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Orin Bloch, Langston T. Holly, Jongsoo Park, Chinyere Obasi, Kee Kim, and J. Patrick Johnson

Object. In recent studies some authors have indicated that 20% of patients have at least one ectatic vertebral artery (VA) that, based on previous criteria in which preoperative computerized tomography (CT) and standard intraoperative fluoroscopic techniques were used, may prevent the safe placement of C1–2 transarticular screws. The authors conducted this study to determine whether frameless stereotaxy would improve the accuracy of C1–2 transarticular screw placement in healthy patients, particularly those whom previous criteria would have excluded.

Methods. The authors assessed the accuracy of frameless stereotaxy for C1–2 transarticular screw placement in 17 cadaveric cervical spines. Preoperatively obtained CT scans of the C-2 vertebra were registered on a stereotactic workstation. The dimensions of the C-2 pars articularis were measured on the workstation, and a 3.5-mm screw was stereotactically placed if the height and width of the pars interarticularis was greater than 4 mm. The specimens were evaluated with postoperative CT scanning and visual inspection. Screw placement was considered acceptable if the screw was contained within the C-2 pars interarticularis, traversed the C1–2 joint, and the screw tip was shown to be within the anterior cortex of the C-1 lateral mass.

Transarticular screws were accurately placed in 16 cadaveric specimens, and only one specimen (5.9%) was excluded because of anomalous VA anatomy. In contrast, a total of four specimens (23.5%) showed significant narrowing of the C-2 pars interarticularis due to vascular anatomy that would have precluded atlantoaxial transarticular screw placement had previous nonimage-guided criteria been used.

Conclusions. Frameless stereotaxy provides precise image guidance that improves the safety of C1–2 transarticular screw placement and potentially allows this procedure to be performed in patients previously excluded because of the inaccuracy of nonimage-guided techniques.