Comparison of safety and stability of C-2 pars and pedicle screws for atlantoaxial fusion: meta-analysis and review of the literature

A systematic review

Robert E. ElliottNeurosurgical Care, LLC, Royersford, Pennsylvania;

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Omar TanweerDepartment of Neurosurgery, Bellevue Hospital, New York University Langone Medical Center; and

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Akwasi BoahDepartment of Neurosurgery, Bellevue Hospital, New York University Langone Medical Center; and

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Michael L. SmithDivision of Spinal Neurosurgery, Department of Neurosurgery, New York University Langone Medical Center, New York, New York

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Anthony Frempong-BoaduDivision of Spinal Neurosurgery, Department of Neurosurgery, New York University Langone Medical Center, New York, New York

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Object

Some centers report a lower incidence of vertebral artery (VA) injury with C-2 pars screws compared with pedicle screws without sacrificing construct stability, despite biomechanical studies suggesting greater load failures with C-2 pedicle screws. The authors reviewed published series describing C-2 pars and pedicle screw implantation and atlantoaxial fusions and compared the incidence of VA injury, screw malposition, and successful atlantoaxial fusion with each screw type.

Methods

Online databases were searched for English-language articles between 1994 and April of 2011 describing the clinical and radiographic outcomes following posterior atlantoaxial fusion with C-1 lateral mass and either C-2 pars interarticularis or pedicle screws. Thirty-three studies describing 2975 C-2 pedicle screws and 11 studies describing 405 C-2 pars screws met inclusion criteria for the safety analysis. Seven studies describing 113 patients treated with C-2 pars screws and 20 studies describing 918 patients treated with C-2 pedicle screws met inclusion criteria for fusion analysis. Standard and formal meta-analysis techniques were used to compare outcomes.

Results

All studies provided Class III evidence. Ten instances of VA injury occurred with C-2 pedicle screws (0.3%) and no VA injury occurred with pars screws. The point estimate of VA injury for C-2 pedicle screws was 1.09% (95% CI 0.73%–1.63%) and was similar to that of C-2 pars screws (1.48%, 95% CI 0.62%–3.52%). Similarly, there was no statistically significant difference in the rate of clinically significant screw malpositions (1.14% [95% CI 0.77%–1.69%) vs 1.69% [95% CI 0.73%–3.84%]). Radiographically identified screw malposition occurred in a higher proportion of C-2 pedicle screws compared with C-2 pars screws (6.0% [95% CI 3.7%–9.6%] vs 4.0% [95% CI 2.0%–7.6%], p < 0.0001). Pseudarthrosis occurred in a greater proportion of patients treated with C-2 pars screws (5 [4.4%] of 113) compared with those treated with C-2 pedicle screws (2 [0.22%] of 900). Point estimates with 95% confidence intervals show a slightly higher rate of successful atlantoaxial fusion in the pedicle screw cohort (97.8% [CI 96.0%–98.8%] vs 93.5% [CI 86.6%–97.0%]; p < 0.0001). Q-testing ruled out heterogeneity between the study groups.

Conclusions

With a thorough knowledge of axis anatomy, surgeons can place both C-2 pars and C-2 pedicle screws accurately with a small risk of VA injury or clinically significant malposition. There may be subtle trade-off of safety for rigidity when using axial pedicle instead of pars screws, and the decision to use either screw type must be made only after careful review of the preoperative CT imaging and must take into account the surgeon's expertise and the particular demands of the clinical scenario in any given case.

Abbreviations used in this paper:

BMP = bone morphogenetic protein; NS = not statistically significant; VA = vertebral artery.
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  • 1

    Abumi K, , Kaneda K, , Shono Y, & Fujiya M: One-stage posterior decompression and reconstruction of the cervical spine by using pedicle screw fixation systems. J Neurosurg 90:1 Suppl 1926, 1999

    • Search Google Scholar
    • Export Citation
  • 2

    Abumi K, , Shono Y, , Ito M, , Taneichi H, , Kotani Y, & Kaneda K: Complications of pedicle screw fixation in reconstructive surgery of the cervical spine. Spine (Phila Pa 1976) 25:962969, 2000

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 3

    Alosh H, , Parker SL, , McGirt MJ, , Gokaslan ZL, , Witham TF, & Bydon A, et al.: Preoperative radiographic factors and surgeon experience are associated with cortical breach of C2 pedicle screws. J Spinal Disord Tech 23:914, 2010

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 4

    American Medical Association: Attributes to Guide the Development and Evaluation of Practice Parameters/Guidelines Chicago, American Medical Association, 1996

    • Search Google Scholar
    • Export Citation
  • 5

    Aryan HE, , Newman CB, , Nottmeier EW, , Acosta FL Jr, , Wang VY, & Ames CP: Stabilization of the atlantoaxial complex via C-1 lateral mass and C-2 pedicle screw fixation in a multicenter clinical experience in 102 patients: modification of the Harms and Goel techniques. J Neurosurg Spine 8:222229, 2008

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 6

    Bransford RJ, , Russo AJ, , Freeborn M, , Nguyen QT, , Lee MJ, & Chapman JR, et al.: Posterior C2 instrumentation: accuracy and complications associated with four techniques. Spine (Phila Pa 1976) 36:E936E943, 2011

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 7

    Chen JF, , Wu CT, , Lee SC, & Lee ST: Posterior atlantoaxial transpedicular screw and plate fixation. Technical note. J Neurosurg Spine 2:386392, 2005

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 8

    Chun HJ, & Bak KH: Targeting a safe entry point for c2 pedicle screw fixation in patients with atlantoaxial instability. J Korean Neurosurg Soc 49:351354, 2011

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 9

    Coyne TJ, , Fehlings MG, , Wallace MC, , Bernstein M, & Tator CH: C1-C2 posterior cervical fusion: long-term evaluation of results and efficacy. Neurosurgery 37:688693, 1995

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 10

    De Iure F, , Donthineni R, & Boriani S: Outcomes of C1 and C2 posterior screw fixation for upper cervical spine fusion. Eur Spine J 18:Suppl 1 26, 2009

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 11

    Dmitriev AE, , Lehman RA Jr, , Helgeson MD, , Sasso RC, , Kuhns C, & Riew DK: Acute and long-term stability of atlantoaxial fixation methods: a biomechanical comparison of pars, pedicle, and intralaminar fixation in an intact and odontoid fracture model. Spine (Phila Pa 1976) 34:365370, 2009

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 12

    Ebraheim N, , Rollins JR Jr, , Xu R, & Jackson WT: Anatomic consideration of C2 pedicle screw placement. Spine (Phila Pa 1976) 21:691695, 1996

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 13

    Ebraheim NA, , Fow J, , Xu R, & Yeasting RA: The location of the pedicle and pars interarticularis in the axis. Spine (Phila Pa 1976) 26:E34E37, 2001

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 14

    Ebraheim NA, , Xu R, , Lin D, , Haman S, & Yeasting RA: Quantitative anatomy of the transverse foramen and pedicle of the axis. J Spinal Disord 11:521525, 1998

    • Search Google Scholar
    • Export Citation
  • 15

    Eck JC, , Walker MP, , Currier BL, , Chen Q, , Yaszemski MJ, & An KN: Biomechanical comparison of unicortical versus bicortical C1 lateral mass screw fixation. J Spinal Disord Tech 20:505508, 2007

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 16

    El Masry MA, , El Assuity WI, , Sadek FZ, & Salah H: Two methods of atlantoaxial stabilisation for atlantoaxial instability. Acta Orthop Belg 73:741746, 2007

    • Search Google Scholar
    • Export Citation
  • 17

    Elliott R, , Tanweer O, , Morsi A, , Boah A, , Ma T, & Frempong-Boadu A, et al.: Is external orthotic bracing necessary after posterior atlantoaxial instrumentation with modern instrumentation: meta-analysis and review of literature. World Neurosurgery [epub ahead of print], 2012

    • Search Google Scholar
    • Export Citation
  • 18

    Farey ID, , Nadkarni S, & Smith N: Modified Gallie technique versus transarticular screw fixation in C1-C2 fusion. Clin Orthop Relat Res 359 126135, 1999

    • Search Google Scholar
    • Export Citation
  • 19

    Finn MA, & Apfelbaum RI: Atlantoaxial transarticular screw fixation: update on technique and outcomes in 269 patients. Neurosurgery 66:3 Suppl 184192, 2010

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 20

    Gluf WM, , Schmidt MH, & Apfelbaum RI: Atlantoaxial transarticular screw fixation: a review of surgical indications, fusion rate, complications, and lessons learned in 191 adult patients. J Neurosurg Spine 2:155163, 2005

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 21

    Goel A, , Desai KI, & Muzumdar DP: Atlantoaxial fixation using plate and screw method: a report of 160 treated patients. Neurosurgery 51:13511357, 2002

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 22

    Goel A, & Laheri V: Plate and screw fixation for atlanto-axial subluxation. Acta Neurochir (Wien) 129:4753, 1994

  • 23

    Gupta S, & Goel A: Quantitative anatomy of the lateral masses of the atlas and axis vertebrae. Neurol India 48:120125, 2000

  • 24

    Hamilton DK, , Smith JS, , Sansur CA, , Dumont AS, & Shaffrey CI: C-2 neurectomy during atlantoaxial instrumented fusion in the elderly: patient satisfaction and surgical outcome. Clinical article. J Neurosurg Spine 15:38, 2011

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 25

    Harms J, & Melcher RP: Posterior C1-C2 fusion with polyaxial screw and rod fixation. Spine (Phila Pa 1976) 26:24672471, 2001

  • 26

    Helgeson MD, , Lehman RA Jr, , Dmitriev AE, , Kang DG, , Sasso RC, & Tannoury C, et al.: Accuracy of the freehand technique for 3 fixation methods in the C-2 vertebrae. Neurosurg Focus 31:4 E11, 2011

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 27

    Hoh DJ, , Liu CY, & Wang MY: A radiographic computed tomography-based study to determine the ideal entry point, trajectory, and length for safe fixation using C-2 pars interarticularis screws. Clinical article. J Neurosurg Spine 12:602612, 2010

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 28

    Howington JU, , Kruse JJ, & Awasthi D: Surgical anatomy of the C-2 pedicle. J Neurosurg 95:1 Suppl 8892, 2001

  • 29

    Johnston TL, , Karaikovic EE, , Lautenschlager EP, & Marcu D: Cervical pedicle screws vs. lateral mass screws: uniplanar fatigue analysis and residual pullout strengths. Spine J 6:667672, 2006

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 30

    Jones EL, , Heller JG, , Silcox DH, & Hutton WC: Cervical pedicle screws versus lateral mass screws. Anatomic feasibility and biomechanical comparison. Spine (Phila Pa 1976) 22:977982, 1997

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 31

    Kang MM, , Anderer EG, , Elliott RE, , Kalhorn SP, & Frempong-Boadu A: C2 nerve root sectioning in posterior C1-2 instrumented fusions. World Neurosurg 78:170177, 2012

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 32

    Kim SW, , Yeom JS, , Kwon YJ, , You SM, , An YH, & Park KW, et al.: Risk of vertebral artery injury: a comparison between C2 subarticular segmental and C1-2 transarticular screws. J Korean Orthop Assoc 43:572578, 2008

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 33

    Lee SH, , Kim ES, , Sung JK, , Park YM, & Eoh W: Clinical and radiological comparison of treatment of atlantoaxial instability by posterior C1-C2 transarticular screw fixation or C1 lateral mass-C2 pedicle screw fixation. J Clin Neurosci 17:886892, 2010

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 34

    Lehman RA Jr, , Dmitriev AE, , Helgeson MD, , Sasso RC, , Kuklo TR, & Riew KD: Salvage of C2 pedicle and pars screws using the intralaminar technique: a biomechanical analysis. Spine (Phila Pa 1976) 33:960965, 2008

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 35

    Lenke LG, , Bridwell KH, , Bullis D, , Betz RR, , Baldus C, & Schoenecker PL: Results of in situ fusion for isthmic spondylolisthesis. J Spinal Disord 5:433442, 1992

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 36

    Li L, , Zhou FH, , Wang H, & Cui SQ: Posterior fixation and fusion with atlas pedicle screw system for upper cervical diseases. Chin J Traumatol 11:323328, 2008

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 37

    Lieberman IH, & Webb JK: Occipito-cervical fusion using posterior titanium plates. Eur Spine J 7:308312, 1998

  • 38

    Liu G, , Buchowski JM, , Shen H, , Yeom JS, & Riew KD: The feasibility of microscope-assisted “free-hand” C1 lateral mass screw insertion without fluoroscopy. Spine (Phila Pa 1976) 33:10421049, 2008

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 39

    Mandel IM, , Kambach BJ, , Petersilge CA, , Johnstone B, & Yoo JU: Morphologic considerations of C2 isthmus dimensions for the placement of transarticular screws. Spine (Phila Pa 1976) 25:15421547, 2000

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 40

    Matz PG, , Anderson PA, , Kaiser MG, , Holly LT, , Groff MW, & Heary RF, et al.: Introduction and methodology: guidelines for the surgical management of cervical degenerative disease. J Neurosurg Spine 11:101103, 2009

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 41

    Mueller CA, , Roesseler L, , Podlogar M, , Kovacs A, & Kristof RA: Accuracy and complications of transpedicular C2 screw placement without the use of spinal navigation. Eur Spine J 19:809814, 2010

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 42

    Mummaneni PV, , Haid RW, , Traynelis VC, , Sasso RC, , Subach BR, & Fiore AJ, et al.: Posterior cervical fixation using a new polyaxial screw and rod system: technique and surgical results. Neurosurg Focus 12:1 E8, 2002

    • Search Google Scholar
    • Export Citation
  • 43

    Mummaneni PV, , Lu DC, , Dhall SS, , Mummaneni VP, & Chou D: C1 lateral mass fixation: a comparison of constructs. Neurosurgery 66:3 Suppl 153160, 2010

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 44

    Naderi S, , Arman C, , Güvençer M, , Korman E, , Senoğlu M, & Tetik S, et al.: An anatomical study of the C-2 pedicle. J Neurosurg Spine 1:306310, 2004

  • 45

    Neo M, , Fujibayashi S, , Miyata M, , Takemoto M, & Nakamura T: Vertebral artery injury during cervical spine surgery: a survey of more than 5600 operations. Spine (Phila Pa 1976) 33:779785, 2008

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 46

    Neo M, , Matsushita M, , Iwashita Y, , Yasuda T, , Sakamoto T, & Nakamura T: Atlantoaxial transarticular screw fixation for a high-riding vertebral artery. Spine (Phila Pa 1976) 28:666670, 2003

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 47

    Neo M, , Sakamoto T, , Fujibayashi S, & Nakamura T: A safe screw trajectory for atlantoaxial transarticular fixation achieved using an aiming device. Spine (Phila Pa 1976) 30:E236E242, 2005

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 48

    Ni B, , Zhu Z, , Zhou F, , Guo Q, , Yang J, & Liu J, et al.: Bilateral C1 laminar hooks combined with C2 pedicle screws fixation for treatment of C1-C2 instability not suitable for placement of transarticular screws. Eur Spine J 19:13781382, 2010

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 49

    Nottmeier EW, & Young PM: Image-guided placement of occipitocervical instrumentation using a reference arc attached to the head-holder. Neurosurgery 66:3 Suppl Operative 138142, 2010

    • Search Google Scholar
    • Export Citation
  • 50

    Ondra SL, , Marzouk S, , Ganju A, , Morrison T, & Koski T: Safety and efficacy of C2 pedicle screws placed with anatomic and lateral C-arm guidance. Spine (Phila Pa 1976) 31:E263E267, 2006

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 51

    Pan J, , Li L, , Qian L, , Tan J, , Sun G, & Li X: C1 lateral mass screw insertion with protection of C1-C2 venous sinus: technical note and review of the literature. Spine (Phila Pa 1976) 35:E1133E1136, 2010

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 52

    Parker SL, , McGirt MJ, , Garcés-Ambrossi GL, , Mehta VA, , Sciubba DM, & Witham TF, et al.: Translaminar versus pedicle screw fixation of C2: comparison of surgical morbidity and accuracy of 313 consecutive screws. Neurosurgery 64:5 Suppl 2 343349, 2009

    • Search Google Scholar
    • Export Citation
  • 53

    Payer M, , Luzi M, & Tessitore E: Posterior atlanto-axial fixation with polyaxial C1 lateral mass screws and C2 pars screws. Acta Neurochir (Wien) 151:223229, 2009

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 54

    Resnick DK, , Lapsiwala S, & Trost GR: Anatomic suitability of the C1-C2 complex for pedicle screw fixation. Spine (Phila Pa 1976) 27:14941498, 2002

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 55

    Sciubba DM, , Noggle JC, , Vellimana AK, , Alosh H, , McGirt MJ, & Gokaslan ZL, et al.: Radiographic and clinical evaluation of free-hand placement of C-2 pedicle screws. Clinical article. J Neurosurg Spine 11:1522, 2009

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 56

    Sim HB, , Lee JW, , Park JT, , Mindea SA, , Lim J, & Park J: Biomechanical evaluations of various C1-C2 posterior fixation techniques. Spine (Phila Pa 1976) 36:E401E407, 2011

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 57

    Simsek S, , Yigitkanli K, , Seckin H, , Akyol C, , Belen D, & Bavbek M: Freehand C1 lateral mass screw fixation technique: our experience. Surg Neurol 72:676681, 2009

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 58

    Smith ZA, , Bistazzoni S, , Onibokun A, , Chen NF, , Sassi M, & Khoo LT: Anatomical considerations for subaxial (C2) pedicle screw placement: a radiographic study with computed tomography in 93 patients. J Spinal Disord Tech 23:176179, 2010

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 59

    Squires J, & Molinari RW: C1 lateral mass screw placement with intentional sacrifice of the C2 ganglion: functional outcomes and morbidity in elderly patients. Eur Spine J 19:13181324, 2010

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 60

    Stokes JK, , Villavicencio AT, , Liu PC, , Bray RS, & Johnson JP: Posterior atlantoaxial stabilization: new alternative to C1–2 transarticular screws. Neurosurg Focus 12:1 E6, 2002

    • Search Google Scholar
    • Export Citation
  • 61

    Stulik J, , Vyskocil T, , Sebesta P, & Kryl J: Atlantoaxial fixation using the polyaxial screw-rod system. Eur Spine J 16:479484, 2007

  • 62

    Taggard DA, , Kraut MA, , Clark CR, & Traynelis VC: Case-control study comparing the efficacy of surgical techniques for C1-C2 arthrodesis. J Spinal Disord Tech 17:189194, 2004

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 63

    Takahashi J, , Shono Y, , Nakamura I, , Hirabayashi H, , Kamimura M, & Ebara S, et al.: Computer-assisted screw insertion for cervical disorders in rheumatoid arthritis. Eur Spine J 16:485494, 2007

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 64

    Tan J, , Li L, , Sun G, , Qian L, , Yang M, & Zeng C, et al.: C1 lateral mass-C2 pedicle screws and crosslink compression fixation for unstable atlas fracture. Spine (Phila Pa 1976) 34:25052509, 2009

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 65

    Thomas JA, , Tredway T, , Fessler RG, & Sandhu FA: An alternate method for placement of C-1 screws. Clinical article. J Neurosurg Spine 12:337341, 2010

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 66

    Vilela MD, , Jermani C, & Braga BP: C1 lateral mass screws for posterior segmental stabilization of the upper cervical spine and a new method of three-point rigid fixation of the C1-C2 complex. Arq Neuropsiquiatr 64:762767, 2006

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 67

    Wang S, , Wang C, , Wood KB, , Yan M, & Zhou H: Radiographic evaluation of the technique for C1 lateral mass and C2 pedicle screw fixation in three hundred nineteen cases. Spine (Phila Pa 1976) 36:38, 2010

    • Search Google Scholar
    • Export Citation
  • 68

    Winegar CD, , Lawrence JP, , Friel BC, , Fernandez C, , Hong J, & Maltenfort M, et al.: A systematic review of occipital cervical fusion: techniques and outcomes. A review. J Neurosurg Spine 13:516, 2010

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 69

    Wright NM, & Lauryssen C: Vertebral artery injury in C1-2 transarticular screw fixation: results of a survey of the AANS/ CNS section on disorders of the spine and peripheral nerves. J Neurosurg 88:634640, 1998

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 70

    Xie Y, , Li Z, , Tang H, , Li M, & Guan Z: Posterior C1 lateral mass and C2 pedicle screw internal fixation for atlantoaxial instability. J Clin Neurosci 16:15921594, 2009

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 71

    Xu R, , Nadaud MC, , Ebraheim NA, & Yeasting RA: Morphology of the second cervical vertebra and the posterior projection of the C2 pedicle axis. Spine (Phila Pa 1976) 20:259263, 1995

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 72

    Yeom JS, , Buchowski JM, , Park KW, , Chang BS, , Lee CK, & Riew KD: Undetected vertebral artery groove and foramen violations during C1 lateral mass and C2 pedicle screw placement. Spine (Phila Pa 1976) 33:E942E949, 2008

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 73

    Yoshida G, , Kamiya M, , Yoshihara H, , Kanemura T, , Kato F, & Yukawa Y, et al.: Subaxial sagittal alignment and adjacent-segment degeneration after atlantoaxial fixation performed using C-1 lateral mass and C-2 pedicle screws or transarticular screws. Clinical article. J Neurosurg Spine 13:443450, 2010

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 74

    Yoshida M, , Neo M, , Fujibayashi S, & Nakamura T: Comparison of the anatomical risk for vertebral artery injury associated with the C2-pedicle screw and atlantoaxial transarticular screw. Spine (Phila Pa 1976) 31:E513E517, 2006

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 75

    Yukawa Y, , Kato F, , Ito K, , Horie Y, , Hida T, & Nakashima H, et al.: Placement and complications of cervical pedicle screws in 144 cervical trauma patients using pedicle axis view techniques by fluoroscope. Eur Spine J 18:12931299, 2009

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 76

    Yusof MI, , Ming LK, & Abdullah MS: Computed tomographic measurement of cervical pedicles for transpedicular fixation in a Malay population. J Orthop Surg (Hong Kong) 15:187190, 2007

    • Crossref
    • Search Google Scholar
    • Export Citation

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