Effect of frameless stereotaxy on the accuracy of C1-2 transarticular screw placement

Object. In recent studies some authors have indicated that 20% of patients have at least one ectatic vertebral artery (VA) that, based on previous cri teria in which preoperative computerized tomography (CT) and standard intra operative fluoroscopic techniques were used, may prevent the safe placement of C1-2 transarticular screws. The authors conducted this study to determi ne whether frameless stereotaxy would improve the accuracy of C1-2 transart icular screw placement in healthy patients, particularly those whom previou s criteria would have excluded. Methods. The authors assessed the accuracy of frameless stereotaxy for C1-2 transarticular screw placement in 17 cadaveric cervical spines. Preoperati vely obtained CT scans of the C-2 vertebra were registered on a stereotacti c workstation. The dimensions of the C-2 pars articularis were measured on the workstation, and a 3.5-mm screw was stereotactically placed if the heig ht and width of the pars interarticularis was greater than 4 mm. The specim ens were evaluated with postoperative CT scanning and visual inspection. Sc rew placement was considered acceptable if the screw was contained within t he C-2 pars interarticularis, traversed the C1-2 joint, and the screw tip w as shown to be within the anterior cortex of the C-l lateral mass. Transarticular screws were accurately placed in 16 cadaveric specimens, and only one specimen (5.9%) was excluded because of anomalous VA anatomy. In contrast, a total of four specimens (23.5%) showed significant narrowing of the C-2 pars interarticularis due to vascular anatomy that would have prec luded atlantoaxial transarticular screw placement had previous nonimage-gui ded criteria been used. Conclusions. Frameless stereotaxy provides precise image guidance that impr oves the safety of C1-2 transarticular screw placement and potentially allo ws this procedure to be performed in patients previously excluded because o f the inaccuracy of nonimage-guided techniques.