C2 pars interarticularis length on the side of high-riding vertebral artery with implications for pars screw insertion

C2 pars interarticularis length (C2PIL) required for pars screws has not been thoroughly studied in subjects with high-riding vertebral artery (HRVA). We aimed to measure C2PIL specifically on the sides with HRVA, define short pars, optimal pars screw length, and incorporate C2PIL into HRVA clusters using machine learning algorithms. A clinical anatomical study based on cervical CT was conducted with STROBE-compliant case-control design. HRVA was defined as accepted. Interobserver, intraobserver, and inter-software agreement coefficients for HRVA were adopted from our previous study. Sample size was estimated with pwr package and C2PIL was measured. Cut-off value and predictive statistics of C2PIL for HRVA were computed with cutpointr package. Unsupervised machine learning clustering was applied with all three pars parameters. 345 potential screw insertion sites (PSIS) were grouped as HRVA (143 PSIS in 110 subjects) or controls (202 PSIS in 101 subjects). 68% participants were females. The median C2PIL in HRVA group was 13.7 mm with interquartile range (IQR) of 1.7, whereas in controls it was 19.8 mm (IQR = 2.7). The optimal cut-off value of C2PIL discriminating HRVA was 16.06 mm with sensitivity of 96.5% and specificity of 99.3%. Therefore, clinically important short pars was defined as <= 16 mm rounding to the nearest screw length. Two clusters were created incorportating three parameters of pars interarticularis. In preoperative planning, the identified C2PIL cut-off of <= 16 mm may assist surgeons in early recognition of HRVA. The average screw lengths of 14 mm for bicortical and 12 mm for safer unicortical purchase in HRVA cases may serve as practical intraoperative reference points, particularly in situations requiring rapid decision-making or when navigation systems are unavailable. Moreover, C2PIL complements the classic HRVA parameters within the dichotomized clustering framework.