Jeevan Kumar Sharma, Kalyan Kumar Varma Kalidindi, Gururaj Sangondimath, Abhinandan Reddy Mallepally, Nandan Marathe, Harvinder Singh Chhabra
  1. Department of Spine Service, Indian Spinal Injuries Center, New Delhi, India.


Copyright: © 2020 Surgical Neurology International This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.

How to cite this article: Jeevan Kumar Sharma, Kalyan Kumar Varma Kalidindi, Gururaj Sangondimath, Abhinandan Reddy Mallepally, Nandan Marathe, Harvinder Singh Chhabra. Clinicoradiological outcomes of Goel and Harms fixation for atlantoaxial instability: An institutional experience. 11-Jul-2020;11:189

How to cite this URL: Jeevan Kumar Sharma, Kalyan Kumar Varma Kalidindi, Gururaj Sangondimath, Abhinandan Reddy Mallepally, Nandan Marathe, Harvinder Singh Chhabra. Clinicoradiological outcomes of Goel and Harms fixation for atlantoaxial instability: An institutional experience. 11-Jul-2020;11:189. Available from:

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Background: Few studies have reported on the long-term outcomes of Goel and Harms C1-C2 fusions in the Asian population.

Methods: This was a retrospective analysis of 53 patients undergoing Goel and Harms fixation (2010 –2018). Clinical outcomes were assessed utilizing the neck disability index (NDI), Japanese Orthopedic Association (JOA) score, and visual analog scale (VAS). Outcomes were then correlated with fusion rates (using dynamic X-rays), atlanto-dens interval (ADI), and space available for cord (SAC) data.

Results: The study’s 53 patients averaged 49.98 years of age and included 42 males and 11 females. The mean preoperative versus postoperative scores on multiple outcome measures showed NDI 31.62 ± 11.05 versus decreased to 8.68 ± 3.76 post, mean JOA score (e.g., in 41 patients with myelopathy) improved from 13.20 ± 3.96 to 15.2 ± 2.17, and the mean VAS decreased from 4.85 ± 1.03 to 1.02 ± 0.87 and showed restoration of the ADI (1.96 ± 0.35 mm) and SAC (20.42 ± 0.35 mm). A 98.13% rate of C1-C2 fusion was achieved at 12 postoperative months.

Conclusion: Goel and Harms technique for C1-C2 fusion resulted in both good clinical and radiological outcomes.

Keywords: Atlantoaxial, Cervical spine, Goel’s technique, Harms, Instability


There are various techniques available for atlantoaxial (A-A) arthrodesis.[ 5 ] In 2001, Harms and Melcher first reported 37 patients undergoing posterior C1-C2 stabilization utilizing lateral mass screws.[ 4 ] Goel et al. subsequently documented the efficacy of an A-A plate/screw fusion technique.[ 3 ] Here, we report our experience in the Asian subcontinent for A-A fusion utilizing the Goel and Harms combined techniques.


We performed a retrospective analysis of clinical and radiological data for 57 patients who underwent Goel and Harms C1-C2 fusions for various pathologies (2010–2018) [ Figure 1 and Table 1 ]. Patients underwent preoperative cervical X-rays, computed tomography angiography (CTA) of the neck, a cervical MRI, and postoperative X-rays (at 3 months, 6 months, and 1 year) [ Figures 2 and 3 ]. Clinical outcomes were assessed at 3 months, 6 months, and 1 year postoperatively using the Japanese orthopedic Association (JOA) score, visual analog scale (VAS), and neck disability index (NDI) scores. Surgical outcomes assessments included length of hospital stay, operative time, blood loss, and intraoperative or postoperative complications. Radiological parameters included fusion, implant failure and, preoperative and postoperative atlanto-dens interval (ADI), and space available for cord (SAC). Fusion was confirmed by the presence of bony trabecular bridging between C1-C2 and/or no abnormal movement on dynamic X-rays.

Table 1:

A table showing the demographics of patients included in the study.


Figure 1:

Flowchart depicting inclusion and exclusion of the patient.


Figure 2:

Preoperative dynamic X-ray (a), CT-angiography of neck (b), and dynamic MRI (c) and for assessment of C1-C2 instability.


Figure 3:

Assessment of postoperative X-ray at 3 months: AP and lateral view (a) and dynamic X-ray to look for stability (b).


Surgical protocol followed in our institute

Dynamic X-rays were used to assess the instability of C1-C2. The diameter of the C2 pedicle was assessed on preoperative CT scan and the CTA documented whether or not there was a high riding vertebral artery. C2 pedicle/pars screws and C1 lateral mass screws were used for fixation, and rods were connected to the screws. Clinical outcomes and dynamic X-rays were performed at 3rd months, 6th months, and then yearly.

Follow-up duration

The mean follow-up duration was 48.90 ± 24.78 months (12–96 months).


Clinical findings

For 53 patients undergoing various surgical procedures, 43 patients had signs of myelopathy. The mean operative time was 175.09 ± 58.21 min, the average blood loss was 143.02 ± 91.38 ml, and the average length of stay was10.85 ± 10.61 days [ Table 2 ].

Table 2:

A table describing the surgical, clinical, and radiological outcomes of patients.


Outcome scores

Postoperatively, the improvement was seen on the JOA, VAS, and NDI scores, while radiological improvement was noted (e.g., X-rays and/or MR) on the ADI and SAC measures [ Table 2 ]. Symptomatic adjacent segment degeneration was not seen in any patient. Notably, 43 of 53 patients neurologically improved at 3 months postoperatively.


There were six complications; a patient with Os- odontoideum deteriorated postoperatively from AIS-E to AIS-C but improved to AIS-D 3 months later, two sustained intraoperative or postoperative CSF leaks, two patients had to undergo revision surgery [ Figure 4 ], and there was one death (cardiac arrest) due to heart failure 12 days postoperatively [ Table 2 ].

Figure 4:

Preoperative dynamic X-ray (a) and immediate postoperative X-ray (b) of the patient who had implant failure with extrusion of left C1 screw.



Gallie, Brooks, and Jenkins used bone grafts for C1-C2 fusion with sublaminar wires to provide A-A stability.[ 1 , 2 ] Magerl introduced transarticular screw fixation to directly support the C1-C2 facet joints, abolishing the use of postoperative support. Later, Harms and Melcher recommended posterior screw fixation of the lateral mass of C1 and pedicles of C2 with C1-C2 rod stabilization.[ 4 ] The Goel and Harms technique proved excellent fusion (e.g., based on biomechanical studies) and reduced the risk of vertebral artery injury. Isik et al. (2018) showed in 28 patients, there were no poorly placed screws, and they observed significant postoperative clinical improvement (e.g., JOA and VAS scores).[ 6 ] Zheng et al., in 2016, also reported significant recovery and a 97.7% fusion rate, a finding (97% fusion rate in 60 patients using Goel/Harms technique) also echoed by Rajinda et al.[ 7 , 8 ] Here, we also found acceptable long-term results utilizing the Goel/Harms technique without any evidence of radiological or clinical deterioration an average of 48.9 months postoperatively. Here, we documented a 98.13% fusion rate utilizing the Goel and Harms technique.


The Goel and Harms technique was a safe and effective technique for treating A-A (C1-C2) instability in the Asian population.

Declaration of patient consent

Patient’s consent not required as patients identity is not disclosed or compromised.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


1. Brooks AL, Jenkins EB. Atlanto-axial arthrodesis by the wedge compression method. J Bone Joint Surg Am. 1978. 60: 279-84

2. Gallie WE. Skeletal traction in the treatment of fractures and dislocations of the cervical spine. Ann Surg. 1937. 106: 770-6

3. Goel A, Desai KI, Mazumdar DP. Atlantoaxial fixation using plate and screw method: A report of 160 treated patients. Neurosurgery. 2002. 51: 1351-7

4. Harms J, Melcher RP. Posterior C1-C2 fusion with polyaxial screw and rod fixation. Spine (Phila Pa 1976). 2001. 26: 2467-71

5. Huang DG, Hao DJ, He BR, Wu QN, Liu TJ, Wang XD. Posterior atlantoaxial fixation: A review of all techniques. Spine J. 2015. 15: 2271-81

6. Isik HS, Sandal E, Cagli S. Clinical outcomes of posterior C1 and C2 screw-rod fixation for atlantoaxial instability. Turk Neurosurg. 2018. 28: 602-9

7. Rajinda P, Towiwat S, Chirappapha P. Comparison of outcomes after atlantoaxial fusion with C1 lateral mass-C2 pedicle screws and C1-C2 transarticular screws. Eur Spine J. 2017. 26: 1064-72

8. Zheng Y, Hao D, Wang B, He B, Hu H, Zhang H. Clinical outcome of posterior C1-C2 pedicle screw fixation and fusion for atlantoaxial instability: A retrospective study of 86 patients. J Clin Neurosci. 2016. 32: 47-50

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