum of three screws is recommended.
Occipito-Cervical Fixation with Occipital Plate
9Contour trial rod
Instruments
388.868 Trial Rod � 3.5 mm
Contour the trial rod to fit the anatomy and to seat fully inthe bone screws. Create the occipito-cervical bend and en-sure sufficient rod length to connect with the occipital plate.
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11Rod Attachment
Instruments
388.407 Holding Forceps for Rods � 3.5 mm
388.392 Screwdriver Shaft Stardrive T15,self-holding, for Quick Coupling
324.107 Handle with Quick Coupling
03.161.041 Positioning Instrument for Occipital Plate
Use the positioning instrument to facilitate rod placementand locking screw insertion.
Insert rod into the rod attachment body. Ensure that therod extends slightly past the end of the plate. Provisionallytighten the locking screw using the screwdriver shaftStardrive with the handle with quick coupling.
10Bend and cut rod
Instruments
389.478 Bending Pliers for Rods � 3.5 mm
391.990 Cutting Pliers for Plates and Rods
Contour the rod using the bending pliers to match the curveof the trial rod.
Cut the rod with the cutting pliers to the appropriate length.
Note: Repeated bending may weaken the rod.
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Optional instruments
03.161.031 Screwdriver Shaft Stardrive T15,self-holding, with Cardan Joint, forQuick Coupling
388.407 Holding Forceps
Alternatively the screwdriver shaft with cardan joint may beused for provisional tightening of the locking screw. Use theholding forceps to provide axial force and stability.
12Insert rod in contralateral side
Repeat steps 9–11 to insert rod in contralateral side.
Occipito-Cervical Fixation with Occipital Plate
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Optional instruments
03.161.031 Screwdriver Shaft Stardrive T15,self-holding, with Cardan Joint, forQuick Coupling
388.407 Holding Forceps
Alternatively the screwdriver shaft with cardan joint may beused for final tightening of the occipital and locking screws.Use the holding forceps to provide axial force and stability. Toprovide counter-torque for tightening the locking screws, thepositioning instrument may be used.
13Final tightening
Instruments
388.392 Screwdriver Shaft Stardrive T15,self-holding, for Quick Coupling
324.107 Handle with Quick Coupling
03.161.041 Positioning Instrument for Occipital Plate
Firmly tighten all occipital and locking screws using thescrewdriver shaft Stardrive with the handle with quick cou-pling. To provide counter-torque for tightening the lockingscrews, the positioning instrument may be used.
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Occipito-Cervical Fixation withOccipital Clamps(Shown in combination with Axon; can also be usedwith CerviFix or StarLock)
1Fixation to the cervical and upper thoracic spine
Recommended set
187.098 Axon
Insert bone screws and/or hooks into the cervical and upperthoracic spine as required by the patient’s pathology. Thetechnique is described in the Axon Technique Guide(036.000.179)
2Contour trial rod
Instruments
388.868 Trial Rod � 3.5 mm
Contour the trial rod to fit the anatomy and to seat fully inthe bone screws. Create the occipito-cervical bend andensure sufficient rod length to connect with the occipitalclamp.
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3Bend and cut rod
Instruments
389.478 Bending Pliers for Rods � 3.5 mm
391.990 Cutting Pliers for Plates and Rods
Contour the rod using the bending pliers to match the curveof the trial rod.
Cut the rod with the cutting pliers to the appropriate length.
Note: Repeated bending may weaken the rod.
4Attach occipital clamp to rod
Instruments
324.107 Handle with Quick Coupling
388.392 Screwdriver Shaft Stardrive T15,self-holding, for Quick Coupling
388.407 Holding Forceps
Provisionally attach the occipital clamp to the rod by tighten-ing the set screw in the clamp.
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Occipito-Cervical Fixation with Occipital Clamps
5Drill pilot hole
Instruments
03.161.023 Drill and Tap Sleeve with Scale
03.161.024 Drill Bit � 3.2 mm with Stop, 2-flute,for Quick Coupling
324.107 Handle with Quick Coupling
388.407 Holding Forceps
Set the drill and tap sleeve to the desired depth. Slide backthe latch of the drill and tap sleeve to release its inner tube.Adjust position of inner tube in window so that the mark onthe inner tube indicates the required depth. Release the latchto lock the drill and tap sleeve at the desired depth.
Drill to desired trajectory and depth using the drill bit anddrill and tap sleeve. Drilling must occur through the occipitalclamp to ensure proper drilling depth.
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6Measure hole depth
Instruments
03.161.028 Depth Gauge
Use the depth gauge to confirm hole depth and selectthe corresponding screw length. The depth gauge must sitdirectly on the bone.
Note: The depth gauge measures the working length, ifreading e.g. 10 mm on the depth gauge, select a 10 mmscrew.
7Tap
Instruments
03.161.023 Drill and Tap Sleeve with Scale
03.161.026 Tap for Screws � 4.5 mm, for QuickCoupling
324.107 Handle with Quick Coupling
Tap to desired depth using the tap and the drill and tapsleeve. Tapping must occur through the occipital clamp toensure proper tapping depth.
Note: Tapping is recommended for all screws.
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2
Occipito-Cervical Fixation with Occipital Clamps
Optional instruments
03.161.027 Tap for Screws � 4.5 mm, with CardanJoint, for Quick Coupling
388.407 Holding Forceps
Set the tap depth by turning the tap sleeve to the desireddepth (1). Lock tap sleeve by turning down the locking nutuntil it contacts the tap sleeve (2). Finger tighten the lockingnut. Use the holding forceps to provide axial force and sta-bility. Tapping must occur through the occipital clamp to en-sure proper tapping depth.
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8Insert screw
Instruments
388.392 Screwdriver Shaft Stardrive T15,self-holding, for Quick Coupling
324.107 Handle with Quick Coupling
Load the selected � 4.5 mm occipital screw from the screwrack. Insert screw and tighten it provisionally.
Note: A � 5.0 mm occipital screw may be used if theprimary screw has less than optimal fixation.
Optional instruments
03.161.031 Screwdriver Shaft Stardrive T15,self-holding, with Cardan Joint, for QuickCoupling
388.407 Holding Forceps
Alternatively the screwdriver shaft with cardan joint may beused to insert the selected screw. Use the holding forceps toprovide axial force and stability.
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Occipito-Cervical Fixation with Occipital Clamps
9Insert remaining screws and clamps
Repeat steps 4 – 8 to insert the remaining screws andclamps.
Note: A minimum of two clamps per rod is recommended.
10Insert second rod and remaining clamps and screws
Repeat steps 2 – 9 to insert implants on the contra-lateralsite.
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11Final tightening
Instruments
388.392 Screwdriver Shaft Stardrive T15,self-holding, for Quick Coupling
324.107 Handle with Quick Coupling
Firmly tighten all occipital screws and occipital clamp setscrews using the screwdriver shaft with the handle withquick coupling.
Optional instruments
03.161.031 Screwdriver Shaft Stardrive T15,self-holding, with Cardan Joint, for QuickCoupling
388.407 Holding Forceps
Alternatively the screwdriver shaft with cardan joint may beused for final tightening all occipital screws and occipitalclamp set screws. Use the holding forceps to provide axialforce and stability.
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Occipito-Cervical Fixation withOcciput Rods(Shown in combination with Axon; can also be usedwith CerviFix or StarLock)
1Fixation to the cervical and upper thoracic spine
Recommended set
187.098 Axon
Insert bone screws and/or hooks to the cervical and upperthoracic spine as required by the patient’s pathology. Thetechnique is described in the Axon Technique Guide(036.000.179)
2Contour trial rod
Instruments
03.161.003 Occiput Trial Rod � 3.5 mm
Contour the occiput trial rod to fit the anatomy and to seatfully in the bone screws.
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3Bend and cut occiput rod
Instruments
389.478 Bending Pliers for Rods � 3.5 mm
391.990 Cutting Pliers for Plates and Rods
Contour the occiput rod using the bending pliers to matchthe curve of the occiput trial rod.
Cut the rod with the cutting pliers to the appropriate length.
Note: Repeated bending may weaken the rod.
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4Drill pilot hole
Instruments
03.161.023 Drill and Tap Sleeve with Scale
03.161.024 Drill Bit � 3.2 mm with Stop, 2-flute,for Quick Coupling
324.107 Handle with Quick Coupling
388.407 Holding Forceps
Set the drill and tap sleeve to the desired depth. Slide backthe latch of the drill and tap sleeve to release its inner tube.Adjust position of inner tube in window so that the mark onthe inner tube indicates the required depth. Release the latchto lock the drill and tap sleeve at the desired depth.
Drill to desired trajectory and depth using the drill bit and thedrill and tap sleeve. Drilling must occur through the occiputrod to ensure proper drilling depth.
Occipito-Cervical Fixation with Occiput Rods
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5Measure hole depth
Instruments
03.161.028 Depth Gauge
Use the depth gauge to confirm hole depth and select thecorresponding screw length. The depth gauge must sit di-rectly on the bone.
Note: The depth gauge measures the working length, e.g. ifreading 10 mm on the depth gauge, select a 10 mm screw.
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2
Occipito-Cervical Fixation with Occiput Rods
6Tap
Instruments
03.161.023 Drill and Tap Sleeve with Scale
03.161.026 Tap for Screws � 4.5 mm, for QuickCoupling
324.107 Handle with Quick Coupling
Tap to desired depth using the tap and the drill and tapsleeve. Tapping must occur through the occiput rod to en-sure proper tapping depth.
Note: Tapping is recommended for all screws.
Optional instruments
03.161.027 Tap for Screws � 4.5 mm, with CardanJoint, for Quick Coupling
388.407 Holding Forceps
Set the tap depth by turning the tap sleeve to the desireddepth (1). Lock the tap sleeve by turning down the lockingnut until it contacts the tap sleeve (2). Finger tighten thelocking nut. Use the holding forceps to provide axial forceand stability. Tapping must occur through the occiput rod toensure proper tapping depth.
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7Insert screw
Instruments
388.392 Screwdriver Shaft Stardrive T15,self-holding, for Quick Coupling
324.107 Handle with Quick Coupling
Load the selected � 4.5 mm occipital screw from the screwrack. Insert screw and tighten it provisionally.
Note: An � 5.0 mm occipital screw may be used if the pri-mary screw has less than optimal fixation.
Optional instruments
03.161.031 Screwdriver Shaft Stardrive T15,self-holding, with Cardan Joint, for QuickCoupling
388.407 Holding Forceps
Alternatively use the screwdriver shaft with cardan joint toinsert the selected screw. Use the holding forceps to provideaxial force and stability.
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Occipito-Cervical Fixation with Occiput Rods
8Insert remaining screws
Repeat steps 4 – 7 to insert the remaining screws.
Note: A minimum of three screws per occiput rod isrecommended.
9Insert second occiput rod and corresponding screws
Repeat steps 2 – 8 to insert the second occiput rod andcorresponding screws.
Note: A minimum of three screws per occiput rod is recom-mended.
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10Final tightening
Instruments
388.392 Screwdriver Shaft Stardrive T15,self-holding, for Quick Coupling
324.107 Handle with Quick Coupling
Firmly tighten all occipital screws using the screwdriver shaftwith the handle with quick coupling.
Optional instruments
03.161.031 Screwdriver Shaft Stardrive T15,self-holding, with Cardan Joint, for QuickCoupling
388.407 Holding Forceps
Alternatively the screwdriver shaft with cardan joint may beused for final tightening the occipital screws. Use the holdingforceps to provide axial force and stability.
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0123 036.
000.
755
SE_0
4424
7A
A50
0600
12©
Syn
thes
2006
Subj
ect
to m
odifi
catio
ns
Presented by:
0x6.000.755_printversion.qxp 15.02.2007 8:38 Uhr Seite Cvr4
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