title: Use of intraoperative fluoroscopy for the safe placement of C2 laminar screws: technical note.
abstract: BACKGROUND
  Rigid fixation of the atlantoaxial joint can be quite challenging due to complex anatomic variants. Numerous techniques have evolved over time, improving the surgeon's adaptability. The recent advent of C2 laminar screws adds to the surgeon's armamentarium, but is not without its own set of limitations. Risk of ventral laminar breach with possible spinal cord injury, CSF leak, or poor bony fixation have led some to recommend prefabricated models or expensive intraoperative spinal navigation to aid screw placement. The purpose of this report is to detail how the use of intraoperative fluoroscopy can be used to aid in the safe placement of C2 laminar screws.
  
  
  METHODS
  One patient with rheumatoid arthritis and progressive cervical myelopathy from C1-2 instability underwent C1-2 fixation using C2 laminar screws. Intraoperative fluoroscopy was used to guide and confirm safe laminar screw placement.
  
  
  RESULTS
  Immediate and 6-month postoperative imaging demonstrated excellent placement of C2 laminar screws without ventral breach. At 6 months, the patient noted significant improvement of her preoperative symptoms.
  
  
  CONCLUSIONS
  Use of intraoperative fluoroscopy is an easy and safe method for the placement of C2 laminar screws. Given its use of readily available equipment, this method can be implemented without significant pre-planning, or as an impromptu salvage maneuver.
authors.affiliation: Department of Neurosurgery, New York University School of Medicine, New York, NY, USA. john.engler@alumni.med.nyu.edu.|Department of Neurosurgery, Naval Medical Center Portsmouth, 620 John Paul Jones Circle, Portsmouth, VA, 23708, USA. john.engler@alumni.med.nyu.edu.
authors.forename: John A
authors.initials: JA
authors.lastname: Engler
authors.affiliation: Department of Neurosurgery, New York University School of Medicine, New York, NY, USA.
authors.forename: Michael L
authors.initials: ML
authors.lastname: Smith
mesh_terms: D001172:Arthritis, Rheumatoid / Q000601:surgery; D001268:Atlanto-Axial Joint / Q000000981:diagnostic imaging / Q000601:surgery*; D001863:Bone Screws; D002574:Cervical Vertebrae / Q000000981:diagnostic imaging / Q000601:surgery; D005260:Female; D005471:Fluoroscopy / Q000379:methods; D006801:Humans; D007430:Intraoperative Care / Q000379:methods; D007593:Joint Instability / Q000000981:diagnostic imaging / Q000601:surgery*; D008875:Middle Aged; D015641:Radiography, Interventional / Q000379:methods*; D013117:Spinal Cord Compression / Q000000981:diagnostic imaging / Q000601:surgery; D013119:Spinal Cord Injuries / Q000517:prevention & control; D013123:Spinal Fusion / Q000379:methods*; D016896:Treatment Outcome
keywords: C1–2 fixation; C2 laminar screw; Fluoroscopy