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Lauren M. Burke, Warren D. Yu, Anthony Ho, Timothy Wagner and Joseph R. O'Brien


Anatomical variability of the C-2 pedicle poses a challenge for C-2 fixation. The use of multidimensional CT scanning is not widely used but might be an asset to preoperative planning. Careful preoperative planning is imperative for instrumentation at C-2. Fine-cut, noncontrast CT scanning is a useful tool for delineating anatomy; however, the axis of the images is not always along the anatomical axis of the vertebra in question. The authors evaluated the suitability of C-2 pedicles for screw placement by using OsiriX (Pixmeo) software to change the gantry angle of CT angiograms to measure the anatomical dimensions of the C-2 pedicle.


The authors conducted a retrospective review of CT angiograms of the head and neck from 47 trauma patients seen consecutively at George Washington University Hospital. For each patient, 3 independent observers determined length and width of each C-2 pedicle (94 samples) by using OsiriX. OsiriX is a DICOM viewer that enables navigation and visualization in multidimensional imaging, such as 3D imaging, which was used for this study. Sex-specific measurements were also determined. Vertebral anatomy was studied to determine whether aberrant anatomy would preclude pedicle fixation. Statistical analyses were performed.


Of the 47 patients, 27 were male. Overall mean C-2 pedicle widths and lengths were 8.272 ± 1.364 mm and 27.052 ± 3.471 mm, respectively. The average widths and lengths of the pedicle in female patients were 8.040 ± 1.262 mm and 27.241 ± 2.731 mm, respectively, and those in male patients were 8.444 ± 1.414 mm and 26.913 ± 3.933 mm, respectively. The sex difference was statistically significant for width (p = 0.012) but not for length (p = 0.41). On the basis of width, the percentages of pedicles that could tolerate a 3.5-mm and 4.0-mm screw were 98% and 97%, respectively. Vertebral anatomy precluded screw length greater than 14 mm for only 3 patients.


Using multidimensional CT or 3D imaging, the authors found that C-2 pedicles in over 90% of patients could tolerate 3.5-mm and 4.0-mm pedicle screws. Vertebral anatomy precluded use of screw lengths greater than 14 mm for only 3 (6%) of 47 patients. Therefore, the C-2 pedicle might be more tolerant of fixation than previously reported.

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Stephen Honeybul, David Anthony Morrison, Kwok M. Ho, Christopher R. P. Lind and Elizabeth Geelhoed


Autologous bone is usually used to reconstruct skull defects following decompressive surgery. However, it is associated with a high failure rate due to infection and resorption. The aim of this study was to see whether it would be cost-effective to use titanium as a primary reconstructive material.


Sixty-four patients were enrolled and randomized to receive either their own bone or a primary titanium cranioplasty. All surgical procedures were performed by the senior surgeon. Primary and secondary outcome measures were assessed at 1 year after cranioplasty.


There were no primary infections in either arm of the trial. There was one secondary infection of a titanium cranioplasty that had replaced a resorbed autologous cranioplasty. In the titanium group, no patient was considered to have partial or complete cranioplasty failure at 12 months of follow-up (p = 0.002) and none needed revision (p = 0.053). There were 2 deaths unrelated to the cranioplasty, one in each arm of the trial. Among the 31 patients who had an autologous cranioplasty, 7 patients (22%) had complete resorption of the autologous bone such that it was deemed a complete failure. Partial or complete autologous bone resorption appeared to be more common among young patients than older patients (32 vs 45 years old, p = 0.013). The total cumulative cost between the 2 groups was not significantly different (mean difference A$3281, 95% CI $−9869 to $3308; p = 0.327).


Primary titanium cranioplasty should be seriously considered for young patients who require reconstruction of the skull vault following decompressive craniectomy.

Clinical trial registration no.: ACTRN12612000353897 (

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Charles Milchteim, Warren D. Yu, Anthony Ho and Joseph R. O'Brien


Cervical transfacet screw placement has been described in the literature. Although the technique shows promise for percutaneous application, parameters for screw placement have not been well delineated. This study used reconstructed CT scans with imaging software to assess the feasibility of percutaneous transfacet screw placement, analyzing potential entry angles, transfacet lengths, and sex differences at each subaxial level.


Fifty consecutive cervical CT scans (obtained in 26 males and 24 females [mean age 41.5 years]) were reformatted using OsiriX software, and transfacet lengths, entry angles, and potential occipital clearance were analyzed at all subaxial levels. Statistical analyses were used to determine the differences, if any, between transfacet lengths, entry angle, and occipital clearance across individual cervical levels. Repeatability was quantified by calculating the intraclass correlation coefficient and Cohen kappa value.


A total of 200 transfacet lengths and 200 entry angles in 50 patients were analyzed. The mean transfacet lengths were 17.9 ± 2.6, 17.6 ± 3.2, 16.3 ± 3.6, and 13.1 ± 2.2 mm at C3–4, C4–5, C5–6, and C6–7, respectively, with mean entry angles at 52.7° ± 7.8°, 56.5° ± 8.0°, 55.0° ± 8.8°, and 53.0° ± 8.7°, respectively. Analysis of variance revealed a significant difference between the mean transfacet lengths, while post hoc analysis revealed significantly larger transfacet lengths in the upper 2 cervical levels (C3–4 and C4–5) than in the lower 2 cervical levels (C5–6 and C6–7). Analysis of variance demonstrated no significant difference between the entry angles. Males had significantly larger transfacet lengths at C5–6 (17.4 vs 15.1 mm) and C6–7 (13.7 vs 12.4 mm) than females. The occiput would have blocked percutaneous screw placement in 86%, 78%, 54%, and 20% of the cases at C3–4, C4–5, C5–6, and C6–7, respectively. Transfacet lengths may accommodate longer screws in the upper cervical spine, but potential screw sizes decrease in the lower subaxial levels. A transfacet entry angle of approximately 50° or greater was associated with a higher incidence of occipital clearance. Additionally, the occiput may pose a significant obstruction to percutaneous transfacet fixation in upper subaxial levels. Interrater reliability was poor for screw angle and length measurements, but was satisfactory in intrarater analysis in 6 of 8 measurements. There was moderate to good agreement of occipital clearance in all but one measurement.


Cervical transfacet screw placement is possible from C-3 to C-7. Because occipital clearance can be difficult at C3–4 and C6–7, the use of curved or flexible instruments may be necessary to obtain the appropriate screw trajectory. Screw lengths varied with spinal level and the sex of the patient.