Radiographic Evaluation of the Technique for C1 Lateral Mass and C2 Pedicle Screw Fixation in Three Hundred Nineteen Cases

Abstract

Retrospective radiographic study of the technique for C1 lateral mass screw (C1LMS) and C2 pedicle screw (C2PS) fixation. To evaluate (1) the accuracy of the C1LMS and C2PS placement; (2) the fusion rate between C1 and C2; (3) the risk for vertebral artery (VA) injury. C1LMS and C2PS fixation is widely used when treating atlantoaxial instability. Several authors have reported their experience focusing on the technical outcomes, with many reporting fusion rates near 100%. However, most of them are relatively small series, and many have applied only plain postoperative radiographs instead of computed tomography (CT). Thus, we feel that the accuracy of C1LMS and C2PS placement has not been fully analyzed, as well as the anatomic relationship between the VA and the screws. Between December 2000 and September 2008, the fusion status and accuracy of the screws were evaluated on the postoperative reconstructive CT of 319 patients with atlantoaxial instability. Cases with malpositioned screws underwent CT angiography or magnetic resonance angiography after surgery, to evaluate potential VA injury. C1LMS of 95.5% and C2PS of 92.8% were found to be in a "good" position. After 2007, six cases had malpositioned screws, which were all in the "out" or "down" area of the C2 pedicle. Five cases underwent CT angiography and 1 had magnetic resonance angiography to evaluate potential VA injury. No occlusion, associated aneurysm or fistula of the VA was found. All cases (100%) achieved solid fusion between C1 and C2. C1LMS of 95.5% and C2PS of 92.8% were confirmed to be in good position. None of the screws including the malpositioned caused VA injury, clinically or radiographically. The technique for C1LMS and C2PS fixation appears to be safe and effective.