Restoring stability at the craniovertebral junction using the Goel technique: Outcomes of posterior C1–C2 fixation in 216 patients

Background: Atlantoaxial instability arising from diverse craniovertebral junction (CVJ) pathologies poses substantial surgical challenges because of complex regional biomechanics and proximity to critical neurovascular structures. Posterior C1–C2 fixation using the Goel–Harms technique is widely adopted; however, large institutional outcome data remain limited. Objective: The objective of this study was to evaluate the clinical and radiological outcomes, perioperative parameters, and complications following posterior C1–C2 fixation in patients with CVJ anomalies and atlantoaxial instability. Materials and Methods: A retrospective cohort study was performed of patients who underwent posterior C1 lateral mass–C2 pedicle screw fixation between January 2008 and December 2023 at a single tertiary center. Clinical outcomes were assessed using the Visual Analog Scale (VAS), Nurick grading system, and Oswestry Disability Index (ODI). Radiological evaluation included the atlantodental interval (ADI), clivus–canal angle, and standard craniometric lines. Perioperative variables, complications, and length of hospital stay were analyzed. Results: A total of 216 patients were included (mean age: 34.6 ± 5.2 years; 62.0% male). Traumatic pathology was the most common etiology (45.4%), followed by congenital (24.1%) and degenerative causes (16.7%). Significant postoperative improvement was observed in VAS (5.39 ± 1.68–1.46 ± 1.21), Nurick grade (3.68 ± 1.26–2.06 ± 0.87), and ODI (49.4 ± 12.2–22.19 ± 9.3) (all P < 0.001). Radiological parameters demonstrated significant correction, including ADI and clivus–canal angle ( P < 0.001). The overall mortality rate was 1.39%. The mean intensive care unit stay was 2.3 ± 1.4 days, and the mean hospital stay was 8.5 ± 3.3 days. Conclusion: Posterior C1–C2 fixation using the Goel–Harms technique provides safe, reproducible, and effective stabilization, with significant clinical and radiological improvement in patients with atlantoaxial instability associated with CVJ anomalies.