Accuracy and complications associated with the freehand C-1 lateral mass screw fixation technique: a radiographic and clinical assessment

Abstract

Object The aims of this study were to evaluate a large series of posterior C-1 lateral mass screws (LMSs) to determine accuracy based on CT scanning findings and to assess the perioperative complication rate related to errant screw placement. Methods Accuracy of screw placement was evaluated using postoperative CT scans obtained in 196 patients with atlantoaxial instability. Radiographic analysis included measurement of preoperative and postoperative CT scans to evaluate relevant anatomy and classify accuracy of instrumentation placement. Screws were graded using the following definitions: Type I, screw threads completely within the bone (ideal); Type II, less than half the diameter of the screw violates the surrounding cortex (safe); and Type III, clear violation of transverse foramen or spinal canal (unacceptable). Results A total of 390 C-1 LMSs were placed, but 32 screws (8.2%) were excluded from accuracy measurements because of a lack of postoperative CT scans; patients in these cases were still included in the assessment of potential clinical complications based on clinical records. Of the 358 evaluable screws with postoperative CT scanning, 85.5% of screws (Type I) were rated as being in the ideal position, 11.7% of screws (Type II) were rated as occupying a safe position, and 10 screws (2.8%) were unacceptable (Type III). Overall, 97.2% of screws were rated Type I or II. Of the 10 screws that were unacceptable on postoperative CT scans, there were no known associated neurological or vertebral artery (VA) injuries. Seven unacceptable screws erred medially into the spinal canal, and 2 patients underwent revision surgery for medial screws. In 2 patients, unilateral C-1 LMSs penetrated the C-1 anterior cortex by approximately 4 mm. Neither patient with anterior C-1 penetration had evidence of internal carotid artery or hypoglossal nerve injury. Computed tomography scanning showed partial entry of C-1 LMSs into the VA foramen of C-1 in 10 cases; no occlusion, associated aneurysm, or fistula of the VA was found. Two patients complained of postoperative occipital neuralgia. This was transient in one patient and resolved by 2 months after surgery. The second patient developed persistent neuralgia, which remained 2 years after surgery, necessitating referral to the pain service. Conclusions The technique for freehand C-1 LMS fixation appears to be safe and effective without intraoperative fluoroscopy guidance. Preoperative planning and determination of the ideal screw insertion point, the ideal trajectory, and screw length are the most important considerations. In addition, fewer malpositioned screws were inserted as the study progressed, suggesting a learning curve to the technique.