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Preoperative Helical CT Angiography for C1-2 Transarticular Screw Placement: A New Technique


Nicholas Theodore, MD†§
Shahram Partovi, MD‡
Matthew T. Walker, MD‡*
Phil Saba, MD‡
Volker K.H. Sonntag, MD†

†Divisions of Neurological Surgery and ‡Neuroradiology, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, Arizona

Current Addresses:
§Division of Neurosurgery, Naval Medical Center, San Diego, CA
*Division of Neuroradiology, Northwestern Memorial Hospital, Chicago, Illinois


Injury to the vertebral artery during transarticular screw placement can have disastrous consequences.  A new radiologic technique using state-of-the-art computerized tomographic angiography as a preoperative adjunct can help decrease the risk of injuring the vertebral artery.

Key Words: computed tomographic angiography, transarticular screw, vertebral artery

Figure 1. Diagrams showing the procedure followed in the reconstruction, which is performed using the console of a spiral computerized tomography (CT) scanner. An axial scout image (upper left) is used to determine the midline of a reconstruction in the sagittal plane (upper right). A marking cursor is placed in the midpoint of the anterior arch of C1 on this reconstructed image. This point (x) represents the ideal target for C1-2 transarticular screws as placed in the operating room. Next, the line on the axial scout image is moved laterally (lower left), 2 to 3 mm from the medial aspect of the facet joint, to create a new sagittal reconstruction (lower right). A second cursor (y) is placed 4 mm cephalad to the C2-3 facet joint, as shown on the sagittal reconstruction (lower right). This point (y) represents the ideal entry point for C1-2 transarticular screws. Finally, a line is drawn between the two cursor points. This line and the horizontal axis form the plane describing the screw trajectory reconstruction. One millimeter thick CT scans above and below this initial scan complete the reconstruction process. [From Paramore CG, Dickman CA, Sonntag VKH: The anatomical suitability of the C1-2 complex for transarticular screw fixation. J Neurosurg 85:221 224, 1996]. With permission from Journal of Neurosurgery.
Ever since Magerl’s original description of transarticular screw placement, the treatment of atlantoaxial instability has remained a formidable task for spinal surgeons.  Furthermore, the associated risk to the patient is considerable.[5,6,8]  Along with neurological injury to a nerve root or the spinal cord, the most daunting potential complication is injury to the vertebral artery.[1,3,11,13]  Although uncommon, an injury to the vertebral artery during this procedure can be fatal.

Numerous techniques and radiologic protocols have been developed to predict which patients can safely undergo placement of a transarticular screw.  None of these strategies, however, address the true arterial morphology and its relationship to the neighboring bony anatomy.  This article reviews a current method of preoperative evaluation and describes a new system that could help decrease the potential of injuring the vertebral artery during the placement of C1-2 transarticular screws.

Current Imaging of the C1-2 Complex

Plain radiography of the cervical spine with and without dynamic views is the diagnostic standard for the evaluation of all atlantoaxial pathologies.  Once a pathology has been diagnosed, magnetic resonance (MR) imaging and computerized tomography (CT) are both useful adjuncts.  MR imaging is valuable because of its ability to delineate injuries to the transverse ligament.[2,4]  Pure ligamentous injuries are incapable of healing without internal fixation and are treated surgically.  In contrast, fractures and avulsions of the tubercle for insertion of the transverse ligament have a high incidence of healing when treated with a rigid orthosis.[2,4]  MR imaging can help to identify appropriate surgical candidates, but it provides no detailed information about regional bony anatomy.[7,9]  As a preoperative adjunct, MR angiography elucidates the morphology and course of the vertebral arteries as well as the presence of an arterial dissection.  The latter is a common sequela in patients with a fractured or unstable cervical spine related to trauma.

CT, however, is without a doubt the most important modality when determining a patient’s suitability for the placement of transarticular screws.  Preoperative CT scanning with appropriate reconstructions in the sagittal and coronal planes allows the C2 transverse foramen and C1-2 facet joint to be evaluated comprehensively.  Using a protocol described by Paramore, Dickman, and Sonntag,[10] all patients at the Barrow Neurological Institute who underwent placement of a C1-2 transarticular screw since 1994 have undergone preoperative evaluation of the atlantoaxial region.  This evaluation follows traditional axial slices with coronal and sagittal reconstructions.

A special screw trajectory is reconstructed by placing a marker on the midportion of the image of the anterior arch of C1 (corresponding to the target seen on intraoperative fluoroscopy during surgery, Fig. 1).  The sagittal image is moved laterally until the image shown is 2 to 3 mm from the lateral border of the spinal canal (as seen on inset axial image).  A second marker is then placed on the sagittal image about 4 mm superior to the C2-3 facet complex, which corresponds to the entry point of the screw.  The two markers are connected, and reconstruction is performed in the plane described by this line and the lateral axis.

This protocol is a useful preoperative adjunct and can predict which patients are at risk for potential vascular injury.  However, it provides no information about the vertebral artery and its intimate relationship with the surrounding bone.  CT angiography is a relatively new modality that uses high-speed scanners with nonionic contrast administration to evaluate vascular structures.  Vessels can be shown in relationship to their surrounding bony confines.  This technique has not been described previously as a method to assess the feasibility of transarticular screw placement before surgery.  In addition to preoperative assessment, this technique can be used in conjunction with image-guided technology to obtain a real-time evaluation of the course of the vertebral artery during placement of transarticular screws or during any other procedure that could place vascular structures at risk.

CT Angiographic Protocol of C1-2 Complex

A General Electric LightSpeed multi-array detector CT scanner (General Electric Company, Milwaukee, WI) is used to perform a helical CT scan of the craniocervical junction, from midC3 through the foramen magnum.  Scanning is performed with a tube rotation time of 1 second.  Slices are 1.25-mm thick at 1-mm intervals, resulting in an overlap of 0.25 mm.  High-quality mode is used and results in a pitch of 3.  Visipaque 320 (100 ml, Nycomed, Inc., Princeton, NJ) is administered intravenously, and scanning is performed with a 9- to 16-second delay based on the patient’s age and cardiac status.  Postprocessing includes three-dimensional reconstructions of the vertebral arteries as well as sagittal and coronal reformatted images of the bony structures.  Multiplanar volume reconstruction images are used to combine the vertebral arteries with the bony structures to obtain a representation of the anatomic interrelationships.

Illustrative Cases

Case 1

A 40-year-old male who suffered an odontoid fracture 20 years ago and was treated with a Gallie-type posterior fusion sought treatment for severe neck pain, Lhermitte’s sign, and episodes of paresthesias and weakness with neck movement.  MR imaging studies demonstrated pannus behind the body of C2 and evidence of an unfused type II odontoid fracture.  Because the anterior compression was minimal, it was believed that posterior arthrodesis of the atlantoaxial complex would be sufficient to treat his chronic instability.  Preoperative CT angiography showed that the vertebral artery was absent on the left (Fig. 2). Therefore, we decided to place a single transarticular screw on the left to avoid the risk of compromising the patient’s entire posterior circulation by placing screws bilaterally. A single transarticular screw satisfactorily immobilizes the atlantoaxial complex.[12] In this case, CT angiography simultaneously provided a clear picture of the relevant arterial and bony anatomy, and placement of a single screw on the side without a vertebral artery avoided a potentially disastrous complication.  Despite his previous failed fusion, the patient developed a solid arthrodesis and recovered completely.

Figure 2. (A) Axial bone window computed tomographic (CT) angiogram through C1 shows a prominent right vertebral artery (arrow) in the transverse foramen and the absence of the left vertebral artery. The vascular structures seen on the left (arrowheads) were shown to be veins on other images. Evidence of the old posterior wire fusion without appreciable surrounding bone growth is noted. (B) Axial CT angiogram through the region of C2 confirms the absence of the left vertebral artery. Because of this anomalous situation, it was decided to place a single screw on the right side to avoid the risk of compromising the vascular supply to the posterior fossa. A simple CT without CT angiography would probably not have elucidated this situation.

Case 2

An 18-year-old female with a history of suboccipital headaches underwent plain radiography, which showed an abnormality in the cervical spine. The patient had an os odontoideum, which was unstable with 15 mm of movement on flexion-extension radiographs. CT angiography demonstrated normal vertebral arteries bilaterally (Fig. 3).  The patient underwent placement of a single transarticular screw on the left because the bony anatomy on the right was inadequate to support a screw. The patient developed a solid C1-2 fusion, and her preoperative symptoms resolved completely.

Figure 3. (A) Axial and (B) three-dimensional reconstruction computed tomographic angiograms show the course and morphology of the bilateral vertebral arteries and their relationship to the surrounding bony anatomy.

Case 3

A 70-year-old woman sustained a fracture at the base of the dens and right lateral mass of C2 in a motor vehicle accident.  She was treated conservatively at an outside institution with rigid cervical orthosis.  On follow-up examination, she still had neck pain. Flexion-extension radiography showed atlantoaxial instability.  CT angiography demonstrated codominant vertebral arteries (Fig. 4). Because of the bony anatomy, the patient underwent placement of a single right-sided transarticular screw and ultimately developed a solid fusion. Her neck pain resolved completely.

Figure 4. (A) Axial computed tomographic (CT) angiogram shows the course of the right vertebral artery. (B) Corresponding coronally reformatted CT angiogram shows the course and morphology of the right vertebral artery. The complexity of the fracture (arrow) is also visible. (C) Axial CT angiogram through C2 shows the course of the left vertebral artery. (D) Corresponding oblique coronally reformatted CT angiogram shows the course and morphology of the left vertebral artery.


CT angiography offers an innovative way to image the critical vascular structures of the craniovertebral junction while preserving the detail of bony structures that is lacking on MR angiography.  CT angiography will become an important part of the preoperative assessment as well as intraoperatively in conjunction with image-guided technology of patients undergoing transarticular screw placement and other spinal procedures that place vascular structures at risk.  In addition to being relatively noninvasive, CT angiography offers much quicker processing and postprocessing than MR imaging.


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