Value of intraoperative true lateral radiograph of C2 pedicle for C1-2 transarticular screw insertion

Abstract

Background context Transarticular C1-2 screws are widely used in posterior cervical spine instrumentation. Injury to the vertebral artery during insertion of transarticular Cl-2 screw remains a serious complication. Use of a computer-assisted surgery system decreases this complication considerably. However, this system encounters problems in ensuring complete accuracy because of positional variations during preoperative and intraoperative imaging generation. Therefore, intraoperative fluoroscopy still is one of the commonly used methods to guide insertion of transarticular Cl-2 screw. Evaluation of a true lateral radiographic view of the C2 pedicle for screw trajectory during C1-2 transarticular screw insertion may help to minimize this potential complication. Purpose To evaluate the value of intraoperative true lateral radiograph of the C2 pedicle for screw trajectory during C1-2 transarticular screw insertion. Study design To compare the height of the C2 pedicle area allowing instrumentation on true lateral view radiograph of the C2 pedicle and computed tomographic (CT) scan with multiplanar reconstruction. Methods Twenty embalmed human cadaveric cervical spine specimens were used to insert a total of 40 C1-2 transarticular screws using Magerl and Seemann technique. One side of the C2 transverse foramen was filled with radiopaque material (lead oxide) to simulate the artery and to demarcate the danger zone for better visualization on radiography. Measurements and calculation of the mean and standard deviation of the height of the area allowing instrumentation of the C2 pedicle were done on true lateral view radiograph of the C2 pedicle, the sagittal and 30° sagittal views relative to the frontal plane passing exactly through the center of the C2 pedicle of CT scans. Student t test was applied to calculate the statistical significance of measured values. Statistical significance was defined as p≤.001. Results On true lateral radiographic views of the C2 pedicle, the height of the area allowing instrumentation of the pedicle was 7.75±0.92 mm (right) and 7.64±0.63 (left), p≥.36. Using sagittal CT scan views, the height of pedicles was 7.71±0.7 mm (right) and 7.58±1.01 mm (left), p≥.23. On 30° sagittal CT scan views, the height of pedicles was 7.84±1.00 mm (right) and 7.76±1.02 mm (left), p≥.27. The p value was ≥.78, ≥.56, and ≥.49 for true lateral radiographic view and sagittal CT scan view, true lateral radiographic view and 30° sagittal CT scan view, and sagittal CT scan view and 30° sagittal CT scan views, respectively. On lateral view of cervical spine, the decline angle of the transarticular screw was 51.3±0.50° (right) and 50.68±0.41° (left), p≥.17. Mean decline angle was 51±0.43°. On the anteroposterior (AP) view, radiograph median angle was 6.87±0.53° (right) and 6.0±0.59° (left), p≥.25. Mean median angle was 6.44±0.62°. Conclusions True lateral radiographic views of the pedicles provide useful information for defining screw trajectory intraoperatively. Using this view along with AP and lateral view of cervical spine and preoperative three-dimensional CT scan may narrow the margin of error in this delicate area.