Complications of cervical pedicle screw fixation for nontraumatic lesions: a multicenter study of 84 patients

Clinical article

Restricted access


The cervical pedicle screw (PS) provides strong stabilization but poses a potential risk to the neurovascular system, which may be catastrophic. In particular, vertebrae with degenerative changes complicate the process of screw insertion, and PS misplacement and subsequent complications are more frequent. The purpose of this study was to evaluate the peri- and postoperative complications of PS fixation for nontraumatic lesions and to determine the risk factors of each complication.


Eighty-four patients who underwent cervical PS fixation for nontraumatic lesions were independently reviewed to identify associated complications. The mean age of the patients was 60.1 years, and the mean follow-up period was 4.1 years (range 6–168 months). Pedicle screw malpositioning was classified on postoperative CT scans as Grade I (< 50% of the screw outside the pedicle) or Grade II (≥ 50% of the screw outside the pedicle). Risk factors of each complication were evaluated using a multivariate analysis.


Three hundred ninety cervical PSs and 24 lateral mass screws were inserted. The incidence of PS misplacement was 19.5% (76 screws); in terms of malpositioning, 60 screws (15.4%) were classified as Grade I and 16 (4.1%) as Grade II. In total, 33 complications were observed. These included postoperative neurological complications in 11 patients in whom there was no evidence of screw misplacement (C-5 palsy in 10 and C-7 palsy in 1), implant failure in 11 patients (screw loosening in 5, broken screws in 4, and loss of reduction in 2), complications directly attributable to screw insertion in 5 patients (nerve root injury by PS in 3 and vertebral artery injury in 2), and other complications in 6 patients (pseudarthrosis in 2, infection in 1, transient dyspnea in 1, transient dysphagia in 1, and adjacent-segment degeneration in 1). The multivariate analysis showed that a primary diagnosis of cerebral palsy was a risk factor for postoperative implant failure (HR 10.91, p = 0.03) and that the presence of preoperative cervical spinal instability was a risk factor for both Grade I and Grade II screw misplacement (RR 2.12, p = 0.03), while there were no statistically significant risk factors for postoperative neurological complications in the absence of evidence of screw misplacement or complications directly attributable to screw insertion.


In the present study, misplacement of cervical PSs and associated complications occurred more often than in previous studies. The rates of screw-related neurovascular complications and neurological deterioration unrelated to PSs were high. Insertion of a PS for nontraumatic lesions is surgically more challenging than that for trauma; consequently, experienced surgeons should use PS fixation for nontraumatic cervical lesions only after thorough preoperative evaluation of each patient's cervical anatomy and after considering the risk factors specified in the present study.

Abbreviations used in this paper: CP = cerebral palsy; CSA = cervical spine amyotrophy; CSM = cervical spondylotic myelopathy; LMS = lateral mass screw; OPLL = ossification of posterior longitudinal ligament; PS = pedicle screw; RA = rheumatoid arthritis.

Article Information

Address correspondence to: Hiroaki Nakashima, M.D., Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai, Shouwa-ku, Nagoya, Aichi 466-8560, Japan. email:

Please include this information when citing this paper: published online December 16, 2011; DOI: 10.3171/2011.11.SPINE11102.

© AANS, except where prohibited by US copyright law.



  • View in gallery

    Studies obtained in a 53-year-old woman with CSM. A: Later radiograph showing cervical kyphosis. B: Lateral radiograph acquired after a C3–7 laminoplasty was performed with posterior reduction and cervical PS–based fusion. The cervical PSs were inserted using the free-hand technique. The patient complained of pain and numbness in the right C-5 area immediately after surgery. CE: Postoperative scans of the C-3 (C), C-5 (D), and C-7 (E) vertebrae. All right-side PSs perforated the medial pedicle wall (all screws were classified as Grade II) and the left C-5 PS perforated the lateral pedicle wall (classified as Grade I). Every misplaced screw was reinserted correctly during revision surgery. The patient's symptoms resolved after surgery.



Abumi KIto MKaneda K: Surgical treatment of cervical destructive spondyloarthropathy (DSA). Spine (Phila Pa 1976) 25:289929052000


Abumi KItoh HTaneichi HKaneda K: Transpedicular screw fixation for traumatic lesions of the middle and lower cervical spine: description of the techniques and preliminary report. J Spinal Disord 7:19281994


Abumi KKaneda K: Pedicle screw fixation for nontraumatic lesions of the cervical spine. Spine (Phila Pa 1976) 22:185318631997


Abumi KShono YIto MTaneichi HKotani YKaneda K: Complications of pedicle screw fixation in reconstructive surgery of the cervical spine. Spine (Phila Pa 1976) 25:9629692000


Abumi KShono YTaneichi HIto MKaneda K: Correction of cervical kyphosis using pedicle screw fixation systems. Spine (Phila Pa 1976) 24:238923961999


Abumi KTakada TShono YKaneda KFujiya M: Posterior occipitocervical reconstruction using cervical pedicle screws and plate-rod systems. Spine (Phila Pa 1976) 24:142514341999


Chiba KToyama YMatsumoto MMaruiwa HWatanabe MHirabayashi K: Segmental motor paralysis after expansive open-door laminoplasty. Spine (Phila Pa 1976) 27:210821152002


Cho KHShin YSYoon SHKim SHAhn YHCho KG: Poor surgical technique in cervical plating leading to vertebral artery injury and brain stem infarction—case report. Surg Neurol 64:2212252005


Dias RCMiller FDabney KLipton GTemple T: Surgical correction of spinal deformity using a unit rod in children with cerebral palsy. J Pediatr Orthop 16:7347401996


Fehlings MGCooper PRErrico TJ: Posterior plates in the management of cervical instability: long-term results in 44 patients. J Neurosurg 81:3413491994


Heller JGSilcox DH IIISutterlin CE III: Complications of posterior cervical plating. Spine (Phila Pa 1976) 20:244224481995


Hojo YIto MAbumi KKotani YSudo HTakahata M: A late neurological complication following posterior correction surgery of severe cervical kyphosis. Eur Spine J 20:8908982011


Holly LTFoley KT: Percutaneous placement of posterior cervical screws using three-dimensional fluoroscopy. Spine (Phila Pa 1976) 31:5365412006


Imagama SMatsuyama YYukawa YKawakami NKamiya MKanemura T: C5 palsy after cervical laminoplasty: a multicentre study. J Bone Joint Surg Br 92:3934002010


Jeanneret BGebhard JSMagerl F: Transpedicular screw fixation of articular mass fracture-separation: results of an anatomical study and operative technique. J Spinal Disord 7:2222291994


Karaikovic EEDaubs MDMadsen RWGaines RW Jr: Morphologic characteristics of human cervical pedicles. Spine (Phila Pa 1976) 22:4935001997


Karaikovic EEKunakornsawat SDaubs MDMadsen TWGaines RW Jr: Surgical anatomy of the cervical pedicles: landmarks for posterior cervical pedicle entrance localization. J Spinal Disord 13:63722000


Kast EMohr KRichter HPBörm W: Complications of transpedicular screw fixation in the cervical spine. Eur Spine J 15:3273342006


Katonis PPapadakis SAGalanakos SPaskou DBano ASapkas G: Lateral mass screw complications: analysis of 1662 Screws. J Spinal Disord Tech 24:4154202011


Kotani YAbumi KIto MMinami A: Improved accuracy of computer-assisted cervical pedicle screw insertion. J Neurosurg 99:3 Suppl2572632003


Kotani YCunningham BWAbumi KMcAfee PC: Biomechanical analysis of cervical stabilization systems. An assessment of transpedicular screw fixation in the cervical spine. Spine (Phila Pa 1976) 19:252925391994


Kothe RRüther WSchneider ELinke B: Biomechanical analysis of transpedicular screw fixation in the subaxial cervical spine. Spine (Phila Pa 1976) 29:186918752004


Lee GYMassicotte EMRampersaud YR: Clinical accuracy of cervicothoracic pedicle screw placement: a comparison of the “open” lamino-foraminotomy and computer-assisted techniques. J Spinal Disord Tech 20:25322007


Neo MSakamoto TFujibayashi SNakamura T: The clinical risk of vertebral artery injury from cervical pedicle screws inserted in degenerative vertebrae. Spine (Phila Pa 1976) 30:280028052005


Oda IAbumi KIto MKotani YOya THasegawa K: Palliative spinal reconstruction using cervical pedicle screws for metastatic lesions of the spine: a retrospective analysis of 32 cases. Spine (Phila Pa 1976) 31:143914442006


Panjabi MMShin EKChen NCWang JL: Internal morphology of human cervical pedicles. Spine (Phila Pa 1976) 25:119712052000


Sakaura HHosono NMukai YIshii TYoshikawa H: C5 palsy after decompression surgery for cervical myelopathy: review of the literature. Spine (Phila Pa 1976) 28:244724512003


Sink ELNewton POMubarak SJWenger DR: Maintenance of sagittal plane alignment after surgical correction of spinal deformity in patients with cerebral palsy. Spine (Phila Pa 1976) 28:139614032003


Suda KAbumi KIto MShono YKaneda KFujiya M: Local kyphosis reduces surgical outcomes of expansive open-door laminoplasty for cervical spondylotic myelopathy. Spine (Phila Pa 1976) 28:125812622003


Takemitsu MCheung KMWong YWCheung WYLuk KD: C5 nerve root palsy after cervical laminoplasty and posterior fusion with instrumentation. J Spinal Disord Tech 21:2672722008


Yukawa YKato FIto KHorie YHida TNakashima H: Placement and complications of cervical pedicle screws in 144 cervical trauma patients using pedicle axis view techniques by fluoroscope. Eur Spine J 18:129312992009


Yukawa YKato FYoshihara HYanase MIto K: Cervical pedicle screw fixation in 100 cases of unstable cervical injuries: pedicle axis views obtained using fluoroscopy. J Neurosurg Spine 5:4884932006




All Time Past Year Past 30 Days
Abstract Views 88 88 12
Full Text Views 134 134 29
PDF Downloads 78 78 10
EPUB Downloads 0 0 0


Google Scholar