title: Anatomic considerations of anterior transarticular screw fixation for atlantoaxial instability.
abstract: METHODS
  Anatomic parameters of C1 and C2 were measured in 30 dried human cervical spines. Anterior transarticular C1-C2 screws were placed in 15 cadaveric spines.
  
  
  OBJECTIVE
  To provide anatomic data for anterior transarticular atlantoaxial screw or C1-C2 screw and plate fixation.
  
  
  BACKGROUND
  A posterior approach to fixation in the atlantoaxial joint has been well described. Damage to the vertebral artery is documented as a rare complication of posterior atlantoaxial transarticular screw fixation. An anterior surgical approach to exposing the upper cervical spine for internal fixation and bone graft recently has been developed. No anatomic information regarding the anterior transarticular atlantoaxial screw or screw and plate fixation between C1 and C2 is available in the literature.
  
  
  METHODS
  Direct measurements using digital calipers and a goniometer were taken from 30 pairs of dried human C1 and C2 vertebrae. The anterior transarticular C1-C2 screw insertion point is at the junction of the lateral edge of the C2 vertebral body to 4 mm above the inferior edge of the C2 anterior arch. The parameters related to anterior transarticular atlantoaxial screw fixation or screw and plate fixation between the C1 lateral mass and the C2 vertebral body were measured. Fifteen embalmed cadavers were used for anterior C1-C2 transarticular screw placement. Longer screws (30-40 mm) were used to detect whether the screw tips violated the upper cervical canal or vertebral arteries.
  
  
  RESULTS
  In the anterior transarticular atlantoaxial screw placement, lateral angulation of the screw placement relative to sagittal plane ranged from 4.8 +/- 1.8 degrees to 25.3 +/- 2.6 degrees. The posterior angulation of the screw placement relative to the coronal plane ranged from 12.8 +/- 3.1 degrees to 22.6 +/- 3.2 degrees. The length of the medial screw path ranged from 14.7 +/- 1.5 mm to 25.4 +/- 2.8 mm. In the anterior screw and plate fixation, the anteroposterior diameter of the inferior facet articular surface ranged from 16.2 +/- 1.6 mm to 17.1 +/- 1.8 mm. The anteroposterior diameter of the C2 vertebral body ranged from 9.3 +/- 1 mm to 16.2 +/- 1.8 mm. The anterior prevascular retropharyngeal approach appropriately exposed the atlantoaxial joint for anterior transarticular C1-C2 screw placement. No screws violated the vertebral artery and cervical canal.
  
  
  CONCLUSIONS
  An anterior transarticular atlantoaxial screw 15-25 mm long can be inserted with a lateral angulation of 5-25 degrees relative to the sagittal plane and a posterior angulation of 10-25 degrees relative to the coronal plane. Additionally, in C1-C2 anterior plate fixation screws 15 mm long could be anchored in the inferior facet of the C1, and screws 9-15 mm long could be anchored in the C2 vertebral body.
authors.affiliation: Department of Orthopaedic Surgery, Medical College of Ohio, Toledo, USA.
authors.forename: J
authors.initials: J
authors.lastname: Lu
authors.forename: N A
authors.initials: NA
authors.lastname: Ebraheim
authors.forename: H
authors.initials: H
authors.lastname: Yang
authors.forename: B E
authors.initials: BE
authors.lastname: Heck
authors.forename: R A
authors.initials: RA
authors.lastname: Yeasting
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001268:Atlanto-Axial Joint / Q000000981:diagnostic imaging / Q000601:surgery*; D001863:Bone Screws; D002102:Cadaver; D002574:Cervical Vertebrae / Q000033:anatomy & histology* / Q000000981:diagnostic imaging; D005260:Female; D006801:Humans; D007593:Joint Instability / Q000000981:diagnostic imaging / Q000601:surgery*; D008297:Male; D015203:Reproducibility of Results; D013123:Spinal Fusion / Q000295:instrumentation*; D014057:Tomography, X-Ray Computed